Running head: OBESITY RISK AND NIGHT SHIFT WORK 1

Association of Obesity with Night Shift Work Among Nurses

Jessie Mbah

Delaware Technical Community College

April 28, 2019

OBESITY RISK AND NIGHT SHIFT WORK 2

Are nurses who work the night shift for two or more years, at increased risk of obesity,

compared to those who work day and evening shifts? According to the Centers for Disease

Control and Prevention (CDC), obesity can be defined as weight that is higher than what will be

considered to be a healthy weight, for a given height. Using the body max index (BMI) as a

screening tool for obesity, a BMI of 25.0 to 30.0 is considered overweight, and a BMI of 30.0

and above, is considered obese. Given the fact that patients need round the clock care, some

nurses have to work the night shift, in order to ensure continuity of care. Some research has

shown that some of the factors that contribute to weight gain in night workers include, the

consumption of high caloric dense snacks during work, inactivity or lack of exercise, and sleep

deprivation, due to desynchronization of their circadian rhythm (Marquez, Lemos, Soares,

Lorenzi-Filho, & Moreno, 2012). Interventions that involve modifying the work environment

such as providing free, healthy snacks for night shift nurses, creating exercise space, providing

educational programs on the health effects of night work, encouraging teamwork and introducing

full lighting spectrum to mitigate the effects of desynchronization of the circadian rhythm, can

lower obesity risks in night shift nurses.

Obesity and overweight related illnesses are on the rise among nurses, especially night

shift nurses. Aside from all other life stressors, night shift and rotating shift work, can have

undesirable health effects. Obese individuals are at increased risk of developing chronic illnesses

such as hypertension, diabetes, cardiovascular diseases and some forms of cancer. When nurses

call out sick, it can have detrimental effects on patient care and can also drive up overall health

care costs. Based on the fact that nursing is a very important part of the health care system,

nurses need to stay healthy, so they can provide safe, efficient and optimal patient care. A

number of interventions can be implemented to lower obesity risks, among night shift nurses.
OBESITY RISK AND NIGHT SHIFT WORK 3

Firstly, health care facilities should provide free, healthy snacks to their workers,

especially for night shift staff. Since it is common practice for night shift nurses to snack at night

so as to stay awake, having healthy snack choices readily available, might help with maintaining

a healthier diet. Even though providing healthier meal options may be costly, a healthier work

force will experience fewer call outs, hence increased productivity (Williams, 2012).

Secondly, employers should make it easy for workers to incorporate exercise in their

daily routine. Providing amenities such as onsite gyms, aerobic classes and walking trails, might

help nurses increase their activity level. Installing equipment such as stationary bikes near the

nurses’ station might be very helpful; instead of indulging in comfort foods, night nurses on less

busy nights, can incorporate light exercise in their schedules. Having such a routine at work

might help night nurses develop good life time exercise habits (Williams, 2012).

Thirdly, employers should provide educational programs on the health effects of night

work. Employers should also encourage teamwork and peer-support programs, programs such as

“counting your steps” where colleagues can post their progress in the program so as to motivate

and encourage one another. Health care facilities can also invest in wellness programs such

standing desks and nutrition counseling to help nurses stay healthy.

Recent studies have shown a link between sleep and obesity where, poor quality sleep

and reduced duration of sleep have been closely related to weight gain (Marqueze et al., 2012).

Research has shown that installing in full spectrum lighting system can help minimize circadian

desynchronization in night shift nurses (William, 2012). Mimicking daytime light at work, will

help night nurses reacclimatize to the normal sleep-wake cycle. Several research studies have

been conducted to support the association between obesity and night work among nurses.
OBESITY RISK AND NIGHT SHIFT WORK 4

One of such studies is an epidemiological cross-sectional study, that was conducted at a

public hospital. Of the 941 nursing professionals at the hospital, 548 of them voluntarily agreed

to participate in the study and 102 of them were further eliminated, leaving actual participants at

446. Data was collected from nurses through questionnaires filled out on sociodemographics,

health, work and lifestyle. The mean age of participants was 34.8 years. The average time

working in nursing was 9.5 years, on day shift and 6 years, on night shift. BMI was calculated

using self-reported body mass in kg and height in m, following the criteria of the World Health

Organization (WHO). A Kolmogorov-Smirnov test was used for descriptive statistics on the

independent and dependent variables. Data was analyzed using univariate and multiple linear

regressions with BMI as the dependent variable and age, time, working in nursing, working

hours in the day, working hours on night shift, and duration of self-reported sleep, were

independent variables. Approval for the research study was granted by the Ethics Committee of

the Faculty of Medicine, of the University of Sao Paulo (Marqueze et al, 2012). Analysis from

the linear regression showed a greater increase in BMI for night shift workers (0.24kg/m2),

compared to day shift workers (0.15kg/m2) per year of work. (Marqueze et al, 2012, p. 2046).

According to Amelsvoort et al, (as cited in Marqueze et al, 2012), the coefficient observed in a

previous study was (0.12 kg/m2). Also, the results did not show any difference in BMI between

day and night nurses in the last year. Even though short sleep duration is associated with weight

gain, it was not the case for night shift nurses in this study. Despite the said limitations, this

study and previous studies, support the findings that night shift nurses will likely see an increase

in body weight with age and number of years worked (Marqueze et al, 2012).

Another cross-sectional study was conducted among 724 female nurses and midwives,

aged, between 40 to 60 years, and who were currently working in a public health setting in Lodz,
OBESITY RISK AND NIGHT SHIFT WORK 5

Poland of which 354 of them worked rotating shifts, and the remaining 370, were day shift

nurses. Data was obtained through structured questionnaires during in-person interviews.

Information collected included occupational history, medical and reproductive history,

demographics, hormone use, physical activity, smoking, alcohol use, diet and sleep quality

(Peplonska, Bukowska, & Sobala, 2015). The Ethical Review Board at the Nofer Institute of

Occupational Medicine approved the study, and signed informed consents were obtained from all

the participants. Weight(kg), height (m), and waist and hip (cm), circumferences of all

participants, were measured. Body mass index (MBI) was calculated using WHO standards

where 25kg/m2 to 29.99kg/m2 was considered overweight, and BMI equal or greater than 30,

was considered obese. The cut-off for waist circumference (WC) was 88 cm, and waist to hip

ratio (WHR), of 0.85 cm. The boundary value for waist to height ration for women less than 50

years was 0.55, and 0.6 for women 50 years and older (Peplonska et al, 2015). A chi-square test

was used for the categorical variables and the Student’s t-test was compared to basic

characteristics of the study groups by their current night shift work status, for the continuous

variable (Peplonska et al, 2015). R version 3.1.1 (Vienna, Austria) was used to perform statistical

analysis. Study results showed a statistically significant link between cumulative night shift work

and BMI, WC, HC, and WHtR with an increase in BMI of 0.477 kg/m2 per 1000-night shift

duties and 0.432 kg/m2 per 1000-night shift hours. WC increased by 1.089 cm for night shift

nurses and 0.997 for day shift duties. WHtR was 0.007 for both night and day shifts. Both

current and cumulative night shift work was consistently associated with obesity. A high

frequency of current night duties and cumulative hours of night shift work was associated with

abdominal obesity. 17 out of 20 previous epidemiological studies showed positive inferences

between night work and anthropometric parameters (Peponska et al, 2015). The study had some
OBESITY RISK AND NIGHT SHIFT WORK 6

limitations. The fact that questionnaires were completed based on recall, it is likely that the

information might not have been accurate. The study did not also include factors such as work

family balance or stress. Although BMI was measured following WHO standards, the cut-off

points that were included in the study for other anthropometric measures was also problematic

because no normal values or standards that can be generalized to every population has been

formulated for these measures. Also, the findings of the study cannot be generalized to other

populations because it was limited to nurses and midwives. That said, findings from the study

provide evidence that prolonged night shift is associated with central obesity. But due to sparse

epidemiological data, more research is needed to confirm the current findings.

Another cross-sectional, non-experimental study was performed in the eighteen largest

hospitals in Rio de Janeiro, Brazil. Data was collected using a comprehensive self-reported

questionnaire with the help of trained interviewers. Objectives of the study was explained to the

participants and written consents were obtained. Questionnaire was submitted to five rounds of

pretesting to improve clarity. BMI was calculated as weight in kg/height in m2 and was used as a

continues variable. A chi-square test was used for descriptive analysis and analysis of variance

(ANOVA) was used for continues variables. Predictions for BMI at different years of exposure

Sto work were made from the final model, considering all covariates. BMI at age 20 years, using

a free software R, version 2.15 (R Development Core Team Vienna, Austria). Ethical clearance

for the studies was obtained from the Oswaldo Cruz Foundation (Fiocruz) Ethics Research

Committee. Trained interviewers gave a brief explanation about the study to the participants and

the participants were informed that participation was voluntary and they were free to withdraw at

any time if they so wished without any repercussions. Of the 2,372 participants, 88.5 % were

women and 11 % were men. The mean age and standard deviation (SD) for women was 39.5
OBESITY RISK AND NIGHT SHIFT WORK 7

(9.8) and that for men was 41.3, (10.2). The overall results showed that night work plays a role in

increases in BMI. The findings showed that the effect on of night work on BMI was greater in

men (0,071) kg/m2 than for women (0.036) kg/m2 per year of night work. The estimated average

BMI was 24.2kg/m2 for the women who did not work at night and 24.3 kg/m2 for those who

worked at night for one year. For men, BMI was estimated at 25.0 kg/m2 for those who did not

work at night and 25.1 kg/m2 for those who worked at night for one year (Griep et al, 2014).

Recommended improvements in the work environment such as, the provision of proper meals to

night workers as well as educational programs on the effects of night work on health, can be

helpful. Two self-reported variables related to the past like weight at 20 years old, and night

work for both current and past night workers could have been affected by workers’ memories.

The small size of the male sample may have influenced the findings, leading to lack of statistical

power to detect the influence of covariates on the association between years worked at night and

BMI. Despite the fact that study findings suggest that night work can cause increased BMI, more

research is needed on this topic to determine if such findings are applicable beyond the current

settings. Further research will also assist to better understand the biological mechanisms

involved and the complex behavioral and social challenges experienced by night shift workers.

A qualitative research study was also conducted to determine if there is an association

between night shift work and obesity among nurses. Data, was collected through twelve focus

group discussions (FGDs) with nurses, and seven key informant interviews (KIIs) with

management personnel. The goal of the FGDs, were to get a better understanding of nurses’

health concerns, their health priorities and barriers to living a healthy life-style. On the other

hand, the aim of the KIIs with management was to get their viewpoint on health promotion in the

work place (Phiri, et al., 2014). All twenty-two hospitals, in the Western Cape Metropole region
OBESITY RISK AND NIGHT SHIFT WORK 8

in South Africa, were eligible to participate but only eleven of them were purposely sampled to

participate in the study. Out of the eleven hospitals, only five accepted to participate in the study

(Phiri, et al., 2014). Purposive sampling was also used to select the nurses in the focus groups.

There were ninety-three nurses in total; fifty-seven, from night shift, and thirty-six from day

shift. None of the nursing managers were invited to the focus groups so as to prevent managerial

intimidation. KIIs, were one-on-one interviews with the seven managers and, the seventh

interview was with three managers (Phiri et al., 2014, p.3). The focus groups and interviews were

conducted by a trained facilitator using guided questions such as: “What are your main personal

health concerns?”, “What are the main health concerns in your workplace?”, and “How does

your work affect your lifestyle behaviors and health?” (Phiri, et al., 2014). According to Phiri et

al., (2014), transcripts were analyzed using thematic analysis with the assistance of Atlas.ti

Qualitative Data Analysis Software (Scientific Software Development GmbH, Berlin, Germany),

with the aim of identifying main themes and sub-themes of the study. Approval for the study was

obtained from the University of Cape Town Research Ethics Committee of the Faculty of Health

Science (REC REF: 212/2012) and from the Western Cape Department of Health, for the

research study to be carried out in their hospitals (Ref No:2012; RP 121). All the participants

gave written consent before participating in the focus groups and interviews (Phiri et al., 2014).

All the 22 public hospitals in the Western Cape region, were eligible for the study. Of the eleven

hospitals invited to participate in the research study, only five agreed to take part in the study:

these included three district hospitals, one specialist hospital, and one tuberculosis hospital. Of

the 102 participants, 9 were management personnel (key informant interviewees), 57 night- shift

nurses and 36 day-shift nurses. Night shift nurses frequently identified weight gain and living

with NCDs such as hypertension as their main health concerns. In addition, they mentioned lack
OBESITY RISK AND NIGHT SHIFT WORK 9

of time to prepare healthy meals due to long working hours and being overtired from work.

Another theme from the focus groups was the unavailability of healthy foods and high caloric

dense foods offered at the hospitals’ cafeterias (Phiri et al., 2014). Nurses, identified preference

for a worksite health promotion program (WHPP), that would provide access to fitness facilities

and massage sessions. The finding of the study, highlighted the need for a WHPP, that involved

nurses in the planning process such that, it is tailored to the needs of the nurses. The WHIPP

aimed at reducing NCD health-related conditions such as obesity and overweight, managing

stress and transforming the work environment to facilitate healthy lifestyles. The strengths of the

study were the naturalistic environment in which the study was conducted and the representation

from various wards and shifts, from different types of hospitals in the Western Cape Town

Metropole area. The limitations of the study were the challenges that night shift nurses had to

attend the FGDs, and the fact that the research study was conducted only in the Western Cape

public hospitals with no private hospitals participating. Furthermore, only five hospitals of the

eleven invited, took part in the study and Primary Health Care facilities were not included. By

conducting group interviews, some participants may have been prohibited from freely voicing

out their thoughts, in the presence of other colleagues. More research is needed on this topic as

such findings, might trigger response to these problems discussed above, thereby Standardizing

the need for inclusive worksite wellness programs to improve nurses’ health and lifestyle

behaviors, including physical activity.

Other research reviews were conducted using experimental, observational and double-

blinded controlled randomized clinical trials. The studies showed prospective evidence that

rotating shift workers had elevated Body Max Index (BMI), are at increased risk of circulatory

diseases and are at increased risk of developing metabolic syndrome over a period of six years
OBESITY RISK AND NIGHT SHIFT WORK 10

(Antunes et al, 2010). Other studies found that, sleep-wake schedules could lead to an increased

daily range in circulating leptin, with the lowest leptin levels upon awaking. The influence of

leptin on food intake and energy balance, could be linked to the increased prevalence of obesity

in the population of shift workers (Antunes et al, 2010). Hence, it is important to provide

guidelines regarding better adaptation, and interventions such as early screening for risk factors

such as obesity and its comorbidities, in order to identify individuals at increased risk. Health

care facilities should also provide lifestyle and dietary counselling; formulate a dietary plan for

shift workers, and introduce exercise and sleep education programs. Further research should be

conducted on the link between the circadian disruption and metabolic conditions in shift workers.

(Antunes et al., 2010). Some of the limitations of the studies include self-reported weights and

heights that were not measured. Also, some samples contained sample heterogeneity whereby

differences in socio-economic status, sex and schooling could have influenced obesity numbers

(Antunes et al., 2010).

Based on the above analysis, it can be concluded that nurses who work the night shift are

at increased risk of obesity, compared to nurses who work day and evening shifts. Such risks can

be lowered if employers invest in improving the work environment, by providing amenities that

encourage physical activity and better eating habits during work. Providing wellness and heath

educational programs for rotating shift workers, might also help to lower obesity risks among

night shift nurses.

OBESITY RISK AND NIGHT SHIFT WORK 11

References
Antunes, L. C., Levandovski, R., Dantas, G., Caumo, W., & Hidalgo, M. P. (2010). Obesity and

shift work: chronobiological aspects. Nutrition Research Reviews, 23(1), 155–168.

https://doi-org./10.1017/S0954422410000016

Griep, R. H., Bastos, L. S., de Jesus Mendes da Fonseca, M., Silva-Costa, A., Fernandes Portela,

L., Toivanen, S., & Rotenberg, L. (2014). Years worked at night and body mass index

among registered nurses from eighteen public hospitals in Rio de Janeiro, Brazil. BMC

Health Services Research, 14(1), 603–620. https://doi-org./10.1186/s12913-014-0603-4

Peplonska B, Bukowska A, Sobala W. Association of Rotating Night Shift Work with BMI and

Abdominal Obesity among Nurses and Midwives. PLoS ONE. 2015;10(7):1-13.

http://doi: 10.1371/journal.pone.0133761.

Phiri, L. P., Draper, C. E., Lambert, E. V., & Kolbe-Alexander, T. L. (2014). Nurses’ lifestyle

behaviours, health priorities and barriers to living a healthy lifestyle: a qualitative

descriptive study. BMC Nursing, 13(1), 38. https://doi.org/10.1186/s12912-014-0038-6

Williams, G. M. (2017). Obesity Among Night Shift Nurses: Time to Intervene. American

Journal of Public Health, 107(1), 41–42. https://doi-org./10.2105/AJPH.2016.303511