Job Strain as Bad as Smoking in Men With Diabetes, Heart Disease

Marlene Busko

June 08, 2018

Among men with cardiometabolic disease — diabetes, coronary heart disease, or stroke — those with a demanding job but little control over decisions (job strain) had a higher risk of dying early in a multicohort study.

Moreover, this risk was almost as great as the risk from smoking, even among the men with a healthy lifestyle and well-controlled blood pressure and diabetes.

"The finding that job strain increases mortality risk, even in subgroups of men with cardiometabolic disease but a favorable cardiometabolic risk profile, suggests that standard care targeting conventional risk factors is unlikely to mitigate the mortality risk associated with job strain," according to lead author Mika Kivimäki, FMedSci, of the University of Helsinki, Finland, and colleagues.

"Other interventions might be needed at least for some patients — possibly including stress management as part of cardiovascular disease rehabilitation, job redesign, or reducing working hours," Kivimäki said in a statement by his institution.

The study, based on seven European cohort studies from the IPD-Work (Individual-Participant-Data Meta-analysis in Working Populations) consortium, was published online June 5 in Lancet Diabetes & Endocrinology.

Among women with cardiometabolic disease, and men and women without cardiometabolic disease, however, job strain was not associated with an increased risk of dying during a mean 13.9 years of follow-up.

However, the overall findings may have been "biased," Yulong Lian, PhD, from the Department of Epidemiology and Statistics, College of Public Health, Nantong University, in Jiangsu, China, notes in an accompanying comment, because the study did not include some "important prognostic factors associated with cardiometabolic disease."

For example, patients with cardiometabolic disease are more likely to have psychological distress, clinical depression, and anxiety, and the researchers did not consider social isolation, loneliness, workplace bullying, or job insecurity in their analysis.  

"Nevertheless, their results are provocative and encourage careful attention to work stress reduction among patients with cardiometabolic diseases," said Lian, adding that the study sheds more light on sex differences in cardiometabolic disease.

Work Stress in Diabetes, Heart Disease

Although guidelines recommend that patients with established cardiometabolic disease should manage work stress, this is based on weak evidence, according to Kivimäki and colleagues.

They identified 102,633 individuals who were enrolled in seven studies in the IPD-Work consortium in Finland, France, Sweden, and the UK from 1985 to 2002 and had replied to questions about job stress.

At enrollment, 3441 participants had cardiometabolic disease, mostly diabetes (78.2%) and less often coronary heart disease (13.6%) or stroke (10.7%).

Those with cardiometabolic disease were a mean age of 48.3 years and 57.4% were men; the other participants were a mean age of 43.8 years and 42.9% were men.

During follow-up, 3841 individuals died.

Among the 1975 men with cardiometabolic disease, those with job strain had a 68% higher risk of dying during follow-up than men without job strain, after adjusting for age, smoking, physical activity, alcohol consumption, body mass index, and socioeconomic status (hazard ratio, 1.68; P = .024).

The increased mortality risk associated with job strain was almost as great as that from current smoking and was greater than the risks from hypertension, high cholesterol, obesity, physical inactivity, and high alcohol consumption (versus not having those risk factors).

Moreover, among men with cardiometabolic disease and a favorable risk profile — that is, they were not obese, physically inactive, smokers, or heavy drinkers, and had normal blood pressure, normal lipids, or both, or high adherence to medications — those with job strain had a two- to six-fold higher risk of premature death than those without job strain.

The authors concluded that more studies are needed "to establish whether systematic screening and management of work stressors, such as job strain, would contribute to improved health outcomes in men with prevalent coronary heart disease, stroke, or diabetes."

This research "would not only improve understanding of the prognosis" of this disease, "but also inform health policymakers and guideline committees about the need for sex-specific workplace interventions for [its] treatment and management," added Lian.   

The IPD-Work consortium was supported by NordForsk (Nordic Research Programme on Health and Welfare), the UK Medical Research Council, and the Academy of Finland. The authors and editorialist have reported no relevant financial relationships.

Lancet Diabetes Endocrinol. Published online June 5, 2018. Full text, Comment

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