The Whitehall Study

Contact: Professor Michael Marmot
Department of Epidemiology and Public Health
University College London
1-19 Torrington Place
London WC1E 6BT
England
Tel: 44 171 391 1717
Fax: 44 171 813 0280
Email: Michael@public-health.ucl.ac.uk

The Whitehall study examined mortality rates over 10 years among male British Civil Servants aged 20-64. The study was an attempt to avoid some of the problems created by the use of general social class groupings, e.g., the heterogeneity of occupations within a single class leaves room for differing interpretations. The Whitehall study concentrates on one “industry” in which there is little heterogeneity within occupational grades and clear social divisions between grades (Marmot, Kogevinas and Elston, 1987).

An inverse association between grade (level) of employment and mortality from CHD and a range of other causes was observed (78). Men in the lowest grade (others = messengers, doorkeepers, etc.) had a three-fold higher mortality rate than men in the highest grade (administrators) (Marmot, Shipley and Rose, 1984).

Grade is also associated with other specific causes of death, whether or not the causes were related to smoking (Marmot, Kogevinas and Elston, 1987). While low status was associated with obesity, smoking, less leisure time physical activity, more baseline illness, higher blood pressure, and shorter height (78), controlling for all of these risk factors accounted for no more than 40% of the grade difference in CHD mortality (Marmot, Shipley and Rose, 1984; Marmot, Kogevinas and Elston, 1987). After controlling for standard risk factors, the lowest grade still had a relative risk of 2.1 for CHD mortality compared to the highest grade (Marmot, 1994).

One possible explanation of the remaining grade differences in CHD mortality is grade differences in job control and job support (Marmot, Kogevinas and Elston, 1987). In addition, blood pressure at work was associated with “job stress”, including “lack of skill utilization”, “tension”, and “lack of clarity” in tasks. The rise in blood pressure from the lowest to the highest job stress score was much larger among low grade men than among upper grade men. Blood pressure at home, on the other hand, was not related to job stress level (78).

Thus, a second longitudinal study of British Civil Servants (Whitehall II) was initiated to investigate occupational and other social influences on health and disease (Marmot, 1994). The final sample was 6900 men and 3414 women aged 35-55 in the London offices of 20 civil service departments (Marmot et al., 1991). Employment grade was strongly associated with work control and varied work (measures of decision latitude) as well as fast pace (a measure of job demands) (Marmot et al., 1991; Marmot, 1994). Lack of control on the job is related to long spells of absence (> 6 days) (Marmot, 1994).

In addition, there was no decrease in the difference in prevalence of ischemia depending upon employment category over the 20 years separating Whitehall I and Whitehall II (Marmot et al., 1991). Plasma cholesterol concentrations did not differ by job category, and the small inverse association between job status and blood pressure in men was reduced from that seen in the Whitehall I study. There was a significant inverse relation between BMI and job status, but, especially in men, the differences were small. The risk factor that differed most between employment categories was smoking. Moderate or vigorous exercise was less common among subjects in lower status jobs (Marmot et al., 1991).

Publications from the Whitehall II Study

1) Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A. Health inequalities among British civil servants: the Whitehall II study. Lancet 1991;337:1387-1393. abstract

2) Brunner EJ, Davey Smith G, Pilgrim J, Marmot MG. Low serum cholesterol and suicide. Lancet 1992;339:1001-1002.

3) Pilgrim JA, Stansfeld SA, Marmot MG. Low blood pressure, low mood? Br Med J 1992;304:739-749.

4) Stansfeld SA, Marmot MG. Social class and minor psychiatric disorder in British Civil Servants: a validated screening survey using the General Health Questionnaire. Soc Sci Med 1992;35:1027-1035.

5) Stansfeld SA, Marmot MG. Deriving a survey measure of social support: the reliability and validity of the Close Persons Questionnaire. Soc Soc Med 1992;35:1027-1035.

6) Brunner EJ, Marmot MG, White IR, et al. Gender and employment grade differences in blood cholesterol, apolipoproteins and haemostatic factors in the Whitehall II study. Atherosclerosis 1993;102:195-207.

7) Marcenes WS, Croucher R, Sheiham A, Marmot MG. The relationship between self-reported oral symptoms and life-events. Psychology and Health 1993;8:123-124.

8) Marmot MG, North F, Feeney A, Head J. Alcohol and sickness absence: from the Whitehall II study. Addiction 1993;88:369-382.

9) North F, Syme SL, Feeney A, Head J, Shipley MJ, Marmot MG. Explaining socioeconomic differences in sickness absence: the Whitehall II study. Br Med J 1993-306:361-366.

10) Roberts R, Brunner EJ, White I, Marmot MG. Gender differences in occupational mobility and structure of employment in the British civil service. Soc Sci Med 1993;37:1415-1425.

11) Stansfeld SA, Davey Smith F, Marmot MG. Association between physican and psychological mobidity in the Whitehall II study. J Psychosom Res 1993;37:227-238.

12) Marmot MG. Social differentials in health within and between populations. Daedulus 1994;123:197-216.

13) Marmot M. Work and other factors influencing coronary health and sickness absence. Work & Stress 1994;8:191-201.

14) Carroll D, Davey Smith G, Sheffield D, Shipley MJ, Marmot MG. Pressor reactions to psychological stress and prediction of future bleed pressure: data from the Whitehall II study. Br Med J 1995;310:771-776.

15) Ferrie JE, Shipley MJ, Marmot MG, Stansfeld S, Davey Smith G. Heath effects of anticipation of job change and non-employment: longitudinal data from the Whitehall II study. Br Med J 1995; 311:1264-1269.

16) Marmot M, Feeney A, Shipley M, North F, Syme SL. Sickness absence as a measure of health status and functioning: from the UK Whitehall II study. J Epidemiol Community Health 1995;49:124-130.

17) Rael EGS, Stansfeld SA, Shipley M, Head J, Feeney A, Marmot M. Sickness absence in the Whitehall II study, London: the role of social support and material problems. J Epidemiol Community Health 1995;49:474-481.

18) Roberts R, Brunner EJ, Marmot M. Psychological factors in the relationship between alcohol and cardiovascular morbidity. Soc Sci Med 1995;41:1513-1516.

19) Stansfeld S, Feeney A, Head J, Canner R, North F, Marmot MG. Sickness absence for psychiatric illness: the Whitehall II study. Soc Sci Med 1995;40:189-197.

20) Stansfeld SA, North FM, White I, Marmot MG. Work characteristics and psychiatric disorder in civil servants in London. J Epidemiol Community Health 1995;49:48-53.

21) White IR, Brunner EJ, Barron JL. A comparison of overnight and 24 Hour collection to measure urinary catecholamines. J Clin Epidemiol 1995;48:263-267.

22) Brunner E, Davy Smith G, Marmot M, Canner R, Beksinska M, O’Brien J. Childhood social circumstances and psychosocial and behavioral factors as determinants af plasma fibrogen. Lancet 1996;347:1008-1013.

23) North FM, Syme SL, Feeney A, Shipley M, Marmot M. Psychosocial work environment and sickness absence among British civil servants: The Whitehall II Study. Am H Public Health 1996;86:332-340. abstract

24) Stansfeld S. Mental health and sickness absence. Occ Health Rev 1996;26-30.

25) Stansfeld SA, Rael EGS, Head J, Shipley M, Marmot M. Social support and psychiatric sickness absence: a prospective study of British civil servants. Psychol Med 1996;27:35-48.

26) Bosma H, Marmot MG, Hemingway H, Nicholson A, Brunner EJ, Stansfeld S. Low job control and risk of coronary heart disease in the Whitehall II (prospective cohort) study. Br Med J 1997;314:558-565. abstract

27) Brunner EJ. Inequalities in diet and health. In: Diet, nutrition and chronic disease: lessons from contrasting worlds, edited by Shetty P, McPherson K. Chichester: Wiley, 1997.

28) Marmot M. Inequality, deprivation and alchohol use. Addiction 1997;92:S13-20.

29) Carroll D, Davey Smith G, Marmot MG, Canner R, Beksinska M, O’Brien J. The relationship between socio-economic status, hostility, and blood pressure reactions to mental stress in men: Data from the Whitehall II study. Health Psychology 1997.

30) Bosma H, Peter R, Siegrist J, Marmot MG. Alternative job stress models and the risk of coronary heart disease: the effort-reward imbalance model and the job strain model. Am J Public Health 1997.

31) Davey Smith G, Brunner EJ. Socio-econimic differentials in health: the role of nutrition. Proc Nutr Soc 1997.

32) Hemingway H, Shipley M, Stansfeld S, Marmot M. Back pain sickness absence, psychosocial work characteristics., employment grade and disease status: the Whitehall II study. Br Med J 1997.

33) Hemingway H, Nicholson A, Roberts R, Stafford M, Marmot M. The impact of socioeconomic status on health functioning as assessed by the SF-36: the Whitehall II study. Am J Public Health 1997.

34) Hemingway H, Stafford M, Stansfeld SA, Marmot MG. Changes in SF-36 health functioning by age, employment grade and disease status: the Whitehall II study. Br Med J 1997.

35) Nicholson AC, White IR, Macfarlane PW, Brunner EJ, Marmot MG. Why do women report more angina than men? Analyses from the Whitehall II study. J Clin Epidemiol 1997.

36) Sheffield D, Davey Smith G, Caroll D, Shipley MJ, Marmot MG. The effects of recent food alcohol, and tobacco intake, and the temporal scheduling of testing on cardiovascular activity at rest and during psychological stress. Psychophysiology 1997.

37) Stansfeld S, Fuhrer R, Hemingway H, Marmot M. Psychiatric disorder as a predictor of coronary heart disease in the Whitehall II study. Assoc Eur Psychiatr 1997 (Abstact).

38) Armstrong NC, Paganga G, Brunner EJ, et al. Reference values for a-tocopherol and B-carotene in the Whitehall II Study. Free Radical Reasearch 1997.

39) Marmot MG, Ryff C, Bumpass L, Shipley MJ, Marks NF. Social inequalities in health: next questions and converging evidence. Soc Sci Med 1997.

40) Kiimaki M, Head, J, Ferrie JE, Shipley MJ, Brunner E, Vahtera J, Marmot MG. Work stress, weight gain and weight loss: evidence for bidirectional effects of job strain on body mass index in the Whitehall II study. International Journal of Obesity (2006) 30, 982–987.

Selected Abstracts from the Whitehall II Study

Bosma H, Marmot MG, Hemingway H, Nicholson AG, Brunner E, Stansfeld A. Low job control and risk of coronary heart disease in Whitehall II (prospective cohort) study. BMJ 1997;Volume 314:558-65.

Objective: To determine the association between adverse psychosocial characteristics at work and risk of coronary heart disease among male and female civil servants.
Design: Prospective cohort study (Whitehall II study). At the baseline examination (1985-98) and twice during follow up a self report questionnaire provided information on psychosocial factors of the work environment and coronary heart disease. Independent assessments of the work environment were obtained from personnnel managers at baseline. Mean length of follow up was 5.3 years.
Setting: London based office staff in 20 civil service departments.
Subjects: 10308 civil servants aged 35-55 were examined-6895 men (67%) and 3413 women (33%).
Main outcome measures: New cases of angina (Rose questionnaire), severe pain across the chest, diagnosed ischaemic heart disease, and any coronary event.
Results: Men and women with low job control, either self reported or independently assessed, has a higher risk of newly reported coronary heart disease during the follow up. Job control assessed in two occasions three years apart, although intercorrelated, had cumulative effects in newly reported disease. Subjects with low job control con both occasions has an odds ratio for any subsequent coronary event of 1.93 (95% confidence interval 1.34 to 2.77) compared with subjects with high job control at both occasions. This association could not be explained by employment grade, negative affectivity, or classic coronary risk factors. Job demands and social support at work were not related to the risk of coronary heart disease.
Conclusion: Low control in the work environment is associated with an increased risk of future coronary heart disease among men and women employed in government offices. The cumulative effect of low job control assessed on two occasions indicates that giving employees more variety in tasks and a stronger say in decisions about work may decrease the risk of coronary heart disease.

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;350:235-39.

Background: The first Whitehall Study showed an inverse social gradient in mortality from coronary heart disease (CHD) among British civil servants – namely, that there were higher rates in men of lower employment grade. About a quarter of this gradient could be attributed to coronary risk factors. We analyzed 5-year CHD incidence rates from the Whitehall II study to assess the contribution to the social gradient of psychosocial work environment, social support, coronary risk factors, and physical height.
Methods: Data were collected in the first three phases of examination of men and women in the Whitehall II study. 7372 people were contacted on all three occasions. Mean length of follow-up was 5-3 years. Characteristics from the baseline, phase 1, questionnaire, and examination were related to newly reported CHD in people without CHD at baseline. Three self-reported CHD outcomes were examined: angina and chest pain from the Rose questionnaire, and doctor diagnosed ischemia. The contribution of different factors to the socioeconomic differences in incident CHD was assessed by adjustment of odds ratio.
Findings: Compared with men in the highest grade (administrators), men in the lowest grade (clerical and office-support staff) had an age-adjusted odds ratio of developing any new CHD of 1-50. The largest difference was for doctor-diagnosed ischemia (odds ratio for the lowest compared with the highest grade 2-27). For women, the odds ratio in the lowest grade was 1-47 for any CHD. Of factors examined, the largest contribution to the socio-economic gradient in CHD frequency was from low control at work. Height and standard coronary risk factors made smaller contributions. Adjustments for all these factors reduced the odds ratios for newly reported CHD in the lowest grade from 1-5 to 0-95 in men, and from 1-47 to 1-07 in women.
Interpretation: Much of the inverse social gradient in CHD incidence can be attributed to differences in psychosocial work environment. Additional contributions were made by coronary risk factors – mainly smoking – and from factors that act early in life, as represented by physical height.

North FM, Syme LS, Feeney A, Shipley M, Marmot M. Psychosocial Work Environment and Sickness Absence among British Civil Servants: The Whitehall II Study. Am J Public Health 1996;86:332-340.

Objectives: This study sought to examine the association between the psychosocial work environment and subsequent rates of sickness absence.
Methods: The analyses were based on a cohort of male and female British civil servants (n=9072). Rates of short spells
( < 7 days) and long spells ( > 7 days) of sickness absence were calculated for different aspects of the psychosocial work environment , as measured by self-reports and personnel managers’ ratings (external assessments).
Results: Low levels of work demands, control, and support were associated with higher rates of short and long spells of absence in men and, to a lesser extent, in women. The differences were similar for the self-reports and external assessments. After adjustment for grade of employment, the differences were diminished but generally remained significant for short spells. The combination of high demands and low control was only associated with higher rates of short spells in the lower grades.
Conclusions: The psychosocial work environment predicts rates of sickness absence. Increased levels of control and support at work could have beneficial effects in terms of improving the health and well-being of employees and increasing productivity.

Marmot MG, Smith GD, Stansfeld S, Patel C, North F, Head J, White I, Brunner E, Feeney A. Health inequalities among British civil servants: the Whitehall II study. The Lancet 1991; 337:1397-93.

The Whitehall study of British civil servants begun in 1967, showed a steep inverse association between social class, as assessed by grade of employment, and mortality from a wide range of diseases. Between 1985 and 1988 we investigated the degree and causes of the social gradient in morbidity in a new cohort of 10314 civil servants (6900 men, 3414 women) aged 35-55 (the Whitehall II study). Participants were asked to answer a self-administered questionnaire and attend a screening examination.
In the 20 years separating the two studies there has been no dimunition in social class difference in morbidity: we found an inverse association between employment grade and prevalence of angina, electrocardiogram evidence of ischemia, and symptoms of chronic bronchitis. Self-perceived health status and symptoms were worse in subjects in lower status jobs. There were clear employment-grade differences in health-risk behaviors including smoking, diet and exercise, in economic circumstances, in possible effects of early-life environment as reflected by height, in social circumstances at work (e.g., monotonous work characterized by low control and low satisfaction), and in social supports.
Healthy behaviors should be encouraged across the whole of society; more attention should be paid to the social environments, job design, and the consequences of income inequality.

The Whitehall Study

10-Year Mortality among British Civil Servants
(age adjusted, 40-64 year old males)

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