1. ISMF’s Årsmøde 12. november 2004 Eigtveds Pakhus Hjertekarsygdomme - risikofaktorer i arbejdsmiljøet Tage Søndergård Kristensen Arbejdsmiljøinstituttet

2. General model for the relationship between work environment and cardiovascular diseases DK-2004-017 The significance of work: 1 + 3 CVD risk factors: Diet, obesity, blood pressure, smoking etc. CARDIO- VASCULAR DISEASES. WORK ENVIRON- MENT 1 2 3

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 PhysiologyPrecursors

4. The cardiovascular tradition from Framingham 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:

5. The occupational medicine tradition from Ramazzini and onwards DK-2004-011 Physical Chemical Psychosocial Ergonomic Biological Risk factors are environmental

6. Arbejdsmiljøets betydning for hjertekarsygdomme

7. 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 factorMenWomen “Sedentary” work42% Job strain6%14% Shift & night work7% Noise1% Chemical exposures0-1%0% Passive smoking2% All factors51%55% All factors except sedentary work16%22%

8. The significance of work environment for mortality Estimates of etiologic fractions in FinlandMenWomen Cardiovascular, total14%7% IHD19%9% Cerebrovascular12%8% Cancer, total13%2% Mental disorders7%2% Respiratory diseases7%1% Accidents4%0% Total10%2% Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.

9. The significance of work environment for hospitalisations Estimates of etiologic fractions in DenmarkMenWomen Circulatory16%18% Cancer8%3% Nervous system17%12% Respiratory16%12% Accidents17%6% Musculoskeletal21%19% Total15%11% Tüchsen et al. Sci Total Environ 2004

10. Etiologic fractions of psychosocial factors for acute myocardial infarctions: The INTERHEART STUDY 11,119 cases and 13,648 controls from 52 countries Etiologic fractions* Work stress9% Home stress8% Financial stress11% Life events10% Locus of control16% Depressive mood9% All psychosocial factors33% Rosengren et al. www.thelancet.com Sept. 3,2004:1-10www.thelancet.com * Adjusted for cardiovascular risk factors

11. Risikofaktorer i arbejdet

12. The pioneering studies Coronary heart disease among London bus drivers and conductors Morris et al. Lancet 1953;iii:1053-7. DK-2004-004 Cases/1000 person-years 1.5 0.8 0.4 2 1.5 1 0.5 0 Bus drivers Conductors

13. The effort-reward model in Whitehall II *Fully adjusted Bosma et al. Am J Public Health 1998;88:68-74 DK-2004-014 Ischemic heart disease 5.3 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 0.0 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. L.E. H.R. H.E. or L.R. H.E. L.R. MenWomenTotal* OR

14. Job strain and effort-reward imbalance as predictors of CVD mortality A 26 years’ follow-up of 812 Finnish employees 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

15. RR* 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. 3,2004:1-10www.the

16. Is marraige worse than work? (For women) A follow-up study of 292 female heart patients in Stockholm 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* (NS)

17. 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) 100 193 215 168 172 250 200 150 100 50 0 SHR DayNightLate evening 24 hour rosters Other irregular

18. 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 0.80 1.04 1.60 Before factory closure (2 years) During factory closure (3 years) After factory closure (3 years) 0 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2

19. Passive smoking and IHD The Nurses’ Health Study Kawachi et al. Circulation 1997;95:2374-9. DK-2004-019 1.0 1.6 1.9 Adjusted RR N = 32,046 never smokers Exposure to passive smoking (work or home)

20. Carotid artery wall thickness and (passive) smoking Diez-Roux et al. Prev med 1995;24:48-55. DK-2004-020 The ARIC Study 0.67 0.68 0.70 0.74 0.73 0.78 No P.S. Men Women mm (adjusted) 0.82 0.90 P.SExS. 1.00 0.80 0.60 0.40 0.20 0 No P.S. P.SExS. Smoking status

21. The Seaton – Sjögren hypothesis Seaton et al. Lancet 1995;345:176-8 Sjögren. Occup Environ Med 1997;54:466-9 Air pollution (dust) Alveolar inflammation (low grade) Release of mediators IHD Increased level of plasma fibrinogen

22. Den nye træthed

23. 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?”No74% Yes26% RR* for IHD* Burnout * Controlled for age, BP, smoking, cholesterol. 59 cases. Appels & Schouten. Behav Med 1991;Summer:53-59

24. 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 IHD Mortality

25. Work-related burnout 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 High Quartiles Karolinska sleep questionnaire (scale)

26. 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

27. 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 1.8 1.3 1.1 1.0  5 RR 1.6 1.4 1.2 1.1 1.0 1.4 6 78  9  5 6 78  9 Adjusted for 14 factors Age-adjusted The Nurses’ Health Study

28. 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

29. Bullying at work and CVD *Adjusted for gender and income Bullying 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

30. The new fatigue Long working hours Shift work, 24 h society High emotional demands Conflicts, bullying High work pace Family/ work conflict Fatigue Burnout Stress Withdrawal Sleep problems Depression Need for recovery Cardiovascular disease

31. 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

32. SLUT!!

33. 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 ActiveMediumSedentary (Postmen) (Cases per 1000 person years) 35 – 44 years0.50.60.8 45 – 54 years2.72.83.4 55 – 59 years4.65.05.4 Total, standardized1.82.02.4

34. 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 Hostility LowHigh 1234 Total mortality1.01.301.332.30 Cardiovascular mortality1.01.761.852.70 Non-CVD mortality1.01.07 2.09

35. 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

36. 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 RR (mortality) 1.1 2.7 1.2 1.0 0.9 Toxic equivalents of PCDD 1.7 1.5 1.6 2.1 IHD CVD Low High Low High

37. Vinyl chloride and hypertension Kotseva. Int Arch Occup Environ Health 1996;68:377-9 DK-2004-022 1.0 RR (adjusted) A five-year follow-up study of Bugarian workers 105 exposed and 105 non-exposed workers Exposure 2.0 4.2

38. CO exposure, CVD and IHD Koskela. Scand J Work Environ Health 1994;20:286-93 DK-2004-023 1.0 2.6 RR (mortality) A study of Finnish foundry workers 1.0 1.4 1.0 6.9 CO exposed CVD IHD