Working Late, Courting Stroke

Source: JAMA Network | JAMA | Working Late, Courting Stroke

When Jeb Bush told a crowd in New Hampshire this past summer that people in the United States need to “work longer hours,” presumably he didn’t know that working longer hours is associated with a higher risk of strokes. According to a recent review and meta-analysis in The Lancet, if people take his advice to heart and start working more than 55 hours a week, their stroke risk will climb (Kivimäki M et al. Lancet. doi:10.1016/S0140-6736(15)60295-1 [published online August 19, 2015]).

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The analysis included 25 prospective cohort studies involving a total of 603 838 men and women with no history of coronary heart disease who were followed up for a mean of 8.5 years and 528 908 men and women with no history of stroke who were followed up for 7.2 years. The investigators found that working 55 hours a week or more was linked with a 33% increased risk of stroke and a 13% increased risk of coronary heart disease. The risk for stroke increased the more hours worked, with individuals working 41 to 48 hours having a 10% higher risk, and those working 49 to 54 hours having a 27% higher risk of stroke when compared with those who worked between 35 and 40 hours a week, an effect that remained stable regardless of sex or geographic location.

According to the US Bureau of Labor Statistics, the average full-time worker in 2014 worked 42.5 hours ( Nearly 10% of nonagricultural workers worked between 49 and 59 hours a week, and among agricultural workers, 20.7% worked more than 60 hours per week (

Hidden in those numbers are a lot of workers at risk for stroke. The question, then, is what to do about it.

Citing the need to protect workers’ health and safety, the European Union has legislation on the books that protects workers’ rights to cap their hours at 48 hours per workweek ( In Japan, the government has passed legislation intended to reduce the incidence of “karoshi,” otherwise known as death by overwork (

Despite the apparent health risk long hours pose to workers, the US Occupational Safety and Health Administration (OSHA) seems unconcerned.

“Currently, there is not a specific OSHA standard for extended or unusual work shifts, and there are no plans to propose one at this time. We continue to follow the issue closely,” wrote OSHA spokesperson Kimberly Darby in an email.

With the government on the sidelines, responsibility for mitigating work-related stroke risk falls largely to individual workers and their physicians.

“[S]troke is a multifactorial disease, and therefore a person’s risk of stroke is almost always the result of multiple interacting risk factors,” Mika Kivimäki, PhD, the first author of the Lancet review, wrote in an email. In the Lancet review, Kivimäki and his coauthors wrote that work-related stroke risk could be a result of repetitive stress response exposure, as well as behavioral risk factors like physical inactivity and heavy alcohol consumption. The authors also wrote that people who work longer hours may be more inclined to ignore symptoms and put off medical care. In an email, however, Kivimäki noted that there is currently no evidence that reducing work hours would also reduce the risk for stroke.

“Prevention of stroke in individuals who work long hours should proceed along established lines of multifactorial cardiovascular disease risk reduction: keeping blood pressure, lipid levels, and blood glucose within the normal range; adequate physical activity; eating and drinking healthfully; avoiding overweight; and avoiding excessive stress,” wrote Kivimäki. He suggested that for patients who work long hours, physicians monitor blood pressure, stress the importance of maintaining a healthy lifestyle, and inform patients about the health risks associated with working long hours.

“The [Lancet] study unfortunately can’t tell us why people who work long hours may have an increased risk of stroke, but it does show an association,” said Ralph L. Sacco, MD, spokesperson for the American Stroke Association and professor and chair of neurology at the University of Miami Miller School of Medicine. Sacco noted that people who are under stress from working long hours may have increased blood pressure—a risk factor for stroke—and that people who don’t get enough sleep are at a greater risk for stroke or cardiovascular disease.

“If you work hard, then you also have to work hard at keeping yourself healthy,” said Sacco, adding that “[P]eople who are working more than 55 hours a week may be more at risk for not paying enough attention to their health.” For patients, said Sacco, paying attention to health would entail getting an annual checkup; knowing blood pressure, cholesterol, and blood glucose numbers; being physically active; being mindful about weight and diet; and getting enough sleep. Physicians, on the other hand, he said, should inquire about the hours that patients work, ask patients about work-related stress, and emphasize the added importance for patients who work long hours of being physically active and following an American Heart Association–approved diet (

Chrisandra Shufelt, MD, associate director of the Preventive and Rehabilitative Cardiac Center at Cedars-Sinai Heart Institute in Los Angeles, suggests that employers can help contribute to worker health by installing standing desks or offering employees worksite wellness programs, on-site access to a gym, or work breaks. But what about those employees whose workload is so heavy that they can’t take advantage of worksite wellness offerings, even when they are available?

“I would advise them to reach out and talk with someone—their boss, a therapist, a human resources representative—to see if their workload priorities can be adjusted to allow them time to take care of their health. Work-life balance is key to good health,” wrote Shufelt in an email. In the meantime, Shufelt would encourage overworked employees to stay active any way they can. “Take the stairs and bypass the elevator. Pick up a pedometer and count your steps,” she wrote.

While practical interventions like these coupled with standard stroke prevention methods may help reduce workers’ risk, some believe that responsibility for employee health should not rest entirely on each individual but be shared with employers.

Some employers use workplace wellness programs to help address not only worker health, but also issues like absenteeism, productivity, and ultimately health care costs. The programs are varied and encourage everything from routine health screenings and healthy eating to financial incentives for weight loss. The Affordable Care Act encourages employee wellness programs but doesn’t require them to be evidence-based (

LuAnn Heinen, MPP, vice president of workforce well-being, productivity, and human capital at the National Business Group on Health, acknowledged that an increased risk of stroke associated with work-related factors could be detrimental for both employers and employees. “When you’re talking about stroke, you’re talking about serious disability,” she said. Still, she noted that there may be a limit to the number of hours employers may be willing to cut. “I don’t think it’s realistic that they’re going to cut hours below a standard [workday],” said Heinen.

“[In] health, [there is] still this assumption that people are the masters of their own destiny,” said Harald Schmidt, PhD, MA, assistant professor of medical ethics and health policy at the Perelman School of Medicine at the University of Pennsylvania. Schmidt noted that while perfectionists may work long hours because they want to, there are also people who have no choice about the kinds of hours their employers require. “[We] have to be careful before we hold people responsible for factors that are beyond their control,” he said.

But with government staying out of the fray, and physicians being somewhat limited to helping patients mitigate risk factors for stroke, workers’ health may indeed remain to some degree at the mercy of the employers who also set the hours.


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