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Ergonomics
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Relationship between prolonged standing and symptoms of varicose veins and nocturnal leg cramps among women and men
Jin Wook Bahk , Hyunjoo Kim , Kyunghee Jung-Choi , Myung-Chul Jung & Inseok Lee
a a b c d e

Department of Occupational and Environmental Health, The Graduate School of Public Health, Seoul National University, Seoul, Korea
b

Department of Occupational and Environmental Medicine, Dankook University Medical College, Cheonan, Korea
c

Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea
d

Department of Industrial and Information Systems Engineering, Ajou University, Suwon, Korea
e

Department of Safety Engineering, Hankyong National University, Anseong, Korea

Available online: 17 Aug 2011

To cite this article: Jin Wook Bahk, Hyunjoo Kim, Kyunghee Jung-Choi, Myung-Chul Jung & Inseok Lee (2012): Relationship between prolonged standing and symptoms of varicose veins and nocturnal leg cramps among women and men, Ergonomics, 55:2, 133-139 To link to this article: http://dx.doi.org/10.1080/00140139.2011.582957

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Ergonomics Vol. 55, No. 2, February 2012, 133139

Relationship between prolonged standing and symptoms of varicose veins and nocturnal leg cramps among women and men
Jin Wook Bahka, Hyunjoo Kimb*, Kyunghee Jung-Choic, Myung-Chul Jungd and Inseok Leee
a

Department of Occupational and Environmental Health, The Graduate School of Public Health, Seoul National University, Seoul, Korea; bDepartment of Occupational and Environmental Medicine, Dankook University Medical College, Cheonan, Korea; c Department of Preventive Medicine, Ewha Womans University School of Medicine, Seoul, Korea; dDepartment of Industrial and Information Systems Engineering, Ajou University, Suwon, Korea; eDepartment of Safety Engineering, Hankyong National University, Anseong, Korea (Received 7 May 2010; nal version received 30 March 2011) The relationships between occupational characteristics and symptoms of varicose veins and nocturnal leg cramps and their gender dierences were explored in a Korean population. The study population was 2165 workers from various occupations (55.6% female). Multiple logistic regression analyses were conducted to reveal factors related to symptoms of varicose veins and nocturnal leg cramps. The prevalence of varicose veins and nocturnal leg cramps was higher among women than men. The characteristics of standing work were dierent according to gender. In gender stratied analysis, the odds ratio of varicose veins was signicantly high for prolonged standing for male and female workers. However, the odds ratio of nocturnal leg cramps was only signicant among prolonged standing male workers. The models including gender, prolonged standing and occupations in this order presented that gender is not signicantly associated with varicose veins after occupations were added to the model. Prolonged standing at work may be a more important risk factor for varicose veins and nocturnal leg cramps than biological dierences between women and men. Therefore, eective interventions to interrupt or reduce prolonged standing at work should be implemented for the prevention of varicose veins and nocturnal leg cramps. Practitioner Summary: This paper shows associations between occupational characteristics and symptoms of varicose veins and nocturnal leg cramps and their gender dierences. These ndings will contribute to knowledge of gender-specic occupational risk factors for symptoms in the distal lower extremities. Keywords: gender dierences; nocturnal leg cramps; prolonged standing; varicose veins

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1.

Introduction

Many workers such as retail workers, catering workers, cleaners and security guards are required to spend most of their time on their feet. The relationship between prolonged standing and health problems has a long history in the eld of occupational health. According to Ramazzini (16331714):
The ailment those who work standing are most aicted by is varicose veins, since contraction of the muscles impedes the ow and reux of blood so that it stagnates in the veins and valves of the legs, leading to the swelling we call varicose. (Ramazzini 2009)

A review of the health risks associated with prolonged standing concluded that risks of chronic venous insuciency, preterm birth, spontaneous abortions and musculoskeletal pain increased with prolonged standing (McCulloch 2002). Since then,

prolonged standing has been associated with distal lower leg symptoms (Messing et al. 2008) and orthostatic intolerance (Ngomo et al. 2008). Some evidence also suggests that prolonged standing is associated with the progression of carotid atherosclerosis (Krause et al. 2000). Prolonged standing without access to a seat has also been associated with musculoskeletal symptoms in the lower leg (Messing et al. 2008) and back (Tissot et al. 2009). Varicose veins and nocturnal leg cramps are common lower extremity symptoms among standing workers. In epidemiological studies, varicose veins were dened as: Any dilated, tortuous and elongated subcutaneous veins of the leg (Malhotra 1972, Beaglehole et al. 1975, Stanhope 1975). The aetiology and the risk factors for varicose veins are still subject to debate, but several studies have shown that higher risks for varicose veins have been associated with age, female gender, family history, pregnancy, obesity and prolonged standing or sitting (Brand et al. 1988,

*Corresponding author. Email: hj7121@gmail.com

ISSN 0014-0139 print/ISSN 1366-5847 online 2012 Taylor & Francis http://dx.doi.org/10.1080/00140139.2011.582957 http://www.tandfonline.com

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J.W. Bahk et al. drivers; telephone operators; security guards; oce workers; manufacturing workers. The survey was conducted from July to August 2009 using a selfadministered questionnaire and the overall participation rate was 84.1% from a total of 2573 workers employed by the 24 companies. The survey population was categorised into prolonged standing (1497 workers, standing 44 h per d) and nonprolonged standing (668 workers, standing 54 h per d) workers. 2.2. Questionnaire All subjects were administered a questionnaire including items on demographic variables, healthrelated variables, prolonged standing characteristics and symptoms of varicose veins and nocturnal leg cramps. Demographic variables included age and gender. Health-related variables consisted of weight, height, smoking status, medical history, history of pregnancy among women and family history of varicose veins among parents or siblings. Prolonged standing characteristics included duration of standing work, consecutive standing hours, occurrences of rest breaks and the type of shoes worn on the job. Prolonged standing and non-prolonged standing was dierentiated by the question, Do you usually stand while you are working? Respondents who reported that they usually stood at work were then asked, How many hours per day do you stand at your work? and respondents who reported over four hours per day were dened as prolonged standing workers. The lifetime occurrence of varicose veins was assessed using the self-administered questionnaire. The relevant question was, Have you ever had clearly visible, dilated, tortuous, and possibly prominent subcutaneous veins of the lower extremities? The accuracy of such self-assessment has been reported in a previous study showing high specicity and sensitivity. The overall estimates of sensitivity was 0.93 and the specicity was 0.92 (Laurikka et al. 1995). The 1-year prevalence of nocturnal leg cramps was assessed by the question, During the past 12 months, have you had trouble with cramps in your calves or feet at night more than once a month?, derived from the previous study carried out by Oboler et al. However, validity of the question was not shown (Oboler et al. 1991). 2.3. Statistical analysis
2

Hobson 1997, Krijnen et al. 1997, Jawien 2003, Kroeger et al. 2004, Beebe-Dimmer et al. 2005, DSouza et al. 2005, Tuchsen et al. 2005, Ahti et al. 2010). There are only a few studies examining the relationship between the characteristics of prolonged standing work and lower extremity symptoms according to gender. Tuchsen et al. (2000, 2005) examined the relationship between the proportion of standing work and the risks of varicose veins for men and women among the Danish population. According to Kontosic et al. (2000), the prevalence of varicose veins was higher among women (34.6%) than among men (18.9%), higher among catering (33.3%) and trade (44.2%) workers than among the other workers (19.726.7%) and higher in standing work (32.8%) than in sitting work (24.3%). Sitting had a protective eect against varicose veins and prolonged standing was signicantly related to varicose veins in women (Lee et al. 2003). However, it is unclear whether and to what degree the higher prevalence of varicose veins in females is caused by biological factors rather than environmental exposures. The exact cause of nocturnal leg cramps is uncertain. In some cases, nocturnal leg cramps may be a symptom of another problem such as peripheral vascular disease and arthritis (Oboler et al. 1991, Abdulla et al. 1999). Gulich et al. (1998) show that the prevalence of varicose veins is higher among women (27.6%) than among men (21.7%) and more prevalent at an older age than a younger age, with a range of prevalence from 12.4% to 39.7%. However, no study has examined the potential relationships between occupational physical demands and nocturnal leg cramps by gender. This relationship is worth examining, since nocturnal cramps are associated with other conditions with occupational components such as varicose veins and venous hypertension (Hirai 2000). This paper examines gender-specic prevalence of varicose veins and nocturnal leg cramps and the relationships between the occupational characteristics and these symptoms in a South Korean working population. Furthermore, the impacts of gender, prolonged standing and various occupations on the symptoms of varicose veins and nocturnal leg cramps are explored. 2. Methods 2.1. Subjects The study population consisted of 2165 workers (1203 women, 962 men) from 24 companies that had a contract with Dankook University Hospital to occupational health examinations in South Korea. The occupations of the workers were as follows: retail cashiers; sales workers; food service workers; street cleaners; receptionists; loss prevention personnel;

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The w test was used for categorical data with a Mantel-Haenszel test for linear association. Continuous variables such as age, BMI, tenure and weekly working hours were compared using the

Ergonomics Student t-test. Multiple logistic regression analyses were conducted to reveal the association of standing work and occupations with symptoms of varicose veins and nocturnal leg cramps. This model was constructed and stratied by gender and adjusted for age (as continuous variable), BMI (kg/m2: under 25/over 25), family history (for varicose veins, yes/no), anaemia (for nocturnal leg cramps, yes/no), pregnancy (among females, yes/no), constipation (for varicose veins, yes/ no), tenure (as continuous variable), smoking(yes/no) and regular exercise(yes/no). Furthermore, to reveal which factors better explain the prevalence of varicose veins and nocturnal leg cramps, four models were further developed, including gender, standing hours per day and occupations in sequential order. Finally, separate evaluations were done for prolonged standing workers to explore the associations of standing work over 8 h per d, rest breaks and type of shoes with the symptoms of varicose veins and nocturnal leg cramps. 3. Results

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Table 1 shows general and clinical characteristics of study populations among men and women according to their working posture. Among women, workers who stood at work were more likely to smoke, had lower

BMI, shorter job tenure, longer weekly working hours and less rest time at work than workers who sat at work. Moreover, female workers who stood at work had higher prevalence of varicose veins and nocturnal leg cramps than the workers who sat at work. Among women respondents, sales workers, food service workers and cashiers were the major occupations of standing work, while telephone operator was the main occupation of non-standing work. Among men, the workers who stood at work were more likely to smoke, had less weekly working hours, less rest time and higher prevalence of varicose veins and nocturnal leg cramps than those who sat at work. About 52% of men and 75% of women who stood at work took a rest break. More than 56% of men who stood at work were street cleaners and 45.5% of men who sat at work were drivers (Table 1). Table 2 shows the characteristics of standing work. Of the women respondents, 39.7% had worked in a standing position for 14 years, 29.5% for 59 years and 20.5% for over 10 years. Among men, 50.2% had worked for over 10 years in a standing position. On a daily basis, 66.6% of women and 56.7% of men respondents stood for over 8 h. Moreover, 59.5% of women and 36.6% of men worked more than four consecutive hours in a standing position. Anti-fatigue mats were not provided to most workers. A workplace

Table 1.

General and clinical characteristics of study population. Women Non- standing (n 389) Prolonged standing (n 814) 35.5 137 324 20.9 387 142 239 157 237 456 6.2 53.4 205 157 381 210 6 21 0 0 39 (11.4) (16.8) (39.8) (2.4) (47.5) (17.4) (29.4) (19.3) (29.1) (56.0) (5.6) (12.1) (25.2) (19.3) (46.8) (25.8) (0.7) (2.6) (4.7) Non- standing (n 279) (10.5) (42.3) (64.9) (2.7) 17 (6.1) 34 (12.2) 10 (3.6) 7 (2.5) 36 (12.9) 11.4 (8.5) 60.1 (13.1) 90 (32.3) 1 2 4 42 21 127 0 79 (0.4) (0.7) (1.4) (15.1) (7.5) (45.5) (28.3) 43.7 118 181 23.9 Men Prolonged standing (n 683) (12.7) (57.1) (64.7) (2.6) 61 (8.9) 76 (11.1) 21 (3.1) 97 (14.2) 199 (29.1) 11.9 (9.8) 56.2 (12.0) 299 (48.3) 9 40 128 67 384 0 0 55 (1.3) (5.9) (18.7) (9.8) (56.2) (8.1) 43.3 390 442 23.5

Age (years), mean (SD) Smoking, n (%)* Exercise, n (%) BMI, mean (SD)* Pregnancy, n (%) Family history of varicose vein, n (%) Constipation, n (%) Anaemia, n (%) Varicose vein, n (%)*{ Nocturnal leg cramp, n (%)*{ Tenure (years), mean (SD)* Weekly working h, mean (SD),*{ No rest break, n (%)*{ Occupations, n (%)*{ Cashier Sales worker Food service worker Guardian Street cleaner Driver Telephone operator Others

34.5 7 163 21.3 172 69 132 49 26 168 8.3 44.4 65 20 10 7 4 2 1 261 85

(7.5) (1.8) (41.9) (2.5) (44.2) (17.7) (33.9) (12.6) (6.7) (43.2) (5.3) (8.9) (16.7) (5.1) (2.6) (1.8) (1.0) (0.5) (0.3) (67.1) (21.9)

*p 5 0.01 from chi-square test between standing and non-standing workers among women. { p 5 0.01 from chi-square test between standing and non-standing workers among men. Note: All p 5 0.01 from chi-square test between genders.

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J.W. Bahk et al. with comfortable chairs was reported by 28.4% of women and 16.0% of men. Among women, the most common type of shoes worn at work was low-heeled shoes followed by sneakers and rubber boots. On the other hand, men wore sneakers, low-heeled shoes and work shoes (Table 2). Table 3 presents the associations of prolonged standing work and type of occupations with varicose veins and nocturnal leg cramps among women and men. Adjusted odds ratios (ORs) for varicose veins were signicantly elevated among prolonged standing workers for both women (OR 2.99 with 95% CI 1.26 7.08) and men (OR 7.93 with 95% CI 3.1519.95). The ORs for nocturnal leg cramps were signicantly elevated among male prolonged standing workers (OR 2.93 with 95% CI 1.734.97) (Table 3). Table 4 shows the ORs of varicose veins and nocturnal leg cramps by a sequential model including gender, prolonged standing and occupations. Females had higher adjusted ORs of varicose veins and nocturnal leg cramps than males in model 1. In model 2, adjusted ORs for varicose veins were signicantly elevated for both females and prolonged standing work. Model 3, where various occupations were inserted into model 1, showed female gender become statistically non-signicant towards varicose veins while female gender remained statistically signicant towards nocturnal leg cramps. In model 4, where various occupations were inserted into model 2, it is shown that adjusted ORs for varicose veins and nocturnal leg cramps were signicantly high among prolonged standing workers (Table 4).

Table 2. Standing work related characteristics by gender among prolonged standing workers only*. Women (n 814) n (%) Duration of standing work 41 year 14 years 59 years 10 years Standing hours per d 45 h 67 h 8 h Consecutive standing hours 51 h 12 h 24 h 4 h 84 323 240 167 (10.3) (39.7) (29.5) (20.5) Men (n 683) n (%) 61 170 109 343 (8.9) (24.9) (16.0) (50.2)

69 (8.5) 203 (24.9) 542 (66.6) 11 30 289 484 (1.4) (3.7) (35.5) (59.5)

74 (10.8) 222 (32.5) 387 (56.7) 36 149 248 250 (5.3) (21.8) (36.3) (36.6)

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Anti-fatigue mat No Yes Chairs No Uncomfortable Comfortable Shoes Low-heeled shoes High-heeled shoes Sneakers Works shoes Rubber boots Other

690 (84.8) 124 (15.2) 353 (43.4) 230 (28.6) 231 (28.4) 303 73 247 44 96 51 (37.2) (9.0) (30.3) (5.4) (11.8) (6.3)

636 (93.1) 47 (6.9) 518 (75.8) 56 (8.2) 109 (16.0) 153 25 323 151 12 19 (22.4) (3.7) (47.3) (22.1) (1.8) (2.7)

*All p values 50.01 from chi-square tests.

Table 3. Associations of type of occupation and prolonged standing with varicose veins and nocturnal leg cramps by gender. Varicose veins OR (95% CI) Women (n 1203) Age Smoking Exercise BMI (kg/m2: 425) Pregnancy Constipation Family history of varicose veins Anaemia Prolonged standing Non-standing occupation Cashier Sales worker Food service worker Street cleaner Other standing occupation 1.03 1.18 0.99 0.39 0.86 1.38 1.89 2.99 1.00 2.10 3.20 1.07 0.35 0.98 (1.011.05) (0.771.82) (0.731.34) (0.160.94) (0.581.28) (1.011.90) (1.322.70) (1.267.08) (0.815.44) (1.248.25) (0.392.93) (0.062.05) (0.283.42) Men (n 962) 1.04 0.79 0.95 1.13 (1.011.07) (0.521.22) (0.611.48) (0.701.83) Nocturnal leg cramp OR (95% CI) Women (n 1203) 0.99 1.18 1.00 0.98 0.73 1.68 1.16 1.00 1.37 2.11 0.95 1.02 0.85 (0.971.01) (0.771.82) (0.781.28) (0.611.57) (0.540.98) (1.212.34) (0.662.05) (0.742.53) (1.123.96) (0.501.84) (0.352.94) (0.371.93) Men (n 962) 1.01 1.05 1.23 1.43 (0.991.02) (0.771.44) (0.891.70) (1.012.01)

1.67 (0.923.03) 1.88 (0.963.67) 7.93 (3.1519.95) 1.00 3.05 (1.039.01) 1.17 (0.472.91) 0.65 (0.331.27) 1.09 (0.353.36) 2.63 2.93 1.00 1.35 2.89 1.26 0.77 1.15 (1.235.62) (1.734.97) (0.315.90) (1.296.48) (0.682.33) (0.471.27) (0.552.39)

OR odds ratio. Note: Smoking: Ref non-smoking; Exercise: Ref non-exercise; BMI (425): Ref BMI 525; Pregnancy: Ref non-pregnancy; Constipation: Ref non-constipation; Family history of varicose veins: Ref no family history of varicose veins; Anaemia Ref no anaemia; Prolonged standing: Ref non-prolonged standing.

Ergonomics Table 5 presents associations of job characteristics with varicose veins and nocturnal leg cramps among standing workers only. Adjusted ORs for varicose veins signicantly decreased with non-heeled shoes for both women (OR 0.69 with 95% CI 0.490.97) and men (OR 0.58 with 95% CI 0.350.96), while ORs increased among men with more than 8 h of standing work per d (OR 1.67 with 95% CI 1.052.66). The OR
Table 4. Associations of gender, prolonged standing and occupations with varicose veins and nocturnal leg cramps*. Varicose veins{ OR (95% C.I) Model 1 Female Model 2 Female Prolonged standing Model 3 Female Non-standing occupation Cashier Sales worker Food service worker Street cleaner Other standing occupation Model 4 Female Prolonged standing Non-standing occupation Cashier Sales worker Food service worker Street cleaner Other standing occupation 2.40 (1.753.3) 2.24 (1.633.07) 5.97 (4.098.72) 1.27 (0.871.85) 1.00 4.99 9.47 2.82 1.97 2.34 (3.078.10) (6.1314.63) (1.824.36) (1.223.20) (1.174.67) Nocturnal leg cramp{ OR (95% C.I) 3.09 (2.433.94) 3.05 (2.43.89) 1.91 (1.552.35) 2.52 (1.923.32) 1.00 1.58 2.92 1.27 1.40 1.11 (1.122.23) (2.183.92) (0.961.69) (1.011.95) (0.71.77)

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for nocturnal leg cramps was signicantly elevated with men who had no rest break during work (OR 1.52 with 95% CI 1.072.17) and women who stood working over 8 h per d (OR 1.72 with 95% CI 1.252.38) (Table 5). 4. Discussion

1.39 (0.952.06) 4.46 (2.57.96) 1.00 1.56 2.74 0.87 0.70 0.84 (0.813.02) (1.455.17) (0.471.59) (0.391.26) (0.381.88)

2.61 (1.983.44) 1.72 (1.192.48) 1.00 1.02 1.82 0.81 0.94 0.77 (0.651.61) (1.182.81) (0.531.22) (0.611.43) (0.451.31)

OR odds ratio. *Female: Ref male; Prolonged standing: Ref non-prolonged standing. { Adjusted for age, BMI, family history of varicose vein, constipation, smoking and regular exercise. { Adjusted for age, BMI, anaemia, smoking and regular exercise.

One of the major ndings is that there was a higher prevalence of varicose veins and nocturnal leg cramps among prolonged standing workers. Furthermore, women showed a higher prevalence of varicose veins and nocturnal leg cramps than men in this study. The higher prevalence of varicose veins among women was consistent with most prior studies (Franks et al. 1992, Sisto et al. 1995, Canonico et al. 1998, Kontosic et al. 2000, Laurikka et al. 2002, Criqui et al. 2003). The prevalence of varicose veins from the present study was 21.8% among women and 9.5% among men, which was lower than the prevalence of varicose veins found to be 34.6% among female workers and 18.9% among male workers in research carried out among working populations in the City of Rijeka. A study of working populations in the City of Rijeka reported that female gender (OR 1.92), as well as standing posture at work, was a risk factor for varicose veins (Kontosic et al. 2000). In addition, the Tampere varicose vein study showed that female gender (adjusted OR 2.2) was a signicant risk indicator for varicose veins, which was determined by selfassessment among elderly populations (Laurikka et al. 2002). Moreover, a multi-ethnic study showed that women had a higher risk (OR 2.18) for varicose veins than men (Criqui et al. 2003). Canonico et al. (1998) showed that women had a higher prevalence of varicose veins than men based upon clinical examination, regardless of previous occupation among elderly populations. In the Danish Work Environment Cohort Survey, the adjusted relative risk was 1.75 for men and 1.82 for women among those with prolonged standing or walking conditions associated with their work (Tuchsen et al. 2005).

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Table 5. Association of job characteristics with varicose veins and nocturnal leg cramps among prolonged standing workers only*. Varicose veins{ OR (95% CI) Women (n 814) No rest break Non-heeled shoes Standing work 48 h/d 1.45 (0.992.14) 0.69 (0.490.97) 1.43 (1.002.05) Men (n 683) 0.64 (0.411.02) 0.58 (0.350.96) 1.67 (1.052.66) Nocturnal leg cramp{ OR (95% CI) Women (n 814) 0.94 (0.661.32) 0.79 (0.581.09) 1.72 (1.252.38) Men (n 683) 1.52 (1.072.17) 0.67 (0.461.00) 1.05 (0.741.48)

OR odds ratio. *No rest break: Ref rest break; Non-heeled shoes: Ref heeled shoes; Standing work 48 h/d: Ref standing work 58 h/d. { Adjusted for age, BMI, family history of varicose vein, pregnancy (for women), constipation, smoking and regular exercise. { Adjusted for age, BMI, pregnancy (for women), anaemia, smoking and regular exercise.

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J.W. Bahk et al. various protective strategies in the prevention of varicose veins and nocturnal leg cramps. There were several limitations in this study. First, the study design was cross-sectional and crosssectional studies can identify only associations, but not causal relationships. Second, the study population was selected by convenience sampling. Various occupational groups were examined from 24 worksites, which may have unique characteristics; therefore, caution is needed before generalising these results. Third, symptoms of varicose veins and nocturnal leg cramps were assessed by a self-reported questionnaire, which may introduce recall or reporting bias about symptoms and exposures. However, in the crosssectional study design, recall bias would be nondierential because processes operated in the same way in all groups (Raphael 1987). Despite these limitations, there are several strengths in this study. First, gender-specic prevalence of varicose veins and nocturnal leg cramps was discovered, together with the role of gender and prolonged standing, in the occurrence of varicose veins and nocturnal leg cramps. The gender-sensitive analysis made it possible to better understand some of the mechanisms that may underlie the association between occupational factors and health problems. Second, to the present authors knowledge, this is the rst report to show the associations between the occupational characteristics and the symptoms of nocturnal leg cramps. Although workers who stood at work have often complained of various symptoms of distal lower extremities, there exists only a few studies that reected this reality, with the exception of some studies of varicose veins (Kontosic et al. 2000, Tuchsen et al. 2000, Lee et al. 2003, Tuchsen et al. 2005). Third, although several studies recommended wearing comfortable shoes and taking rest breaks for the prevention of leg swelling or fatigue, long-term health outcomes such as varicose veins have rarely been studied. The ndings of this study suggest that reducing the prolonged standing time could decrease the risks of varicose veins in the workers who are required to stand at work. In conclusion, prolonged standing at work may be a more important risk factor for varicose veins and nocturnal leg cramps than biological dierences between women and men. Therefore, eective interventions to interrupt or reduce prolonged standing at work should be implemented to prevent varicose veins and nocturnal leg cramps. References
Abdulla, A.J., Jones, P.W., and Pearce, V.R., 1999. Leg cramps in the elderly: prevalence, drug and disease associations. International Journal of Clinical Practice, 53 (7), 494496.

Womens higher prevalence of varicose veins may be explained by gender dierences and dierent exposure factors in types of occupation. In the present study, there was a signicant relationship between female gender and varicose veins. However, the prevalence ORs of varicose veins for female gender became non-signicant when adjusted by various occupations (Table 4, model 3). This shows that, in the prevalence of varicose veins, occupational characters could be more inuential than gender itself. A partial reason why women had a higher prevalence of varicose veins may be explained by the dierent circumstances and conditions associated with standing at work between women and men. In this study, most of the men who stood at work were street cleaners, whose standing work involved slow walking, whereas about half of the women were sales workers, who stood in a static position for over 70% of their work time (Laperriere et al. 2006, Jung et al. 2010). Regarding nocturnal leg cramps, women showed higher prevalence of nocturnal leg cramps irrespective of their work posture and this was consistent with a previous study (Abdulla et al. 1999). Furthermore, gender had signicant associations with nocturnal leg cramps even after adjusted for prolonged standing and various occupations. Therefore, biological dierences between women and men could play an important role in the occurrence of nocturnal leg cramps in response to prolonged standing. However, signicant relationships between prolonged standing and nocturnal leg cramps still exist where gender eects remain. Higher prevalence of nocturnal leg cramps in women appears to be due to both biological and occupational factors. Unfortunately, no studies that explore the relationship between occupational factors and nocturnal leg cramps or intervention studies dealing with occupational factors were found. Thus, further studies are needed. On the other hand, several intervention studies demonstrated that using a sitstand chair, wearing soft shoes, using shoe insoles, standing on a soft surface or standing on a oor mat helped to reduce leg swelling, discomfort and fatigue in the lower extremities (Hansen et al. 1997, Madeleine et al. 1998, Chester et al. 2002, King 2002, Orlando and King 2004, Zander et al. 2004). This study found that standing at work with non-heeled shoes decreased the prevalence ORs for varicose veins in both genders. Women with nonheeled shoes (53.8%) show OR 0.69 with 95% CI 0.49 0.97 and men with non-heeled shoes (73.9%) show OR 0.58 with 95% CI 0.350.96 among prolonged standing workers. However, the prevalence OR of nocturnal leg cramps was not signicant according to the type of shoes. The reason why these interventions were not eective in cases of nocturnal leg cramp is unclear. A prospective study should examine the role of the

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