The Stressed Executive: Sources and Predictors of Stress Among Participants in an Executive Health Program

The World Health Organization has declared stress as the health epidemic of the 21st century.¹ This declaration is based on the high prevalence of perceived stress^2,3 and its effect on the society.^4–7 Chronic stress is a well-documented risk factor for various medical disorders, diseases, and symptoms.^8–20 A particular demographic group with a high stress level is corporate executives.

The high prevalence of stress among executives^5,21–31 is due in part to considerable performance pressure in a competitive world.²⁸ While executive stress is of concern in every population subset, the effect of stress among corporate executives has an outsized effect on the society because of their leadership roles and influence on their organizations, the stakeholders, and their employees. Management of corporate stress has considerable individual and societal value.

A proportion of executives have started opting for various stress management techniques and coaching^21,28,31 to handle their stress levels and related symptoms. The triggers for their seeking help with stress management are unclear, as are the type of stressors and whether these stressors are associated with the quality of life. A thoughtful evaluation of stressors, lifestyles, and other characteristics that predict increased stress may inform health-care providers and wellness teams to design evidence-based approaches to better help executives with stress management.

The present study was designed to assess the most common sources of stress, predictors of high stress, and other correlates among a cohort of corporate executives participating in an executive health program at a large academic medical center.

Survey responses were summarized with frequencies and percentages or mean (SD) and ranges as appropriate. Stress level was dichotomized as high (high or very high; 4 and 5 on the Likert-type scale) or low to moderate (very low, low, or moderate; 1, 2, and 3 on the Likert-type scale, respectively). The well-being measures were treated continuously on a scale from 1 (poor) to 5 (excellent). Categorical respondent characteristics were compared between those with high stress and those with low-to-moderate stress through χ² tests; continuous characteristics were compared with 2-sample t tests. Physical activity level and relaxation program practice frequency were compared between the 2 stress groups with Wilcoxon rank sum tests. Associations with high- versus low-to-moderate stress were also assessed with multivariable logistic regression models. P values less than .05 were considered statistically significant. All analyses were performed with SAS statistical software (version 9.4; SAS Institute Inc.).

This study showed that among executives referred for individualized stress consult, the 3 main sources of stress in their lives were work, family, and health problems. Participants struggled most with sleep, anxiety, energy level, and healthy diet, and the largest difference between low and high stress level in the unadjusted model was observed for anxiety and sleep. Highly stressed participants also reported significantly less physical activity. In the 2 adjusted models, younger age was significantly associated with greater stress. By comparison, higher levels of anxiety, worse diet, and worse sleep were each predictive of high stress. Sex was not significant in the multivariable analysis.

In 2007, the Center for Creative Leadership reported that 80% of executives described work as a major personal stressor.³² This is in contrast to the 40% of persons in the United States who acknowledged feeling very stressed in the 1999 report of the National Institute of Occupational Safety and Health.³³ Our study showed that 64.4% of the executive patients struggled with work-related stress, a percentage similar to that reported by the Center for Creative Leadership and about 50% more than the general U.S. population.

For executives, the stresses created by work were magnified because increased demands are made on their time. These demands include frequent and lengthy meetings, navigation of organizational bureaucracy, professional development of employees, and development and maintenance of business relationships. Secondary to the time demands of work, many executives also struggle with the stress of maintaining interpersonal relationships, including with family, which often leads to social isolation.³² This conclusion is supported by our data, which showed that a majority of executives reported struggling with demand-resource imbalance at work as well as issues of work–life balance. Many of them reported more than 1 stressor in their life. These results depict that the high stress level of executives is a combination of work and other social or personal and ecological factors that are not related to work.

The relationship between stress and physical activity has been reported in prior studies, with self-care behaviors, including exercise, that decrease the higher stress level.^34–37 The association of stress with worse sleep, anxiety, energy level, and diet has been reported previously and gives added impetus to provide stress management as an integral part of care for patients who are executives.

Our final adjusted multivariable models indicated that multilevel factors—younger age, higher anxiety level, poor sleep quality, and worse diet and physical activity levels—are strongly predictive of high stress levels among healthy executives. These results support previous studies that reported the association of anxiety and sleep quality and insomnia with stress levels.^13,38–40 We also observed that younger executives are more prone to psychological stress. Our study extends to the healthy executive group the association of poor dietary habits with stress that has been reported previously among working women, students, and adolescents.^41–43 Prior studies also showed that improvement in diet quality and food types may lead to improved psychological resilience.^44,45 Addressing good dietary habits might be worthwhile for executives with high stress levels.

Our study has several limitations. The study design was cross-sectional with no longitudinal follow-up. Thus, we can only suggest associations and cannot cite causation in this study. Further, the participants were a cohort of self-selected patients requesting assistance with stress management, thereby causing selection bias. With a study that relied on self-report measures, we recognize the inherent bias in such assessments. We also used Likert-type scales and not the more elaborate validated scales for assessing the well-being measures.

In 2017, the American Psychologic Association recorded the highest average level of stress ever measured in its annual Stress in America report.⁴⁶ While stress is a physiologic response to a physical or perceived threat and has in small discrete episodes important survival benefit, prolonged stress has been linked to worsening in physical health, mental health, health behaviors, and the quality of life.³⁴ These stressors can occur in the personal, family, community, or work realm.

At this time, work appears to account for a disproportionally large share of stressors due to numerous workplace variables, including political issues and hierarchy, career development goals, institutional culture, job-related demands, and performance metrics that may influence continued employment and promotion.⁴⁷ Work-related stress has been associated with increased use of sick leave, poor job satisfaction, cynicism, presentism, and, ultimately, burnout.⁴⁸ Investigators have further established that chronic stress impairs intellectual functioning, formation of memories, and recall.^49,50 These changes are concerning for workers but are especially concerning for executives, who may have a larger societal impact. Our study adds strength to the evidence that stress management training is needed,^36,37 particularly in formats that are brief and scalable for the executive patient.^37,51,52 Corporations may want to consider offering these programs to their employees and investigate the effect of changes in the work environment on perceived stress.

We determined that work, family life, and health concerns are the primary source of stressors among executives seeking consult for stress management. We also found that executives struggle most with poor quality sleep, anxiety, low energy levels, physical activity, and not eating a healthy diet. We noted a robust association of younger age with high stress. The findings of our study suggest that executives with high levels of stress might be best helped by a multimodality stress management program.

Future large prospective cross-sectional studies would be helpful in determining the effects of modifying individual correlates of stress and the effect of changes in work culture at various management levels and leadership positions.