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Cortisol, sleep, and recovery - Some gender

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Article in Psychoneuroendocrinology · June 2011

DOI: 10.1016/j.psyneuen.2011.05.003 · Source: PubMed

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Psychoneuroendocrinology (2012) 37, 56—64

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / p s y n e u e n

Cortisol, sleep, and recovery — Some gender

differences but no straight associations
Frida Eek a,*, Björn Karlson a, Anne Helene Garde b, Åse Marie Hansen b,
Palle Ørbæk b

a
Department of Occupational and Environmental Medicine, Barngatan 2, Lund University Hospital, SE-221 85 Lund, Sweden
b
National Research Centre for the Working Environment, Lersø Parkallé 105, DK-2100 København Ø, Denmark

Received 26 October 2010; received in revised form 5 May 2011; accepted 6 May 2011

KEYWORDS Summary
Cortisol; Background: Work related fatigue has been suggested as a link in the assumed sequence of events
Recovery; between repeated adverse work demands and the development of work related stress, which may
Sleep; be associated with changes in concentrations of cortisol, psychological overload and, in the long
Fatigue run, health problems. Insufficient sleep is a contributing factor to lack of recovery, but previous
studies on associations between subjective aspects of sleep and recovery, and cortisol, have been
inconclusive. The aim with the present study was to examine possible associations between
cortisol measures and (I) self-rated recovery, (II) occupational fatigue and (III) subjective sleep
quality the night preceding cortisol sampling. Further, possible gender differences were tested.
Methods: Salivary cortisol was measured in 581 persons during a working day, at awakening,
+30 min and in the evening. Various measures of subjective sleep and recovery were analyzed in
relation to cortisol.
Results: Few correlations between cortisol and any sleep- or recovery parameters were found.
However, some significant associations were found between cortisol and a few measures of more
chronic aspects of sleep and recovery. Gender stratified analyses showed somewhat differing
associations among men and women. This indicates that possible associations and pathways
between lack of recovery/sleepiness and cortisol, and in the long run, unhealth, may not be
similar for men and women.
# 2011 Elsevier Ltd. All rights reserved.

1. Introduction consequences of exposure to stress depend on cognitive

According to many stress theories, such as the Cognitive
Activation Theory of Stress (CATS), the responses to and
* Corresponding author. Tel.: +46 46 177437; fax: +46 46 177285.
E-mail address: frida.eek@med.lu.se (F. Eek).
mechanisms (Ursin and Eriksen, 2001). Therefore, it is logical
to expect an association between subjective reports of stress
and physiological stress responses such as alterations in the
HPA-axis’ release of cortisol. One of the most early stress
theories, formulated by Selye, is the general adaptation
syndrome (GAS). According to GAS, exposure to a stressor
is followed by three stages, with similar patterns regardless

0306-4530/$ — see front matter # 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.psyneuen.2011.05.003
Cortisol and recovery
of the nature of the stressor (Browne et al., 1939). The acute
phase (phase one), often described as the ‘‘fight or flight’’
phase, is triggered by exposure to any kind of potentially
harmful stimulus. In this phase, the body quickly mobilizes
energy to handle the potential threat (Cannon, 1929). After
this acute and rapid mobilization comes a stage of resistance
or adaptation, when the physiological response decline
(Selye, 1938). If the duration of the stressor exposure con-
tinues, the body may eventually reach a stage of exhaustion,
the third phase. This stage is considered as a dysfunctional
state with hormonal imbalance. In this stage, when exposed
to a stressor that would normally result in a strong response,
the physiological response is instead weak, i.e. the body has
lost the ability to mobilize the energy needed to handle a
potential threat.
Another term, frequently used in stress theory, is the
concept of allostasis, ‘‘stability through change’’. Most phy-
siological variables show a diurnal variation, determined by
specific behavioral states and environmental events (Sterling
and Eyer, 1988). Important for maintaining health is the
ability to respond by appropriate arousal when facing an
environmental challenge. Hence, health may be defined as a
state of responsiveness, including the ability to restitute as
well. Sustained arousal, resulting from an insufficient resti-
tution may eventually lead to the inability to respond appro-
priately (Sterling and Eyer, 1988).
Hence, according to the stress theories mentioned above,
an acute stress response could be expected to result in
increased release of cortisol. On the other hand, a prolonged
exposure to stress not being adequately coped with or suffi-
ciently recovered from has been suggested to result in a
gradually decreased cortisol levels and eventually a flattened
day profile, and in the long run increase the risk for negative
health effects (McEwen, 1998; Sluiter et al., 2001). Although
the cortisol awakening response (CAR) has frequently been
used as a measure of (anticipatory) stress, later research has
suggested that the most important aspect of a ‘‘healthy’’
cortisol pattern may be the dynamic over the day, i.e. the
ability to mobilize energy when appropriate, but also to
restitute during periods of rest, reflected in low evening
cortisol values. Hence, diurnal deviation measures have
recently gained more attention.
Work related fatigue, and thus a high need for recovery, has
been suggested as a link in the assumed sequence of events
between repeated adverse work demands and the develop-
ment of work related stress, psychological overload and, in the
long run, health problems (Sluiter et al., 2003). Work char-
acteristics are, however, not the only cause of need for
recovery; work characteristics alone explained 39% of the
variation in subjective need for recovery (Sluiter et al.,
2001). Persons suffering from low levels of self-rated recovery,
thus classified as fatigued, have been found having an
increased risk for high allostatic load, although cortisol was
not included in this measure (von Thiele et al., 2006). Allo-
static load was here defined as an aggregated index of various
biomarkers including measures of cardiovascular activity,
blood lipids and cholesterol, serum DHEAS, glucose and HbA1c,
prolactin and waist/hip ratio. However, there were no signifi-
cant differences regarding individual biomarkers between
recovered and unrecovered (von Thiele et al., 2006).
Insufficient sleep is a contributing factor to lack of recov-
ery, and may as such contribute to long-term negative health
57
effects. Insufficient sleep may also in itself be an effect of
ongoing stress activation and hence likely to be associated
with cortisol measures. The association between sleep and
cortisol levels have previously been examined in various
laboratory settings. Total sleep deprivation in laboratory
studies have been found to result in a significant decrease
in plasma cortisol levels the next day, while indices of sleep
disturbance, i.e. wake and stage 1 sleep, were positively
correlated with cortisol levels (Vgontzas et al., 1999). Partial
and total sleep deprivations have also been shown to result in
increased evening cortisol (Leproult et al., 1997; Spiegel
et al., 1999). Polysomnographically recorded sleep in the
home environment have shown associations between
increased frequency of micro arousals during sleep and
increased concentrations of cortisol upon awakening the
following morning (Ekstedt et al., 2004). Previous studies
on associations between subjective aspects of sleep and
recovery, and cortisol, have been inconclusive. Subjective
sleep disturbances have been found to correlate with
decreased awakening cortisol concentrations (Backhaus
et al., 2004). Subjective measures of insufficient recovery
from work were in one study associated with high morning
cortisol in 25 female and male white collar workers (Gus-
tafsson et al., 2008). Another study found a long-term rela-
tionship between subjective need for recovery and evening
cortisol among women, but not among men. However, the
association was in the opposite direction of what was
expected; high need for recovery was associated with lower
evening cortisol levels four years later (Rydstedt et al.,
2009). In a study of shift workers morning cortisol showed
significant positive correlations with ‘‘diurnal type’’ (morn-
ing person) and sufficient sleep before the morning shift, but
several sleep- and recovery parameters such as exhaustion
upon awakening, disturbed sleep, and sleepiness problem did
not show any significant general correlation with morning
cortisol in this study (Axelsson et al., 2003).
Some gender differences have previously been found in
sleep-endocrine regulation as well as in the overall regula-
tion and secretion of cortisol and other stress related
hormones. Women were found to have higher plasma cor-
tisol levels during the first part of the night, and showed
slightly different EEG-recorded sleep parameters compared
to men, although this difference was not reflected in
different HPA axis activity during the second half of the
night (or the night as a whole) (Antonijevic et al., 1999).
Pre-menstrual women appeared to have slightly lower mean
cortisol levels over the day, compared to men in similar
ages. This difference was mostly attributable to lower
morning peak values. Among female students, the cortisol
awakening response was higher during a period of high
examination stress, while the CAR was not affected among
men (Weekes et al., 2008). Women, but not men, also
showed an age-related elevation in the morning cortisol
levels (Van Cauter et al., 1996). However, a later study
instead found age related changes (increase) in CAR among
men but not among women (Almeida et al., 2009), and
other studies have not either shown any general differences
in cortisol levels among men and women (Hansen et al.,
2003b). According to Lundberg (2005) previous studies have
shown that gender roles and psychological factors appear to
be more important than biological factors for the differing
stress responses between men and women.
58
Given the assumed complex role of fatigue, sleep and
recovery in relation to stress, cortisol and negative health
outcomes, and the so far inconclusive results the associations
between these factors need further clarifications. The aim
with the present study was to examine possible associations
between cortisol measures and (I) self-rated recovery, (II)
occupational fatigue and (III) subjective sleep quality the
night preceding cortisol sampling. Further, possible gender
differences were tested.
2. Participants and methods
2.1. Participants
The study group consisted of 581 persons working day time;
352 women and 229 men aged 19—65 years (mean 46.3 SD
10.7 years), recruited from seven companies, all located in
the Southern part of Sweden: one high school (n = 172), one
telecommunication company (costumer service) (n = 101),
one regional social insurance office (n = 39), one pharmaceu-
tical company (n = 91), one wood industry (n = 34), one
medical clinic (n = 53), one manufacturing plant (n = 42)
and one construction work place (n = 49).
2.2. Data sampling methods
2.2.1. Questionnaire data
The questionnaires were distributed and responded to at
the workplace during a work day, and then collected by the
researchers. The questionnaire included six single item
questions about recovery rated on five-point scales with
verbal labeling at each point but varying across items;
‘‘How often do you feel tired in your head (mental fatigue)
after work’’ (response alternatives from ‘‘always’’ to
‘‘never’’), ‘‘How long time, after each work week, does
it take until you feel recovered?’’ (response alternatives
‘‘less than one day’’, 1 day, 2—3 days, more (than 3 days),
and ‘‘never get recovered’’), ‘‘How would you, in general,
rate your sleep quality’’ (response alternatives ‘‘very good’’
to ‘‘very poor’’), ‘‘Do you get enough sleep’’ (response
alternatives from ‘‘definitely enough’’ to ‘‘far from
enough‘‘), How often do you feel a need to sleep through
(response alternatives ‘‘never’’ to ‘‘always (most days)’’)
and ‘‘How often do you have the possibility to sleep through
when you feel in need for it (response alternatives ‘‘never’’
to ‘‘always (almost every time)’’. The internal non-
responses to these questions were between 0.9% (n = 5)
and 2.8% (n = 16). The recovery items are not previously
validated, but are similar to questions used in previous
studies that has found significant associations with cortisol
(Gustafsson et al., 2008).
Work related fatigue was measured by Swedish Occupa-
tional Fatigue Inventory (SOFI-20), an instrument that
assesses five dimensions of fatigue after a typical workday:
lack of energy, physical exertion, physical discomfort, lack of
motivation, and sleepiness, together with a global scale
computed as the subject’s mean score across all items (Åhs-
berg et al., 1997). SOFI-20 contains 20 items, four items for
each of the five subscales, and all items are rated on a seven-
point scale with two verbal anchors: (i) ‘‘not at all’’ and (vii)
‘‘to a very high degree’’.
F. Eek et al.
2.2.2. Logbook
The participants also filled in a logbook during the day of
cortisol sampling. In the morning notes, they specified their
awakening time. The morning scoring further included the
Karolinska Sleep Diary (KSD), which assesses a number of
sleep parameters during the most recent night (Akerstedt
et al., 1994). In the present study, the two indices Disturbed
sleep and Ease of awakening were examined. The disturbed
sleep score was calculated as the mean score of four items
asking whether the person during the most recent night had
(i) difficulties falling asleep; (ii) disturbed/restless sleep; (iii)
repeated awakenings; and (iv) premature awakenings.
Higher scores represent increasingly disturbed sleep (score
range 1—5). The awakening score was calculated as the mean
score for three items concerning (i) ease of awakening; (ii)
whether the respondent felt well rested; and (iii) subjective
sleep quality, where higher scores represented a more satis-
factory awakening (score range 1—5). A correlation matrix of
the included KSD and SOFI scales is presented in Table 1.
2.2.3. Definition of dichotomized lack-of-recovery
variables
The six single-item questions concerning work related recov-
ery were dichotomized, with the two most negative response
alternatives as outcome. ‘‘Often mentally fatigued after
work’’ was defined as responding ‘‘Always’’ or ‘‘Mostly’’ on
the question ‘‘How often do you feel tired in your head
(mental fatigue) after work?’’. ‘‘Long time to recover’’
was defined as responding ‘‘more than 3 days’’ or ‘‘never
get recovered’’ to the question ‘‘How long time, after each
work week, does it take until you feel recovered?’’. ‘‘Poor
sleep quality’’ was defined as responding ‘‘quite poor’’ or
‘‘very poor’’ on the question ‘‘How would you, in general,
rate your sleep quality?’’. ‘‘Not enough sleep’’ was defined as
responding ‘‘definitely not enough’’ or ‘‘far from enough’’ on
the question ‘‘Do you get enough sleep?’’. ‘‘Need to sleep
through’’ was defined as responding ‘‘mostly’’ or ‘‘always’’
on the question ‘‘How often do you feel a need to sleep
through?’’. ‘‘No possibility to sleep through’’ was defined as
responding ‘‘never’’ or rarely’’ to the question ‘‘How often do
you have the possibility to sleep through when you feel in
need for it?’’
2.2.4. Cortisol sampling
The participants collected saliva at three pre-specified
time points during one work day; at awakening, 30 min
after awakening, and at 2100 h. In order to standardize
the sampling procedure as much as possible, participants
were instructed to collect saliva during an ordinary work
day, excluding the first and last day of the work week (hence
most samples are collected during Tuesday—Thursday). A
previous study showed that there were no differences in
cortisol values these between week days (Garde et al.,
2003b). Verbal instructions were given to each participant
how to place the swab from the saliva sampling tube in the
mouth until hydrated, but no longer than 5 min. Each
person also received written information together with
the set of sampling tubes (Salivette1, Sarstedt Ltd., Lei-
cester, UK). Restrictions were issued concerning teeth-
brushing, smoking, and heavy meals 1 h prior to saliva
sampling. After completed sampling, the samples were
returned in the pre-stamped envelope together with the
Cortisol and recovery 59

completed questionnaire. On arrival to the clinic, the

8. SOFI global
samples were stored at 20 8C until analyzed.

2.3. Analysis of cortisol in saliva

index

2.42
1.09
1
The assay used for determination of cortisol in saliva was a
competitive radio immuno-assay (RIA) (Spectria Cortisol
sleepiness

Coated Tube RIA) purchased from Orion Diagnostica, Espoo,

7. SOFI

Finland. The assay was designed for quantitative in vitro

0.83
2.84
1.53
measurement of cortisol in serum, plasma, urine and saliva.

1
A method evaluation of certified reference material in water
showed no bias of the method, with a 97% recovery (CI 94%;
6. SOFI lack of

100.9%). Limit of detection (LOD) was 1.59 nmol/l. Between-

motivation

run CVs were 19% at 11.5 nmol/l and 16% at 49.2 nmol/l. To
show equivalence between different runs, natural saliva
0.59
0.77
2.06
1.30
samples at two concentrations (11.5 nmol/l and
1

49.2 nmol/l) were used as control materials and analyzed

together with the samples. Westgard control charts were
5. SOFI physical

used to monitor and control variation, and ensure that the

analytical methods remained stable. The performance of the
discomfort

methods was further evaluated by participation in inter-

laboratory comparison schemes (Westgard et al., 1981;
0.49
0.54
0.81
2.33
1.33

Garde et al., 2003a; Hansen et al., 2003a).

1

The cortisol variables analyzed in the present study were:

(i) the mean cortisol concentration over the day, (ii) the
Correlation matrix and descriptives (mean, SD) of included sleep, fatigue and recovery scales.

4. SOFI physical

cortisol concentration (nmol/l) at the three time points, (iii)

the relative awakening response (defined as % increase
between the first and the second sample (CAR)), (iv) the
exertion

cortisol morning peak (CMP) (nmol/l), (v) the mean morning

0.59
0.36
0.40
0.65
1.48
0.87

concentration (that is, the mean of the two morning samples)

1

and (vi) the cortisol decline over the day (CDD) (nmol/l
difference between the CMP and the 2100 h sample).
3. SOFI lack of

2.4. Statistical analyses

energy

0.47
0.64
0.60
0.67
0.88
3.41
1.72

For the dichotomized variables, the linear MIXED models

1

module in SPSS 14 (SPSS Inc., 2001) was used to specify a

repeated measures model for the analysis of cortisol con-
2. KSD disturbed

centration over the day. The models were solved using the
restricted maximum likelihood (REML) method. The catego-
rical predictors were group (‘‘non-recovered’’ or ‘‘recov-
ered’’ category for each of the single-item questions), and
sleep

time point of sampling. The statistical modeling also

0.28
0.15
0.31
0.15
0.20
0.28
2.07
0.82

included the two-way interaction group  time point of

1

sampling, to find possible differential patterns of reactions

between recovery profiles. For the analyses, a series of first-
of awakening
1. KSD ease

order autoregressive covariance structures was tested, as

well as a compound symmetry covariance structure (CS). The
0.54
0.41
0.22
0.35
0.26
0.31
0.40
3.20
0.77

Schwarz’ Bayesian Information Criterion was used to guide

1

the final selection of covariance structure. The non-repeated

cortisol variables (CAR, CMP and mean morning concentra-
tion, and CDD) were analyzed by General Linear Modeling
5. SOFI physical discomfort
6. SOFI lack of motivation
1. KSD ease of awakening

4. SOFI physical exertion

(GLM) Univariate ANOVA. Awakening time (i.e. time at the

2. KSD disturbed sleep
3. SOFI lack of energy

first sample), age, and gender were introduced as covariates

8. SOFI global index

in the model. The modeling also included the interaction

7. SOFI sleepiness

group by gender, to examine possible differences in associa-

tions between recovery and cortisol for men and women. The
limit of significance of covariates to be included was set to
Table 1

0.20 in all models, that is, variables or interactions not

Mean

reaching a p-value below 0.20 were in the next step elimi-

SD

nated from the model (Greenland, 1989; Maldonado and

60 F. Eek et al.

Greenland, 1993). For the study variables, p-values 0.05
were considered statistically significant. Due to skewed data
distribution, the cortisol concentrations were logarithmically
transformed before carrying out the statistical analyses.
Regarding the variables CAR and CDD, which also were skewly
distributed but did include negative values, the data was
ranked before statistical analysis.
For the continuous measures of sleep quality and fatigue
(SOFI subscales and KSD subscales), bivariate correlations
with cortisol measures were analyzed with Pearson correla-
tion coefficients (r). Since poor sleep and recovery is sup-
posed to be associated with mainly morning cortisol
concentrations, analyses were performed for the two morn-
ing samples separately, as well as for the mean morning
concentration. Also correlations with CMP, CAR and CDD were
tested. In a second step, gender-stratified correlations were
analyzed.
2.5. Ethics
The study was conducted in accordance with the Declaration
of Helsinki. All participation in the study was completely
voluntary and with the adequate understanding of the sub-
jects.
3. Results
Of the six lack-of-recovery variables Need to sleep through
was the most frequently reported (Table 2). However, the
gender difference was evident; almost half of the women
reported an almost constant need to sleep through, while
only 22% of the men did. Among men, Lack of possibility to
sleep through was the most frequent type of lack of recovery
reported, followed by Mental fatigue after work.
Few persons, only 5%, experienced five or six of the lack-
of-recovery conditions measured, while 38.6% experienced
none of them, indicating a fulfilled recovery. 42.1% experi-
enced one or two of the conditions, indicating a somewhat
unmet need for recovery. Women also had lower mean scores
on the KSD ease of awakening index, indicating a less satis-
factory awakening, compared to men while the disturbed
sleep index score did not differ much between men and
women (Table 2).
3.1. Dichotomized lack-of-recovery variables
and cortisol
There were no significant differences between any of the
dichotomized groups of lack-of-recovery variables, regarding
mean cortisol concentration during the day, and no signifi-
cant interactions between group and time point, indicating
similar cortisol pattern over the day for recovered- and non-
recovered profiles. For the non-repeated cortisol measures
CMP, CAR, and CDD there were only differences between a
few of the lack-of-recovery dichotomies. One of these was a
significant interaction effect between gender and Long time
to recover for the variable CAR ( p < 0.001). Women who
needed more than three days to recover after a work week
had significantly higher CAR compared to women who felt
recovered in less than three days ( p < 0.001), while men who
needed long time to recover had a significantly flattened CAR
compared to men who recovered in less than three days
( p < 0.001) (Fig. 1a and b). Descriptive cortisol values for
men and women are presented in Table 2.
3.2. Correlations between cortisol and
continuous variables of fatigue and sleep
disturbances
There were no significant correlations between the KSD
subscales disturbed sleep and Ease of awakening, and any
of the examined cortisol variables. However, a few significant
correlations were found between SOFI-subscales and CAR,
which was significantly positively correlated with Lack of
energy (r = 0.11, p = 0.024), Lack of motivation (r = 0.10,
p = 0.036) and Physical exertion (r = 0.11, p = 0.023). Physi-
cal exertion was also significantly negatively correlated with
cortisol concentration at awakening (r = 0.10, p = 0.032).

Table 2 Proportion of persons experiencing various aspects of lack of recovery and mean Karolinska Sleep Diary scores for ‘‘Ease of
awakening’’ and ‘‘Disturbed sleep’’ and descriptive cortisol values.

Men Women Total

Often mentally fatigued after work (%) 21.9 31 27.4
Need >3 days to recover after work week (%) 11.2 13.7 12.7
Poor sleep quality (%) 12.1 20.5 17.2
Not enough sleep (%) 9.8 16.5 13.9
Need to sleep through (%) 21.6 41.8 33.9
No possibility to sleep through (%) 25.5 26.4 26.0
KSD ease of awakening (mean; SD) 3.4; 0.7 3.1; 0.8 3.2; 0.8
KSD Disturbed sleep score (mean; SD) 2.0; 0.8 2.1; 0.8 2.1; 0.8
Cortisol awakening response CAR (MD (10;90th 31.5 ( 40.5; 219) 51.6 ( 38.7; 261) 45.7 ( 38.8; 251.0)
percentile)) %
Cortisol morning peak CMP (MD (10; 90th 22.5(12.5; 37.7) 23.1 (13.4; 41.2) 22.7 (13.3; 39.9)
percentile)) nmol/l
Cortisol decline over day CDD (MD (10; 90th 18.2 ( 35.1; 6.3) 18.6 ( 36.9; 8.2) 18.4 ( 36.0; 7.6)
percentile)) nmol/l
Mean morning concentration (MD (10; 90th 18.0 (10.6; 28.0) 18.6 (10.8; 31.1) 18.1 (10.6; 29.9)
percentile)) nmol/l
Cortisol and recovery 61

a 30,0 women than among men. Among women, the correlation

between CAR and lack of energy (r = 0.17, p = 0.007),
between CAR and physical exertion (r = 0.16, p = 0.010) as
well as between cortisol concentration at awakening and
25,0 Physical exertion (r = 0.17, p = 0.005) was stronger than in
short
the total group. None of the correlations turned out signifi-
long (>3 days)
cant among men, when analyzed separately (r = 0.023,
r = 0.02, r = 0.006, respectively, all p > 0.75). No other
20,0 correlations were significant among either men or women.
Cortisol (nmol/l)

4. Discussion
15,0
Several previous studies have found associations between
sleep and cortisol, when sleep is manipulated and registered
in laboratory settings. However, subjective ratings of sleep
10,0 and recovery in every day life may be quite different from
variables and conditions measured in laboratory settings.
One previous small group study reported rather strong asso-
ciations also between self rated recovery, and cortisol (Gus-
5,0 tafsson et al., 2008). Another study, including 24 women,
found rather strong long term associations between need for
recovery and evening cortisol, where high need for recovery
was associated with lower evening cortisol concentrations
0,0 (Rydstedt et al., 2009). The present study intended to cor-
05:00 11:00 17:00 23:00 roborate these findings and further explore possible relation-
Time ships between cortisol and various measures of subjective
sleep and recovery by including a larger group of participants
b 30,0 and additional measures of both cortisol and sleep/recovery.
Women did more frequently than men report all aspects of
lack of recovery. The gender difference was most evident
regarding constant need to sleep through, which was
25,0
short reported by almost half of the women, but only 22% of the
men. Lack of possibility to sleep through when needing it was
long (>3 days)
instead the factor most often reported among the men,
20,0 although it was even more frequently experienced by the
women. However, if the men more rarely feel a need to sleep
Cortisol (nmol/l)

through, the lack of possibility may be of limited impact. The

constant need to sleep through among many women may
15,0 reflect their ‘‘double burden’’ by still being the ones that
most often take the largest responsibility of child care and
house hold work. Women also showed a general tendency
towards more frequent reports of various physical symptoms,
10,0 which may be considered as an increased symptom percep-
tion that may also be reflected in the higher report of lack of
recovery (Gijsbers Van Wijk and Kolk, 1997).
Regarding the association between on the one hand sleep
5,0 and recovery, and on the other cortisol, we failed to confirm
previous findings of rather strong associations. The few sig-
nificant findings in the present study should be interpreted in
the light of the mass significance issue rising from the vast
0,0
amount of analyses performed. However, some of the gender
05:00 11:00 17:00 23:00 interaction effects do, for women, point in the same direc-
Time tion as in the previous study. Gustafsson et al. (2008) found
high morning cortisol being associated with self-reported
Figure 1 Cortisol profile (median nmol/l) over the day for men insufficient recovery from work in 25 female and male white
(a) and women (b) who experience a need for long (more than 3 collar workers. Recovery was in that study measured by
days) and short time to recover after a work week. questions like ‘‘Do you feel thoroughly rested when you start
working in the morning’’ and ‘‘Do you feel rested and recov-
The correlations remained significant after controlling for
ered when you return to work after a weekend’’. Thus the
awakening time.
questions were quite similar to the ones used in the present
Gender stratified analyses showed that the association
study, where only few significant correlations were found
between cortisol and SOFI-subscales were stronger among
62
between cortisol and any sleep- or recovery parameters,
despite the much larger study group.
No significant correlations were found among cortisol and
‘‘acute’’ sleep parameters, as measured with the Karolinska
Sleep Diary (KSD). This instrument intends to measure the
sleep quality during the night/morning preceding the cortisol
sampling in terms of disturbed sleep and ease of awakening
after the night’s sleep. However, some significant associations
were found between cortisol and a few other measures of more
chronic aspects of sleep, fatigue, and recovery. A higher Lack
of energy, Lack of motivation, and Physical exertion were
correlated with a higher CAR; Physical exertion also with a
lower cortisol concentration at awakening. This finding was
supported in a recent study among 389 white collar-workers
which found high concentration of salivary cortisol was asso-
ciated with high perceived energy and that vigorous physical
activity reduced cortisol concentration. Vigorous physical
activity was associated with high perceived energy (Hansen
et al., 2009). Gender stratified analyses showed that these
correlations were found only among women. This was not
simply a question of power, as may be expected with the
smaller group of men participating in the study. The correla-
tion coefficients were not only insignificant but also very close
to 0 for the male group, while it was higher, although not
impressively so, in the female group. This indicates that
possible associations and possibly pathways between lack of
recovery/fatigue and cortisol, and in the long term, unhealth,
may not be similar for men and women.
Also analyses of the different lack-of-recovery variables in
relation to cortisol showed differences among men and
women. Regarding association between Long time to recover
and CAR, the men showed the expected pattern according to
our theoretical assumptions. Among males, those needing a
long time to recover after a work week tended to show a
flatter awakening response compared to males needing
shorter time to recover. This result corresponds to the
hypothesis that a prolonged state of lack of recovery may
result in flattened cortisol day profiles. A previous study in
line with this hypothesis found associations between lack of
vitality and a flatter cortisol profile over the day (i.e. CDD).
However, in the present study, no significant associations
between the CDD parameter and any of the examined
lack-of-recovery variables were found, which, although lack
of recovery and lack of vitality is not exactly synonymous,
also points towards the disparity in results within this topic.
This disparity is also illustrated by an opposite pattern of
associations in women: those needing a longer time to
recover after a work week showed a significantly higher
CAR compared to women needing shorter time to recover,
which is in contrast to our expectations. Striving for an
interpretation, this result could possibly be discussed in
terms of a high taxing of available resources in women. These
may be reflected in fatigue after work, a frequent inability to
sleep through, a high need for energy mobilization in the
morning, and a need for longer time to recover after the work
week. It has previously been suggested that women may be
more sensitive than men to work stress with respect to
cortisol excretion (Alderling et al., 2006). However, due to
the relative nature of the CAR measure, lower awakening
concentrations may lead to relatively higher CAR. Hence, the
correlations are not in themselves contradictory but still not
self-evident how to interpret.
F. Eek et al.
Taken together, these interpretations seem quite spec-
ulative and even dubious, considering both the mass signifi-
cance issue and the lack of consistency in the results. Still,
regarding gender interaction effects, they resemble the
results from the mentioned study by Gustafsson et al.
(2008), reporting higher morning cortisol values among 12
women who rarely felt rested after a weekend, but no such
positive association among 13 men, who instead showed a
weak tendency towards the opposite pattern. In that study
CAR was not analyzed, since the first sample was collected
15—30 min after awakening. The most comparable measure
in our study would be the second morning sample or the
maximum morning value not being significantly associated
with any of the different recovery variables.
Even though a few significant associations between sleep
or recovery and cortisol emerged in the present analyses, the
picture was far from clear. In total, we were not able to
confirm previous findings of clear associations between
sleep- or recovery parameters and cortisol, even though
the present study group is relatively large, and the methods
used for analyses were comparable to previous studies (i.e.
Gustafsson et al., 2008) both regarding measures of cortisol
and self-reported recovery. Nor did we find any association
between the additional measures of sleep and cortisol,
included in the present study. With the starting point in
the hypothesis that the development of exhaustion may go
from initially increased cortisol release towards a gradually
flattening day profile, there is an obvious problem with cross
sectional studies. Persons may have come variously far in this
development. Some persons in the initial phase may have
increased cortisol response while others who have experi-
enced lack of recovery and exhaustion during a longer period
may instead have lower cortisol concentrations and flatter
day profiles. However, on group level, such differential
responses may level each other out, resulting in support of
the null hypothesis.
This illustrates the precarious point in the measure and
interpretation of salivary cortisol, and its relation to sub-
jective experiences of stress or strain. In order to elucidate
the complexity of the interplay between cortisol and self
reported measures of strain and recovery, it is important to
publish also inconsistent findings, or lack of significant
results. However, the previous study by Gustavsson et al.
was based on a very homogenous sample of white collar
workers with similar occupations, whereas the present study
included workers from several different companies with
varying occupational categories, forming a more heteroge-
nous group of workers with a wide variety of work tasks.
Possible differences in salivary cortisol related to differences
in recovery among these workers could have been masked by
the influence from other work related factors and individual
differences. Perhaps it could be possible to demonstrate a
stronger association between recovery and cortisol with a
more homogenous group of workers.
4.1. Study limitations
Given the large number of statistical analyses performed in
the present study, it is inevitable to reflect on the possibility
of mass significance findings. Still, the significant results may
nevertheless be reflected on and discussed. The present
study examines variations of normal self-reported sleep
Cortisol and recovery
patterns and states of recovery during everyday circum-
stances, contrary to laboratory studies recording more exact
measures of sleep quality, often during quite extremely
manipulated sleep. The aim of the study was, accordingly,
to study associations between cortisol and various self
reported measures of everyday sleep, fatigue and recovery,
and our results should not be extrapolated to sleep depriva-
tion situations. Self reports of sleep may not be as exact as
e.g. polysomnography recordings, but since there are other
limitations with laboratory studies such as limited general-
izability to every day life, and restriction in possible (realis-
tic) study groups, the use of self reports of sleep and recovery
are still highly relevant. Some of the measures used in the
present study, such as the SOFI and KSD-scales, are well
established and validated measures (Akerstedt et al.,
1994; Åhsberg et al., 1997), while the recovery items are
not previously validated. The reason for analysing individual
(and dicothomised) items was that the initial and primary aim
with the present study was an attempt to reproduce the
results from Gustafsson et al. (2008), who found strong
associations between cortisol and individual recovery items,
similar to those used in our study, despite including only a
small study sample. In that study, the most consistent results
emerged for dicothomised items. Analyzing individual items
also allows for an exploration of whether different aspects of
(lacking) recovery may show differing associations with cor-
tisol. Including both well established scale measures of
fatigue and sleep, and these individual recovery items,
allows for analyses of a wide range of different aspects of
sleep, fatigue and recovery.
Previous studies have shown that there is a high intrain-
dividual variation in cortisol, especially during the morning
(Carlsson Eek et al., 2006). Ideally, cortisol samples should be
collected during several days for each participant. In the
present study, saliva was collected during one day only, which
makes it more vulnerable to the high intraindividual varia-
tion. Compliance with cortisol sampling instructions is
another important aspect in field studies. Lacking compli-
ance, for example a delay between awakening and first
morning sample may, due to the relatively rapid changes
in cortisol concentration during early morning hours, affect
especially the CAR-measure, but also other cortisol mea-
sures. All participants were carefully instructed about the
importance of taking the first sample immediately at awa-
kening, however, we had no possibility to control whether
instructions were followed or not. Poor compliance may
hence possibly have contributed to the lack of significant
associations. There could also be gender differences in com-
pliance that may explain why some significant associations
were found among women only. The study sample consists of
persons with a wide spread in age. Age was included as
covariate in the analyses of individual recovery items and
cortisol, while scale measures was analyzed by zero-order (or
gender stratified) correlations. Hence, age differences could
possibly have affected some of the results.
Even though some methodological issues may have
affected the result, there is no reason to believe that meth-
odological limitations were the full explanation for the lack
of significant findings. In the present study, we could not
confirm previous findings of associations between cortisol
and lack of recovery, although we found some gender inter-
actions. Not either could we find any associations between
63
cortisol and acute measures of sleep quality preceding night.
Few associations were found, among women only, between
cortisol and some measures of subscales of the occupational
fatigue index. However, these findings should be interpreted
in light of the potential mass significance effect. The present
results points out the importance of replication of especially
small sample studies, in order to further confirm possible
associations. More research is needed before the final con-
clusion about possible associations between cortisol and self-
rated sleep and recovery can be drawn, by examining large,
and perhaps more homogenous, study samples.
Role of funding sources
There were no impact from funding source(s) on any aspect of
the work with the current manuscript (design, data collec-
tion, analyse, interpretation, writing, or submission).
Conflict of interest
There are no conflicts of interest for any of the authors.
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