Reference
Catalina-Romero C, Calvo E, Sánchez-Chaparro MA, et al. The relationship between job stress and dyslipidemia. Scand J Public Health. 2013;41(2):142-149.
Design
Observational, cross-sectional analysis ancillary to the insurance-based Ibermutuamur Cardiovascular Risk Assessment (ICARIA) cohort study
Participants
The study included 73,332 working employees of insurance companies in Spain, aged 18-60 years. Approximately 70% of the sample was male. A total of 6,239 (8.5%) reported job stress as defined by the INTERHEART study.1
Study Parameters Assessed
Job stress, total cholesterol, LDL-C, HDL-C, triglycerides, age, gender, smoking status, alcohol consumption, obesity, occupational level, leisure physical activity, and use of lipid lowering therapy
Primary Outcome Measures
Bivariate and multivariable associations between job stress and lipid measures (eg, total cholesterol, LDL-C, HDL-C, triglycerides)
Key Findings
Job stress was significantly associated with female gender, age, educational level, having a “white collar” position, and dyslipidemia, including previous or current diagnosis of dyslipidemia, being on lipid-lowering therapy, and/or having high total cholesterol, high LDL-C, and low HDL-C.
Multivariable adjustment for age, sex, smoking status, alcohol consumption, obesity, occupational level, and physical activity did not diminish the associations between dyslipidemia and job stress.
Practice Implications
This analysis by Catalina-Romero et al2 provides an important reminder to the clinician about the contribution of psychosocial stress, including job strain, to cardiovascular risk. Their results reinforce the previous results of the INTERHEART case-control study, which found workplace stress accounted for 8% of population attributable risk for first myocardial infarction (MI).3 Also supporting the findings of Catalina-Romero and colleagues is the massive meta-cohort study by Kivimaki and colleagues,4 which combined individual level data from 30 separate European studies, collecting a total of 197,473 participants, 15% of whom reported job strain. Job strain was determined to be a significant independent risk factor for coronary disease, contributing a 3.4% population attributable risk (PAR).
In addition to workplace stress, other domains of psychosocial stress are also associated with risk for cardiovascular events. In the INTERHEART study,1,3 low locus of control, financial stress, history of major life stress (ie, business failure, depression, and chronic stress at work or home) were all associated with increased MI risk, account for 16%, 11%, 10%, 9% and 8% of PAR for first MI respectively. Combined, these factors contributed 32.5% of PAR for first MI.
In order to provide comprehensive preventive care for patients at risk for cardiovascular disease (which is everyone), psychosocial stress factors should be assessed, and ideally quantified. Of course, creating a safe therapeutic relationship in which patients feel able to openly discuss their life stress and the contribution it has on their health behaviors is essential. Clinical questionnaires (ie, “screeners” like the Patient Health Questionnaire5,6 and the GAD-76) provide quick screening tools for depression and anxiety respectively. Other domains of psychosocial health can be assessed through a detailed patient history, or by incorporating additional questionnaires into a clinical intake (eg, one that includes locus of control). Using instruments like the Patient Health Questionnaire can help facilitate counseling, cognitive behavioral therapy, or other intervention and can be used longitudinally to help ensure therapeutic progress. In my clinic we provide comprehensive integrative cardiovascular disease care and have recreated and included the INTERHEART psychosocial stress index into our initial intake, allowing us to quickly quantify and address critical psychosocial elements of disease risk.
Despite adjustment for many potentially confounding variables, such as physical activity, smoking, age, and gender, it would have also been interesting to see if adjustment for dietary behaviors and/or dietary patterns would have affected the results of Catalina-Romero and colleagues. The inclusion of dietary practices would have likely diminished the magnitude of the associations between job strain and lipid-related risk, because psychosocial stress and job strain specifically have been associated with increased intake of energy-dense foods and lower intake of fruits and vegetables.7 When we consider social predictors of increased intake of fruits and vegetables and knowledge of healthy diet, higher self-efficacy and more social support emerge as critically important.8,9 Understanding these contributors provides multiple opportunities for the clinician to impact health behaviors. Providing social support and education on healthy dietary patterns and encouraging dietary changes are achievable in clinical practice. Available evidence suggests integrative practitioners such as naturopathic doctors are able to improve behaviors including dietary practices in patients at increased cardiovascular disease risk.10,11
Of note, building confidence to change behavior and encouraging effectiveness at work and in the home may be challenging for patients who have job strain and have a vey low locus of control at work. Oppression in the workplace fosters reduced confidence and fundamentally limits self-efficacy, yet not everyone can change employers or positions. This scenario requires additional patient support and often specific cognitive behavioral training to re-engage in the activities of daily life and encourage activities in which the patient can maintain a higher locus of control. As social support is an important predictor of increased fruit and vegetable intake, creating a cardiovascular disease support group or group Mediterranean diet cooking class is a fun and efficient way to provide education and social support and increase self-efficacy all in one intervention.
Identifying and addressing psychosocial risk factors is necessary for holistic management of cardiovascular disease and for prevention of cardiovascular disease. As demonstrated by Catalina-Romero et al, although diet and health education are important elements to reduce risk, external factors like job strain also greatly impact risk. Additionally, for many people job strain extends to behaviors outside of the workplace, and may have a directly negative impact on disease risk. Ironically, although there is increasing attention in the workplace to providing employees with access to healthier food options, a more effective workplace intervention may be to create a work environment in which employees feel trusted, valued, and free to perform their work duties without oppression.
