Tarani Chandola

Chronic stress at work and the metabolic syndrome: prospective study

Abstract Objectives To investigate the association between stress at work and the metabolic syndrome. Table 4 Risk of having the metabolic syndrome by relative index of inequality of employment grade. Multivariate multiple imputation logistic regression models: non-retired men and women in the Whitehall II cohort at phase 5 Odds ratio (95% CI) P for linear trend Reduction in log odds from model I Age+sex (model I) 2.33 (1.38 to 3.93) <0.01 Age+sex+work stress 2.13 (1.22 to 3.71) 0.01 10.5% Age+sex+health behaviours 2.04 (1.05 to 3.95) 0.04 15.6% Age+sex+work stress+behaviours 1.86 (0.96 to 3.61) 0.07 26.4% Design Prospective cohort study investigating the association between work stress and the metabolic syndrome. Participants 10 308 men and women, aged 35-55, employed in 20 London civil service departments at baseline (the Whitehall II study); follow-up was an average of 14 years. Main outcome measures Work stress based on the iso-strain model, measured on four occasions (1985-99). Biological measures of the metabolic syndrome, based on the National Cholesterol Education Program definition, measured in 1997-9. Results A dose-response relation was found between exposure to work stressors over 14 years and risk of the metabolic syndrome, independent of other relevant risk factors. Employees with chronic work stress (three or more exposures) were more than twice as likely to have the syndrome than those without work stress (odds ratio adjusted for age and employment grade 2.25, 95% confidence interval 1.31 to 3.85). Conclusions Stress at work is an important risk factor for the metabolic syndrome. The study provides evidence for the biological plausibility of the link between psychosocial stressors from everyday life and heart disease.

Work stress and coronary heart disease: what are the mechanisms?

AIMS To determine the biological and behavioural factors linking work stress with coronary heart disease (CHD). METHODS AND RESULTS A total of 10 308 London-based male and female civil servants aged 35-55 at phase 1 (1985-88) of the Whitehall II study were studied. Exposures included work stress (assessed at phases 1 and 2), and outcomes included behavioural risk factors (phase 3), the metabolic syndrome (phase 3), heart rate variability, morning rise in cortisol (phase 7), and incident CHD (phases 2-7) on the basis of CHD death, non-fatal myocardial infarction, or definite angina. Chronic work stress was associated with CHD and this association was stronger among participants aged under 50 (RR 1.68, 95% CI 1.17-2.42). There were similar associations between work stress and low physical activity, poor diet, the metabolic syndrome, its components, and lower heart rate variability. Cross-sectionally, work stress was associated with a higher morning rise in cortisol. Around 32% of the effect of work stress on CHD was attributable to its effect on health behaviours and the metabolic syndrome. CONCLUSION Work stress may be an important determinant of CHD among working-age populations, which is mediated through indirect effects on health behaviours and direct effects on neuroendocrine stress pathways.

Patients’ experiences and satisfaction with health care: results of a questionnaire study of specific aspects of care

Objective: To determine what aspects of healthcare provision are most likely to influence satisfaction with care and willingness to recommend hospital services to others and, secondly, to explore the extent to which satisfaction is a meaningful indicator of patient experience of healthcare services. Design: Postal survey of a sample of patients who underwent a period of inpatient care. Patients were asked to evaluate their overall experience of this episode of care and to complete the Picker Inpatient Survey questionnaire on specific aspects of their care. Sample: Patients aged 18 and over presenting at five hospitals within one NHS trust in Scotland. Method: 3592 questionnaires were mailed to patients’ homes within 1 month of discharge from hospital during a 12 month period. Two reminders were sent to non-responders; 2249 (65%) questionnaires were returned. Results: Almost 90% of respondents indicated that they were satisfied with their period of inpatient care. Age and overall self-assessed health were only weakly associated with satisfaction. A multiple linear regression indicated that the major determinants of patient satisfaction were physical comfort, emotional support, and respect for patient preferences. However, many patients who reported their satisfaction with the care they received also indicated problems with their inpatient care as measured on the Picker Inpatient Survey; 55% of respondents who rated their inpatient episode as “excellent” indicated problems on 10% of the issues measured on the Picker questionnaire. Discussion: The evidence suggests that patient satisfaction scores present a limited and optimistic picture. Detailed questions about specific aspects of patients’ experiences are likely to be more useful for monitoring the performance of various hospital departments and wards and could point to ways in which delivery of health care could be improved.

Association Between Fear of Crime and Mental Health and Physical Functioning

OBJECTIVES Studies have reported an inverse association between fear of crime and subjective mental and physical health. We investigated the direction of causality and the curtailment of physical and social activities as a possible mediating pathway. METHODS We analyzed data from 2002 to 2004 of the Whitehall II study, a longitudinal study of more than 10 000 London-based civil servants aged 35 to 55 years at baseline. RESULTS Fear of crime was associated with poorer mental health, reduced physical functioning on objective and subjective indicators, and lower quality of life. Participants reporting greater fear were 1.93 (95% confidence interval [CI]=1.55, 2.41) times as likely to have depression as those reporting lower fear of crime and had lower mental health scores (0.9 points on the Medical Outcomes Survey Short Form 36; 95% CI=0.4, 1.3). They exercised less, saw friends less often, and participated in fewer social activities compared with the less fearful participants. Curtailed physical and social activities helped explain the link between fear of crime and health. CONCLUSIONS Fear of crime may be a barrier to participation in health-promoting physical and social activities. Public health practitioners should support fear-reduction initiatives.

Validating self-rated health in different ethnic groups.

Background. Subjective accounts of health status are increasingly utilized in social surveys and medical research to assess functioning and well-being. Despite the fact that substantial research evidence suggests that self-rated health is meaningful and provides valid and reliable data, some authors have raised concerns that different social groups may interpret the notion of health in different ways, and hence complete health measures in systematically different ways. This study evaluates the validity of using self-rated health status to measure health status in different ethnic groups. Methods. Logistic regression models were used to examine the association of selfrated health with more objective measures of morbidity in different ethnic groups. Sample. Two sources of data were used-the Health Survey for England (HSE) 1991-96 combined file and the Fourth National Survey of Ethnic Minorities (Ethmins4). Measures of health. Hypertension, presence of cardiovascular disease or diabetes, limiting health and number of visits to a doctor. Self-rated health was measured on 5-point scale ranging from excellent to very poor. Results. Poorer self-rated health was associated with greater morbidity within each ethnic group. Furthermore, there was little evidence that the association of self-rated health with more objective measures of morbidity differed between ethnic groups. Conclusion. The evidence reported here suggests that the use of a single item measure of self-rated health to measure health status in different ethnic groups is valid. Further research might usefully explore the validity of using more comprehensive profile measures of health status in different ethnic groups.

Social Gradients in Oral and General Health

There are social gradients in general health and oral health. However, there have been few studies addressing whether similarities exist in the gradients in oral and general health in the same individuals. We set out to test, using data from NHANES III, whether there are social gradients in oral health, and whether they resemble the gradients in general health. Income, indicated by poverty-income ratio, and education gradients were examined in periodontal diseases, ischemic heart disease, and perceived oral/general health. Our analysis demonstrated consistent income and education gradients in all outcomes assessed. In the adjusted regression models, the probabilities of having poorer clinical and perceived health were attenuated, but remained significantly higher at each lower level of income and education for most outcomes. The results showed similar income and education gradients in oral and general health, implying commonalities of the social determinants of both oral and general health.

Social inequalities in self reported health in early old age: follow-up of prospective cohort study

Objective To describe differences in trajectories of self reported health in an ageing cohort according to occupational grade. Design Prospective cohort study of office based British civil servants (1985-2004). Participants 10 308 men and women aged 35-55 at baseline, employed in 20 London civil service departments (the Whitehall II study); follow-up was an average of 18 years. Main outcome measures Physical component and mental component scores on SR-36 measured on five occasions. Results Physical health deteriorated more rapidly with age among men and women from the lower occupational grades. The average gap in physical component scores between a high and low grade civil servant at age 56 was 1.60 and this gap increased by 1 over 20 years. The average physical health of a 70 year old man or woman who was in a high grade position was similar to the physical health of a person from a low grade around eight years younger. In mid-life, this gap was only 4.5 years. Although mental health improved with age, the rate of improvement is slower for men and women in the lower grades. Conclusions Social inequalities in self reported health increase in early old age. People from lower occupational grades age faster in terms of a quicker deterioration in physical health compared with people from higher grades. This widening gap suggests that health inequalities will become an increasingly important public health issue, especially as the population ages.

Psychophysiological biomarkers of workplace stressors

UNLABELLED Workplace stressors are associated with greater coronary heart disease risk, although there is debate over the psychophysiological consequences of work stress. This study builds on recent reviews and examines the literature linking work stress with sympatho-adrenal biomarkers (plasma catecholamines and heart rate variability) and HPA axis biomarkers - the post-morning profile of cortisol. METHODS Relevant studies using appropriate search terms were searched using the bibliographic databases PubMed, Embase, Biosys and Toxline. Four studies on plasma catecholamines, 10 studies on heart rate variability, and 16 studies on post-morning cortisol were reviewed. RESULTS In the majority of studies that examined the association of HRV and work stress, greater reports of work stress is associated with lower heart rate variability. The findings for plasma catecholamines and cortisol secretion are less clear cut and suffer from poorer quality of studies in general. CONCLUSION There is evidence that work stress is related to elevated stress responses in terms of sympatho-adrenal and HPA axis biomarkers.

Childhood IQ in relation to obesity and weight gain in adult life: the National Child Development (1958) Study

Objective:To examine the relation of childhood intelligence (IQ) test results with obesity in middle age and weight gain across the life course.Methods:We analysed data from the National Child Development (1958) Study, a prospective cohort study of 17 414 births to parents residing in Great Britain in the late 1950s. Childhood IQ was measured at age 11 years and body mass index (BMI), an indicator of adiposity, was assessed at 16, 23, 33 and 42 years of age. Logistic regression (in which BMI was categorised into obese and non-obese) and structural equation growth curve models (in which BMI was retained as a continuous variable) were used to estimate the relation between childhood IQ and adult obesity, and childhood IQ and weight gain, respectively.Results:In unadjusted analyses, lower childhood IQ scores were associated with an increased prevalence of adult obesity at age 42 years. This relation was somewhat stronger in women (ORper SD decrease in IQ score [95% CI]: 1.38 [1.26, 1.50]) than men (1.26 [1.15, 1.38]). This association remains statistically significant after adjusting for childhood characteristics, including socio-economic factors, but was heavily attenuated following control for adult characteristics, particularly education (women: 1.11 [0.99, 1.25]; men: 1.10 [0.98, 1.23]). When weight gain between age 16 and 42 years was the outcome of interest, structural equation modelling revealed that education and dietary characteristics in adult life mediated the association with childhood IQ.Conclusions:A lower IQ score in childhood is associated with obesity and weight gain in adulthood. In the present study, this relation appears to be largely mediated via educational attainment and the adoption of healthy diets in later life.

Health selection in the Whitehall II study, UK

There has been considerable debate over the importance of the health selection hypothesis for explaining social gradients in health. Although studies have argued that it may not be an important explanation of social gradients in health, previous analyses have not estimated, simultaneously, the relative effect of health on changes in social position and of social position on changes in health (social causation). Cross-lagged longitudinal analyses using structural equation models enable the estimation of the relative size of these pathways which would be useful in determining the relative importance of the health selection hypothesis over the social causation hypothesis. Data from four phases of the Whitehall II study (initially consisting of 10,308 men and women aged 35-55 in the British civil service) were collected over a 10 year period. There was no evidence for an effect of mental (GHQ-30 and SF36) or physical health (SF-36) on changes in employment grade. When financial deprivation was used as a measure of social position, there was a significant effect of mental health on changes in social position among men although this health selection effect was over two and a half times smaller than the effect of social position on changes in health. The results suggest that the development of social gradients in health in the Whitehall II study may not be primarily explained in terms of a health selection effect.