Organizational Injustice and CVD

“British civil servants reporting high relational injustice (low supervisor support) were 41% more likely to develop heart disease over a follow-up period of 8.7 years [71]. Similarly, Finnish factory workers reporting low supervisor support were 64% more likely to develop heart disease over 25 years [72]. These increased risks were seen after adjusting for age, gender, standard risk factors such as cholesterol, high blood pressure, and smoking, and job strain and effort-reward imbalance.”

Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

71. Kivimaki, M., J. Ferrie, E. Brunner, et al., Justice at Work and Reduced Risk of Coronary Heart Disease among Employees: The Whitehall II Study, Archives of Internal Medicine, 165, pp. 2245-2251, 2005.

72. Elovainio, M., P. Leino-Arjas, J. Vahtera, and M. Kivimaki, Justice at Work and Cardiovascular Mortality: A Prospective Cohort Study, Journal of Psychosomatic 61 pp. 271-274, 2006.

Blood Pressure

“In a review conducted in 2000, a majority of the 11 cross-sectional studies of job strain (or its components) and ABP (Ambulatory Blood Pressure) among men found a relationship between job strain and higher work ABP [56]. In the five studies where ABP measurements were also made outside of work, men with job strain also had higher non-work systolic ABP, showing that the impact of job strain on ABP occurred across the whole day and night. Of the six cross-sectional studies of job strain and ABP among women published by 2000, four showed that women with job strain had higher work systolic ABP [94]. Workers with job strain typically have about 4-8 mm Hg higher work systolic ABP than those without job strain. The only longitudinal (long-term) study of job strain and ABP, the New York City Work Site Blood Pressure Study (WSBPS), began in 1985. At the first round of data collection (Time 1), men with job strain showed increases in the size of their heart’s left ventricle, a sign of damage to the heart [95], and had higher levels of work, home, and sleep ABP, after taking into account other risk factors, such as age, race, and weight, than men without job strain [96, 97]. These findings were recently replicated by the Belgian Job Stress Project [98]. Since the study participants returned 3 years later (Time 2), had their BP measured, and completed questionnaires about their jobs, it was possible to create a measure of chronic or longer-term exposure to job strain. Men facing job strain at both Time 1 and Time 2 (longer-term exposure) had an 11-12 mm Hg higher systolic and 6-9 mm Hg higher diastolic work ABP than men not facing job strain at either time. This difference is substantial, more than twice the difference between African Americans and whites in this sample and more than the effect on BP in this study sample of aging 25 years or gaining 50 pounds in weight [99]. To give an idea of the potential benefit of leaving a situation of job strain, those men reporting job strain at Time 1 but no job strain at Time 2 showed a drop in blood pressure 5.3 mm Hg systolic ABP at work and 4.7 mm Hg systolic ABP at home [99].”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

56. Belkic, K., P. A. Landsbergis, P. Schnall, et al., Psychosocial Factors: Review of the Empirical Data among Men, in The Workplace and Cardiovascular Disease Occu- pational Medicine: State of the Art Reviews, Schnall, P., K. Belkic, P. A. Landsbergis, and D. Baker (eds.), Hanley and Belfus, Philadelphia, PA, pp. 24-46, 2000.

94. Brisson, C., Women, Work and Cardiovascular Disease, in The Workplace and Cardiovascular Disease Occupational Medicine: State of the Art Reviews, Schnall, P., K. Belkic, P. A. Landsbergis, and D. E. Baker (eds.), Hanley and Belfus, Philadelphia, pp. 49-57, 2000.

95. Schnall, P. L., C. Pieper, J. E. Schwartz, et al., The Relationship between ‘Job Strain,’ Workplace Diastolic Blood Pressure, and Left Ventricular Mass Index. Results of a Case-Control Study [published erratum appears in JAMA 1992 Mar 4;267(9):1209], Journal of the American Medical Association, 263:14, pp. 1929-1935, 1990.

96. Landsbergis, P. A., P. L. Schnall, K. Warren, T. G. Pickering, and J. E. Schwartz, Association between Ambulatory Blood Pressure and Alternative Formulations of Job Strain, Scandinavian Journal of Work, Environment and Health, 20:5, pp. 349-363, 1994.

97. Schnall, P. L., J. E. Schwartz, P. A. Landsbergis, K. Warren, and T. G. Pickering, Relation between Job Strain, Alcohol, and Ambulatory Blood Pressure, Hypertension, 19, pp. 488-494, 1992.

98. Clays, E., F. Leynen, D. De Bacquer, et al., High Job Strain and Ambulatory Blood Pressure in Middle-Aged Men and Women from the Belgian Job Stress Study, Journal of Occupational and Environmental Medicine, 49, pp. 360-367, 2007.

99. Schnall, P. L., P. A. Landsbergis, J. Schwartz, K. Warren, and T. G. Pickering, A Longitudinal Study of Job Strain and Ambulatory Blood Pressure: Results from a Three-Year Follow-Up, Psychosomatic Medicine, 60, pp. 697-706, 1998.

Reduced Heart Rate Variability

“In the United States, more than 120,000 people die each year suddenly and without warning from a sudden cardiac catastrophe. One possible reason is reduced heart rate variability, which is an important predictor of heart disease, as well as death from arrhythmias (heart rate rhythm disturbances) following a heart attack. A healthy heart will show lots of variation in heart rate over the course of a day, as the body responds to various demands and challenges. One study has shown a connection between job strain and reduced heart rate variability [123]. Other workplace stressors related to reduced heart rate variability are heavy mental workload, long work hours, or shift work [124].”

Social Class

“Extensive research has documented that CVD is more common not only among people facing work stressors [11, 12], but also among people of lower social class or socioeconomic position (SEP), for example, lower levels of education, income, or occupational status (see chapter 3). One possible explanation for the social class differences in CVD is greater exposure to unhealthy working conditions among lower SEP groups. For example, job control was “the biggest factor contributing to the socioeconomic gradient” in heart disease “risk across civil service employment grade” in a major study of British civil servants [14, 15] (see Figure 2). The higher CVD risk among men and women in lower SEP groups, for example, blue-collar workers, began to appear in the 1950s [16-18] and has risen progressively since then [19]. Among U.S. men aged 25-64, in 1969-70, low SEP men had a 30% greater risk of dying of CVD than high SEP men of the same age. However, it had increased to an 80% greater risk by 1997-98 [19]. Differences between higher and lower SEP groups in new cases of CVD, whether fatal or not, are also increasing [20, 21].”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

11. Karasek, R. and T. Theorell, Healthy Work: Stress, Productivity, and the Reconstruction of Working Life, Basic Books, New York, 1990.

12. Schnall, P., K. Belkic, P. A. Landsbergis, and D. E. Baker, The Workplace and Cardiovascular Disease, in Occupational Medicine: State-of-the-Art Reviews, Hanley and Belfus, Philadelphia, PA, 2000a.

14. Kawachi, I. and M. Marmot, What Can We Learn from Studies of Occupational Class and Cardiovascular Disease?, American Journal of Epidemiology, 148, pp. 160-163, 1998.

15. Marmot, M. G., H. Bosma, H. Hemingway, E. Brunner, and S. Stansfeld, Contribution of Job Control and Other Risk Factors to Social Variations in Coronary Heart Disease Incidence, Lancet, 350, pp. 235-239, 1997.

16. Gonzalez, M. A., F. R. Artalejo, and J. R. Calero, Relationship between Socioeconomic Status and Ischaemic Heart Disease in Cohort and Case-Control Studies: 1960-1993, International Journal of Epidemiology, 27:3, pp. 350-358, 1998.

17. Marmot, M., A. M. Adelstein, N. Robinson, et al., Changing Social Class Distribution of Heart Disease, British Medical Journal, 2, pp. 1109-1112, 1978.

18. Wing, S., P. Dargent-Molina, M. Casper, W. Riggan, C. G. Hayes, and H. A. Tyroler, Changing Association between Community Structure and Ischaemic Heart Disease Mortality in the United States, Lancet, 2:8567, pp. 1067-1070, 1987.

19. Singh, G. K. and M. Siahpush, Increasing Inequalities in All-Cause and Cardiovascular Mortality among US Adults Aged 25-64 Years by Area Socioeconomic Status, 1969-1998, International Journal of Epidemiology, 31, pp. 600-613, 2002.

20. Hallqvist, J., M. Lundberg, F. Diderichsen, and A. Ahlbom, Socioeconomic Differences in Risk of Myocardial Infarction 1971-1994 in Sweden: Time Trends, Relative Risks and Population Attributable Risks, International Journal of Epidemiology, 27, 
pp. 410-415, 1998.

21. Tuchsen, F. and L. A. Endahl, Increasing Inequality in Ischaemic Heart Disease Morbidity among Employed Men in Denmark 1981-1993: The Need for a New Preventive Policy, International Journal of Epidemiology, 28, pp. 640-644, 1999.

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Work Stressors and Social Class (2004)

Jeffrey V. Johnson, PhD
University of Maryland

Social class position is a powerful predictor of illness and death from many forms of both chronic and infectious disease. Those in the upper class live longer and are healthier while doing so. Those in lower classes die at a younger age and are considerably less healthy over their entire life course (Evans, 1994). Moreover, numerous studies have found that a “gradient” exists along the social class continuum – with increasingly higher class position, health improves, and with descending class position health deteriorates (Marmot et al, 1978, Lynch & Kaplan, 2000). Although there continues to be a considerable discussion as to what explains this class gradient, there is an emerging consensus that social class is a “fundamental determinant” of population health. (Link & Phalen, 1995) Together with race and gender, class constitutes a core social structure (House & Williams, 2003). SSocial class is more than a property of individuals, rather, , it is more than a ‘position’ one occupies — it is also an expression of macro-societal forcessystem that “produces” stratified hierarchies within modern societies. As a societal structure social class is associated withpositions. It is a social structure that creates the enormous inequalities that we observe in nearly every aspect of human existence across the entire life course. Social class is also intimately bound up with work and the labor process (Johnson & Hall, 1995, Wright, 1988). It is through our work, and the work of our parents, that we enter into the life chances and circumstances of a particular social class.

Some of the pathways linking lower social class position to ill health include economic deprivation, lack of educational opportunities, and adverse exposures associated with differences in geographic and community environmental characteristics such as exposure to violence and to toxic substances like lead and carbon monoxide (Lynch & Kaplan, 2000, Evans & Kantrowitz, 2002). Other pathways involve class differences in consumption patterns including unhealthy foods, cigarettes, alcohol and illicit drug usage (Cockerham, 2000)usage. Social class position is also strongly associated with access (or lack there of) to social and public resources, informal social networks, institutional resources, and inter-generational resources. Still another pathway involves differences in the nature of the social and work environments, and includes the class differences in stress from adverse labor market experiences, including unemployment, underemployment and chronic exposure to stressful work organizations (House & Williams, 2003, Seigrist & Marmot, 2004). These specific pathways linking social class to health may change over time. New causal paths might emerge, others might be removed, yet as long as the society continues to have a social class structure it is almost certain there will continue to be health “disparities” (differences) between classes – this is what is meant when we say class is a “fundamental determinant” of health (Link & Phalen, 1995).

Social class position is frequently defined with respect to one’s occupation. Until recently skill levels have been used to distinguish different occupational class groups. Frequently a 5 occupational class scheme is used: 1st Class: Upper Level Managers and Professionals; 2nd Class: Medium Level Managers and Professionals; 3rd Class: Lower Level Office and Service Workers; 4th Class: Skilled Manual Workers; 5th Class: Unskilled Manual Workers. Critics have pointed out a number of problems with this definition of social class. Some have suggested that the degree to which the work has become routine is a more meaningful distinguishing characteristic today than skill. Others argue that the degree of control over the work process is the most important underlying element of social class (Marmot & Bartley, 2002).

There are, in fact, marked differences in a number of work organization characteristics across the different social class groups (Kristensen, 2002). The degree of control at work is strongly associated with social class position (Johnson & Hall, 1995). Social support at work, by contrast is only weakly (but [but positively?)] associated with social class. Other exposures tend to be much more present in certain class groups than others. Hazardous work exposures and heavy physical job demands are often present in lower level service and manual groups while being almost non-existent in managerial/professional class groups (Johnson & Hall, 1992). When examining patterns of multiple exposures across social class groups it becomes evident that Social Class 3 (the lower level office and service workers) is much more like Social Classes 4 and 5 (manual workers) than they are like Social Classes 1 and 2 (managerial/professional workers). The managerial/professional class tends to have high psychological job demands, high levels of work control, and very low levels of physical demands and low levels of hazardous exposure. They work longer work hours and their jobs require considerable flexibility (Johnson & Hall, 1992). Working class jobs by contrast have much less control, are more routine, and have fewer psychological job demands and considerable monotony. Working class jobs also have much higher physical demands and more hazardous exposures (Johnson & Hall, 1992). In addition, recent research findings using the two most prominent conceptual models of work stress have shown that those in lower social class positions are more likely to be exposed to high demands and low control as well as experience jobs with high demands for effort coupled with low rewards (Seigrist & Marmot, 2004). WWork environment exposure comes bundled by social class, and the most meaningful distinction is between a managerial/professional class on the one hand and a working class on the other. (Johnson & Hall, 1992, 1995).

The impact of adverse work organization exposure also varies markedly by social class. For example, a number of studies have shown that the impact of Job Strain (high demand/low control jobs) and Iso-Strain (high demand/low control/low social support jobs) is significantly greater for individuals in working class occupations compared to those in managerial/professional jobs (Johnson & Hall, 1988; Johnson Hall & Theorell; 1989, Landsbergis et al, 2003). Moreover, research findings also indicate that class differences in adverse work organization exposure (particularly in job control, or lack thereof) may be an important causal mechanism that helps explain the relationship between social class position and health (Marmot & Theorell, 1988, Marmot et al, 1997). Recent findings from the European Science Foundation’s Study on Social Variation in Health Expectancy strongly suggest that workers in lower social class positions are more vulnerable to the impact of both Job Strain (high demands and low control) and effort/reward imbalance (Seigrist & Marmot, 2004). 

In addition to looking at differences in exposure between social class groups, it is important to examine how and why these kinds of disparities exist. Clearly there are great structural differences between classes in terms of the ownership of wealth and control over workplace institutions. The class structure of modern society is an expression of dynamic political and economic forces operating over time at macro-societal and increasingly global levels (Moody, 1997; Navarro, 2002). Although social classes have been present since the agricultural revolution and early urban settlement, their present form emerged with the industrial revolution and the growing centrality of the market economy as the predominant influence over the structure of society. It has been suggested that market economies today have three fundamental social classes: (1) a very small elite made up of the most wealthy and powerful members of the society who own and control large corporations and other powerful institutions, (2) an increasingly large working class whose members provide and care for the human energy that produces the goods and services that are bought and sold in the marketplace and (3) a third class made up of managers and professionals that share some of the characteristics of both the elite class and the working class, and hence are said to occupy a “contradictory class location” in that their work involves administering bureaucratic organizations in the interests of the elite, yet their personal history, work experience and professional training and ethics may lead them to identify with the working class (Wright, 1988; Moody, 1997; Perrucci & Wysong, 1999; ).

In order to survive in dynamic and competitive environments, corporations must continue to grow by increasing the rate at which profits are generated. Historically, one important way in which this has occurred is through managerial and technological innovations focused on increasing productivity – often by changes in work organization designed to reduce labor costs. ‘Scientific Management’ or ‘Taylorism’ is perhaps the most well known example of how this process can lead to a transformation in how work is organized. (Braverman, 1974). In the late 19th and early 20th Century F.redrick W.inslow Taylor, advocated a radical program of removing planning and decision-making authority from skilled workers on the shop floor, while, at the same time centralizing mental and conceptual work in the hands of a new managerial class. By fragmenting the work process into its simplest possible components, the proponents of “scientific management” hoped to both reduce labor costs by employing fewer skilled workers and to increase productivity through their newly won control over the pace, speed and intensity of the production process itself. Work environments that have been designed in this way implicitly embody class relations. To the extent that work is fragmented and deskilled for the working class, it becomes more manageable by the employing class (Braverman, 1974, Moody, 1997). The control over pace and intensity of work performance has historically been transferred from workers to owners for the purpose of increasing the profitability of the enterprise. The technical aspects of this work transformation have been implemented by the managerial/professional class, indeed, “Scientific management” techniques became the bedrock of industrial engineering, and they continue to dominate the ways in which jobs are designed even today (Kanigel, 1997).

The work organizations created by “scientific management” are highly stressful jobs (Johnson, 1980). These workplaces produce high levels of “job strain” (see section 4A) because they have very high demands for performance and productivity and, at the same time, very low levels of control over meaningful decisions about how the work is to be performed. These principles of job design have also had an enormous influence over changes in work organizations in the health care and human service sector. Moreover, “lean production” methods (see section 2Biii) have led to an even more intensified form of Taylorism, referred to by some observers as a kind of “management by stress.” (Moody, 1997).

Managerial and technological innovations, though seemingly class-neutral, represent a kind of ‘social choice’ (Noble, 1977). The nature of specific character of these choices that have been made in the United Statesour country suggests a deep suspicion of and a fear directed toward the working class. Researchers have pointed out that the degree to which workers have been stripped of skills and authority in the workplace has far exceeded that which would in reality have been the most rational and efficient approach (Noble, 1984). This ‘irrationality’ has also been the case with the intense waves of downsizing and restructuring that have swept through work organizations over the last two decades – the health of firms, and their capacity to creatively produce has often been harmed by these types of extreme measures.

The globalization of work and the labor process has also taken on a class character. The transfer of many jobs to low wage countries, and perhaps even more importantly, the threat that this transfer might occur, has severed much of the social contract that existed in the U.S. between classes in the post wworld wwar ttwo era. In many ways, we have returned to the starker realities of the 19th century social landscape with an increasing polarization between society’s ‘winners’ and ‘losers’. Third World Workers have also become victims of a “downward leveling” – a “race to the bottom” where we see the working conditions for most of the working class being pulled in the direction of the most desperate and least empowered (Brecher & Costello, 1994; Moody, 1997) Yet, if at the most only 20% of the society can be considered ‘winners’ in the process of economic globalization, what will become of the remaining 80%? In the past century, social movements (such as the labor movement) developed to challenge economic and political inequalities . The same kind of social movements are being mobilized today, only now on a global level. These movements for economic and global justice may transform the politics of the 21st century and could improve work organization and working conditions and reduce job stress in both developed and developing countries (Teivainen T, 2002) .

References

Braverman H. Labor and Monopoly Capital. New York, Monthly Review Press, 1974.

Brecher J, Costello T. Global Village or Global Pillage. Boston, Mass: South End Press, 1994.

Cockerham WC. The Sociology of Health Behavior and Health Lifestyles. Pages 159-172 in Bird CE, Conrad P, Fremont AM (Eds.) Handbook of Medical Sociology. Upper Saddle River, NJ: Prentice Hall, 2000.

Evans GW, Kantrowitz E. Socioeconomic Status and Health: The Potential Role of Environmental Risk Exposure. Annual Review of Public Health 2002;23;303-31.

Evans RG. Chapter 1: Introduction. Pages 3-26 in Evans RG, Barer ML, Marmor TR (Eds.) Why Are Some People Healthy and Others Not? The Determinants of Health in Populations. New York: Aldine De Gruyter, 1994.

House JS, Williams DR. Understanding and Reducing Socioeconomic and Racial/Ethnic Disparities in Health. Pages 89-131 in Hofrichter R (Ed) Health and Social Justice. San Francisco, CA: Jossey-Bass, 2003.

Johnson JV. Work Fragmentation, Human Degradation and Occupational Stress. Washington DC, U.S. Department of Labor, Occupational Health and Safety Administration, 1980.

Johnson JV, Hall EM. Job Strain, Work Place Social Support, and Cardiovascular Disease: A Cross-Sectional Study of a Random Sample of the Swedish Working Population. American Journal of Public Health, 1988;78(10): 1336-1342.

Johnson JV, Hall EM, Theorell T. Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population. Scandinavian Journal of Work Environment and Health 1989;15;271-279.

Johnson JV, Hall EM. Towards an Understanding of the Interconnectedness of Class, Work and Health. Paper Prepared for Author’s Working Conference on Society and Health, Harvard University, October 1992.

Johnson JV, Hall EM. Class, Work, and Health. Pages 247-271 in Amick BC, Levine S, Tarlov, AR, Walsh DC (Eds.) Society and Health. New York: Oxford University Press, 1995.

Kanigel R. The One Best Way: Frederick Winslow Taylor and the Enigma of Efficiency. New York: Viking, 1997.

Kristensen TS, Borg V, Hannerz H. Socioeconomic Status and Psychosocial Work Environment: Results from a Danish National Study. Scand J Public Health. 2002;Suppl 59:41-8.

Landsbergis P, Schnall P, Pickering T, Warren K, Schwartz J. Lower socioeconomic status among men in relation to the association between job strain and blood pressure. Scandinavian Journal of Work, Environment and Health 2003;29(3):206-215.]

Link BG, Phelan JC. Social conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior. Extra Issue. 80-94, 1995.

Lynch J, Kaplan G. Socioeconomic Postion. Pages 13-35 in Berkman LF, Kawachi I (Eds.) Social Epidemiology. New York: Oxford University Press, 2000.

Marmot MG, Rose G, Shipley M, Hamiltion PJS. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 32:244-9, 1978.

Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. Lancet 1997;350:235-9.

Marmot M, Bartley M. Social class and coronary heart disease. Pages 5-19 in SA Stansfeld & MG Marmot (Eds). Stress and the Heart. London: BMJ Books, 2002.

Marmot M, Theorell T. Social Class and Cardiovascular Disease: The Contribution of Work. International Journal of Health Services 1988; 18:659-74.

Moody, K. Workers in a Lean World. London: Verso, 1997.

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Teivainen T. The World Social Forum and Global Democratisation: Learning from Porto Alegre. Third World Quaterly 2002;23(4):621-632.

Wright EO. Classes. London: Verso, 1985.

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Social Inequality, Stress and Health

Joseph E. Schwartz Schwartz, J. E. (2001): Social inequality, stress, and health. In Blau, J. R. (Ed.) The Blackwell Companion to Sociology. Malden: Blackwell Publishers Inc.

Research into the determinants of disease morbidity and mortality during most of the 20th century has been dominated by a biological model of disease as has the practice of medicine itself. Illnesses and other physical disorders were thought to be caused by harmful agents (e.g., bacteria or viruses causing infectious diseases, toxic chemicals, tobacco smoke, cholesterol, etc.) and/or a breakdown in one or more of the body’s organ systems. Consistent with this biomedical model, primary prevention of disease has focused on reducing the population’s exposure to toxic substances and procedures to control the spread of infections – for example, ensuring a clean water supply, quarantining infected individuals, and vaccinating individuals to make them immune to specific diseases.
It was not until 1977 that Engel published his seminal article setting forth the now widely accepted biopsychosocial model of disease. This article urged physicians and researchers to acknowledge and investigate the role of social, psychological, and behavioral factors in the prevention, etiology, and treatment of both physical and mental illnesses. Despite its wide acceptance, at least in principle, the vast majority of the medical literature ignores the role of psychological and sociological factors. A review of medical school curricula or the contents of leading journals (e.g. Journal of the American Medical Association or Lancet) suggests that the medical establishment remains skeptical about the relevance of psychosocial factors in the etiology of disease.
The above not withstanding, the subfield of “psychosomatic medicine,” historically dominated by psychiatrists, has a long tradition of emphasizing mind-body connections. Increasingly, a broader array of researchers have been investigating the impact of personality, behavior, and a variety of social factors on morbidity and mortality. While the majority are psychologists, there are also physicians, social epidemiologists, sociologists, anthropologists, and others. Many of these researchers identify themselves with one or more of the interdisciplinary fields of psychosomatic medicine, “behavioral medicine,” and “health psychology.”
In this chapter I review selected empirical findings and issues from behavioral medicine that are likely to interest sociologists. The first section is primarily descriptive, reviewing the fact that the risk of many diseases, and death itself, is socially patterned. Much of the emphasis is on mortality and cardiovascular disease, but the general point applies to other causes of death and many non-fatal diseases. Since, in my opinion, the subfield of social stratification lies at the core of sociology, and this section emphasizes the link between stratification and health. While many mechanisms surely contribute to this relationship, I am particularly interested in the effect that stress may have on health and the possibility that differential exposure to stress in the social environment partially accounts for social class differences in health. The latter part of the chapter presents select findings from studies of animals and humans pertaining to the impact of social stress on health.

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The MacArthur Research Network on Socioeconomic Status and Health is a multi-disciplinary collaboration comprising leading scholars from the fields of psychology, sociology, psychoneuroimmunology, medicine, epidemiology, neuroscience, biostatistics, and economics who have been working together for the last decade. The network research agenda is organized around an integrated conceptual model of the environmental and psychosocial pathways by which socioeconomic status alters the performance of biological systems, thereby affecting disease risk, disease progression, and ultimately mortality.

The network has enhanced understanding of the mechanisms by which socioeconomic factors affect the health of individuals and their communities through the development of innovative research methods, creation of significant new data sets, novel findings, and identification of new concepts, hypotheses and directions for research. Building on this work the network has contributed to discussions of economic and social policy to foster better health among individuals and communities across the socioeconomic spectrum.

http://www.macses.ucsf.edu/

Smoking and Job Strain

“Studies have shown that workers facing job strain (or its components—high job demands and low job control) smoke more (if they are smokers) or have greater difficulty quitting smoking [110-113]. In some studies, workers with job strain are heavier and exercise less [110, 114, 115]. Workers with low job control have higher levels of plasma fibrinogen, a chemical in the blood that contributes to atherosclerosis, that is, hardening of the arteries [116, 117]. And workers with low job control or job strain, in some studies, show greater atherosclerosis in the arteries in the heart or the arteries going to the brain [118-121]. High blood pressure also contributes to atherosclerosis [122].”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

110. Hellerstedt, W. L. and R. W. Jeffery, The Association of Job Strain and Health Behaviours in Men and Women, International Journal of Epidemiology, 26:3, pp. 575-583, 1997.

111. Kawakami, N., T. Haratani, and S. Araki, Job Strain and Arterial Blood Pressure, Serum Cholesterol, and Smoking as Risk Factors for Coronary Heart Disease in Japan, International Archives of Occupational and Environmental Health, 71:6, pp. 429-432, 1998.

112. Green, K. L. and J. V. Johnson, The Effects of Psychosocial Work Organization on Patterns of Cigarette Smoking among Male Chemical Plant Employees, American Journal of Public Health, 80, pp. 1368-1371, 1990.

113. Landsbergis, P. A., P. L. Schnall, D. K. Deitz, K. Warren, T. G. Pickering, and J. E. Schwartz, Job Strain and Health Behaviors: Results of a Prospective Study, American Journal of Health Promotion, 12:4, pp. 237-245, 1998.

114. Siegrist, J. and A. Rodel, Work Stress and Health Risk Behavior, Scandinavian Journal of Work Environment and Health, 32:6, pp. 473-481, 2006.

115. Johansson, G., J. V. Johnson, and E. M. Hall, Smoking and Sedentary Behavior as Related to Work Organization, Social Science and Medicine, 32, pp. 837-846, 1991.

116. Markowe, H. L., M. G. Marmot, M. J. Shipley, et al., Fibrinogen: A Possible Link between Social Class and Coronary Heart Disease, British Medical Journal, 291, pp. 1312-1314, 1985.

117. Brunner, E. J., G. D. Smith, M. G. Marmot, R. Canner, M. Beksinska, and J. O’Brien, Chi l dhood Soci al Ci r cumst ances and Psychosoci al and Behavi or al Fact or s as Determinants of Plasma Fibrinogen, Lancet, 347, pp. 1008-1013, 1996.

118. Langosch, W., B. Brodner, and M. Borcherding, Psychosocial and Vocational Long- Term Outcomes of Cardiac Rehabilitation with Postinfarction Patients under the Age of Forty, Psychosomatic Medicine, 40, pp. 115-128, 1983.

119. Muntaner, C., F. J. Nieto, L. Cooper, J. Meyer, M. Szklo, and H. A. Tyroler, Work Organization and Atherosclerosis: Findings from the Aric Study. Atherosclerosis Risk in Communities, American Journal of Preventive Medicine, 14, pp. 9-18, 
1998.

120. Hintsanen, M., M. Kivimaki, M. Elovainio, et al., Job Strain and Early Atherosclerosis: The Cardiovascular Risk in Young Finns Study, Psychosomatic Medicine, 67:5, pp. 740-747, 2005.

121. Rosvall, M., P. O. Ostergren, B. Hedblad, S. O. Isacsson, L. Janzon, and G. Berglund, Work-Related Psychosocial Factors and Carotid Atherosclerosis, International Journal of Epidemiology, 31:6, pp. 1169-1178, 2002.

122. Steptoe, A. and M. Marmot, Atherogenesis, Coagulation and Stress Mechanisms, Occupational Medicine: State of the Art Reviews, 15:1, pp. 136-138, 2000.

Eating less salt doesn’t cut heart risks: study I Reuters

Is nothing sacred? For 100 years now it has been gospel that salt plays an important role in the etiology of ESSENTIAL Hypertension, despite the fact that the evidence for the role of salt has always been contradictory (e.g., feeding people unlimited amounts of salt doesn’t increase bp as our bodies have enormous ability to excrete salt in the urine). This article provides further evidence that the role in sodium in the etiology and treatment of hypertension is even more problematic than previously thought.  The key sentence from below of their results  “participants with the lowest salt intake had the highest rate of death from heart disease during the follow up (4 percent), and people who ate the most salt had the lowest (less than 1 percent).”

Diabetes & Obesity

DIABETES & OBESITY:

“Studies show that diabetes impacts employment, absenteeism, and work productivity [55, 76] and that obesity is strongly associated with absenteeism and other health risks [47]. Moreover, obesity also may act as a co-risk factor for the development of a number of work-related diseases, such as occupational asthma and cardiovascular disease. It is theorized that obesity may modify the worker’s response to occupational stress, immune response to chemical exposures, and risk of disease from occupational neurotoxins [47].

Work-induced risk factors, such as long work hours and sedentary work, are contributing to the epidemic of obesity, one which will be far greater than the epidemic of the present, while the changing ethnic fabric of the population in the coming decades will no doubt exacerbate significantly the epidemic of diabetes. The anticipated and alarming growth in the epidemics of obesity and diabetes, influenced by both changing patterns of work and ethnicity, will act like a tsunami, contributing to both hypertension and cardiovascular diseases which will, in turn, have tremendous impacts at both the societal and individual levels. Given the poor efforts toward preventing and treating the present epidemics of obesity and diabetes, there is little reason to think that status quo measures will be more successful in addressing epidemics of a far greater scale. Prevention is, and will continue to be, critical.”

Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

47. Schulte, P. A., G. R. Wagner, A. Ostry, et al., Work, Obesity, and Occupational Safety and Health, 97:3, pp. 428-436, 2007.

55. Stewart, W. F., J. A. Ricci, E. Chee, A. G. Hirsch, and N. A. Brandenburg, Lost Productive Time and Costs Due to Diabetes and Diabetic Neuropathic Pain in the US Workforce, Journal of Occupational and Environmental Medicine, 49:6, pp. 672-679, 
2007.

76. Tunceli, K., C. J. Bradley, D. Nerenz, L. K. Williams, M. Pladevall, and J. Elston Lafata, The Impact of Diabetes on Employment and Work Productivity, Diabetes Care, 28:11, pp. 2662-2667, 2005.

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Overweight and Blood Pressure

The Measurement of Weight

There are several methods used to calculate distribution of body fat:

1. Waist-hip ratios are valuable in clinical use as they are easily measured and analyzed. It is the method used to primarily measure abdominal and visceral fat, as more fat is located in the waist area and less in the hip area. Waist refers to the circumference of the body at the level of the umbilicus (belly button) and hip refers to circumference of the body around the trochanter (at the level of the hip). The normal waist-hip ratio for men is 1.0, and for women is 0.8. Individuals with ratios above the normal are considered upper-body obese.

2. Body Mass Index (BMI) is commonly used to compare subjects in a research study. It can be calculated using the formula, weight (kg)/height(m)2. The average male BMI is 25 (considered normal). A body mass index of 28 for males is considered overweight, while 31 depicts obesity. For females, the numbers are slightly smaller: 21 is normal, 25 is overweight, and 29 is obese.

Both waist-hip ratios and BMI are good predictors of hypertension.

3. Skin fold thickness is another measure of percentage of body fat and distribution of body fat. Skinfolds of the subscapular and triceps among others are measured to calculate subcutaneous fat. An analysis reported in the Health and Nutrition Examination Survey (HANES) suggests that centrally located fat measured by the subscapular skinfolds are better predictors of hypertension than the triceps skinfold. In addition, CT and MR scans measure subcutaneous and visceral fat. Other determinations of fat have been accomplished by underwater weighing and fat biopsy.

Reasons Why People are Overweight

Genetics (data from studies of twins), overeating, smoking cessation, alcohol consumption, lack of exercise, change in life-style, energy intake vs. energy expenditure (consider resting metabolic expenditure), environmental factors, salt/potassium retention, major depression/anxiety/other psychological, medical illness, medications, during and after pregnancy, cultural (perceptions on obesity), socioeconomic factors.

Symptoms of Obesity (Overweight)

Fatigue (especially with exercise), shortness of breath, decreased energy, palpitations, irregular heart beat, edema (especially swelling of the feet and legs), sleep apnea (Pickwickian syndrome), respiratory obstruction (for obesity to cause sleep apnea and repitory obstruction it must be severe).

Physical Signs of Obesity (Overweight)

Hypertension (increased blood pressure), coronary heart disease, predisposition to diabetes, hyperlipidemia (increased cholesterol level), metabolic abnormalities, increased risk for gallbladder disease, gout, some types of cancer, development of osteoarthritis of the weight-bearing joints.

Relationship of Weight to Blood Pressure

Being overweight is a significant risk factor for the development of hypertension. The prevalence of hypertension in the U.S. is greatly increased by the fact that one quarter to one half of all adults (prevalence varies by study) are overweight. Although the association between higher body fat and blood pressure has been recognized for years, recent studies have discovered a 50% to 300% higher incidence of hypertension among adults who consider themselves overweight compared to those classified as normal weight. Similar findings are revealed from studies involving children and young adults, in which the correlation coefficient between weight and blood pressure has been observed to be as high as 0.4. Two proposed mechanisms underlying this correlation are the stimulation of sodium retention and increased catecholamine release, which are results of increased sodium sensitivity and hyperinsulinemia. Age, gender, and race are modifiers/confounders of obesity, and should be considered when studying preventive interventions. Hypertension and obesity treatment are necessary to avoid potential morbidity and mortality from coronary heart disease or stroke.

Treatment of Hypertension (Chronic High Blood Pressure)

1. Nonpharmacologic treatment of mild hypertension could include dietary salt restriction (NaCl), dietary potassium supplementation, and/or weight reduction, physical exercise, meditation and other therapies (e.g., biofeedback).

Salt restriction is recommended for those individuals with hypertension who are “salt-sensitive,” or are prone to retaining sodium, gaining weight, and developing a rise in blood pressure as a result of a high-salt diet. Those who are “salt-resistant,” on the other hand, do not experience change in weight or blood pressure on either high or low-salt diets. For the salt-sensitive population, extreme amounts of salt restriction are not needed for improvement of blood pressure. Several studies have shown that diets containing 1600 to 2300 mg of sodium per day are associated with average reductions in systolic pressure of -9 to -15 mm Hg and in diastolic pressure of -7 to -16 mm Hg in salt sensitive individuals. Thus, salt restriction in this range is recommended in the dietary management of most individuals with hypertension. 
The blood pressure lowering effect of supplemental potassium may be greater in patients receiving a high-salt diet. The amount of dietary potassium required to obtain this effect, however, is not easily obtained. 
Six controlled studies of patients with hypertension concluded that short-term weight loss is usually associated with a reduction of blood pressure. In patients who experienced a weight loss of 11.7 kg (~25.7 lb.), an average blood pressure reduction of -20.7/-12.7 mm Hg was recorded. A similar study found that a decrease in blood pressure of -2.5/-1.5 mm Hg per kilogram of reduction of weight, further demonstrated a significant correlation between weight change and blood pressure change. 
Physical exercise is a critical component of any program to reduce and control weight on a long term basis. See the following website for additional information on exercise (link under construction).

2. Pharmacologic treatment of hypertension is essential when the disease has advanced to a more chronic phase. The most common forms of treatment are diuretics, beta blockers, and calcium channel blockers. Controversial and expensive alternatives to dieting in treating obesity are surgery and/or liposuction, which should be used only as a last alternative. Future research for treating obesity includes inhibiting gastric emptying, stimulating lipid oxidation, increasing thermogenesis, and blocking carbohydrate or lipid digestion.

Methods of Weight Loss

Dietary change, exercise, behavior modification, drug treatment, and/or a combination of these interventions. Limitations on dietary intake, the most common method used for weight loss, can last several weeks to months, depending on individual need and motivation. Altering dietary proportions of fat, protein, carbohydrate, using macronutrient substitutes, and taking vitamins, diet supplements or meal replacements are all techniques to modify food intake. In addition, low calorie diets (1000-1500 calories/day) and very low calorie diets (800 or less calories/day) help patients lose weight. Physician supervision is recommended, however, to prevent adverse side effects, such as excessive loss of lean body mass, particularly in individuals with chronic health problems such as hypertension. Eating and chewing food slowly will send nervous system signals to the stomach that it is “full,” and will assist in weight loss and deter weight gain after dieting, especially if a healthy diet is selected. Exercising is another way to lose weight, although the average weight loss from exercise alone is 4-7 lb. (8.8-15.4 kg.), greater weight loss is possible. Regular workouts are advantageous to increasing high-density lipoprotein cholesterol and lean body mass, and diminishing rapid weight gain. Along with changing eating patterns and increasing physical activity, behavior modification produces gradual change.

Four steps to behavior modification include: 1) identifying eating or related life-style behaviors to be modified, 2) setting specific behavioral goals, 3) modifying determinants of the behavior to be changed, and 4) reinforcing the desired behavior. Drug treatment is another method used for weight loss. With prolonged use, however, loss of weight is minimized as it reaches a plateau. Some side effects are common. An example of an over the counter drug is phenylpropanolamine which, however, has a negative effect on blood pressure, and little is known about it’s long-term side-effects.

On average, 1-1.5 lb./week (~.45-.68 kg./week) are lost by combining excercise, reducing dietary intake, and behavior modification. Successful weight loss involves a combination of these methods that are suitable to the individual in a slow and steady process. Remember who won the race.

References:

1. Fraser G. Preventive Cardiology. Oxford University Press, New York, 1986, pp. 134-5.

2. Gerber L, Schnall P, and Pickering T. Body fat and its distribution in relation to casual and ambulatory blood pressure. Endocrinology and Metabolism Clinics of North America, Sept. 1995, 24(3).

3. Hurst JW, Logue RB, Rackley CE, et. al. The Heart, Sixth Edition. McGraw-Hill Book Company, New York, 1986, pp. 1078-9.

4. Methods for voluntary weight loss and control. NIH Technology Assessment Statement, 1992 March 30-April 1,(10).

5. Moore T and McKnight J. Dietary factors and blood pressure regulation. Endocrinology and Metabolism Clinics of North America, Sept. 1995, 24(3).

Heart Disease

“Cardiovascular disease (CVD), including heart disease and stroke, is the major cause of disease and death in the industrialized world and is projected to become the most common cause of death worldwide by the year 2020. CVD and hypertension (high blood pressure) appear to be epidemics of recent historical origin, developing along with industrialization and urbanization, and now increasing in the context of economic globalization. Modern medicine focuses on individual risk factors for hypertension and CVD, often ignoring the important role that social factors, such as social class, work organization, and work-related psychosocial stressors, play in the development of hypertension and CVD. Social factors need to be fully integrated into explanations of disease development.

Increased CVD risk has been associated with job characteristics such as long work hours, shift work, “job strain” (a combination of high psychological work demands and low job decision latitude, or job control), high job efforts combined with low job rewards, injustice, job insecurity, and work that involves maintaining a high level of vigilance in order to avoid disaster, such as loss of human life. Sources of stress on the job (job stressors), besides acting directly on the human nervous system, may increase the risk of hypertension and CVD through a variety of mechanisms, including inhibiting healthy behaviors such as smoking cessation and exercise, or by producing psychological distress, such as anxiety and depression. Public health strategies are needed to address the pandemic of CVD, including worksite surveillance, development of the field of occupational cardiology, integration of health promotion with occupational health approaches, and job redesign.”*

*Taken from: Schnall PL, Dobson M, Rosskam E, Editors Unhealthy Work: Causes, Consequences, Cures. Baywood Publishing, 2009.

Mental Illness

When stress becomes a prolonged or chronic experience, it can result in psychological distress, including generalized anxiety, burnout, and depressive symptoms. Work-related stress can also be a factor in exacerbating pre-existing mental illnesses and may even precipitate clinically diagnosable symptoms of depression. A growing body of empirical evidence in the occupational health field is making connections between the way work is organized and burnout, as well as more long-term adverse psychological health outcomes such as chronic anxiety and clinical depression. In turn, psychological distress has been linked to absenteeism, “presenteeism,” job dissatisfaction, and turnover [1-3]. The wear and tear of long working hours and physical harm to the body motivated the social reforms of the early years of industrialization, including the 8-hour work day and the 40-hour work week. Laws were established to allow for physical and mental recovery time from work; they are now seriously compromised to the detriment of the psychological (and physical) well-being of workers. Not only should the psychological effects of work stress be a concern for individuals, but also for employers, labor unions, and society as a whole.

Musculoskeletal Disorders

‘Musculoskeletal disorders include a wide range of inflammatory and degenerative conditions affecting the muscles, tendons, ligaments, joints, peripheral nerves, and supporting blood vessels. These include clinical syndromes such as tendon inflammations and related conditions (tenosynovitis, epicondylitis, bursitis), nerve compression disorders (carpal tunnel syndrome, sciatica), and osteoarthrosis, as well as less well standardized conditions such as myalgia, low back pain and other 
regional pain syndromes not attributable to known pathology. Body regions most commonly involved are the low back, neck, shoulder, forearm, and hand, although recently the lower extremity has received more attention.

Musculoskeletal disorders (MSDs) are widespread in many countries, with substantial costs and impact on quality of life. Although not uniquely caused by work, they constitute a major proportion of all registered and/or compensable work-related diseases in many countries. Accurate data on the incidence and prevalence of musculoskeletal disorders are difficult to obtain, and official statistics are difficult to compare across countries. Nevertheless, MSDs are the single largest category of work-related illness, representing a third or more of all registered occupational diseases in the United States, the Nordic countries, and Japan 
[6,49,54,73]. Numerous surveys of working populations have reported upper extremity symptom prevalences of 20 to 30% or even higher. In the United States, Canada, Finland, Sweden, and England, musculoskeletal disorders cause more work absenteeism or disability than any other group of diseases [4,15,39,54,63,65].

MSDs occur in certain industries and occupations 
with rates up to three or four times higher than the overall frequency. High-risk sectors include nursing facilities; air transportation; mining; food processing; leather tanning; and heavy and light manufacturing (vehicles, furniture, appliances, electrical and electronic products, textiles, apparel and shoes) [6]. Upper extremity musculoskeletal disorders are also highly 
prevalent in manual-intensive occupations, such as clerical work, postal service, cleaning, industrial inspection and packaging [63]. Back and lower limb disorders occur disproportionately among truck drivers, warehouse workers, airplane baggage handlers, construction trades, nurses, nursing aides and other patient-care workers, and operators of cranes and other large vehi- cles [54].