DOI 10.1007/s10654-010-9438-4
CARDIOVASCULAR DISEASE
Received: 14 August 2009 / Accepted: 4 March 2010 / Published online: 18 March 2010
Springer Science+Business Media B.V. 2010
had adverse triglyceride levels. Adjustment for socioeconomic, occupational factors and health behaviours
explained most associations except for adiposity and
C-reactive protein. Our results highlight night and early
morning working associations with an adverse profile of
CVD risk factors, which are partly explained by socioeconomic, other occupational factors and health behaviours.
Keywords Cardiovascular disease Cohort studies
Employment Shift work Work hours
Abbreviations
BMI
Body mass index
CHD
Coronary heart disease
CI
Confidence interval
CRP
C-reactive protein
CVD
Cardiovascular disease
HbA1c Glycosylated haemoglobin
HDL
High density lipoprotein
SD
Standard deviation
UK
United Kingdom
WC
Waist circumference
Introduction
Understanding the links between exposures in the workplace, such as shift-work, and cardiovascular disease (CVD)
is essential to tackling socioeconomic inequalities in health
[1]. Not only being in work but experiencing good working
conditions are vital for health and well-being [2, 3].
More than 3.5 million people are employed as shiftworkers in the UK [4]. Although most research on the
health consequences of shift-work focuses on night or
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C. Thomas, C. Power
Methods
Measurement of shift-work
Study sample and design
Data are mainly from the 45 years and 42 years surveys of
the 1958 British birth cohort. The cohort consists of 18,558
individuals: born in one week in March 1958 in England,
Scotland and Wales (17,638) with the addition of immigrants
(n = 920) with the same birth dates up to age 16 years [23].
At 45 years, 11,971 cohort members who had not died or
emigrated, were still in contact with the survey, and who
were able to provide informed consent were invited to a
clinical examination undertaken in their home by a trained
nurse; 9,377 (78%) participated. Ethical approval for the
45 years follow-up was given by the South East MultiCentre Research Ethics Committee. Information from earlier
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307
Results
Men had less favourable levels of all risk factors for CVD
compared to women except for CRP and were also more
likely to undertake shift-work (Table 1). Evening work
(18002200) was most common for both men and women
(54 and 37%, respectively), while men were more likely to
participate in all forms of shift-work. Approximately 50%
of those working nights also worked early mornings, while
94 and 75% of night and morning workers, respectively,
also worked evenings (Supplementary Table 1).
Most shift-work types were associated with risky health
behaviours with a few notable exceptions (Table 2). There
was no difference in the percentage of evening workers
who smoked. Lack of exercise was associated only with
weekend work, and frequency of fried food and chip consumption was not always consistently related to shift-work.
Alcohol consumption was higher for evening and weekend,
but not for night or morning work.
First for total burden of shift-work, Fig. 1 presents differences in CVD risk factors according to the number of
types of regular shift-work. For men, there was a significant positive linear trend between number of shift-work
types and BMI, WC, total cholesterol, triglycerides, HbA1c
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308
C. Thomas, C. Power
Table 1 Shift work patterns at 42 years and CVD risk factors at 45 years in 4,141 Male and 3,698 Female Members of the 1958 Cohort
Men
Women
Total N
n (%)
Total N
n (%)
P-valueb
4,138
2,710 (65.5)
3,696
1,665 (45.0)
\0.001
368 (10.0)
\0.001
662 (16.0)
Morning (04000700)
776 (18.7)
300 (8.1)
\0.001
Evening (18002200)
2,226 (53.8)
1,357 (36.7)
\0.001
Weekend
1,358 (32.8)
864 (23.4)
\0.001
1,428 (34.5)
2,031 (55.0)
1 type
865 (23.4)
2 types
782 (18.9)
474 (12.8)
3 types
4 types (all)
471 (11.4)
196 (4.7)
228 (6.2)
98 (2.7)
\0.001
Night/mornings C1/week
0 (no night or morning)
3,056 (73.9)
3,203 (86.7)
1 (night or morning)
726 (17.5)
318 (8.6)
356 (8.6)
175 (4.3)
1,552 (37.5)
2,071 (56.0)
1 (evening or weekend)
1,558 (38.4)
1,029 (27.8)
998 (24.1)
596 (16.1)
\0.001
Evenings/weekends C1/week
Mean (SD)
2
BMI (kg/m )
4,131
27.82 (4.22)
\0.001
Mean (SD)
3,687
26.92 (5.47)
\0.001
4,114
98.38 (10.94)
3,666
85.26 (12.56)
\0.001
4,116
132.91 (14.95)
3,659
120.32 (15.50)
\0.001
\0.001
4,116
82.08 (10.39)
3,659
75.59 (10.24)
Triglycerides (mmol/l)c
3,510
2.08 (1.22)
3,074
1.34 (0.71)
\0.001
3,523
6.07 (1.13)
3,081
5.68 (0.99)
\0.001
HDL-cholesterol (mmol/l)
3,510
1.44 (0.33)
3,079
1.70 (0.40)
\0.001
HbA1c (%)c
3,565
5.27 (0.57)
3,120
5.15 (0.47)
\0.001
3,393
0.91 (0.95)
2,931
0.94 (1.13)
0.19
3,444
2.86 (0.56)
3,016
3.00 (0.61)
\0.001
Fibrinogen (g/l)e
BMI body mass index; HbA1c glycosylated haemoglobin; HDL high density lipoprotein
a
and CRP levels. Trends for fibrinogen and HDL were nonsignificant. For those with the heaviest shift-work burden,
regularly working all four shift-work types, CVD risk
factors were approximately 0.10.2 standard deviations
(SD) higher than non shift-workers. For example, this
equates to an increased BMI and WC of 0.8 kg/m2 and
1.2 cm, respectively. For women, there was a positive
linear trend for triglyceride levels only, but an inverse
relationship for DBP. The associations for CVD risk
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309
Table 2 Relationships between shift-work, confounding and health behaviour mediating variables at 42 years
Nights, %
Mornings, %
Evenings, %
\1/week
C1/week
\1/week
C1/week
\1/week
Self-employed
14.0
18.7***
14.7
14.3
20.1
40.2***
19.7
41.2***
33.8
39.2***
32.0
50.6***
39.8
Weekends, %
C1/week
\1/week
C1/week
9.5
20.8***
10.8
24.3***
10.6
39.1***
16.2
41.8***
28.3***
33.5
37.3***
Current smoker
22.1
26.4***
21.6
29.4***
22.8
22.6
21.7
25.3***
Exercises B1/week
33.7
34.5
33.6
35.1
33.3
33.2
32.5
37.1***
42.2
46.1*
42.0
47.0**
40.4
45.4***
41.1
46.6***
45.8
43.8
49.2*
45.9
46.0
43.2
47.9
49.4***
43.2
45.2
49.9***
42.6*
45.2
43.0
48.9**
46.8**
20.8
21.2
21.2
18.7
18.4
23.8***
20.2
22.5*
Fig. 1 Differences in CVD risk factor SD scores in association with number of types of regular shift work (nights, early mornings, evenings or
weekends C1/week). * Trend P \ 0.05. Vertical bars represent 95% confidence intervals
Next, for separate analyses of night/morning and evening/weekend work, associations were found primarily for
the former and few for the latter (Fig. 2). Among men,
adverse levels of all CVD risk factors except for blood
123
42
-29
0.019 (-0.007, 0.045)
24
-50
-58
-65
0.011 (-0.011, 0.034)
-37
-66
-70
-32
All
%
Health behavioursb
Physical activity, diet, smoking and alcohol (plus BMI and WC in non-adiposity models)
27
29
0.049 (0.018, 0.080)
3,020
Triglycerided
3,153
DBPd
-26
0.023 (-0.004, 0.051)
0.031 (0.006, 0.056)
3,329
3,441
Triglycerided
CRP
Women
7
0.029 (-0.001, 0.059)
3,495
-24
-38
0.018 (-0.006, 0.043)
-40
HbA1cc
4,048
WC
Men
%
Confoundersa
Adjustments
Unadjusted
N
123
-54
Discussion
Outcome
Table 3 Differences in CVD risk factor SD scores (95% CI) per unit increase in number of regular shift types with adjustments for confounders and health behaviours
-36
C. Thomas, C. Power
-46
310
311
Fig. 2 Differences in CVD risk factor SD scores in association with regular (C1/week) night/early morning work and evening/weekend work.
* Trend P \ 0.05. Vertical bars represent 95% confidence intervals
detect gender differences in associations between shiftwork and CVD risk factors, which could be due to the
smaller number of women participating in shift-work.
Although the only significant finding for women who regularly undertook night-work was increased triglycerides,
associations with adiposity and HDL were of a similar
magnitude to those seen for men, suggesting that women
may be similarly affected by night-work. Our findings are
consistent with those from other population-based studies
that have also reported increased adiposity and triglyceride
levels in female night-workers [9, 10]. We also found that
women regularly working shift-work had lower DBP, thus
raising the possibility of selection effects, such that women
with hypertension do not undertake shift-work [35].
Selection effects may also explain the lack of association
seen for blood pressure in men. Evidence for an association
between night-work and blood pressure is generally weak
[20]. Effect sizes may be underestimated if selection out of
shift-work is related to high blood pressure, which is
plausible given the free health assessments offered to nightworkers under the European working hours directive [36].
In accordance with previous studies, we found regular
night-work to be associated with adverse levels of several
123
123
3,441
3,441
3,495
3,329
3,377
HDL
Triglycerided
HbA1cc
CRP
Fibrinogen
3,453
Total chol
Unadjusted
Confoundersa
Adjustments
Physical activity, diet, smoking and alcohol (plus BMI and WC in non-adiposity models)
Adjusted for diabetes treatment
Social class, total hours worked/week, employee or self employed, evening/weekend work index
4,048
BMI
Men
Evening/weekend work
Triglycerided
3,020
4,048
Women
4,048
WC
BMI
Men
Night/morning work
Outcome
-37
-105
-26
-40
-16
-56
29
-11
-23
-33
Health behavioursb
-24
10
-49
-77
-52
-54
-110
-75
All
-47
100
-54
-84
-43
-91
-59
-56
-15
-30
Table 4 Differences in CVD risk factor SD scores (95% CI) per unit increase in night/morning work and evening/weekend work with adjustments for confounders and health behaviours
312
C. Thomas, C. Power
313
from funding support from the Medical Research Council in its
capacity as the MRC Centre of Epidemiology for Child Health. This
work was presented at the Society for Social Medicine Annual
Meeting, Southampton, UK, September 2008.
References
1. MacDonald LA, Cohen A, Baron S, Burchfiel CM. Occupation as
socioeconomic status or environmental exposure? A survey of
practice among population-based cardiovascular studies in the
United States. Am J Epidemiol. 2009;169(12):141121.
2. Black C. Working for a healthier tomorrow. London: The Stationary Office; 2008.
3. Coats D, Max C. Healthy work: productive workplaces: why the
UK needs more good jobs. London: The Work Foundation and
The London Health Commission; 2005.
4. Health and Safety Executive. Shift work and fatigue. 30/11/2007
[cited 1/2/2008]. Available from: URL: http://www.hse.gov.uk/
humanfactors/shiftwork/index.htm.
5. Monk T, Folkard S. Making shift work tolerable. London: Taylor
and Francis; 1992.
6. Rajaratnam SM, Arendt J. Health in a 24-h society. Lancet.
2001;358(9286):9991005.
7. Bggild H, Knutsson A. Shiftwork, risk factors and cardiovascular disease. Scand J Work Environ Health. 1999;25:8599.
8. Di Lorenzo L, De Pergola G, Zocchetti C, LAbbate N, Basso A,
Pannacciulli N, et al. Effect of shift work on body mass index:
results of a study performed in 319 glucose-tolerant men working
in a Southern Italian industry. Int J Obes Relat Metab Disord.
2003;27(11):13538.
9. Karlsson B, Knutsson A, Lindahl B. Is there an association
between shift work and having a metabolic syndrome? Results
from a population based study of 27, 485 people. Occup Environ
Med. 2001;58(11):74752.
10. Lasfargues G, Vol S, Caces E, Le CH, Lecomte P, Tichet J.
Relations among night work, dietary habits, biological measure,
and health status. Int J Behav Med. 1996;3(2):12334.
11. Morikawa Y, Nakagawa H, Miura K, Soyama Y, Ishizaki M,
Kido T, et al. Effect of shift work on body mass index and
metabolic parameters. Scand J Work Environ Health. 2007;
33(1):4550.
12. Niedhammer I, Lert F, Marne MJ. Prevalence of overweight and
weight gain in relation to night work in a nurses cohort. Int J
Obes Relat Metab Disord. 1996;20(7):62533.
13. Parkes KR. Shift work and age as interactive predictors of body
mass index among offshore workers. Scand J Work Environ
Health. 2002;28(1):6471.
14. van Amelsvoort LG, Schouten EG, Kok FJ. Duration of shiftwork
related to body mass index and waist to hip ratio. Int J Obes Relat
Metab Disord. 1999;23(9):9738.
15. Nagaya T, Yoshida H, Takahashi H, Kawai M. Markers of insulin
resistance in day and shift workers aged 3059 years. Int Arch
Occup Environ Health. 2002;75(8):5628.
16. Morikawa Y, Nakagawa H, Miura K, Ishizaki M, Tabata M,
Nishijo M, et al. Relationship between shift work and onset of
hypertension in a cohort of manual workers. Scand J Work
Environ Health. 1999;25(2):1004.
17. Fialho G, Cavichio L, Povoa R, Pimenta J. Effects of 24-h shift
work in the emergency room on ambulatory blood pressure
monitoring values of medical residents. Am J Hypertens. 2006;
19(10):10059.
18. Romon M, Nuttens MC, Fievet C, Pot P, Bard JM, Furon D, et al.
Increased triglyceride levels in shift workers. Am J Med.
1992;93(3):25962.
123
314
19. Mikuni E, Ohoshi T, Hayashi K, Miyamura K. Glucose intolerance in an employed population. Tohoku J Exp Med. 1983;
141(Suppl):S2516.
20. Knutsson A, Bggild H. Shiftwork and cardiovascular disease: a
review of disease mechanisms. Rev Environ Health. 2000;15:
35972.
21. van Amelsvoort LG, Jansen NW, Kant I. Smoking among shift
workers: more than a confounding factor. Chronobiol Int.
2006;23(6):110513.
22. Kivimaki M, Kuisma P, Virtanen M, Elovainio M. Does shift
work lead to poorer health habits? A comparison between women
who had always done shift work with those who had never done
shift work. Work Stress. 2001;15:313.
23. Power C, Elliott J. Cohort profile: 1958 British birth cohort
(National Child Development Study). Int J Epidemiol. 2006;35:
3441.
24. Wood AM, White I, Thompson SG, Lewington S, Danesh J.
Regression dilution methods for meta-analysis: assessing longterm variability in plasma fibrinogen among 27, 247 adults in 15
prospective studies. Int J Epidemiol. 2006;35(6):15708.
25. Pearson TA, Mensah GA, Alexander RW, Anderson JL, Cannon
RO III, Criqui M, et al. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for
Disease Control and Prevention and the American Heart Association. Circulation. 2003;107(3):499511.
26. Parsons TJ, Manor O, Power C. Changes in diet and physical
activity in the 1990s in a large British sample (1958 birth cohort).
Eur J Clin Nutr. 2005;59:4956.
27. White H. A heteroskedasticity-consistent covariance matrix
estimator and a direct test for heteroskedasticity. Econometrica.
1980;48(4):81738.
123
C. Thomas, C. Power
28. Atherton K, Fuller E, Shepherd P, Strachan DP, Power C. Loss
and representativeness in a biomedical survey at age 45 years:
1958 British birth cohort. J Epidemiol Community Health.
2008;62:21522.
29. Riedmann A, Bielenski H, Szcurowska T, Wagner A. Working
time and work-life balance in European companies. 14/1/2008
[cited 1/2/2008]. Available from: URL: http://www.eurofound.
europa.eu/publications/htmlfiles/ef0627.htm.
30. Beese B. Comparative survey on operating hours and working
time. 11/7/2006 [cited 1/2/2008]. Available from: URL: http://
www.eurofound.europa.eu/ewco/2006/05/DE0605059I.htm.
31. McOrmond T. Changes in working trends over the past decade. 8/
1/2004 [cited 1/2/2008]. Available from: URL: http://www.
statistics.gov.uk/CCI/article.asp?ID=684&Pos=2&ColRank=2&
Rank=224.
32. MacDonald LA, Cohen A, Baron S, Burchfiel CM, MacDonald,
et al. Respond to search for preventable causes of cardiovascular
disease. Am J Epidemiol. 2009;169(12):14267.
33. Bansal S, Buring JE, Rifai N, Mora S, Sacks FM, Ridker PM.
Fasting compared with nonfasting triglycerides and risk of cardiovascular events in women. JAMA. 2007;298(3):30916.
34. Nordestgaard BG, Benn M, Schnohr P, Tybjaerg-Hansen A.
Nonfasting triglycerides and risk of myocardial infarction,
ischemic heart disease, and death in men and women. JAMA.
2007;298(3):299308.
35. Knutsson A. Methodological aspects of shift-work research.
Chronobiol Int. 2004;21(6):103747.
36. Harrington JM. Health effects of shift work and extended hours
of work. Occup Environ Med. 2001;58:6872.
37. Lavie L, Lavie P. Elevated plasma homocysteine in older shiftworkers: a potential risk factor for cardiovascular morbidity.
Chronobiol Int. 2007;24(1):11528.
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