American Journal

of Lifestyle Medicine
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Occupational Stress: The Influence of Obesity and Physical Activity/Fitness on Immune Function
Chun-Jung Huang and Edmund O. Acevedo
AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2011 5: 486 originally published online 2 September 2011
DOI: 10.1177/1559827611418168
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American Journal of Lifestyle Medicine

Nov Dec 2011

Chun-Jung Huang, PhD,

and Edmund O. Acevedo, PhD

Occupational Stress:
The Inuence of Obesity
and Physical Activity/Fitness
on Immune Function
Abstract: Occupational stress can
affect physiological and psychological
homeostasis. In addition, the
occupational challenges associated
with firefighting and law enforcement
have been linked to increased
mortality ratios for ischemic heart
disease when compared with other
population cohorts. Laboratory studies
have shown that the exacerbation of
stress hormones (eg, catecholamines)
following dual challenge (physical
and psychological stress) may affect
immune system responses, which
may partially explain the link
between cardiovascular disease and
inflammation. Physical fitness has been
shown to attenuate both cardiovascular
and inflammatory cytokine responses
following physical and/or psychological
stress; however, criteria for safe and
effective occupation-specific fitness
levels have not been established.
In addition, firefighters and police
officers have high overweight and
obesity rates, which also contribute
significantly to the development
of cardiovascular disease. Future
investigation on the possible interaction
(additive or synergistic) of obesity and
psychological stress on the development
of cardiovascular diseases in these

professions is warranted, and a

criterion for fitness level should be
established for safe and effective
participation in occupation-related
activities.
Keywords: firefighters; police; military;
exercise; psychological stress; immunity;
cytokines; inflammation; obesity

unique combination of physical and

psychological stress. This combined
challenge may be associated with
elevated mortality risks.1 For example,
law enforcement officers and firefighters
have high mortality rates for ischemic
heart disease.1-4 Furthermore, Kales and
colleagues5 have demonstrated that
fire suppression activities result in an

A critical area of current interest is

the link between the CVD
[cardiovascular disease] and the
immune system that may explain, at
least in part, the relationship
between stress and CVD.
Overview of Occupational
Stress and the
Immune System
Numerous occupations, especially
emergency responders (ie, firefighters,
ambulance personnel, and police
officers), are often subject to a

increased risk of death to firefighters

(12-136 times higher) when compared
with nonemergency duties. These
professionals are exposed to a broad
range of stressful stimuli that may affect
the development of cardiovascular
disease (CVD). A critical area of current
interest is the link between the CVD and

DOI: 10.1177/1559827611418168. From the Department of Exercise Science and Health Promotion, Florida Atlantic University, Boca Raton, Florida (CJH) and the
Department of Health and Human Performance, Virginia Commonwealth University, Richmond, Virginia (EOA). Address correspondence to Chun-Jung Huang, PhD, 777
Glades Road, FH-11A, Rm 126A, Boca Raton, FL 33431; e-mail: chuang5@fau.edu.
For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2011 The Author(s)
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vol. 5 no. 6

the immune system that may explain, at

least in part, the relationship between
stress and CVD.
Stress hormones (ie, cortisol and
catecholamines) are thought to have
detrimental effects on the immune
system, leading to an imbalance between
innate (immediate antigen-nonspecific
defense) and adaptive immunity (specific
response to a particular foreign antigen
creating immunological memory) via
cytokine release from immune cells.6
In response to acute stress, the innate
immune promptly prepares to provide
immune protection followed by adaptive
immunity when exposed to repeated
or prolonged stress, whereas chronic
stress can suppress these immune
defenses. This stressimmune interaction
is an important antiviral defense and
fosters the elimination of invading
microorganisms.7,8 This review will focus
on the stress-induced changes in immune
cell distribution,9-12 which ensures that
the bodies immune response is efficient
or elicits an effective immunoprotection.
More directly related to the
cardiovascular system, this review will
also focus on the stress-induced proinflammatory response. Finally, recent
studies have reported approximately
77% overweight and obesity rates in
professionals such as young emergency
responders (firefighters and ambulance
recruits), police officers, and military
personnel.13-16 Thus, this review will also
discuss the synergistic effects of physical
activity, obesity, and psychological stress
on inflammation, which may enhance
our understanding of the link between
obesity, stress, and CVD.
CatecholamineInduced Immune
Cell Redistribution to
Concurrent Stress
Many studies in
psychoneuroimmunology have
investigated the effects of physical and
psychological stress on immune system
responses. An appropriate distribution of
peripheral immune cells provides for the
performance of surveillance and effector
functions of the immune system.17
The release of both catecholamines

American Journal of Lifestyle Medicine

and cortisol in response to either

psychological stress or physical stress
can mediate changes in the immune
cell distribution.18,19 However, Isowa
and colleagues11 have concluded that,
under acute psychological stress, the
influence of cortisol on immune function
is minimal and that the acute immune
response is primarily regulated by
catecholamines.
A number of experimental protocols
using laboratory-induced acute
psychological stressors have observed
transient immune cell redistribution via
b-adrenergic activation.10,18,20,21 Specifically,
following acute psychological stress,
elevation in monocytes, natural killer
(NK) cells, and cytotoxic T cells have been
observed,9,10,22 whereas helper T cells and
B cells have been shown to decrease.9-12
Furthermore, in response to acute physical
stress (physical activity), the magnitude of
these immune cell responses is dependent
on exercise intensity and duration.23
High-intensity exercise has been shown
to induce the release of catecholamines
with corresponding alterations in various
immune cells.24 Typically, following
exercise monocytes and NK cells exhibit
the greatest fluctuation followed by T
cells and B cells.25,26 Previous research
has demonstrated that the percentage
of CD3+ T cells and CD19+ B cells
(adaptive immunity) decrease with an
elevation in the percentage of NK cells
(innate immunity) following incremental
exercise.27 These findings indicate that
acute stress enhances innate immunity
and possibly suppresses adaptive
immunity and that these alterations can
be likely enhanced at higher intensities
of psychological and physical stress. The
appropriate redistribution of immune
cells in response to psychological and/
or physical stress is imperative to an
effective and efficient immune response
in preparation for potential invaders and
injury.17,28 This direction of enhancement
and suppression on immune function
is dependent on the duration and
magnitude of stress response. However,
when exposed to chronic stress,
immunoprotection can be suppressed
by decreasing immune cell number and
function, thereby promoting susceptibility
to diseases.

Previous studies have demonstrated

greater epinephrine (EPI) and
norepinephrine (NE) responses
to combined mental and physical
stress (dual stress condition) relative
to physical challenge/stress alone
in apparently healthy individuals29
and professional firefighters.30 This
finding suggests that the greater
catecholamine response to dual stress
may further alter the components of
innate immunity, specifically the proinflammatory components. Furthermore,
this response may be associated with
the combined mental and physical
stress of conducting fire suppression
activities and help explain the high
mortality rates in firefighters.5,31
Recently, Huang et al32 examined the
associations among catecholamines
and immune cell distribution in
professional firefighters exposed to a
computerized firefighting strategies and
tactics drill (FSTD; mental challenge)
while participating in moderate intensity
exercise. Firefighters participated in 2
counterbalanced exercise conditions on
a cycle ergometer: 37 minutes of cycle
ergometry at 60% Vo2max (exercise alone
condition; EAC) and 37 minutes of cycle
ergometry at 60% Vo2max along with 20
minutes of FSTD (firefighting strategies
condition; FSC). As expected, FSC elicited
significantly greater HR, NE, and EPI
when compared with EAC. Furthermore,
both EAC and FSC elicited increases in
NK cells. The percentages of CD3+ T
cells, CD3+CD4+ helper T cells, CD4/
CD8 ratio, CD19+ B cells, and total
lymphocytes were lower immediately
following both conditions. Although no
group differences were found in this
study, these results provide the basis for
further examination of the lymphocyte
subset redistribution following prolonged
or repeated bouts of physical and/or
psychological stress.
In addition, Huang et al32 found that
following the dual challenge, NE area
under the curve was negatively correlated
with percentage of CD19+ B cells
immediately after challenge, and HR was
negatively associated with the percentage
change in the CD4/CD8 ratio from before
to after challenge. These elevations in
NE and heart rate simultaneously in
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American Journal of Lifestyle Medicine

Nov Dec 2011

response to the dual challenge suggest

greater sympathetic activation that, in
turn, could possibly explain the alteration
in the distribution of lymphocyte subsets,
resulting in ineffective cell-mediated
immune responses.33,34 It is important
to note that firefighters are engaged in
fire suppression activities with standard
work-to-rest ratios; approximately 15 to
20 minutes of work and then resting for
approximately 10 minutes.35 The repeated
workrest regimen of firefighting may
potentially exacerbate catecholamine
and heart rate responses,36,37 further
contributing to the perturbation of
lymphocyte subsets. Early studies have
reported reduced NK and cytotoxic cell
number/cytotoxicity and suppression
of lymphocyte proliferation in humans
after exposure to chronic stress.38,39 The
examination of the lymphocyte subset
redistribution following prolonged
or repeated bouts of physical and/or
psychological stress is warranted.
Synopsis

Elevated stress hormones alter immune

cell responses, and this important immune
system response coordinates a number
of the bodys adaptations to the stressor.
However, a combined physical and
psychological stress often experienced
chronically by emergency responders
exacerbates these stress hormone
responses, which may be a contributing
factor to the elevated risk of CVD and
increased proportionate mortality risks.
A greater understanding of stress
immune system interaction can assist in
finding strategies (eg, exercise training) to
overcome the inherent psychobiological
challenges associated with mentally and
physically demanding professions.
The Synergistic Effects
of Concurrent Stress
on Inflammation
Singhai40 has stated that one of
the earliest subclinical stages in the
atherosclerotic process is an impairment
of endothelium-dependent vasodilation,
also known as endothelial dysfunction,
and acute psychological stress induces
transient endothelial dysfunction.41 One
potential mechanism that links acute

psychological stress to endothelial

dysfunction is the level of circulating
pro-inflammatory cytokines, such as
tumor necrosis factor-a (TNF-a) and
interleukin-6 (IL-6), which have been
shown to play important roles in the
initiation and propagation of vascular
inflammation and may provide insight
into the mechanisms that explain the
inflammatory processes in health and
stress-related diseases.7,8,42-44
Many studies have used laboratoryinduced acute psychological stressors
to examine the inflammatory response.
Previous research has suggested
that individuals who have a greater
laboratory-induced stress response
are more likely to experience higher
stress in daily life,45 and this response
is associated with increased risk
for atherosclerosis.46 An increase in
circulating TNF-a and IL-6 was observed
following acute psychological stress47 via
activation of nuclear factor-kappa B.48,49
In addition, previous research has shown
that acute psychological stress exposure
is also associated with increased proinflammatory cytokine, IL-2 levels.50
Using a more prolonged stress model,
Uchakin et al51 have examined several
inflammatory cytokines following 24
hours of an examination in medical
students and found that IL-2 levels were
lower than the control group, but no
changes were observed in interferon-g
(IFN-g) and IL-10. Furthermore, Kang and
Fox52 also examined chronic academic
stress during examinations and found
that decreased IL-2 (in both peripheral
blood mononuclear cell [PBMC] and
whole blood measures) and IFN-g (only
PBMC) levels were observed whereas an
elevation was seen in IL-6 (in both PBMC
and whole blood measures).
The magnitude and direction of
inflammatory cytokine response (eg,
IL-2 and IL-6) to exercise vary and are
dependent on the acute or chronic nature
of the stimuli (intensity and duration).
For example, Akimoto et al53 examined
the effects of brief anaerobic maximal
exercise and found that plasma IL-12
increased significantly after exercise.
IL-12 has been demonstrated to generate
the IL-2 response, further enhancing
the activity of cytotoxic T cells and NK

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cells.54-56 In addition, Steensberg et al57

found that IL-6 increased following
2.5-h of treadmill exercise at 75% of
maximal oxygen uptake. It is important
to note that although IL-6 acts as a proinflammatory cytokine, it has also been
identified as an anti-inflammatory agent.
More specifically, Steensberg et al58
infused IL-6 to attain intense exerciseinduced concentrations in human
subjects and observed elevated antiinflammatory cytokines (eg, IL-10) 1
hour after IL-6 infusion. These findings
indicate that an elevation in circulating
IL-6 following exercise may initiate a
reciprocal anti-inflammatory response
that can promote recovery.
In a recent study, Ramey et al2
examined the inflammatory cytokine
response in law enforcement officers
and found that the job demand
(physical and psychological) assessed
by the Job Content Questionnaire was
positively associated with resting IL-b
and IL-6. Furthermore, Huang and
colleagues30 examined stress hormone
and immunological responses to a dual
challenge in professional firefighters.
This study used an FSTD as the mental
challenge and cycling at 60% of Vo2max
(physical stress) as described above.
This combination of physical and
psychological challenge activated the
sympatheticadrenalmedullary axis,
eliciting the release of catecholamines
(NE and EPI) and elevating HR.
Furthermore, firefighters demonstrated
greater IL-2 levels following the dual
challenge with a significant increase in
CD56+ lymphocytes (mostly NK cells)
in both conditions, but no change
was observed in cytotoxic T cells and
IL-6. These findings suggest that the
addition of a mental challenge to
physical stress can alter the hormonal
and immunological responses during
firefighting activities and, if exacerbated
or prolonged, may play a role in the
development of stress-related diseases.
Other investigators have found changes
in IL-6 following exercise using a
different protocol.59 More specifically,
Brenner et al59 used a protocol of 2
hours of cycle ergometry at 60% Vo2max,
whereas the duration in the Huang
et al study was 37 minutes. Furthermore,

vol. 5 no. 6

although the study by Huang et al30

did not demonstrate elevations in IL-6,
it is possible that changes occurred
following the last measure that was
taken at 1 hour of recovery. Previously,
an increase in IL-6 has been reported
to occur between 45 and 120 minutes
after acute psychological stress (eg,
Stroop Color Word and Mirror Tracing
Tasks).60-63 Interestingly, Groer et al64
examined blood and salivary IL-6 levels
in police officers following simulated
incident scenarios: motorcycle scenario
(2 minutes of a chase and traffic stop of a
person on a motorcycle) and workplace
scenario (6 minutes of tracking a gunman
through a building). This study did not
find elevated blood IL-6 levels in either
scenario, but a significant increase
in salivary IL-6 was observed in the
workplace scenario group after 10 and
30 minutes of stimulation. To foster a
better understanding of the cytokine
responses to occupational stress, further
studies with extended recovery periods
are needed.
A limited number of studies have
used a combination of acute laboratory
stressors as a paradigm to examine
the neuroendocrine and immuneinflammatory adaptations to physical
and mental challenge. To alleviate
the potential for the negative health
outcomes in these occupations (ie,
firefighting and law enforcement),
investigators should examine possible
mechanisms that may help explain
the inflammatory processes in health
and stress-related diseases. In turn, a
greater understanding of inflammatory
responses will facilitate efforts to address
the potential negative impact of the
immune system responses associated
with professions exposed to the dual
challenge.
Psychoneuroimmunological
Responses and Physical
Activity/Fitness
The benefits of physical activity
and fitness on physiological and
psychological health have been widely
investigated. One of the purported
benefits associated with aerobic fitness

American Journal of Lifestyle Medicine

is the attenuation of the cardiovascular

response during psychological stress
and recovery.65-67 Dienstbier65 has
proposed that this physiologically
toughened response is demonstrated by
an attenuation of central nervous system
activation, including the sympathoadrenal
axis, in response to a perceived threat.
More specifically, aerobically trained
individuals exhibit lower reactivity of the
sympathetic nervous system
(eg, heart rate) following acute
psychological stress.67-69 Furthermore,
physically active individuals have
exhibited lower state anxiety
responses.69,70 Although criteria for
safe and effective fitness level has not
been established in many occupations,
the International Association of Fire
Fighters71 and the National Fire Protection
Association72 have recommended
that firefighters achieve a maximal
oxygen uptake of at least 42 ml/kg/
min. Previous studies have documented
firefighter fitness levels (Vo2max) and
found an average Vo2max of 35 ml/kg/
min.32,73 However, Roberts et al73 has also
demonstrated an improvement in fitness
level (Vo2max) of 28% (35-45 ml/kg/min)
following 16 weeks of exercise training.
Most important, Yoo et al74 showed that
approximately 23% of law enforcement
officers who reported metabolic
syndrome were physically inactive. In a
cross-sectional study of 527 firefighters,
Durand et al75 demonstrated the CVD
risk factors such as triglyceride and lowdensity lipoprotein cholesterol levels
are negatively associated with time
and frequency of physical activity per
week. Furthermore, epidemiological
evidence consistently shows that regular
physical activity and exercise are
effective prevention and treatment for
CVD, type II diabetes, and stress-related
diseases.76-80 More specifically, previous
research has examined the effects of
physical fitness on the inflammatory
response. For example, a reduction in
pro-inflammatory levels (TNF-a and IL-6)
was found in patients with coronary
heart disease following aerobic exercise
training,81 and lower IL-6 concentrations
have been observed in individuals who
had self-reported higher physical activity

levels.82 In a cross-sectional study of

1004 participants, those who participated
in moderate to high physical activity
exhibited lower resting IL-6 levels
compared with sedentary individuals.83
Additionally, participation in exercise
training may result in beneficial
adaptations of physiological systems
(eg, low inflammatory response) that
are activated during acute psychological
stress. Interestingly, in response to
acute psychological stress, physical
fitness is associated with a diminished
pro-inflammatory cytokine response.84
Poole et al85 have also shown that mood
change is associated with IL-6 levels
following exercise withdrawal and
training. These findings indicate that
increased physical activity and higher
levels of physical fitness may result in
a more resilient immune defense and
greater stress protection. Thus, exercise
training program is likely a beneficial
intervention to reduce the risks of CVD
and stress-related diseases in occupations
such as firefighting and law enforcement,
and consideration should be given to
annual physical performance evaluations.
Future Research
Directions: Obesity and
Psychological Stress
Obesity-attributable illnesses are
associated with chronic inflammatory
responses such as elevated proinflammatory cytokine production and
activation of inflammatory signaling
pathways.86 A recent study reported
77% of young emergency responders
(firefighters and ambulance recruits)
were overweight and obese.13 Further
studies also reported similar overweight
and obese rates in other professions
such as law enforcement14 and the
military profession.14-16 Along with
physical illnesses, obesity is associated
with psychosocial disorders such as
depression and chronic anxiety.87,88
Interestingly, Yoo and Franke89 have
reported that obesity is the most
significant contributor of CVD in female
law enforcement officers, who elicit a
higher job-related stress level than male
law enforcement officers. Furthermore,
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American Journal of Lifestyle Medicine

Nov Dec 2011

chronic stress has been shown to be

associated with disturbances of the
hypothalamicpituitaryadrenal and
sympatheticadrenalmedullary axes
and is linked to abdominal adiposity.90
For example, elevated cortisol responses
to mental stress are associated with
high central adiposity,91-93 and with
corresponding elevations in pulse
pressure and heart rate.94,95 Interestingly,
Wirtz et al45 have demonstrated that
individuals with higher body mass index
demonstrated lower glucocorticoid
sensitivity, resulting in a diminished
ability to inhibit production of TNF-a
following acute psychological stress.
This finding suggests that in response
to acute psychological stress individuals
with higher body mass index exhibit
elevations in pro-inflammatory
cytokine production (eg, TNF-a) due to
diminished glucocorticoid suppression.
Recent studies have shown that obese
subjects exhibit higher circulating and
in vitro IL-6 levels compared with
normal-weight subjects in response to
acute psychological stress.92,96 Because
b-adrenergic receptors have been
shown to have an inhibitory effect
on the release of pro-inflammatory
cytokines (ie, TNF-a and IL-6),97,98
these results suggest the possibility that
obesity could diminish the inhibitory
effect of b-adrenergic receptors on the
release of pro-inflammatory cytokines
in response to psychological stress. In
addition, leptin, an adipocyte-derived
hormone, is positively associated with
elevated percentage body fat and
plays an important role in metabolism,
adiposity, and vascular inflammation,
and it has recently been implicated
in the development of coronary heart
disease.99 Furthermore, recent research
has shown that people who undergo
acute psychological stress demonstrate
increases in leptin levels, and these
increases are positively correlated with
waist circumference.100,101 Brydon and
colleagues101 also showed that a positive
correlation between basal circulating
leptin and IL-6 responses in response to
mental stress.
It is important to note that a recent
investigation has demonstrated that

peripheral blood mononuclear cells were

involved in the elevated concentrations
of pro-inflammatory cytokines (eg,
TNF-a and IL-6) in obese individuals,102
but no differences in the number
of immune cell subsets including
peripheral blood mononuclear cells
(eg, monocytes and lymphocytes)
have been observed between normalweight and obese subjects following
acute psychological stress.92 This
suggests that the association of obesity
with pro-inflammatory cytokines in
response to acute psychological stress
is not likely due to differences in
immune cell subsets, and thus, the
possible mechanisms contributing to
the relationship of the stress response,
obesity, and pro-inflammatory
cytokines still remains unknown. Future
investigation on the possible interaction
(additive or synergistic) of obesity and
psychological stress on the development
of cardiovascular diseases in these
professions is warranted and may help in
finding practical and innovative strategies
(eg, weight loss, exercise training, and
pharmacological interventions) for the
prevention and treatment of stressrelated diseases.
Conclusion
Occupational stress, in particular
combined physical and psychological
stress, often experienced by firefighter,
military personnel, and law enforcement
officers may be a contributing factor
to the elevated risk of CVD and stressrelated diseases and relative increased
mortality. Many studies have supported
the benefits of physical activity on
physiological and psychological health
including greater immune defense and
stress protection. Furthermore, high
rates of obesity have been reported in
many occupations, and studies have
demonstrated that obesity exacerbates
the inflammatory responses (eg, elevated
pro-inflammatory cytokine production)
following psychological stress. Thus, it
seems apparent that a criterion for fitness
level should be established for safe and
effective participation in occupationrelated activities. Fitness training

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programs should also be implemented

to improve physical fitness levels for
workers in these occupations, and
annual physical fitness and performance
evaluations should be conducted. Finally,
while the mechanisms contributing to
the relationship of the stress response,
obesity, and pro-inflammatory cytokines
still remains unknown, programs to
encourage and support emergency
responders in achieving and/or
maintaining healthy body weight may
produce health benefits. AJLM
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