Study: Work stress and dyslipidemia

reference

Catalina-Romero C, Calvo E, Sánchez-Chaparro MA, et al. The relationship between work stress and dyslipidemia.Scand J Public Health.2013;41(2):142-149.

design

Observational cross-sectional analysis as a complement to the insurance-based Ibermutuamur Cardiocular Risk Assessment (ICARIA) cohort study.

Participant

The study involved 73,332 working insurance company employees in Spain aged 18 to 60. Approximately 70% of the sample was male. A total of 6,239 (8.5%) reported occupational stress as defined in the INTERHEART study.¹

Evaluated study parameters

Work 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 relationships between work stress and lipid levels (e.g. total cholesterol, LDL-C, HDL-C, triglycerides)

Key findings

Work stress was significantly associated with female gender, age, education level, having a “white collar” position, and dyslipidemia, including previous or current diagnosis of dyslipidemia, lipid-lowering therapy, and/or high total cholesterol, LDL-C, and low HDL-C.

Multivariate adjustment for age, sex, smoking status, alcohol consumption, obesity, occupational level, and physical activity did not reduce the associations between dyslipidemia and work stress.

Effects on practice

This analysis by Catalina-Romero et al²Provides the clinician with an important reminder of the contribution of psychosocial stress, including occupational stress, to cardiovascular risk. Their findings confirm previous findings from the INTERHEART case-control study, which found that workplace stress accounts for 8% of the population risk of a first myocardial infarction (MI).³Catalina-Romero and colleagues' findings are also supported by the large metacohort study by Kivimaki and colleagues.⁴It combined individual-level data from 30 different European studies and included a total of 197,473 participants, 15% of whom reported occupational stress. Occupational exposure was found to be a significant independent risk factor for coronary disease, contributing to a population-based risk (PAR) of 3.4%.

In addition to workplace stress, other areas of psychosocial stress are also associated with the risk of cardiovascular events. In the INTERHEART study^1.3Poor control ability, financial stress, past serious stress (e.g., business failure, depression, and chronic stress at work or home) were all associated with increased risk of MI, accounting for 16%, 11%, 10%, 9%. or 8% of the PAR for the first MI. Together, these factors contributed 32.5% of the PAR for the first myocardial infarction.

In order to be able to comprehensively prevent patients at risk of cardiovascular diseases (that's all of them), psychosocial stress factors should be recorded and ideally quantified. Of course, it is critical to establish a safe therapeutic relationship in which patients feel able to talk openly about their life stresses and the impact these have on their health behaviors. Clinical questionnaires (i.e. “screeners” such as the Patient Health Questionnaire).^5.6and the GAD-7⁶) offer quick screening tools for depression or anxiety. Other areas of psychosocial health can be assessed through a detailed patient history or by including additional questionnaires in a clinical intake (e.g., one that includes the site of control). The use of tools such as the Patient Health Questionnaire can help facilitate counseling, cognitive behavioral therapy, or other interventions and can be used long-term to ensure therapeutic progress. At my clinic, we provide comprehensive integrative care for cardiovascular disease and have recreated the INTERHEART psychosocial stress index and incorporated it into our initial intake, allowing us to quickly quantify and address critical psychosocial elements of disease risk.

Despite adjusting for many potentially confounding variables such as physical activity, smoking, age, and gender, it would also have been interesting to see whether adjusting for dietary behavior and/or eating habits would have influenced the results of Catalina-Romero and colleagues. Incorporating dietary practices would likely have reduced the magnitude of associations between workload and lipid-related risk, as psychosocial stress and workload were specifically associated with increased intake of energy-dense foods and lower intake of fruits and vegetables.⁷When we consider social predictors of increased fruit and vegetable consumption and knowledge of healthy eating, higher self-efficacy and more social support prove crucial.^8.9Understanding these contributors provides the clinician with numerous opportunities to influence health behavior. In clinical practice, social support and education about healthy eating habits as well as encouraging dietary changes are possible. Available evidence suggests that integrative practitioners, such as naturopathic physicians, have the ability to improve behavior, including nutritional practices, in patients at increased risk of cardiovascular disease.^10,11

Of note, building confidence to change behavior and promoting effectiveness at work and at home can be challenging for patients with occupational stress and very low levels of control in the workplace. Oppression in the workplace promotes a loss of self-confidence and fundamentally limits self-efficacy. However, not everyone can change employers or positions. This scenario requires additional patient support and often specific cognitive behavioral training to re-engage in activities of daily living and promote activities in which the patient can maintain greater control. Since social support is an important indicator of increased fruit and vegetable consumption, starting a cardiovascular disease support group or a Mediterranean diet group cooking class is a fun and efficient way to provide education and social support and increase self-efficacy in a single intervention.

The identification and treatment of psychosocial risk factors is necessary for the holistic treatment of cardiovascular disease and the prevention of cardiovascular disease. As Catalina-Romero et al. have shown that while nutrition and health education are important elements in risk reduction, external factors such as workload also have a strong impact on risk. In addition, for many people, occupational stress also extends to behaviors outside of the workplace and can have a direct negative impact on the risk of illness. Although there is increasing emphasis in the workplace on providing employees with access to healthier foods, paradoxically, a more effective workplace intervention is to create a work environment in which employees feel trusted, valued, and have the freedom to perform their work tasks without oppression.