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Work Stress, Weight Gain and Weight Loss: Evidence for Bidirectional Effects
of Job Strain on Body Mass Index in the Whitehall II Study

Article  in  International Journal of Obesity · July 2006

DOI: 10.1038/sj.ijo.0803229 · Source: PubMed

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 International Journal of Obesity (2006) 30, 982–987
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ORIGINAL ARTICLE
Work stress, weight gain and weight loss: evidence for
bidirectional effects of job strain on body mass index
in the Whitehall II study
M Kivimäki1, J Head2, JE Ferrie2, MJ Shipley2, E Brunner2, J Vahtera1 and MG Marmot2
1
Finnish Institute of Occupational Health, University of Helsinki, Helsinki, Finland and 2International Centre for Health and
Society, Department of Epidemiology and Public Health, University College London, London, UK

Objective: Previous research has focused on overall associations between work stress and body mass index (BMI) ignoring the
possibility that stress may cause some people to eat less and lose weight and others to eat more. Using longitudinal data, we
studied whether work stress induced weight loss in lean individuals and weight gain in overweight individuals.
Design: Prospective cohort study.
Subjects: A total of 7965 British civil servants (5547 men and 2418 women) aged 35–55 at study entry (The Whitehall II study).
Measurements: Work stress, indicated by the job strain model and measured as job control, job demands and job strain, was
assessed at baseline and BMI at baseline and at 5-year follow-up.
Results: In men, the effect of job strain on weight gain and weight loss was dependent on baseline BMI (Pp0.03). In the leanest
quintile (BMIo22 kg/m2) at baseline, high job strain and low job control were associated with weight loss by follow-up, whereas
among those in the highest BMI quintile (427 kg/m2), these stress indicators were associated with subsequent weight gain. No
corresponding interaction was seen among women.
Conclusion: Inconsistent findings reported by previous studies of stress and BMI have generally been interpreted to indicate the
absence of an association. In light of our results, the possibility of differential effects of work stress should also be taken into
account.
International Journal of Obesity (2006) 30, 982–987. doi:10.1038/sj.ijo.0803229; published online 17 January 2006

Keywords: psychosocial factors; work stress; body mass index; weight gain; weight loss

Introduction associated with lower BMI.15,16 Associations of job strain and

Work stress and high body mass index (BMI) are both risk
factors for cardiovascular disease,1–4 but the extent to which
they are associated with each other remains unclear.
According to a dominant theoretical model, persistent work
stress is generated by a combination of high job demands
and low control at work: job strain.5 While some studies
have found an association between high strain,6,7 high
demands,6,8,9 low control,3,10 and increased BMI, other
studies have reported no associations between these psycho-
social characteristics of the work environment and BMI,11–14
and, in some samples, high strain or low control were
Correspondence: Professor M Kivimäki, Finnish Institute of Occupational
Health, Topeliuksenkatu 41 aA, FIN-00250 Helsinki, Finland.
E-mail: mika.kivimaki@ttl.fi
Received 4 June 2005; revised 18 October 2005; accepted 23 November
2005; published online 17 January 2006
its components with BMI have been found to vary by sex,
but not in a consistent manner17 and stress has also been
proposed to be linked with BMI beyond the work context.18
Mixed findings on work stress and BMI may reflect a
failure to take into account the possibility that stress may
cause some people to eat more, but others to eat less.19
Dalman et al.20 demonstrated that eating high fat and
carbohydrate caloric content ‘comfort’ food may help in
reducing biological stress system activity and concomitant
negative emotions during chronic stress. The tendency to eat
such energy-dense foods under stress is likely to contribute
to weight gain.18,21 Both physical inactivity and lack of time
to prepare healthy meals further increase weight gain among
people with chronic stress.18,22 On the other hand, chronic
stress may also trigger physiological processes which lead to
weight loss,20,23 in particular, among individuals for whom
chronic work stress is associated with suppressed appetite
and increased physical activity.18 As sex is a factor that

appears to confer differential sensitivity to stress and may
also affect choice of coping strategy,24–28 it is important to
examine stress effects on eating and weight change sepa-
rately for men and women.
In this report from the Whitehall II study, we examined
the association between work stress and BMI with particular
attention to the hypothesis that chronic work stress may
induce weight gain in some individuals but weight loss in
others. If such individual differences are stable and accumu-
late, then the tendency to weight gain under stress is likely
to be more common among people with high BMI while
among those with low BMI the tendency will be towards
further weight loss.
Methods
Participants
The target population for the Whitehall II study is all
London-based office staff working in 20 Civil Service
departments during recruitment in 1985–1988.29 With a
participation rate of 73%, the baseline cohort consisted of
10 308 civil servants: 6895 men and 3413 women aged 35–55
years. The true participation rate was probably higher,
however, because around 4% of those invited had, in fact,
moved employment before the study and were not eligible
for inclusion. Baseline screening and a follow-up screening
in 1991–1993 included the assessment of BMI. This study
focused on those 5547 men and 2418 women with data on
job strain at baseline and BMI at baseline and follow-up. The
2343 employees excluded had slightly higher BMI (25.0 vs
24.5 kg/m2), were older (45.0 vs 44.3 years), more likely to be
women (42 vs 36%) and in the lowest employment grade (36
vs 19%) (all P-valueso0.001).
Measurements
Assessment of work stressors was based on a modified Job
Content Questionnaire comprised of the job demand scale (4
items, Cronbach’s a ¼ 0.67) and job control scale (15 items,
a ¼ 0.84).4 Job demand and job control scores are standar-
dized mean scores from the respective scales. Job strain is a
standardized score derived from the equation: job demand
score – job control score,30 a continuous variable of highly
predictive validity for coronary heart disease in the White-
hall II study.31 We repeated the analyses with a more
commonly used binary variable defining job strain as a
job demand score above the median combined with a
job control score below the median. Other baseline charac-
teristics were sex, age (years), employment grade
(1 ¼ administrative, 2 ¼ professional, 3 ¼ clerical) and BMI,
calculated as weight in kilograms divided by height in meters
squared. Weight was measured with all items of clothing
removed except underwear. A Soehnle scale was used to read
weight to the nearest 0.1 kg. If the reading alternated
between two readings 40.1 kg apart with the participant
standing still, the higher reading was recorded. Height was
Work stress and BMI
M Kivimäki et al
983
measured to the nearest mm using a stadiometer with the
participant standing completely erect with the head in the
Frankfurt plane.32 Assessment of BMI was repeated at follow-
up. Weight gain was indicated if BMI increased and weight
loss if BMI decreased between the measurements.
Data analysis
The associations between each work stressor (high strain,
high demands and low control) and BMI at follow-up were
examined with separate linear regression models including
age, grade and BMI at baseline as covariates. The associations
between each work stressor and weight gain or loss were
examined by using logistic regression analysis. Adjustments
were made for age, grade and BMI at baseline. We tested the
effect of an interaction between each stressor and baseline
BMI on weight gain and weight loss by including the
corresponding interaction term in regression models that
already included the main effects. To illustrate the form of
significant interactions, the associations between stressors
and weight gain/weight loss were calculated separately for
the top and bottom quintiles of baseline BMI in addition to
the combined three middle quintiles. A significant interac-
tion supports our hypothesis that the work stressor predicts
weight gain in the top quintile (i.e., in overweight subjects),
weight loss in the bottom quintile (in lean subjects), and is
not associated with weight change in the middle quintiles.
In addition, we tested potential interaction between employ-
ment grade and baseline BMI on weight gain and weight
loss, as employment grade is associated with metabolic
syndrome in the Whitehall II study.33 All analyses were
conducted separately for men and women. All analyses were
performed with the use of SAS software, version 8.2 (SAS
Institute).
Results
Table 1 presents sample characteristics by sex. On average,
the men were younger than the women and a greater
proportion were employed in higher-grade jobs. Men also
had higher job demands, higher job control, lower job strain,
and lower BMI at baseline and follow-up (Po0.001). In both
sexes, BMI increased over the 5-year-period between the two
Phases (Po0.0001), 0.6 kg/m2 among men and 1.1 kg/m2
among women.
Table 2 shows the associations between work stressors at
baseline and BMI at follow-up after adjustment for age, grade
and BMI at baseline. In men, no association between
stressors and subsequent BMI was found. In women, higher
job demands were weakly associated with higher BMI at
follow-up.
Table 3 presents results of the tests of interaction between
stressors and baseline BMI on weight gain and weight loss (as
only one woman and four men had exactly the same BMI at
baseline and at follow-up, the P-values were similar for the
International Journal of Obesity
 Work stress and BMI
M Kivimäki et al
984
Table 1 Sample characteristics: the Whitehall II study men or for any work stressors among women. Repeating the
analysis with the cruder dichotomous job strain variable also
Variable Men Women
failed to provide significant interaction (P ¼ 0.25 in men and
N Mean (s.e.) % N Mean (s.e.) % P ¼ 0.60 in women).
To illustrate the significant interactions, the effects of high
Baseline (1985–1988)
Age (years) 5547 44.0 (0.1) 2418 45.0 (0.1) strain and low job control as predictors of weight gain and
Grade weight loss are presented by baseline BMI level in Table 4.
Administrative 2199 39.6 308 12.7 The pattern was the opposite to that of the regression
Professional 2923 52.7 1033 42.7
towards mean. Among the 986 men who already had high
Clerical 425 7.7 1077 44.6
BMI at baseline (427 kg/m2, the top quintile), higher job
BMI (kg/m2) 5547 24.5 (0.1) 2418 24.6 (0.1) strain and lower job control were associated with greater
BMI category (kg/m2) likelihood of weight gain, a 1 s.d. increase in job strain or
o22 1042 18.8 659 27.3
decrease in job control being related to an odds ratio of 1.2
22–27 3519 63.4 1224 50.6
427 986 17.8 535 22.1 (P ¼ 0.006 and 0.10, respectively). In contrast, higher strain
and lower control were associated with a higher likelihood of
Job strain score 5547 0.08 (0.01) 2418 0.18 (0.02) weight loss among the 1042 men with low baseline BMI
Job demand score 5547 60.4 (0.3) 2418 53.7 (0.4) (o22 kg/m2, the bottom quintile). The corresponding odds
Job control score 5547 68.8 (0.2) 2418 58.5 (0.3)
ratios were 1.1 (P ¼ 0.07) and 1.3 (P ¼ 0.002), respectively.
Follow-up (1991–1993) Among the 3519 men with intermediate BMI at baseline
BMI (kg/m2) 5547 25.1 (0.1) 2418 25.7 (0.1) (between 22 and 27 kg/m2), no association between job
strain, job control, weight gain and weight loss was found.
There was no interaction between employment grade and
baseline BMI on weight gain or weight loss (P ¼ 0.96 in men;
Table 2 Linear regression analyses of work stressors at baseline on BMI at P ¼ 0.09 in women).
follow-up adjusted for age, employment grade and BMI at baseline

Stress indicator Men (N ¼ 5547) Women (N ¼ 2418)

a
B (s.e.) P-value Ba (s.e.) P-value Discussion
Job strain 0.005 (0.021) 0.82 0.062 (0.042) 0.14
Job demands 0.026 (0.022) 0.23 0.099 (0.046) 0.03 This prospective study suggests that work stress, as indicated
Job control 0.028 (0.026) 0.28 0.013 (0.048) 0.79 by job strain and low job control, increases the likelihood of
The Whitehall II study. aRegression coefficient refers to change in BMI per 1 weight gain among men with a higher BMI, but seems to
s.d. increase in the standardized stress score. predict weight loss among lean men who have no need for
weight reduction. In contrast to these bidirectional effects,
there was some evidence of a prospective association
Table 3 Interaction between work stressors and BMI at baseline on weight between work stress and increased BMI in women. Our
gain/weight lossa by follow-up investigation is based on a large well-characterized cohort of
Stress indicator Men (N ¼ 5547) Women (N ¼ 2418) British employees and a prospective study design with an
average follow-up of 5 years.
No. with weight gain 3924 1848 A recent review concluded that evidence does not support
No. with weight loss 1619 569
a consistent association between job strain and BMI and this
Interaction term baseline BMI and P-valueb P-valueb conclusion seems also to apply to studies that were not
Job strain 0.05 0.66 included in the review.17 Data from employees in New York
Job demands 0.98 0.60 City public and private sector worksites revealed no associa-
Job control 0.02 0.97
tion between change in job demands or job control, the
The Whitehall II Study. aBased on change in BMI between baseline and follow- components of job strain, and change in overweight.14
up. As only five participants had exactly the same BMI at both occasions, the Similarly, a Finnish study of industrial employees found no
P-values were similar for the tests examining weight gain and weight loss. bAll
association between job strain, job demands and subsequent
P-values were computed from regression analyses for weight gain/weight loss
that included adjustment for age and employment grade at baseline. BMI, but low job control predicted a modest increase in BMI
during a 10-year follow-up.3
Our findings of bidirectional effects for work stress in men
tests examining interaction for weight gain and weight loss raise the possibility that the overall null associations
and are therefore presented only once). In men, the between work stress and BMI observed in previous studies
interactions of baseline BMI with job strain, treated as a represent the canceling out of these opposing relationships.
continuous variable, and job control were statistically Existing physiological models, which describe plausible
significant. No interaction was found for job demands in mechanisms indicate that work stress may result in either

International Journal of Obesity


Table 4 Logistic regression analyses of weight gain and weight lossa by follow-up on job strain and job control among men by BMI category at baseline
Outcomea Bottom quintile in baseline BMIb (N ¼ 1042)
Stress indicator Odds ratio (95% CI) P-value
Weight gain
No. with weight gain 773
High strainc 0.88 (0.76–1.01) 0.07
Low controlc 0.75 (0.63–0.90) 0.002
Weight loss
No. with weight loss 269
High strainc 1.14 (0.99–1.32) 0.07
Low controlc 1.33 (1.11–1.59) 0.002
Odds ratios and 95% confidence intervals are adjusted for age, grade and BMI at baseline. The Whitehall II Study. aBased on change in BMI between baseline and
follow-up. bOur hypothesis (bold) was that eating less would be a more common response to stress among lean men with baseline BMIo22 kg/m2 (the bottom
quintile), eating more would be more common among overweight men with baseline BMI427 kg/m2 (the top quintile) and that there would be no consistent
weight change in either direction among others with more normal weight with BMI between 22 and 27 kg/m2. cStandardized score, odds ratio relates to 1 s.d.
change in stress indicator.
weight gain or weight loss. On one hand, a stress-induced
increase in glucocorticoid levels is assumed to increase
ingestion of comfort food,20 but, on the other hand, stress
may inhibit appetite through activation of the sympathetic
nervous system which suppresses upper gastrointestinal
motility and stimulates energy substrate mobilization.18
Animal studies, which offer the opportunity to examine
the effect of stress on food intake while controlling for
confounding factors, have generally reported hypophagia
(reduced food intake) in relation to chronic stress models.23
However, systematic manipulations of stressor intensity
suggest that hypophagia is induced at higher intensities,
but that at lower intensities hyperphagia (increase in food
intake) is seen.21 In human beings, bidirectional effects are
widely recognized in relation to depression, another con-
sequence of chronic work stress.8,34,35 Indeed, the American
Psychiatric Association’s Diagnostic and Statistical Manual
includes opposite pairs, such as weight gain/weight loss and
hyperphagia/hypophagia, among criteria for a diagnosis of
depression.
Although the determinants of body weight are not well
understood, interactions between genes and environmental
factors are likely.36 Stable individual differences may deter-
mine which reaction pattern, that is, weight gain, weight
loss or neither, would prevail under stressful conditions for
each individual. A field study of middle-aged men and
women, who kept stress diaries and at the same time
recorded their dietary intake, identified three reactions to
stress.37 Some subjects consistently ate more during stressful
periods than other times, some consistently ate less and
there were also subjects with no stress-related change in
eating patterns. In line with this, a study of university
students found both a self-reported tendency for some
students consistently to eat more during examination
periods while others consistently ate less during these
periods.19 A follow-up revealed greater weight gain among
stress eaters. Our study suggests that BMI may be a marker
Work stress and BMI
M Kivimäki et al
985
Middle quintiles in baseline BMIb (N ¼ 3519) Top quintile in baseline BMIb (N ¼ 986)
Odds ratio (95% CI) P-value Odds ratio (95% CI) P-value
2484 667
1.00 (0.93–1.08) 0.98 1.22 (1.06–1.41) 0.006
0.94 (0.86–1.03) 0.19 1.15 (0.97–1.37) 0.10
1031 319
1.00 (0.93–1.08) 0.98 0.82 (0.71–0.94) 0.006
1.07 (0.97–1.17) 0.18 0.87 (0.73–1.03) 0.10
(and a long-term consequence) of such stable individual
differences. In addition to eating patterns, stress could
contribute to weight change through changes in physical
activity level or metabolic rate. However, tendency toward
weight gain during work stress seems to characterize
employees with a higher BMI whereas a tendency to weight
loss during chronic stress was found to be dominant among
employees with a lower BMI.
It is unclear why the bidirectional effect of work stress was
not seen among the women. There are apparent sex
differences in physiological responses to experimental and
real-life stressors24–28 and the links between secretion of
cortisol (a stress hormone) and central adiposity varied
between men and women in a Whitehall II subsample
study.26 These sex differences are potential contributors to
our findings, though small scale studies do not report
consistent differences in stress eating patterns between
men and women.19,37 The assessment of stress in the
occupational setting is another potential explanation of
the null finding. For women the stress of unpaid work at
home (e.g. child care) may be more important because
women still carry a larger share of the responsibility for
doing domestic duties.38,39 A Swedish study showed that a
combination of stressful conditions at work and at home
predicted perceived symptoms in white-collar women
whereas for men symptoms were more strongly determined
by work stress alone.40 It is therefore possible that by also
including stress beyond work life an association between
stress and BMI among women would be revealed.
Study limitations and implications for further research
When interpreting these findings, at least five issues warrant
consideration. First, 20% of the baseline cohort was lost to
follow-up, the loss being slightly greater among women,
clerical workers, older participants and those with higher
BMI. This may not be a major source of bias because all
International Journal of Obesity
 Work stress and BMI
M Kivimäki et al
986
analyses were carried out separately for men and women
and all estimates were adjusted for age and employment
grade. However, as our target population was London-based
civil servants, further research is needed to evaluate general-
izability of the present findings to other working popula-
tions.
Second, the interaction effect among men was seen with
continuous measures of job control and job strain, but not
with a commonly used binary job strain variable. Substan-
tially larger sample sizes are needed to detect interactions
than main effects and we believe that the null finding
for a binary job strain variable was attributable to a cruder
operationalization with information loss due to dichotomi-
zation. However, replications with larger cohorts are needed
to confirm this.
Third, we illustrated the interaction between work stress
and initial BMI with subgroups defined by BMI categories
with approximately 20% of men in the lowest and highest
categories (cut-points 427, 22–27 and o22 kg/m2). Among
these two extreme groups, we found a higher proportion of
men who, respectively, eat less or more in response to stress,
a pattern opposite to that of the regression towards mean.
For the 60% of men in the middle BMI category, we expected
the bidirectional effects of stress on weight change to cancel
out, as in the whole cohort. The contrasting effects of stress
are not solely attributable to the specific BMI categories used
in this study, since the stress-BMI interaction was found for
continuous BMI. In a small-scale questionnaire survey the
proportions who reported eating either more or less in
response to stress were between 25 and 35%.19 Further
research is needed to determine whether use of self-reported
stress eating patterns would provide more contrasting effects
on weight change than the initial BMI categories used in our
study.
The fourth issue requiring consideration is that long-
standing illness is a common source of weight loss and thus a
potential confounding factor for the stress effects seen
among men with low BMI. In our results for lean men, such
confounding is unlikely, because additional adjustment for
longstanding illness attenuated the association between low
control and weight loss by o2%.
Lastly, further research is needed to link the epidemiolo-
gical evidence with the neuroendocrine, metabolic and
behavioral mechanisms that may underlie the effects of
work stress (or its absence) on BMI among men and women.
As disturbances of hypothalamic–pituitary–adrenocortical
axis function are assumed to contribute in particular to
central obesity,26,41,42 determining stress effects on change in
waist circumference or waist/hip ratio, in addition to BMI,
would be important.
Conclusions
Prospective evidence suggests a bidirectional effect of work
stress on BMI among men. While stress seems to result in
weight gain among overweight and obese men employees,
International Journal of Obesity
weight loss is more likely among their lean colleagues.
Inconsistent findings reported by previous studies of stress
and BMI have generally been interpreted to indicate the
absence of an association. In the light of the present
findings, the possibility of differential effects of work stress
should also be taken into account.
Acknowledgements
The work for this paper was supported by the Health and
Safety Executive. The Whitehall II study has been supported
by grants from the Medical Research Council; British Heart
Foundation; Health and Safety Executive; Department of
Health; National Heart Lung and Blood Institute (HL36310),
US, NIH: National Institute on Aging (AG13196), US, NIH;
Agency for Health Care Policy Research (HS06516); and the
John D and Catherine T MacArthur Foundation Research
Networks on Successful Midlife Development and Socio-
economic Status and Health. MK, also working at the
University of Helsinki, Finland, and JV were supported by
the Academy of Finland (projects 104891 and 105195), the
Finnish Environment Fund and the Yrjö Jahnsson Founda-
tion, JEF is supported by the MRC (Grant number
G8802774), MJS by a grant from the British Heart Founda-
tion, and MGM by an MRC Research Professorship. We thank
all participating Civil Service departments and their welfare,
personnel, and establishment officers; the Occupational
Health and Safety Agency; the Council of Civil Service
Unions; all participating civil servants in the Whitehall II
study; all members of the Whitehall II study team.
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The effect of control at home on CHD events in the Whitehall II
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