Anxiety and dyslipidemia among primary health care professionals: A Cross-sectional study

1 Introduction

Primary Health Care (PHC) is a preferred gateway to the Brazilian health system. Thus, the PHC is the initial contact of the user with health services and must be able to respond most healthcare demands presented by such user, including actions of promotion, prevention and rehabilitation [1].

In this regard, the Ministry of Health provides for including nursing professionals at this healthcare system level, whose work involves the development of numerous activities, always considering the population health needs, in the perspective of meeting and strengthening the principles of the Sistema Único de Saúde (Brazilian Public Health System) [2].

Several political, economic, and social changes have taken place in the labor world in recent years, reached the healthcare sector and resulted in an unsatisfactory scenario within PHC. Nowadays there is a mismatch between the increasing demand on the part of users, who add new and old health problems, as well as reduced operational capacity to face such problems [3].

In this scenario, emotionally oppressed and with little resolution capacity, nursing professionals are daily required to deal with several demands and dissatisfaction of the population. In addition, political-administrative aspects impose maximum quality of processes and results, without adequately predicting the structure variable. These stressful factors ultimately culminate in the impairment of workers’ mental health, especially in virtue of anxiety [4–8].

In this context, anxiety is a manifestation that determines the occurrence of harmful factors in individuals and is characterized as a dull feeling of fear and restlessness followed by great physical and psychic malaise, which generates an atmosphere of constant distress and agony [9]. Among PHC nursing professionals, literature points out to an anxiety prevalence of 30%, indicating a propitiating context of imbalance and illness [10].

Anxiety symptoms bring physical disorders, primarily to the endocrine system, such as abdominal obesity, insulin resistance, systemic arterial hypertension (SAH) and dyslipidemia, the latter being conceptualized as high serum concentration of low density lipoprotein (LDL-c) and triglycerides (TG) and/or reduced high density lipoprotein (HDL-c) [11]. There is scientific evidence to attest that anxiety is associated with the dyslipidemia [12–15].

From a physiological perspective, certain anxiety tendency of individuals comes from chronic stress exposure, with higher levels of allostatic load in comparison to those who could manifest this exposure in another way [6, 17]. Considering chronic stress as a trigger factor of anxiety, it is worth considering the consequent development of dyslipidemia through the recruitment of the hypothalamic-pituitary-adrenal axis and the release of cortisol. The determinant effect of chronic stress, therefore, occurs on lipid metabolism [18].

However, in the specialized literature, little is known about the association between anxiety and dyslipidemia when considering the work variable. Moreover, working conditions in PHC are predictors for the emergence of anxiety and possibly endocrine disorders among workers, which is a relationship that needs to be better clarified [19–22]. At the Brazilian level, no publications were proposed to investigate the phenomenon under this study. Therefore, the objective of this research is to estimate the association between anxiety and dyslipidemia in Primary Health Care nursing professionals in Feira de Santana, Bahia, Brazil.

2 Material and methods

3 Results

The study sample was consisted of 303 PHC nursing workers, with the following predominant sociodemographic characteristics: 98.3% were female, with a mean age of 39 years (RD±8.96), with 63.7% up to 40 years of age and 92.1% black. Regarding the lifestyle habits, 60.7% of the workers did not practice physical exercises, 47.5% did not have healthy eating, 2.3% currently smoke, and 2.0% consumed alcoholic beverages (Table 1).

Regarding occupational characteristics, Table 1 shows a predominance of nursing technicians (64%), with precarious work ties (91.4%), who are exposed to night shift (51.5%), satisfied with their current occupation (92.1%) and who reported not suffering aggression in the workplace (68.3%).

Estimated prevalence of dyslipidemia was 54.8% (166 affected), with a statistically significant association with anxiety (PR = 2.07; 95% CI = 1.74–2.45). It should be noted that 26.1% of the workers presented moderate/severe anxiety.

The prevalence of dyslipidemia was higher among the following variables: men (p = 60.0%); older than 40 years (p = 56.4%); black men (p = 54.8%); absence of physical exercise (p = 60.7%), healthy eating (p = 52.5%), smokers (p = 97.7%) and ones who did not consume alcoholic beverages (p = 98.0%). However, none of the observed associations presented statistical significance (Table 1).

The associations of occupational characteristics with dyslipidemia were also not statistically significant, but, as expected, the highest prevalence of the outcome was observed among nursing technicians (p = 64.0%), those with precarious work ties (p = 91.4%) and exposed to night shift (P = 51.5%). On the other hand, professionals who were satisfied with the current work (p = 92.1%) and did not suffer aggression at work (p = 68.3%) had higher prevalence of the outcome under analysis (Table 1).

The variable “physical exercise” was presented as a modifier of the effect between anxiety and dyslipidemia by the intuitive method and the homogeneity test (p-value = 0.03). There were no significant variations between the measurement of gross and adjusted association, thus, only the theory was considered for the confounding (Table 2).

Two multivariate models were evaluated for each category of the effect modifier variable (physical exercise practice), that is, model 1 refers to nursing professionals who perform physical exercises and model 2 refers to those who do not perform physical exercises. For adjustment purposes, the following variables were considered: gender, age, healthy diet, professional category, work relationship, night shift, professional satisfaction, and experience of aggression at work. It was observed that anxiety exposes the worker to dyslipidemia for both groups, even after adjustment (Table 3).

Both models presented satisfactory diagnostic performance, i.e., discrimination high power of dyslipidemia among PHC nursing professionals, either among those who perform physical activity (area under the ROC curve = 0.80) or among those who do not perform it (area under the ROC curve = 0.71). In addition to being well suited to the data (Goodness-of-fit p value > 0.05) (Table 3).

According to our knowledge, this is the first Brazilian study to investigate the association between anxiety and dyslipidemia among Primary Health Care nursing professionals.

The estimated prevalence of dyslipidemia was 54.8% among PHC nursing professionals, which suggests that lipid alterations may be proving to be an important cardiovascular risk factor for health workers. This was equally found in a study conducted by Viana et al. [32], where they found high frequencies of dyslipidemia in workers with occupational diseases.

About the prevalence of anxiety, 26.1% of workers presented moderate/severe anxiety. From the Analytical Psychology’s point of view, it is possible to establish some PHC symbologies related to the nursing professionals. As the preferred gateway to Brazilian health system, PHC is symbolically feminine, i.e., the one who assists and protect. The symbol is never entirely exhausted to be understood and it lies at a conscious and unconscious level. Exhausting and emptying the understanding of a given symbol leads it to a sign status [33].

It is believed that working conditions, insecurity due to precarious working ties, goals to be met, overload of healthcare, as well as the fragile interpersonal relationships with head officers in the context of PHC are deleterious to the health of workers and trigger anxiety and other mental disorders [34, 35]. In his 1961’s article called “The Symbolic Life”, Jung defines the symbolic emptying as a causal factor of anxiety [36]. Deterioration of working conditions may lead to a symbolic emptying, where nursing professionals found themselves at an environment not appropriate to promote their human motivation. Given this context, the transcendental function is lost and, according to Jung, such function self-regulates the psyche balance [37].

There was a statistically significant association between anxiety and dyslipidemia. The specialized literature allows us to support the hypothesis that anxiety is capable of culminating with metabolic disease through the physiological response to stress. Based on this assumption, the review of scientific production indicated that anxiety leads to excessive activation of the sympathetic nervous system and the Hypothalamic Pituitary Adrenal (HPA) axis, thus associated with several inflammatory and hypercoagulability markers [38, 39]. These changes in homeostasis have several implications on metabolic processes and may lead to a broad spectrum of cardiovascular risk factors, such as visceral obesity, insulin resistance and dyslipidemia. In addition, inflammatory markers have already been associated with psychological disorders in previous studies, presenting a possible pathway through which psychological conditions can affect metabolism [40].

Therefore, anxiety disorders can adversely affect the homeostatic functions working in the metabolic disease pathophysiology by several mechanisms, namely: deregulation of the HPA axis; activation of the sympathetic autonomic nervous system; the elevation of inflammatory markers such as Tumor Necrosis Factor Alpha (TNF-α), Interleukin-6 (IL-6) and C-reactive Protein (CRP). This last marker in particular seems to be determinant for maintaining the state of low-grade inflammation in anxious people, increasing the dyslipidemia risk [41].

There are few studies to evidence that anxiety is associated with the dyslipidemia occurrence [12] It is noteworthy that Nasser et al. [42], found dyslipidemic events in individuals diagnosed with severe depression and pathologies associated with anxiety.

When evaluating Primary Health Care professionals, Garcez et al. [43], observed 87.7% of global dyslipidemia prevalence in women. Our findings present a higher prevalence among men (60.0%) when compared to women (54.7%). This condition is justified for the small number of men participating in the study.

Regarding the practice of physical activity, this study points out to a possible effect of modification on the path between anxiety and dyslipidemia. Physical activity has proven to be an important ally to prevent dyslipidemic events. This was demonstrated in the pilot study by Merces et al. [44], which identified an association of Burnout Syndrome and metabolic conditions in Primary Health Care professionals. In this study, 70% of the participants reported sedentary lifestyle. According to the authors, this may contribute to the increased likelihood of overweight and obesity among individuals, which can also be inferred from the present findings.

However, it was curious to observe that the prevalence of dyslipidemia was high among individuals who reported having a healthy diet (54.1%). Therefore, it is valid to rethink how the concept of nutrition is understood by the participants of this research and even by individuals in general. Regardless of this, it should be considered that the workload, as well as night shifts, might potentiate the vulnerability of health workers to adopt inadequate eating habits, such as inappropriate schedules and nutritional compositions, incurring potential dyslipidemic conditions. Besides this thought, a cross-sectional study carried out in Colombia, 2014, was not able to show significant association between shift work and being overweight/obese in health care workers [45].

Also in reference to nutrition, in a study on the risk and protective factors for the development of chronic diseases in nursing professionals of a university hospital, Grillo et al. [46], concluded that adherence to healthy habits provides better living and working conditions for nurses. Therefore, it is suggested that health institutions develop strategies to favor healthier habits, including reviewing the menu options offered to their employees.

Regarding occupational variables, the precarious employment relationship and the professionals who are exposed to night shifts showed high prevalence related to the outcome, 55.6% and 53.2%, respectively. A study conducted by Moura et al. [10], showed that the factors identified by PHC nurses as triggers of anxiety in the work environment permeate the type of labor bond and its particularities. However, in the present study, a contradiction was detected since the professionals who were more satisfied with the work (55.8%) and who did not suffer aggression in the service (54.1%) revealed high prevalence for dyslipidemia. Therefore, it is valid to think about the possibility that insecurity to report situations that generate discomfort or disagreement may have caused an effect modification of these variables, or an under-measurement of job satisfaction and negative aggression at work environment. Therefore, new types of research are required, and they could consider such possibility, seeking methodological strategies that can reveal the effect of worse working conditions on the genesis of dyslipidemia.

Professional satisfaction exerts a meritorious impact on workers’ health and unfolds in the conditions of employment ties, such as recognition of the service provided by health managers, appropriate workload, compatible remuneration, work environment and mutual respect in interpersonal relations aimed at the mental and physical health of these individuals in the performance of their various functions [47].

To sum up, the results obtained suggest that negative changes are relevant in the workers’ mental health and may compromise their physical health, such as the development of metabolic and lipid disorders. This can be verified in the high prevalence of anxious signs and symptoms ranging from minimal/mild (73.9%) to moderate/severe (26.1%) in the investigated workers. Thus, it is possible to think about the possibility of simultaneous occurrence of anxiety with dyslipidemic and/or metabolic disorders, so they might be considered as potential indicators of cardiometabolic health condition, as well as a possible causal effect.

The present study presents the following limitations: the transversal and association character that does not allow establishing a causal relationship; mostly self-reported variables; and effects of healthy worker, which permeates the underestimating of anxiety and dyslipidemia. It is plausible to score that the methodological framework used in this study confirmed the robustness of the results found. In addition, attention to the goodness-of-fit test and area under the ROC curve demonstrate that such models have a good predictive capacity.

Given the limitations scored, our study presented a high response rate (88.8%), the dyslipidemia diagnosis was performed by using blood samples, which minimizes memory bias, and the data collection was followed and calibrated to reduce measurement bias.

The results of this study allow us to conclude that there is a positive association between anxiety and dyslipidemia among the Primary Health Care nursing professionals who were evaluated. We found significant prevalence of anxiety and dyslipidemia.

To extend the hypothesis discussed, it is important to encourage studies that demonstrate a robust methodology, including longitudinal studies and randomized clinical trials. All efforts and preventive measures should be taken to reduce the risk of dyslipidemia, prevention, and to control the signs and symptoms of anxiety disorders. Therefore, public policies on occupational health may be developed to mitigate the deleterious effects on the workers’ mental health, especially for nursing professionals.