Association of diurnal patterns in salivary cortisol with all-cause and cardiovascular mortality: findings from the Whitehall II study

J Clin Endocrinol Metab. 2011 May;96(5):1478-85. doi: 10.1210/jc.2010-2137. Epub 2011 Feb 23.


Context: Evidence for the association of cortisol with mortality or disease events is mixed, possibly due to a failure to consider diurnal cortisol patterns.

Objective: Our objective was to examine the association of diurnal cortisol patterns throughout the day with cardiovascular and noncardiovascular mortality in a community-dwelling population.

Design: This was a prospective cohort study among 4047 civil servants, the Whitehall II study, United Kingdom. We measured diurnal cortisol patterns in 2002-2004 from six saliva samples obtained over the course of a normal weekday: at waking, +30 min, +2.5 h, +8 h, +12 h, and bedtime. Participants were subsequently followed for all-cause and cause-specific mortality until January 2010.

Participants: Participants included 4047 men and women aged 61 yr on average at baseline.

Outcomes: We assessed all-cause, cardiovascular, and noncardiovascular death.

Results: There were 139 deaths, 32 of which were deaths due to cardiovascular disease, during a mean follow-up period of 6.1 yr. Flatter slopes in cortisol decline across the day were associated with increased risk of all-cause mortality (hazard ratio for 1 sd reduction in slope steepness 1.30; 95% confidence interval (CI) = 1.09-1.55). This excess mortality risk was mainly driven by an increased risk of cardiovascular deaths (hazard ratio = 1.87; 95% confidence interval = 1.32-2.64). The association with cardiovascular deaths was independent of a wide range of covariates measured at the time of cortisol assessment. There was no association between morning cortisol, the cortisol awakening response, and mortality outcomes.

Conclusions: These findings demonstrate, for the first time, the relationship between a flatter slope in cortisol levels across the day and an increased risk of cardiovascular disease mortality in a nonclinical population.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Age Factors
  • Aged
  • Cardiovascular Diseases / mortality*
  • Circadian Rhythm / physiology*
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Health Behavior
  • Humans
  • Hydrocortisone / metabolism*
  • Male
  • Middle Aged
  • Mortality*
  • Prospective Studies
  • Risk Factors
  • Saliva / metabolism*
  • Sex Factors
  • Socioeconomic Factors
  • Stress, Psychological / metabolism
  • Stress, Psychological / mortality
  • United Kingdom / epidemiology


  • Hydrocortisone