1. Tage S. Kristensen Psychosocial Department National Institute of Occupational Health Copenhagen, Denmark 27th International Congress on Occupational Health Iguassu Falls, Brazil L:\PSA01\8. PERSONLIGE ARKIVER\LNA\Forskere\Tage ICOH-Symposium on Psychosocial Factors

2. Cardiovascular mortality for Danish men. Farmers Architects Military officers Professors Gardeners Doctors All employed men Journalists Sailors Bus drivers Cooks Waiters Salvage corps drivers Restaurant owners Taxi drivers 67 68 69 71 75 77 100 121 122 127 135 150 162 185 SMR

3. Heart disease and work ”Little is known about occupational risks for coronary heart disease” Kyle Steenland. NIOSH. Am J Ind Med 1996;30:495-9

4. The connection between work and CVD

5. General model for the relationship between work environment and cardiovascular diseases WORK ENVIRON- MENT CARDIO- VASCULAR DISEASES CVD risk factors: Diet obesity, blood pressure, smoking etc. 3 1 2 THE SIGNIFICANCE OF WORK: 1+3

6. Work and death How many deaths are due to working conditions? MenWomenTotal Death, all causes10%2%7% Heart disease19%9%17% Stroke12%8%11% Cancer14%2%8% Respiratory diseases7%1%4% Accidents, violence4%0.4%3% All proportions apply to Finland Nurminen & Karjalainen. Scand J Work Environ Health 2001;27:161-213.

7. The impact of work on cardiovascular diseases Etiologic fractionMen16% Women22% Etiologic fractionIHD17% Stroke11% Nurminen & Karjalainen. Scand J Work Environ Helath 2001;27:161-213. Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10

8. Empirical evidence

9. Etiological fractions of work environment for cardiovascular diseases in Denmark (Olsen & Kristensen. J Epidemiol Community Health 1991;45:4-10) Proportion of CVD Risk factorMenWomen ”Sedentary” work42% Job Stressors6%14% Shift & night work7% Noise1% Chemical exposures0-1%0% Passive smoking2% All factors51%55% All factors except sedentary work16%22%

10. Standardized Hospitalization Ratios (SHR’s) for IHD among Danish men aged 20-59 years (Tüchsen. Int J Epidemiol 1993;22:215-21) SHR

11. Relative risk of IHD among shift workers 15 years of follow-up 1 1.5 2 2.2 2.8 0.4 RR (Knutsson et al. Lancet 1986;II:89-92 3 2.5 2 1.5 1 0.5 0

12. Work noise and AMI Noise level: OR (adjusted) A case control study of 395 cases and 2,148 controls from Berlin. Ising et al. Soz Präventivmed 1997;42:216-22. 1.0 1.4 2.0 3.8 4 3.5 3 2.5 2 1.5 1 0.5 0

13. The two main psychosocial models on work and CVD The job strain model –demands –control –support The effort reward imbalance model –effort (extrinsic) –rewards (money, esteem, career opportunities) –personality (instrincis effort – overcommitment ) Good – but not excellent – empirical support for the two models

14. Hospital admission for CVD in a group of unemployed men compared with a control group 0.80 1.04 1.60 (Iversen et al. BMJ 1989;299:1073-6) 1.6 1.4 1.2 1 0.8 0.6 0.4 0 RR 0.2 Before factory closure (2 years) During factory closure (3 years) After factory closure (3 years)

15. Issues in research and prevention

16. The cardiovascular tradition from Framingham and onwards. Physiological: Cholesterol Fibrinogen Triglycerides Glucose Blood pressure Heart rate Obesity Behavioral: Smoking Physical inactivity Type A Salt intake Diet Alcohol Risk factors are individual.

17. The individualistic bias of cardiovascular epidemiology and prevention Sampling:Representative samples of individuals Variables:Physiological and behavioral factors Risk factors:Individual characteristics (e.g. high cholesterol) or behaviors (e.g. smoking) Prevention strategies:Interventions aiming at the individual: High risk intervention or mass intervention

18. The missing connection between cardiovascular and occupational medicine Occupational medicine focuses on:  Cancer  Lung diseases  Musculoskeletal disorders  Reproductive disorders  Allergies –but not CVD Preventive cardiology focuses on:  Tobacco  Cholesterol  Blood pressure  Physical activity  Diet –but not work environment

19. The basic dimensions of stressors at work The ”Copenhagen Stress Model” Influence (with regard to the conditions of daily work) Meaning (purpose and connection to the overall production) Predictability (relevant information about future changes and events) Social support (from supervisors and colleagues) Rewards (salary, appreciation, and possibilities for a good and secure future) Demands (quantitative and qualitative) Kristensen. Scand J Work Environ Health 1999;25:550-557.

20. Topics for future research Human service work: New organisations: Unstable labour markets: Emotional demands Burnout fatigue CVD Work without limits Workaholism CVD Downsizing, unemployment, temporary work Uncertainty, stress CVD ? ? ? ? ? ?

21. Causal network for CVD Social & Environmental Factors Behavior Physiology Precursors Individual characteristics Upstream Downstream Tobacco Job strain Physical activity Fitness Cholesterol Athero- sclerosis Social isolation Obesity Blood pressure Throm- bosis Unem- ployment DietType AFibrinogen Arr- hythmia NoiseAlcoholStressGlucose ECG- changes SES & Occupation CVD

22. Integrated prevention at the workplace Health promotion Work environment improvements Workplace rehabilitation

23. This presentation can be found at: www.ami.dk/presentations