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1 Nofer Institute of Occupational Medicine, Łódź, Poland

Department of Environmental Epidemiology

2 Polish Social Insurance Institution, Second Branch in Łódź, Łódź, Poland 3 Medical University of Lodz, Łódź, Poland

Department of Nutrition Hygiene and Dietetics Abstract

The shift work system may affect the temporal distribution of eating and diet quality. The paper aimed at reviewing a body of research examining the associations between night shift work and dietary habits among nurses. Data from the PubMed and Google Schoolar databases, as well as references lists in selected papers were searched. The authors used the following keywords: nurses, shift work, diet, nutrition. Papers published in English or Polish were selected for the review, and as many as 19 papers published in 2000−2017 were eventually identified. The studies varied greatly with respect to the study size, subjects’ age and the duration of night shift work. The major problem was the heterogeneity of the tools used for dietary assessment. Self-administered questionnaires were used and analyses were rarely adjusted for confounders. Alcohol consumption was the most frequently analyzed aspect (N = 8 studies), followed by the total energy (N = 7), protein, fat (N = 6), and carbohydrate intake, coffee and fruit consumption (N = 5). The results showed quite a consistent association of night work with higher coffee (caffeine) consumption, as well as lower alcohol, and fruit and vegetables consumption. Few studies also reported more frequent snacks consumption, later time of the last meal, eating at night, meals irregularity, and a poorer diet quality among night shift nurses when compared to the reference. The review showed some poor nutritional habits among nurses working night shifts. However, the topic warrants further attention, owing to the relatively small number of the studies performed so far, and their numerous methodological limitations. Med Pr. 2019;70(3):363–76

Key words: shift work, lifestyle, nurses, circadian rhythms, nutrition, night work

Corresponding author: Beata Pepłońska, Nofer Institute of Occupational Medicine, Department of Environmental Epidemiology, św. Teresy 8, 91-348 Łódź, Poland, e-mail: beata.peplonska@imp.lodz.pl

Received: September 13, 2018, accepted: November 22, 2018

THE ASSOCIATION BETWEEN NIGHT SHIFT WORK

AND NUTRITION PATTERNS AMONG NURSES:

A LITERATURE REVIEW

REVIEW PAPER

BACKGROUND

About 20% of the workforce in general work night

shifts [1]. The shift work system, and night work in

par-ticular, is frequently found in health care, due to the 24-h

medical service required for hospital patients. Nurses’

work frequently involves shift work and night work.

Many epidemiological studies conducted among

shift workers have shown a higher risk of chronic

diseas-es, including cardiovascular disease, diabetdiseas-es, metabolic

syndrome or even cancer [2]. Moreover, such conditions

as sleep disorders [3] and obesity [4] are more

frequent-ly observed among night shift workers than among day

workers. Circadian rhythm disruption has been

pro-posed as one of the possible underlying mechanisms [3].

Among the issues closely related to irregular

work-ing hours is the irregularity of food consumption. How-

ever, this abnormal circadian timing of meals may have

adverse effects on the processes of digestion, nutrient

absorption, enzyme activity, and metabolism, as well as

the sensations of hunger, appetite and satiety [5].

The association between the shift work system and

nutrition has been investigated since the mid-1960’s.

Lowden et al. identified as many as 21 research articles

published between 1967−2009 that reported on studies

concerning a possible relationship between shift work

and dietary habits [6]. They concluded that shift work

significantly affected the temporal distribution of

eat-ing, diet quality, and energy distribution over the course

of the day. The authors of another review covering the

Funding: This research was supported by the Nofer Institute of Occupational Medicine (statutory institutional grant No. 10.32/2017 entitled: “The association between night shift work and nutrition patterns of nurses and midwives,” principal investigator: Beata Pepłońska, M.D., Ph.D.).

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period of 1990−2007 noted that in most of the 7

stud-ies identified (including 2 conducted among nurses)

some adverse effects on nutrition were observed, such

as more frequent and poor quality meals [7]. The most

recent review of research in this field [8] has also

point-ed out a poorer diet quality among shift workers. The

reviews have identified certain methodological

limita-tions of the studies, such as small population samples,

the use of less-valid dietary assessment methods, or the

lack of comparisons with the non-exposed, reference

group of day workers [6,8].

To the best of the authors’ knowledge, no review of

the studies devoted to the assessment of shift work and

night work among nurses, and their nutrition habits,

have been performed to date. The shift work of nurses is

usually organized according to the fast rotating scheme,

and it often involves night work. It can be assumed that

the nurses' professional background implies a better

understanding of health-related issues, including also

those related to healthy diet and nutrition, as compared

to that expected in the general population and among

blue collar workers performing shift work. Some

spe-cific factors, like an insufficient time for rest or stress,

may also influence dietary choices in this professional

group. Therefore, it can be presumed that the

conclu-sions from the previously reported reviews may not

di-rectly apply to nurses.

In the present report, the authors aimed at

review-ing the research devoted to the associations between

night shift work of nurses and their dietary habits,

seeking to determine whether any improper behaviors

might be the case.

MATERIAL AND METHODS

The literature review was based on data from the

PubMed and Google Scholar databases, as well as on

the citations search performed in selected papers. The

following combinations of keywords: “nurses and shift

work and diet” or “nurses and shift work and nutrition”

were used. Papers published in English or Polish were

selected for the review, and only those that concerned

the differences in nutrition patterns by the system of

work among nurses were included. Eventually, as many

as 19 publications were identified in this field.

RESULTS

The basic characteristics of the studies that were

sub-ject to review, including study design, population size,

shift work characteristics, diet characteristics and major

findings, are displayed in Table 1.

The studies are presented in chronological order,

with the focus on methodological aspects.

The study by Geliebter et al. included 85 subjects:

nurses, nurses aids and security personnel [9]. The

dif-ferences in dietary characteristics were compared

be-tween late shift (evening and night) workers and day

workers. The study focused on the times and number

of main meals, time of the last meal, and whether daily

food intake changed since the start of the current shift.

The study showed that the late shift workers reported

fewer meals than the day workers, and a later hour of

the their last daily meal. A trend could also be noted

for the late shift workers to eat more since the

begin-ning of the later shift. The analysis included age, years

of shift work and smoking as covariates. The study was

limited by a small population size and the use of an

un-validated questionnaire. Moreover, the night shift and

evening shift workers were combined into 1 category;

consequently, the differences in effects between these

2 groups could not be distinguished.

Reeves et al., in their study assessing the dietary

hab-its of 36 subjects who were the male and female staff of

nursing homes and hospitals, used 6-day food diaries [10].

The researchers also asked questions about the

num-ber of main meals and snacks. The data collected were

then analyzed using Diet 5 for Windows, which allows

for determining the total energy, carbohydrate, fat and

protein intake, as well as alcohol consumption. No

dif-ferences between the night shift and day workers were

observed in terms of the total energy consumption. The

night shift workers reported consuming food during

night hours while on night duty. Women working

night shifts were more likely to consume fewer meals

but more snacks per day than day workers. Moreover,

they reported drinking more coffee and tea cups per day

than female day workers. The study was limited by its

small population size and crude comparisons.

The study by Bilski et al. was conducted among

241 female nurses (171 working night shifts), and their

dietary habits were evaluated based on a set of

ques-tions inquiring about health behaviors during the night

shift [11]. The analysis showed that only 9.9% of nurses

had a hot meal during the night duty, which was

usu-ally some stodgy food, and as many as 9.9% reported

drinking only coffee during the night duty. The overall

daily coffee consumption was higher among the night

shift workers although no statistics were presented. The

study was limited by the lack of comparisons between

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Ta ble 1 . Th e m ai n c ha ra ct er ist ic s a nd r es ul ts o f t he 1 9 s tu di es i nc lu de d i n t he r ev ie w, a na ly zi ng d ie ta ry h ab its a cc or di ng t o t he s hi ft w or k s ta tu s a mo ng n ur se s Ref er en ce St udie d p op ul at io n Sys tem o f w or k/ Shift h our s Diet ar y a ss es sm en t t oo l (va lid at io n +/–) Diet c ha rac ter ist ics M os t im po rt an t r es ul ts G elie bt er et a l. (2000), USA, cros s-s ec tio na l [9] hos pi ta l w or ker s: n ur ses, nur ses a id s, s ec ur ity (m en an d w om en, N = 85): − la te s hift (e venin g o r nig ht) w or ker s (N = 49), m ea n a ge: 45.2 y ea rs, w or k d ura tio n: 10.1 y ea rs − da y w or ker s (N = 36), m ea n a ge: 41.6 y ea rs, w or k d ura tio n: 7.6 y ea rs 3 s hift sys tem: − da y s hift: 8:00 a.m.–4:00 p .m. − ev enin g s hift: 4:00 p .m.–12:00 a.m. − nig ht s hift: 12:00 a.m.–8:00 a.m. th e o rig in al q ues tio nn air e in quir ed ab out : − th e u su al t im e o f m ain m ea ls, in cludin g sn ac ks − ch an ges in t he a bo ve sin ce t he sta rt o f t he c ur ren t j ob − ch an ges in d ai ly f oo d in ta ke sin ce t he s ta rt o f t he c ur ren t shift (in cr ea se o r de cr ea se in en er gy in ta ke) (−) us ua l t im es o f m ain m ea ls a nd sn ac ks, ch an ges in d ai ly f oo d in ta ke sin ce t he s ta rt o f th e c ur ren t s hift la te s hift w or ker s r ep or te d: − ea tin g t he l as t m ain m ea l a t a l at er h our : 10:27 p .m. vs. 5:52 p .m. (p < 0.005) − co ns umin g f ew er m ea ls t ha n d ay w or ker s (1.9±0.9 vs. 2.5±0.9) (p = 0.002) − co ns umin g m or e sin ce t he b eg innin g o f t he la te s hift (p = 0.06) no diff er en ce in t he n um ber o f co ns um ed sn ac ks Re ev es et a l. (2004), G re at Br ita in, cr os s-s ec tio na l [10] sta ff o f t he r esiden tia l n ur sin g ho m es a nd h os pi ta ls (N = 36 [16 m en, 20 w om en]): − fem ale d ay w or ker s (N = 10), m ea n a ge: 28 y ea rs − fem ale nig ht w or ker s (N = 10), m ea n a ge: 26 y ea rs 6-d ay di ar y (t he p ar tici pa nts w er e as ke d t o r eco rd d at a a bo ut t heir en tir e f oo d a nd dr in k in ta ke); fo od in ta ke a na lyze d in Diet 5 f or W in do ws (U ni va tio n, A ber de en) (+) co ns um pt io n o f: − to ta l en er gy (kJ) − ca rb oh ydra tes (g) − fa ts (g) − pr ot ein s (g) − alco ho l (g) − coff ee − te a tim e o f co ns um pt io n ov er 24 h o n t he w or k da y a nd t he r es t d ay in ta ke a m on g nig ht w or ker s vs. d ay w or ker s (a m on g f em ales): − en er gy : 6 604 kJ vs. 6 990 kJ (1 577 k ca l vs. 1 669 k ca l) − ca rb oh ydra tes: 195 g vs. 188 g − fa ts: 64 g vs. 108 g − pr ot ein s: 52.5 g vs. 53 g − alco ho l: 0 g vs. 0 g shift w or ker s: − co ns um e f ew er m ain m ea ls a nd m or e sn ac ks (p < 0.05) − dr in k m or e co ffe e a nd t ea (p < 0.01) − ea t d ur in g t he nig ht w hen w or kin g nig ht s hift Bi lsk i (2006), Po la nd , cr os s-s ec tio na l [11] hos pi ta l n ur ses w or kin g ro ta tin g nig ht s hifts (w om en, N = 171), a ge: 22−50 y ea rs (M = 33.5), w or k d ura tio n: 1−31 y ea rs (M = 12.5) 12-h t w o-s hift sys tem: − 7:00 a.m.–7:00 p .m. − 7:00 p .m.–7:00 a.m. th e o rig in al q ues tio nn air e in quir ed abo ut food be ha vi or s (−) co ns um pt io n o f : − coff ee − ho t me al − fru it − te a − sw eets dur in g t he nig ht s hift: − 7.6% o f n ur ses do n ot e at a ny m ea l − 17.5% dr in k ex clu siv ely co ffe e − 9.9% e at h ot m ea l − 6.4% e at f rui t a nd dr in k t ea − 3.5% e at sw eets w ith o th er f oo ds Zh ao et a l. (2011), Austra lia, cr os s-s ec tio na l [12] nur ses a nd mid w iv es (w om en, N = 2 494), a ge: 20−70 y ea rs: − da y w or ker s (N = 1 259), m ea n a ge: 45.1 y ea rs − shift w or ker s (N = 1 235), m ea n a ge: 41.3 y ea rs ca teg or ies: − da y w or k (ex clu siv ely) − shift w or k: co nt in uo us shift w or k, e venin g s hifts on ly, nig ht s hifts o nl y, m or nin g a nd e venin g shifts o nl y, o r e venin g an d nig ht s hifts o nl y on lin e s ur ve y; Au str al ia n Re co m me nd ed F oo d S co re (ARFS) m ea sur ed diet q ua lit y, 74 i tem s in str um en t (y es−n o); Se m iq ua nt ita tive F ood F re que nc y Q ue sti on na ire – q ues tio ns a bo ut ho w o ften, o n a vera ge , t he res po nden ts dr in k o ne g la ss, b ot tle , ca n o f b eer (h ea vy) o r b eer (lig ht), re d o r w hi te w in e, o r s pir its (e .g ., v od ka) (+) diet q ua lit y acco rdin g t o ARFS s co res:  ≤ 24 p ts, 25−30 p ts, 31−34 p ts, 35−39 p ts, ≥40 p ts – m or e s co res bet ter diet q ua lit y, alco ho l co ns um pt io n in c at eg or ies: − abs ta in f ro m al coh ol − lo w-r isk dr in ker s − ris ky dr in ker s − hig h-r isk dr in ker s shift w or ker s, w hen co m pa re d t o d ay w or ker s, w er e les s f re quen tly c la ssifie d a s r isk y (5.3% vs. 8.7%) o r hig h-r isk dr in ker s (2.5% vs. 3.1%), an d t he y m or e o ften a bs ta in ed f ro m a lco ho l (18.1% vs. 12.9%) (p = 0.009) no diff er en ce in diet q ua lit y b et w een d ay an d s hift w or ker s (p = 0.747)

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Ta ble 1 . Th e m ai n c ha ra ct er ist ic s a nd r es ul ts o f t he 1 9 s tu di es i nc lu de d i n t he r ev ie w, a na ly zi ng d ie ta ry h ab its a cc or di ng t o t he s hi ft w or k s ta tu s a mo ng n ur se s – c on t. Ref er en ce St udie d p op ul at io n Sys tem o f w or k/ Shift h our s Diet ar y a ss es sm en t t oo l (va lid at io n +/–) Diet c ha rac ter ist ics M os t im po rt an t r es ul ts Sa hu et a l. (2011), I ndi a, cr os s-s ec tio na l [13] hos pi ta l n ur ses (w om en, N = 75): − shift w or ker s (N = 40), m ea n a ge: 41 y ea rs − da y w or ker s (N = 35), m ea n a ge: 40 y ea rs 3 s hift sys tem: − m or nin g: 7:00 a.m.– 1:00 p .m. − aft er no on: 1:00 p .m.– 8:00 p .m. − nig ht: 8:00 p .m.– 7:00 a.m. di ar y − t he s ub je cts r eco rde d t he item o f f oo d t ak en a nd t he a pp ro x. qu an tit y o f e ac h i tem co ns um ed dur in g e ac h m ea l; t he q ua nt ities of c arb oh ydra tes, p ro tein a nd fa t co ns um ed w er e c alc ul at ed u sin g th e f oo d va lue t ab le in I ndi a (−) tim es o f m ain m ea ls (ac tu al vs. p ref er re d): − no m ea ls p er d ay − no sn ac ks p er d ay − ap pe tit e co ns um pt io n o f: − to ta l en er gy (k ca l) − ca rb oh ydra tes (g) − pr ot ein s (g) − fa ts (g) − vi ta min s (c ar ot en e, thi amin e, ni acin, r ib ofl av in) − ca lci um (C a) − iro n (F e) am on g s hift w or ker s a sig nific an t diff er en ce b et w een th e ac tu al a nd p ref er re d t im e o f b re ak fa st a nd dinn er (p < 0.005); a m on g nig ht w or ker s d ur in g nig ht s hift w or k a lo w er n um ber o f m ain m ea ls − 1.43 vs. 2.01, w hen w or kin g d ur in g t he d ay (p < 0.005), a nd m or e sn ac ks (3.63 vs. 2.01); a m on g nig ht s hift w or ker s a lo w er (p < 0.05) t ha n a m on g d ay w or ker s co ns um pt io n o f: − ca rb oh ydra tes: 251.2 g vs. 410.8 g − pr ot ein s: 65.1 g vs. 99.8 g − fa ts: 44.3 g vs. 70.4 g − to ta l en er gy : 1 698 k ca l vs. 2 926 k ca l no diff er en ce f or v ita min s, C a a nd F e m et al s co ns um pt io n Sa ksv ik-Le ho ui llier et a l. (2012), N or wa y, cr os s-s ec tio na l [14] shift w or ker s (m en a nd w om en, N = 749): − ne w t o nig ht w or k (N = 322) − w or k d ura tio n < 1 y ea r, m ea n ag e: 27.2 y ea rs − exp er ien ce d s hift w or ker s (N = 427) − w or k d ura tio n  > 6 y ea rs, m ea n a ge: 36.5 y ea rs 3-s hift sys tem: m or nin g, aft er no on, nig ht or ig in al q ues tio nn air e – q ues tio ns ab ou t t he u su al co ns um pt io n (in c ups) o f co ffe e, co la o r t ea (w ith c aff ein e) p er d ay ; A lcoh ol Us e D iso rd er s I den tifi ca tio n T es t Con su m pt ion (A UD IT -C) – 3 i tem s co ncer ne d w ith t he am oun ts a nd f re quen cy o f a lco ho l co ns um pt io n (+) ca ffein e co ns um pt io n (c ups per d ay – co ffe e, t ea w ith ca ffein e, co la); a lco ho l co ns um pt io n (s co re) exp er ien ce d n ur ses, w hen co m pa re d t o t hos e n ew to nig ht w or k, h ad a hig her co ns um pt io n o f c aff ein e (c ups p er d ay): 3.36 (2.47) vs. 2.40 (2.73), p < 0.01 an d a lo w er A UD IT -C s co re: 3.54 (1.69) vs. 4.42 (1.72), p < 0.01 Prze or et a l. (2013), P ol an d, cr os s-s ec tio na l [15] hos pi ta l n ur ses w or kin g ro ta tin g s hifts (w om en, N = 51): − ag ed 31−50 y ea rs (y oun ger w om en – Y W ) (N = 41) − ag ed 51−65 y ea rs (o lder w om en – O W ) (N = 10) 12-h s hift sys tem 3-d ay di ar y (t he p ar tici pa nts re co rde d t he t im e, k in d o f m ea l an d q ua nt ity co ns um ed), q ua nt ity sp ecifie d w ith u se o f a b oo k co nt ainin g im ag es o f p ro duc ts an d m ea ls; d at a a na lyze d w ith Diet et yk 2009 s oft wa re (+) th e n um ber o f m ea ls, t he co ns um pt io n o f t ot al en er gy , micr o- a nd m acr on ut rien ts, an d f oo d i tem s va lues co m pa re d t o t he r eco mm en de d: − to ta l en er gy in ta ke: − YW – 1 802±494 k ca l, 81.9% n or m − O W – 2 030±601 k ca l, 92.3% n or m − g re at er t ha n r eco mm en de d en er gy f ro m (in Y W a nd O W , r es pe ct iv ely) [%]: − pr ot ein s (127.0, 126.5) − fa ts (120.5, 119.0) − sac ha ros e (105.9, 123.6) − lo w er t ha n r eco mm en de d in ta ke (Y W , O W ) [%]: − fib er (73.8, 79.2) − Mg (90.7, 97.0) − Ca (57.0, 71.7) − K (62.3, 69.6) − Fe (60.0, 60.8) − vi ta min D (61.0, 60.3) − gr ea ter t ha n r eco mm en de d in ta ke (Y W , O W ) [%]: − dig es tib le c arb oh ydra tes (156.7, 184.6) − ch oles ter ol (109.7, 118.0) − anim al p ro tein (265.6, 303.3) − fa ts (101.1, 110.9) − N a (103.6, 104.2) − Zn (123.0, 128.9) − Cu (184.3, 155.0) − P (174.4, 192.8) − vi ta min A (158.4, 140.1) − vi ta min E (122.9, 231.1) − vi ta min C (101.1, 196.3) − in ta ke b elo w t he r eco mm en de d (Y W , O W ) [%]: − cer ea l p ro duc ts (44.2) − veg et ab les (51.5) − fr ui t (43.4) − mi lk a nd d air y p ro duc ts (30.5, 87.4) − fis h (70.9) − veg et ab le fa ts (82) − in ta ke a bo ve t he r eco mm en de d (Y W , O W ) [%]: − m ea t, p ou ltr y (170.7) − eg gs (198.6) − anim al fa ts (149.3) − sw eets, s uga r (244.4) Kim et a l. (2013), So ut h K or ea, cr os s-s ec tio na l [16] nur ses (w om en, N = 9 989): − shift w or ker s (N = 5 287), m ea n a ge: 29.2 y ea rs, s hift w or k d ura tio n: 0.08−38 y ea rs − da y w or ker s (N = 4 702), m ea n a ge: 37.6 y ea rs or ig in al q ues tio nn air e, q ues tio ns ab ou t diet ar y h ab its, i .e., s ki pp in g br ea kfa st, l un ch, dinn er , dr in kin g alco ho l (“ regu la r” defin ed a s m or e th an o nce p er m on th) (−) regu la r a lco ho l dr in kin g if > 1 p er m on th; s ki pp in g: − bre ak fa st − lu nc h − dinn er regu la r a lco ho l dr in kin g m or e o ften r ep or te d a m on g shift w or ker s (53.5% vs. 42.9%) (p < 0.001), b ut a de cr ea sin g t ren d o f a lco ho l dr in kin g b y s hift w or k dura tio n (p < 0.001); s ki pp in g: − br ea kfa st – m or e o ften r ep or te d a m on g s hift w or ker s (43.1% vs. 29.2%), a de cr ea sin g t ren d w ith shift w or k d ura tio n (p < 0.001) − lun ch – m or e o ften r ep or te d a m on g s hift w or ker s (2.0% vs. 0.5%), p < 0.001, a de cr ea sin g t ren d w ith shift w or k d ura tio n (p < 0.001) − dinn er – a de cr ea sin g t ren d w ith s hift w or k dura tio n (p < 0.001) N ag has hp ou r (2013), I ra n, cr os s-s ec tio na l [17] nur ses (w om en, N = 98): − shift w or ker s (N = 43), m ea n a ge: 33 y ea rs − da y w or ker s (N = 55), m ea n a ge: 33 y ea rs shift w or k defin ed a s ou tside h our s: 8:00 a.m.– 4:00 p .m. 3-d ay 24-h r ec al l (2 w or kin g d ays an d 1 d ay o ff – r eco rde d t im e, th e k in d o f f oo d a nd q ua nt ity co ns um ed); d at a v er ifie d b y a n ut rit io ni st a nd a na lyze d w ith Ira ni an F oo d P ro ces so r s oft wa re (th e I ra ni an I ns tit ut e o f N ut rit io n Res ea rc h a nd F oo d I nd us tr y) (+) da ily co ns um pt io n o f: − to ta l en er gy (k ca l) − vi ta min s: t hi amin, rib ofl av in, ni acin, py rido xin e, co ba la min, fo la te , a sco rb at e, t oco ph er ol , ret in ol , c ho le ca lcif er ol − m ag nesi um, c alci um, zin c, iro n am on g s hift w or ker s a lo w er d ai ly co ns um pt io n (p < 0.05) o f t hi amin, r ib ofl av in, ni acin, f ol at es, m ag nesi um, ir on; no sig nific an t diff er en ce o bs er ve d f or t he t ot al en er gy in ta ke , a nd r em ainin g v ita min s a nd n ut rien ts Tad a (2014), Ja pa n, cr os s-s ec tio na l [18] nur ses (w om en, N = 2 758), ag e: 20−59 y ea rs: − shift w or ker s (N = 1 579), m ea n a ge: 41.1 y ea rs − da y w or ker s (N = 1 179), m ea n a ge: 42.1 y ea rs Se m iq ua nt ita tive F ood F re que nc y Q ue sti on na ire – diet ar y in ta ke o ver th e p re vio us m on th; d at a a na lyze d w ith E xc el E iy ok un F oo d F ref en cy Q ue sti on na ire s (+) da ily in ta ke o f: − fo od p ro duc ts − to ta l en er gy − pr ot ein s − fa ts − ca rb oh ydra tes nig ht s hift w or ker s co ns um ed sig nific an tly (p < 0.05) m or e co nf ec tio na ries, sw eet en ed b ev era ges a lco ho l; alo ng w ith f ew er p ot at oes, s ta rc hes, g re en a nd y el lo w veg et ab les, f rui t, a lgae , fi sh a nd s he llfi sh, m ea t a nd pr ot ein; no sig nific an t diff er en ce o bs er ve d f or t he in ta ke o f to ta l en er gy , fa ts a nd c arb oh ydra tes

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Ta ble 1 . Th e m ai n c ha ra ct er ist ic s a nd r es ul ts o f t he 1 9 s tu di es i nc lu de d i n t he r ev ie w, a na ly zi ng d ie ta ry h ab its a cc or di ng t o t he s hi ft w or k s ta tu s a mo ng n ur se s – c on t. Ref er en ce St udie d p op ul at io n Sys tem o f w or k/ Shift h our s Diet ar y a ss es sm en t t oo l (va lid at io n +/–) Diet c ha rac ter ist ics M os t im po rt an t r es ul ts Sa hu et a l. (2011), I ndi a, cr os s-s ec tio na l [13] hos pi ta l n ur ses (w om en, N = 75): − shift w or ker s (N = 40), m ea n a ge: 41 y ea rs − da y w or ker s (N = 35), m ea n a ge: 40 y ea rs 3 s hift sys tem: − m or nin g: 7:00 a.m.– 1:00 p .m. − aft er no on: 1:00 p .m.– 8:00 p .m. − nig ht: 8:00 p .m.– 7:00 a.m. di ar y − t he s ub je cts r eco rde d t he item o f f oo d t ak en a nd t he a pp ro x. qu an tit y o f e ac h i tem co ns um ed dur in g e ac h m ea l; t he q ua nt ities of c arb oh ydra tes, p ro tein a nd fa t co ns um ed w er e c alc ul at ed u sin g th e f oo d va lue t ab le in I ndi a (−) tim es o f m ain m ea ls (ac tu al vs. p ref er re d): − no m ea ls p er d ay − no sn ac ks p er d ay − ap pe tit e co ns um pt io n o f: − to ta l en er gy (k ca l) − ca rb oh ydra tes (g) − pr ot ein s (g) − fa ts (g) − vi ta min s (c ar ot en e, thi amin e, ni acin, r ib ofl av in) − ca lci um (C a) − iro n (F e) am on g s hift w or ker s a sig nific an t diff er en ce b et w een th e ac tu al a nd p ref er re d t im e o f b re ak fa st a nd dinn er (p < 0.005); a m on g nig ht w or ker s d ur in g nig ht s hift w or k a lo w er n um ber o f m ain m ea ls − 1.43 vs. 2.01, w hen w or kin g d ur in g t he d ay (p < 0.005), a nd m or e sn ac ks (3.63 vs. 2.01); a m on g nig ht s hift w or ker s a lo w er (p < 0.05) t ha n a m on g d ay w or ker s co ns um pt io n o f: − ca rb oh ydra tes: 251.2 g vs. 410.8 g − pr ot ein s: 65.1 g vs. 99.8 g − fa ts: 44.3 g vs. 70.4 g − to ta l en er gy : 1 698 k ca l vs. 2 926 k ca l no diff er en ce f or v ita min s, C a a nd F e m et al s co ns um pt io n Sa ksv ik-Le ho ui llier et a l. (2012), N or wa y, cr os s-s ec tio na l [14] shift w or ker s (m en a nd w om en, N = 749): − ne w t o nig ht w or k (N = 322) − w or k d ura tio n < 1 y ea r, m ea n ag e: 27.2 y ea rs − exp er ien ce d s hift w or ker s (N = 427) − w or k d ura tio n  > 6 y ea rs, m ea n a ge: 36.5 y ea rs 3-s hift sys tem: m or nin g, aft er no on, nig ht or ig in al q ues tio nn air e – q ues tio ns ab ou t t he u su al co ns um pt io n (in c ups) o f co ffe e, co la o r t ea (w ith c aff ein e) p er d ay ; A lcoh ol Us e D iso rd er s I den tifi ca tio n T es t Con su m pt ion (A UD IT -C) – 3 i tem s co ncer ne d w ith t he am oun ts a nd f re quen cy o f a lco ho l co ns um pt io n (+) ca ffein e co ns um pt io n (c ups per d ay – co ffe e, t ea w ith ca ffein e, co la); a lco ho l co ns um pt io n (s co re) exp er ien ce d n ur ses, w hen co m pa re d t o t hos e n ew to nig ht w or k, h ad a hig her co ns um pt io n o f c aff ein e (c ups p er d ay): 3.36 (2.47) vs. 2.40 (2.73), p < 0.01 an d a lo w er A UD IT -C s co re: 3.54 (1.69) vs. 4.42 (1.72), p < 0.01 Prze or et a l. (2013), P ol an d, cr os s-s ec tio na l [15] hos pi ta l n ur ses w or kin g ro ta tin g s hifts (w om en, N = 51): − ag ed 31−50 y ea rs (y oun ger w om en – Y W ) (N = 41) − ag ed 51−65 y ea rs (o lder w om en – O W ) (N = 10) 12-h s hift sys tem 3-d ay di ar y (t he p ar tici pa nts re co rde d t he t im e, k in d o f m ea l an d q ua nt ity co ns um ed), q ua nt ity sp ecifie d w ith u se o f a b oo k co nt ainin g im ag es o f p ro duc ts an d m ea ls; d at a a na lyze d w ith Diet et yk 2009 s oft wa re (+) th e n um ber o f m ea ls, t he co ns um pt io n o f t ot al en er gy , micr o- a nd m acr on ut rien ts, an d f oo d i tem s va lues co m pa re d t o t he r eco mm en de d: − to ta l en er gy in ta ke: − YW – 1 802±494 k ca l, 81.9% n or m − O W – 2 030±601 k ca l, 92.3% n or m − g re at er t ha n r eco mm en de d en er gy f ro m (in Y W a nd O W , r es pe ct iv ely) [%]: − pr ot ein s (127.0, 126.5) − fa ts (120.5, 119.0) − sac ha ros e (105.9, 123.6) − lo w er t ha n r eco mm en de d in ta ke (Y W , O W ) [%]: − fib er (73.8, 79.2) − Mg (90.7, 97.0) − Ca (57.0, 71.7) − K (62.3, 69.6) − Fe (60.0, 60.8) − vi ta min D (61.0, 60.3) − gr ea ter t ha n r eco mm en de d in ta ke (Y W , O W ) [%]: − dig es tib le c arb oh ydra tes (156.7, 184.6) − ch oles ter ol (109.7, 118.0) − anim al p ro tein (265.6, 303.3) − fa ts (101.1, 110.9) − N a (103.6, 104.2) − Zn (123.0, 128.9) − Cu (184.3, 155.0) − P (174.4, 192.8) − vi ta min A (158.4, 140.1) − vi ta min E (122.9, 231.1) − vi ta min C (101.1, 196.3) − in ta ke b elo w t he r eco mm en de d (Y W , O W ) [%]: − cer ea l p ro duc ts (44.2) − veg et ab les (51.5) − fr ui t (43.4) − mi lk a nd d air y p ro duc ts (30.5, 87.4) − fis h (70.9) − veg et ab le fa ts (82) − in ta ke a bo ve t he r eco mm en de d (Y W , O W ) [%]: − m ea t, p ou ltr y (170.7) − eg gs (198.6) − anim al fa ts (149.3) − sw eets, s uga r (244.4) Kim et a l. (2013), So ut h K or ea, cr os s-s ec tio na l [16] nur ses (w om en, N = 9 989): − shift w or ker s (N = 5 287), m ea n a ge: 29.2 y ea rs, s hift w or k d ura tio n: 0.08−38 y ea rs − da y w or ker s (N = 4 702), m ea n a ge: 37.6 y ea rs or ig in al q ues tio nn air e, q ues tio ns ab ou t diet ar y h ab its, i .e., s ki pp in g br ea kfa st, l un ch, dinn er , dr in kin g alco ho l (“ regu la r” defin ed a s m or e th an o nce p er m on th) (−) regu la r a lco ho l dr in kin g if > 1 p er m on th; s ki pp in g: − bre ak fa st − lu nc h − dinn er regu la r a lco ho l dr in kin g m or e o ften r ep or te d a m on g shift w or ker s (53.5% vs. 42.9%) (p < 0.001), b ut a de cr ea sin g t ren d o f a lco ho l dr in kin g b y s hift w or k dura tio n (p < 0.001); s ki pp in g: − br ea kfa st – m or e o ften r ep or te d a m on g s hift w or ker s (43.1% vs. 29.2%), a de cr ea sin g t ren d w ith shift w or k d ura tio n (p < 0.001) − lun ch – m or e o ften r ep or te d a m on g s hift w or ker s (2.0% vs. 0.5%), p < 0.001, a de cr ea sin g t ren d w ith shift w or k d ura tio n (p < 0.001) − dinn er – a de cr ea sin g t ren d w ith s hift w or k dura tio n (p < 0.001) N ag has hp ou r (2013), I ra n, cr os s-s ec tio na l [17] nur ses (w om en, N = 98): − shift w or ker s (N = 43), m ea n a ge: 33 y ea rs − da y w or ker s (N = 55), m ea n a ge: 33 y ea rs shift w or k defin ed a s ou tside h our s: 8:00 a.m.– 4:00 p .m. 3-d ay 24-h r ec al l (2 w or kin g d ays an d 1 d ay o ff – r eco rde d t im e, th e k in d o f f oo d a nd q ua nt ity co ns um ed); d at a v er ifie d b y a n ut rit io ni st a nd a na lyze d w ith Ira ni an F oo d P ro ces so r s oft wa re (th e I ra ni an I ns tit ut e o f N ut rit io n Res ea rc h a nd F oo d I nd us tr y) (+) da ily co ns um pt io n o f: − to ta l en er gy (k ca l) − vi ta min s: t hi amin, rib ofl av in, ni acin, py rido xin e, co ba la min, fo la te , a sco rb at e, t oco ph er ol , ret in ol , c ho le ca lcif er ol − m ag nesi um, c alci um, zin c, iro n am on g s hift w or ker s a lo w er d ai ly co ns um pt io n (p < 0.05) o f t hi amin, r ib ofl av in, ni acin, f ol at es, m ag nesi um, ir on; no sig nific an t diff er en ce o bs er ve d f or t he t ot al en er gy in ta ke , a nd r em ainin g v ita min s a nd n ut rien ts Tad a (2014), Ja pa n, cr os s-s ec tio na l [18] nur ses (w om en, N = 2 758), ag e: 20−59 y ea rs: − shift w or ker s (N = 1 579), m ea n a ge: 41.1 y ea rs − da y w or ker s (N = 1 179), m ea n a ge: 42.1 y ea rs Se m iq ua nt ita tive F ood F re que nc y Q ue sti on na ire – diet ar y in ta ke o ver th e p re vio us m on th; d at a a na lyze d w ith E xc el E iy ok un F oo d F ref en cy Q ue sti on na ire s (+) da ily in ta ke o f: − fo od p ro duc ts − to ta l en er gy − pr ot ein s − fa ts − ca rb oh ydra tes nig ht s hift w or ker s co ns um ed sig nific an tly (p < 0.05) m or e co nf ec tio na ries, sw eet en ed b ev era ges a lco ho l; alo ng w ith f ew er p ot at oes, s ta rc hes, g re en a nd y el lo w veg et ab les, f rui t, a lgae , fi sh a nd s he llfi sh, m ea t a nd pr ot ein; no sig nific an t diff er en ce o bs er ve d f or t he in ta ke o f to ta l en er gy , fa ts a nd c arb oh ydra tes

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Ta ble 1 . Th e m ai n c ha ra ct er ist ic s a nd r es ul ts o f t he 1 9 s tu di es i nc lu de d i n t he r ev ie w, a na ly zi ng d ie ta ry h ab its a cc or di ng t o t he s hi ft w or k s ta tu s a mo ng n ur se s – c on t. Ref er en ce St udie d p op ul at io n Sys tem o f w or k/ Shift h our s Diet ar y a ss es sm en t t oo l (va lid at io n +/–) Diet c ha rac ter ist ics M os t im po rt an t r es ul ts Buc hv old et a l. (2015), Nor wa y, cr os s-s ec tio na l [19] nur ses (m en a nd w om en, N = 2 059): − did n ot w or k nig ht s hift in th e p re vio us y ea r (N = 568), m ea n a ge: 34.9 y ea rs − 1−30 nig ht s hift in t he pr ev io us y ea r (N = 860), m ea n a ge: 32.4 y ea rs − > 30 nig ht s hifts in t he pr ev io us y ea r (N = 631), m ea n a ge: 32.4 y ea rs or ig in al q ues tio nn air e, q ues tio ns ab ou t t he u su al co ns um pt io n (in cu ps) o f co ffe e, co la o r t ea (w ith ca ffein e) p er d ay ; A UD IT -C – 3 i tem s co ncer ne d w ith t he am oun ts a nd f re quen cy o f a lco ho l co ns um pt io n (+) ca ffein e co ns um pt io n (c ups p er d ay − co ffe e, te a w ith c aff ein e, co la); alco ho l co ns um pt io n (A UD IT -C SC O RE) alco ho l co ns um pt io n lo w er a m on g n ur ses w ith s hift w or k d ura tio n > 5 y ea rs (β = −0.52, p < 0.05); th e n um ber o f nig ht s hifts in t he p re vio us y ea r as so ci at ed w ith a g re at er c aff ein e co ns um pt io n (O R = 1.00, 95% CI: 1.00−1.01) Ra min et a l. (2015), US, coho rt [20] nur ses (w om en, N = 54 724), ag e: 25−42 y ea rs: − ne ver w or k nig ht s hift (N = 15 391) − ev er w or k nig ht s hift (N = 39 333) nig ht s hift: 11:00 p .m.–7:00 a.m. th e s ta ff e ver w or kin g at nig ht defin ed a s nur ses w or kin g ro ta tin g nig ht s hifts or p er m an en t nig hts Se m iq ua nt ita tive F ood F re que nc y Q ue sti on na ire − 130 i tem s; diet ar y co ns um pt io n o f a lco ho l, c aff ein e an d t ot al en er gy co ns um pt io n as ses se d in 2007 (+) ca ffein e co ns um pt io n ≥ 131 m g/d ay , t ot al ca lo ries in ta ke ≥ 1 715 k ca l/d ay , alco ho l co ns um pt io n (g/d ay) am on g t he s ta ff e ver w or kin g a t nig ht w hen co m pa re d to t hos e w ho n ev er w or k a t nig ht: − gr ea ter c aff ein e in ta ke: 184 m g/d vs. 167 m g/d (p < 0.0011, O R: 1.16 (1.12−1.22)) − hig her t ot al c alo ries in ta ke: 1 882 k ca l/d ay vs. 1 722 k ca l/d ay (p < 0.0011, O R:1.09 (1.04−1.13)) no diff er en ce f or a lco ho l co ns um pt io n: 6.3 g/d ay vs. 6.3 g/d ay Yos hiza ki et a l. (2016), J ap an, cr os s-s ec tio na l [21] nur ses (w om en, N = 171), ag e: 19−63 y ea rs: − nig ht s hift w or ker s (2- o r 3-s hift sys tem) (N = 123) − da y w or ker s (N = 39) da y w or k: 8:30 a.m.–5:15 p .m. nig ht w or k: − 2 s hifts: 8:30 a.m.–5:15 p .m., 4:30 p .m.–9:15 a.m. − 3 s hifts: 8:30 a.m.–5:15 p .m., 4:30 p .m.–1:00 a.m., 0:45 a.m.–9:45 a.m. Ea ting B eh av io r Q ue sti on na ire (Ja pa n S ociet y f or t he S tud y o f O besi ty) − 55 i tem s (+) ea tin g b eh av io rs: − m ot iva tio n f or e at in g − ea tin g a s a di ver sio n − fe elin g o f s at iet y − ea tin g s ty le − m ea l co nt en ts − tem po ra l e at in g p at ter ns am on g nig ht s hift w or ker s p oo rer e at in g b eh av io r w ith res pe ct t o: − m ea l co nt en ts − tem po ra l e at in g p at ter ns p < 0.05 in t he uni va ria te a na lys es, in sig nific an t r es ul ts in t he m ul tiva ria te a na lysi s in cludin g c hr on ot yp e H ak im et a l. (2016), E gyp t, cr os s-s ec tio na l [22] nur ses (w om en, N = 400), ag e: < 40 y ea rs (82%) or ig in al q ues tio nn air e; 10 q ues tio ns r ega rdin g t he a vera ge in ta ke o f s ele ct ed f oo ds p er w ee k (−) typ es o f diet: “h ea lth y,” “s emi-h ea lth y,” “un he al th y” “un he al th y diet ” o bs er ve d m or e o ften a m on g n ur ses w or kin g nig ht s hifts > 10 y ea rs (13.6%) t ha n a m on g th os e w or kin g < 5 y ea rs (6.8%) a nd 5−10 y ea rs (6.9%) (p = 0.004) Gład ysz et a l. (2016), P ol an d, cr os s-s ec tio na l [23] − hos pi ta l n ur ses (w om en, N = 140), m ea n a ge: 34.3 y ea rs, in cludin g 109 s hift w or ker s da y w or k 8-h o r 12-h shift sys tem (12 h): − 7:00 a.m.–7:00 p .m. − 7:00 p .m.–7:00 a.m. or ig in al q ues tio nn air e (t es te d in pi lo t), q ues tio ns a bo ut n ut rit io na l be ha vio r (+/−) m ea ls p at ter n: − no m ea ls/d ay − no me al s a t w ork − no m ea ls a t nig ht − m ea ls r egu la rit y no diff er en ces o bs er ve d f or t he n um ber o f m ea ls p er da y, lo ng er s hift w or k r el at ed t o a g re at er n um ber of m ea ls co ns um ed p er d ay (p < 0.001) a nd e at in g at nig ht s hift (p = 0.046) A lm ajwa l (2016), Sa udi A ra bi a, cr os s-s ec tio na l [24] nur ses (w om en a nd m en, N = 395), a ge < 40 y ea rs (68.6%): − wo rk in g nig ht s hift (N  =  258) − da y w or ker s (N = 137) D ut ch Ea tin g B eh av io ur Q ue sti on na ire (D EB Q) – 33 i tem s m ea sur in g un he al th y e at in g be ha vio rs; t he f re quen cy o f e at in g fa st f oo ds a nd sn ac ks, t he n um ber of s er vin gs o f f rui t a nd v eg et ab les, an d s er vin g sizes; B in ge e at in g (+) ea tin g s ty le: − “r es tra in ed ” − “em ot io na l” − “ext er na l” th e f re quen cy o f e at in g fa st f oo d, b in ge , sn ac ks, an d f rui t a nd v eg et ab les nig ht s hift a ss oci at ed w ith “ res tra in ed e at in g” (O R = 1.53, p = 0.029) a nd “ ext er na l e at in g” (O R = 0.55, p = 0.026); hig her f re quen cy o f t he nig ht shifts 4−7/m on th, a nd > 7/m on th a ss oci at ed w ith “r es tra in ed ” (O R = 2.13, O R = 1.89) a nd “ em ot io na l” ea tin g (O R = 1.48); b in ge a nd fa st f oo d e at in g m or e fre quen t a m on g s hift w or ker s H an et a l. (2016), So ut h K or ea, cr os s-s ec tio na l [25] nur ses (w om en, N = 340), m ea n a ge: 30 y ea rs: − ro ta tin g nig ht s hifts (N = 252) − ro ta tin g s hifts (n o nig hts) (N = 35) − da y w or ker s (N = 53) 8-h s hifts or ig in al q ues tio nn air e; q ues tio ns ab ou t u su al diet ar y b eh av io rs (−) diet ar y b eh av io rs, t he num ber o f m ea ls p er d ay , sn ac ks, m ea ls r egu la rit y, sk ip pin g b re ak fa st, ov er ea tin g, t he f re quen cy of f rui t a nd v eg et ab les co ns um pt io n nig ht s hift w or ker s, w hen co m pa re d t o t hos e w or kin g shifts b ut n ot nig ht s hifts a nd d ay w or ker s, s ho w ed: − m or e f re quen t m ea ls ir regu la rit y: 86.9% vs. 65.7% an d 37.7 − br ea kfa st s ki pp in g: 41% vs. 26% a nd 26% − ea tin g sn ac ks a t nig ht: 44% vs. 25.7% a nd 5.7% − les s f re quen t co ns um pt io n o f 3 m ea ls p er d ay : 21% vs. 40% a nd 55% − fr ui t a nd v eg et ab les co ns um pt io n > 1 p or tio n p er da y: 54% vs. 77% a nd 62% Be eb e et a l. (2017), USA, cros s-s ec tio na l [26] nur ses (w om en, N = 103), m ea n a ge: 38.8 y ea rs: − nig ht w or ker s (N = 53) − da y w or ker s (N = 50) Food F re que nc y Q ue stio nn ai re (134 f oo d i tem s, 8 s up plem en ts); D iet H istor y Q ue sti on na ire II (D H Q II) (Th e N at io na l C an cer In sti tu te , 2016) (+) diet q ua lit y, e at in g f rui t, veg et ab les, g re en s a nd be an s, d air y, t ot al p ro tein fo od s, s eafo od an d p lan t pr ot ein s, fa tty acid s, g ra in s, so di um, em pt y c alo ries no sig nific an t diff er en ces o bs er ve d b et w een t he co m pa re d g ro ups Ros ko den et a l. (2017), G er m an y, cr os s-s ec tio na l [27] w or ker s o f t he M edic al U ni ver sit y D ep ar tm en t (m en a nd w om en, N = 44): − nig ht s hift n ur ses (N = 23), m ea n a ge: 31 y ea rs − da y w or ker s (N = 21), m ea n a ge: 41.6 y ea rs 7 d ays di ar y (t im es, k in d a nd am oun t o f co ns um ed f oo d); da ta a na lyze d b y O pt iDiet so ftw are (+) to ta l en er gy , m acr o an d micr on ut rien ts co ns um pt io n A sig nific an tly lo w er fa ts a nd sig nific an tly hig her ca rb oh ydra tes co ns um pt io n a m on g n ur ses w or kin g nig ht s hifts, co m pa re d t o c ler ks

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Ta ble 1 . Th e m ai n c ha ra ct er ist ic s a nd r es ul ts o f t he 1 9 s tu di es i nc lu de d i n t he r ev ie w, a na ly zi ng d ie ta ry h ab its a cc or di ng t o t he s hi ft w or k s ta tu s a mo ng n ur se s – c on t. Ref er en ce St udie d p op ul at io n Sys tem o f w or k/ Shift h our s Diet ar y a ss es sm en t t oo l (va lid at io n +/–) Diet c ha rac ter ist ics M os t im po rt an t r es ul ts Buc hv old et a l. (2015), Nor wa y, cr os s-s ec tio na l [19] nur ses (m en a nd w om en, N = 2 059): − did n ot w or k nig ht s hift in th e p re vio us y ea r (N = 568), m ea n a ge: 34.9 y ea rs − 1−30 nig ht s hift in t he pr ev io us y ea r (N = 860), m ea n a ge: 32.4 y ea rs − > 30 nig ht s hifts in t he pr ev io us y ea r (N = 631), m ea n a ge: 32.4 y ea rs or ig in al q ues tio nn air e, q ues tio ns ab ou t t he u su al co ns um pt io n (in cu ps) o f co ffe e, co la o r t ea (w ith ca ffein e) p er d ay ; A UD IT -C – 3 i tem s co ncer ne d w ith t he am oun ts a nd f re quen cy o f a lco ho l co ns um pt io n (+) ca ffein e co ns um pt io n (c ups p er d ay − co ffe e, te a w ith c aff ein e, co la); alco ho l co ns um pt io n (A UD IT -C SC O RE) alco ho l co ns um pt io n lo w er a m on g n ur ses w ith s hift w or k d ura tio n > 5 y ea rs (β = −0.52, p < 0.05); th e n um ber o f nig ht s hifts in t he p re vio us y ea r as so ci at ed w ith a g re at er c aff ein e co ns um pt io n (O R = 1.00, 95% CI: 1.00−1.01) Ra min et a l. (2015), US, coho rt [20] nur ses (w om en, N = 54 724), ag e: 25−42 y ea rs: − ne ver w or k nig ht s hift (N = 15 391) − ev er w or k nig ht s hift (N = 39 333) nig ht s hift: 11:00 p .m.–7:00 a.m. th e s ta ff e ver w or kin g at nig ht defin ed a s nur ses w or kin g ro ta tin g nig ht s hifts or p er m an en t nig hts Se m iq ua nt ita tive F ood F re que nc y Q ue sti on na ire − 130 i tem s; diet ar y co ns um pt io n o f a lco ho l, c aff ein e an d t ot al en er gy co ns um pt io n as ses se d in 2007 (+) ca ffein e co ns um pt io n ≥ 131 m g/d ay , t ot al ca lo ries in ta ke ≥ 1 715 k ca l/d ay , alco ho l co ns um pt io n (g/d ay) am on g t he s ta ff e ver w or kin g a t nig ht w hen co m pa re d to t hos e w ho n ev er w or k a t nig ht: − gr ea ter c aff ein e in ta ke: 184 m g/d vs. 167 m g/d (p < 0.0011, O R: 1.16 (1.12−1.22)) − hig her t ot al c alo ries in ta ke: 1 882 k ca l/d ay vs. 1 722 k ca l/d ay (p < 0.0011, O R:1.09 (1.04−1.13)) no diff er en ce f or a lco ho l co ns um pt io n: 6.3 g/d ay vs. 6.3 g/d ay Yos hiza ki et a l. (2016), J ap an, cr os s-s ec tio na l [21] nur ses (w om en, N = 171), ag e: 19−63 y ea rs: − nig ht s hift w or ker s (2- o r 3-s hift sys tem) (N = 123) − da y w or ker s (N = 39) da y w or k: 8:30 a.m.–5:15 p .m. nig ht w or k: − 2 s hifts: 8:30 a.m.–5:15 p .m., 4:30 p .m.–9:15 a.m. − 3 s hifts: 8:30 a.m.–5:15 p .m., 4:30 p .m.–1:00 a.m., 0:45 a.m.–9:45 a.m. Ea ting B eh av io r Q ue sti on na ire (Ja pa n S ociet y f or t he S tud y o f O besi ty) − 55 i tem s (+) ea tin g b eh av io rs: − m ot iva tio n f or e at in g − ea tin g a s a di ver sio n − fe elin g o f s at iet y − ea tin g s ty le − m ea l co nt en ts − tem po ra l e at in g p at ter ns am on g nig ht s hift w or ker s p oo rer e at in g b eh av io r w ith res pe ct t o: − m ea l co nt en ts − tem po ra l e at in g p at ter ns p < 0.05 in t he uni va ria te a na lys es, in sig nific an t r es ul ts in t he m ul tiva ria te a na lysi s in cludin g c hr on ot yp e H ak im et a l. (2016), E gyp t, cr os s-s ec tio na l [22] nur ses (w om en, N = 400), ag e: < 40 y ea rs (82%) or ig in al q ues tio nn air e; 10 q ues tio ns r ega rdin g t he a vera ge in ta ke o f s ele ct ed f oo ds p er w ee k (−) typ es o f diet: “h ea lth y,” “s emi-h ea lth y,” “un he al th y” “un he al th y diet ” o bs er ve d m or e o ften a m on g n ur ses w or kin g nig ht s hifts > 10 y ea rs (13.6%) t ha n a m on g th os e w or kin g < 5 y ea rs (6.8%) a nd 5−10 y ea rs (6.9%) (p = 0.004) Gład ysz et a l. (2016), P ol an d, cr os s-s ec tio na l [23] − hos pi ta l n ur ses (w om en, N = 140), m ea n a ge: 34.3 y ea rs, in cludin g 109 s hift w or ker s da y w or k 8-h o r 12-h shift sys tem (12 h): − 7:00 a.m.–7:00 p .m. − 7:00 p .m.–7:00 a.m. or ig in al q ues tio nn air e (t es te d in pi lo t), q ues tio ns a bo ut n ut rit io na l be ha vio r (+/−) m ea ls p at ter n: − no m ea ls/d ay − no me al s a t w ork − no m ea ls a t nig ht − m ea ls r egu la rit y no diff er en ces o bs er ve d f or t he n um ber o f m ea ls p er da y, lo ng er s hift w or k r el at ed t o a g re at er n um ber of m ea ls co ns um ed p er d ay (p < 0.001) a nd e at in g at nig ht s hift (p = 0.046) A lm ajwa l (2016), Sa udi A ra bi a, cr os s-s ec tio na l [24] nur ses (w om en a nd m en, N = 395), a ge < 40 y ea rs (68.6%): − wo rk in g nig ht s hift (N  =  258) − da y w or ker s (N = 137) D ut ch Ea tin g B eh av io ur Q ue sti on na ire (D EB Q) – 33 i tem s m ea sur in g un he al th y e at in g be ha vio rs; t he f re quen cy o f e at in g fa st f oo ds a nd sn ac ks, t he n um ber of s er vin gs o f f rui t a nd v eg et ab les, an d s er vin g sizes; B in ge e at in g (+) ea tin g s ty le: − “r es tra in ed ” − “em ot io na l” − “ext er na l” th e f re quen cy o f e at in g fa st f oo d, b in ge , sn ac ks, an d f rui t a nd v eg et ab les nig ht s hift a ss oci at ed w ith “ res tra in ed e at in g” (O R = 1.53, p = 0.029) a nd “ ext er na l e at in g” (O R = 0.55, p = 0.026); hig her f re quen cy o f t he nig ht shifts 4−7/m on th, a nd > 7/m on th a ss oci at ed w ith “r es tra in ed ” (O R = 2.13, O R = 1.89) a nd “ em ot io na l” ea tin g (O R = 1.48); b in ge a nd fa st f oo d e at in g m or e fre quen t a m on g s hift w or ker s H an et a l. (2016), So ut h K or ea, cr os s-s ec tio na l [25] nur ses (w om en, N = 340), m ea n a ge: 30 y ea rs: − ro ta tin g nig ht s hifts (N = 252) − ro ta tin g s hifts (n o nig hts) (N = 35) − da y w or ker s (N = 53) 8-h s hifts or ig in al q ues tio nn air e; q ues tio ns ab ou t u su al diet ar y b eh av io rs (−) diet ar y b eh av io rs, t he num ber o f m ea ls p er d ay , sn ac ks, m ea ls r egu la rit y, sk ip pin g b re ak fa st, ov er ea tin g, t he f re quen cy of f rui t a nd v eg et ab les co ns um pt io n nig ht s hift w or ker s, w hen co m pa re d t o t hos e w or kin g shifts b ut n ot nig ht s hifts a nd d ay w or ker s, s ho w ed: − m or e f re quen t m ea ls ir regu la rit y: 86.9% vs. 65.7% an d 37.7 − br ea kfa st s ki pp in g: 41% vs. 26% a nd 26% − ea tin g sn ac ks a t nig ht: 44% vs. 25.7% a nd 5.7% − les s f re quen t co ns um pt io n o f 3 m ea ls p er d ay : 21% vs. 40% a nd 55% − fr ui t a nd v eg et ab les co ns um pt io n > 1 p or tio n p er da y: 54% vs. 77% a nd 62% Be eb e et a l. (2017), USA, cros s-s ec tio na l [26] nur ses (w om en, N = 103), m ea n a ge: 38.8 y ea rs: − nig ht w or ker s (N = 53) − da y w or ker s (N = 50) Food F re que nc y Q ue stio nn ai re (134 f oo d i tem s, 8 s up plem en ts); D iet H istor y Q ue sti on na ire II (D H Q II) (Th e N at io na l C an cer In sti tu te , 2016) (+) diet q ua lit y, e at in g f rui t, veg et ab les, g re en s a nd be an s, d air y, t ot al p ro tein fo od s, s eafo od an d p lan t pr ot ein s, fa tty acid s, g ra in s, so di um, em pt y c alo ries no sig nific an t diff er en ces o bs er ve d b et w een t he co m pa re d g ro ups Ros ko den et a l. (2017), G er m an y, cr os s-s ec tio na l [27] w or ker s o f t he M edic al U ni ver sit y D ep ar tm en t (m en a nd w om en, N = 44): − nig ht s hift n ur ses (N = 23), m ea n a ge: 31 y ea rs − da y w or ker s (N = 21), m ea n a ge: 41.6 y ea rs 7 d ays di ar y (t im es, k in d a nd am oun t o f co ns um ed f oo d); da ta a na lyze d b y O pt iDiet so ftw are (+) to ta l en er gy , m acr o an d micr on ut rien ts co ns um pt io n A sig nific an tly lo w er fa ts a nd sig nific an tly hig her ca rb oh ydra tes co ns um pt io n a m on g n ur ses w or kin g nig ht s hifts, co m pa re d t o c ler ks

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night shift and day workers. Moreover, the

question-naire used was developed by the researchers themselves

and no information on its validation was provided.

Zhao et al. analyzed diet quality and alcohol

consump-tion in an e-cohort of 2494 nurses and midwives [12]. Diet

quality was measured using Australian Recommended

Food Score (ARFS), which is a 74-item validated

instru-ment. The average alcohol consumption was assessed

with semiquantitative FFQ, and the subjects were

clas-sified into 4 categories: abstaining from alcohol,

low-risk drinkers, low-risky drinkers and high-low-risk drinkers. The

analysis showed no differences in diet quality between

the day and shift workers. The latter more frequently

re-ported abstaining from alcohol, and were less frequently

classified as risky or high-risk drinkers. The difference

in the distribution was statistically significant, and the

analysis was adjusted for age.

A group of 40 female hospital nurses and 35 day

working nurses were studied in India [13]. Their

di-etary habits were assessed based on data from diaries

in which the subjects recorded the specific food items

and amounts consumed. Food value tables were used to

calculate total energy, protein and carbohydrate intake,

as well as some vitamin and mineral intake. The average

values of the last 2 items were calculated on the basis

of 15 days consumption data. According to the study

results, the night shift workers reported to consume

fewer main meals but more snacks during the day with

the night duty, when compared to the day workers. They

were also found to have a lower energy, protein, fat and

carbohydrate intake. No difference was observed for

vitamin or mineral consumption. The subjects in both

groups were of similar age, and the night shift workers

were slightly slimmer than the day workers. Only crude

analyses were performed in this study.

A population of 749 Norwegian nurses working night

shifts was investigated by Saksvik-Lehouillier et al. [14].

The study population included 322 women with less than

1 year of experience in night shift work and 427 with

over 6 years of respective experience. During the study,

the researchers inquired about the number of coffee,

coke or tea cups usually consumed daily. Alcohol

con-sumption was measured with Alcohol Use Disorders

Identification Test Consumption (AUDIT-C), a validated

tool. The crude comparison performed showed a

signifi-cantly higher coffee consumption and a lower AUDIT-C

score among more experienced nurses.

A cross-sectional study on a population of 51

hos-pital nurses working night shifts was carried out in

Po-land [15]. The nurses completed a diary reporting their

food consumption over a 3-day period: before the night

duty, during the duty and on the day off. The dietary

data (total energy, daily macro- and micronutrient

con-sumption) were analyzed with computer software. The

study results revealed lower than recommended values

of the total energy consumption, and those of fiber, Ca,

Mg, Fe, K, vitamin D, folic acid, and fluid intake, and

a higher intake of animal proteins, fat, cholesterol, Na, P,

Zn, Cu, and vitamins A, E, B and C. This finding was

as-sociated with a lower consumption of cereals, fruit,

veg-etable, dairy products, processed meat products, fish,

and vegetable fats, and a higher than recommended

consumption of meat, poultry, eggs, animal fats, sweets,

and sugar. In this study, no formal reference group was

established. Instead, the calculated values were

com-pared with recommended standards, and the results

indicated potential disparities. The findings pointed to

a lower than recommended energy intake, but at the

same time, the BMI for some subjects was at the upper

limit value or even indicated overweight, which would

imply a dietary underreporting.

A large cross-sectional study of 9989 Korean nurses

was carried out by Kim et al., who used the web-based

survey [16]. A self-administered questionnaire

includ-ed questions on alcohol consumption and dietary

hab-its. Night shift nurses reported a higher consumption

of alcohol when compared to day workers, but the

fre-quency of a regular drinking habit decreased with an

increasing duration of shift work. The shift work nurses

more frequently reported skipping breakfast and/or

lunch, but this tendency was found to significantly

de-crease with an increasing duration of shift work. The

crude analyses performed did not include any

adjust-ments for covariates.

The cross-sectional study to assess dietary habits

among 98 Iranian hospital nurses employed 24-h recalls

of a 3-day period [17]. The dietary data were verified by

a nutritionist. The total energy, vitamin and

micronu-trient intakes were calculated. The data analysis showed

that shift workers consumed less thiamin, riboflavin,

niacin, folates, magnesium, and iron. No differences

between the shift and day workers were observed with

respect to daily consumption of total energy,

pyridox-ine, cobalamin, ascorbate, tocopherol, retinol,

cholecal-ciferol, zinc, and calcium. The crude means were

com-pared using Student’s t-test.

Dietary intake over a 1-month period was evaluated

in a cross-sectional study of 2758 nurses in Japan [18]. In

this study, a semiquantitative food frequency

question-naire was used and total energy consumption, as well as

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product groups and nutritional elements, were

evaluat-ed. Women working shifts reported a higher

consump-tion of sweets, sugar-sweetened beverages and alcohol,

and a lower consumption of potatoes and starch, green

and yellow vegetables, white vegetables, fruit, algae,

fish and shellfish, and meat. Protein consumption was

significantly lower among the shift workers, but no

dif-ference was observed for the intake of total energy, fats

and carbohydrates. The analysis was adjusted for total

calories intake.

A cross-sectional study of 2259 Norwegian nurses

investigated the association between night shift work

duration (> 5 years vs. < 5 years) and its intensity,

ex-pressed as the number of night shifts over the previous

year, and daily caffeine consumption and alcohol

con-sumption [19]. Alcohol concon-sumption was measured

using AUDIT-C. The study found a statistically

signif-icant inverse association between a longer duration of

night shift and alcohol consumption. A higher number

of night duties during the year preceding the study was

significantly associated with coffee consumption. The

multivariate analysis included age, gender, the average

number of working hours and cohabitating children as

covariates.

In a large Nurses Health II cohort study of 54 725 wo-

men (39  333 ever working night shifts), the authors

examined the association between shift work and total

energy intake, as well as coffee and alcohol

consump-tion [20]. Dietary data were collected via a validated

semiquantitative food frequency questionnaire

cover-ing 130 food items. For the logistic regression analysis,

the total energy consumption was classified into 2

cat-egories: ≥ 1712 kcal/day and < 1712 kcal/day, and

cof-fee consumption ≥ 131 mg/day and < 131 kcal/day. The

analysis showed a statistically significant association

be-tween higher calories and coffee consumption, and ever

working night shifts. The multivariate analysis included

a number of covariates, such as age, partner’s education,

smoking, physical activity chronotype, and BMI. The

basic characteristics of the study population did not

show any differences in alcohol consumption due to the

night shift status.

Yoshizaki et al. investigated dietary habits in a group

of 162 nurses (including 123 working night shifts) [21].

The dietary behaviors were measured with the

self-ad-ministered questionnaire. The questionnaire used was

developed by the Japan Society for the Study of Obesity

and employed a scoring system for the measurement of

obesity-related behaviors such as cognition of

constitu-tion, motivation for eating, eating as a diversion, feeling

of satiety, eating style, meal contents and temporal

eat-ing patterns. The crude data analysis showed that the

night shift workers had a more unbalanced diet with

a greater preference for high-fat diet and sweets, and an

abnormal eating pattern, including a greater

irregular-ity in the timing and number of meals, and later time

of meals. The multivariate analysis that included age,

marital status, residential status, smoking, alcohol

sta-tus, and the number of night shifts during the previous

month revealed an association with the chronotype but

not with the night shift work.

Hakim et al. investigated nutritional behaviors

among 400 nurses, considering the duration of night

shift work [22]. They used a 10-item questionnaire to

inquire about the usual frequency of particular food

item consumption per week. Dietary data were analyzed

based on the scoring system, categorizing women into

3 groups of ‘healthy,’ ‘semi-healthy’ and ‘unhealthy’ diet.

The crude analysis of group distribution according to

shift work duration showed a more frequent ‘unhealthy’

diet in the group of nurses working night shifts for a

pe-riod of more than 10 years. These differences were not

statistically significant.

The nurses’ dietary habits at the workplace were

examined in a study of 140 hospital nurses in Poland

(including 109 shift work nurses) [23]. In this study,

a questionnaire developed by the study authors was

used to elicit data on the number of meals per day, the

number of meals while at work, main meals, meals

regu-larity, and eating at night. Nurses with a history of night

shift work of more than 20 years reported consuming

more meals per day than the nurses who had a shorter

history of night shift work. Nurses working night shifts

and those who had a 12-h duty but only during the day,

were more frequently found to have meals at night than

the nurses who had a 8-h day time duty. The findings

were analyzed using crude χ

2

test unadjusted for any

co-variates.

A population of 395 nursing staff at 2 hospitals in

Saudi Arabia was investigated in a cross-sectional study

by Ajmawal [24]. The Dutch Eating Behaviour

Ques-tionnaire, a validated tool comprising 33 questions, was

used to categorize subjects into the following categories:

restrained (a tendency to restrict food intake to control

body weight), emotional (to cope with negative

emo-tions) and external eating (the extent to which external

cues of food trigger the eating episodes). The author

found a statistically significant positive association

be-tween night shift work, particularly a higher frequency

of night shifts per month, and restrictive or emotional

(10)

eating, and an inverse association with external eating.

The analyses included age, gender, education, and

mar-ital status as covariates.

Han et al. conducted a cross-sectional study of

340 nurses in South Korea, evaluating their dietary

be-haviors, the number of main meals, snacks, meals irregu-

larity, skipping breakfast, overeating, and the

frequen-cy of fruit and vegetable consumption [25]. The

ques-tionnaire inquired about the items that matched the

recommendations of the Korean Dietary Guidelines.

The night shift workers more frequently than the day

workers reported meals irregularity, skipping breakfast,

and eating snacks at night, while less frequently eating

3 main meals per day and more fruit servings per day.

The crude comparisons did not include any covariates.

Diet quality and night shift work were evaluated

among 103 hospital nurses in the USA (53 working

night shifts) [26]. Diet History Questionnaire II (DHQII)

developed by the National Cancer Institute was used to

ask questions about the frequency and amount of

con-sumption of 134 food items and 8 dietary supplements

over a period of one month preceding the study. The

findings revealed no differences in diet quality of the

night shift nurses when compared to the day nurses.

The crude analysis did not account for any covariates.

Nutritional habits were evaluated in a small group

(N  = 46) of medical university staff (23 nursing staff

working night shifts, 10 nurses working during the days,

and 13 clerical staff) in Germany [27]. The information

about the foods consumed was collected via diaries

cov-ering a 7-day period. Data were analyzed with OptiDiet

software to calculate macro- and micronutrient intake.

In this study, no differences in the total energy intake

were found between night shift and day workers. Both

the nurses working night shifts and those working only

during days consumed significantly less fats than did the

clerical staff. Carbohydrate intake among the night shift

nurses was significantly higher than among the office

staff, but not when compared to the day nurses. No

co-variates were included in the crude analyses of the data.

CONCLUSIONS

The aim of the present review was to evaluate the

ex-isting epidemiological data on the association between

shift work, with special regard to night shift work, and

the nutritional habits of nurses working according to

that pattern. The authors have identified altogether as

many as 19 papers describing studies in this area, which

were published in 2000–2017. The total number of studies

in this field is relatively small, but an increasing

inter-est has been noted over the last decade, and as many

as 16 of the 19 papers identified have been published

since 2011.

The studies varied greatly with respect to the size

and age of the study populations, and the duration of

night shift work. The major problem which could be

identified is the heterogeneity of the tools used for

di-etary assessment. Therefore, the data aggregation, as

well as direct comparisons and meta-analyses, are

pre-cluded at this stage.

Table 2 presents the findings of the studies reviewed,

by the dietary items or behaviors examined, providing

the number of studies that evaluated a specific item,

and referencing the studies that found the

consump-tion higher, lower or equal among shift work nurses

when compared to the reference. Alcohol consumption

was the most frequently analyzed (8 studies), followed

by the total energy (7 studies), protein, fat (6 studies),

and carbohydrate intake, as well as coffee and fruit

consumption which were evaluated in 5 studies, i.e., in

about one-third of the studies covered by this review.

The other food items were examined even less frequently.

The results were fully consistent with respect to

cof-fee (caffeine) consumption, indicating a more frequent

or higher coffee consumption among the nursing staff

working night shifts [10,11,14,19,20]. Coffee

consump-tion seems to be related to a longer duraconsump-tion and a

high-er frequency of night shift work [14,19]. Two studies

re-ported the consumption of more than 3 cups of caffeine

drinks per day as being related to both a higher number

of the night duties worked in the previous year and to

night shift work seniority [19,28]. Dietary

recommen-dations generally accept coffee consumption of up to

3 cups per day. Coffee helps overcome sleepiness and

fatigue, and this may explain its higher consumption

among night workers. The recent umbrella review of

the observational and interventional studies of coffee

consumption and any health outcomes has

conclud-ed that coffee drinking seems safe within the usual

patterns of consumption except for pregnant women

and women with an increased risk of fractures [29].

It should be borne in mind that the drinks containing

coffee or caffeine may disturb the sleep pattern [30],

with frequent awakenings and prolonged sleep latency.

Thus, the sleep effectiveness and night work tolerance

may decrease in the long run.

Given the increasing evidence on a higher risk of

obesity among night shift workers, the data on the

total energy intake are of particular interest. Among

(11)

the 7 studies that evaluated the total energy intake by

the shift work status, 4 studies reported no difference

[10,17,18,26,27], 1 reported a higher energy

consump-tion among shift workers [20] and 2 indicated a lower

consumption [13,15]. Most of these studies were

small-scale, and thus they may have been underpowered to

Table 2. Food items from observational studies analyzing dietary habits according to the shift work status of nurses

Dietary characteristic Reference Studies[n]

+ – no difference Total energy 20 13, 15 10, 17, 18, 27 7 Proteins 15 13, 18 10, 26, 27 6 Fats 15 13, 27 10, 18, 26 6 Carbohydrates 15, 27 13 10, 18 5 Cereal products 15 18, 26 3 Potatoes, starches 18 1 Pulses 18, 26 2 Nuts, seeds 18 1 Algae 18 1

Fish and shellfish 18 26 1

Eggs 15 18 2

Dairy products 18, 26 2

Sweets 15, 18 26 3

Vitamins 15

(A, E, B1, B2, B6, PP, C, folic acid) (B1, B2, B3, folates)17 (B6, B12, C, E, retinol, D)13, 17 3

Iron 15, 17 2 Magnesium 15, 17 2 Calcium 15, 17 2 Zinc 15 17 2 Red meat 15 18 2 Alcohol 16, 18 12, 14, 16a, 19 10, 20 8 Tea 10 1 Coffee (caffeine) 10, 11, 14, 19, 20 5 Fruit 15, 18, 24*, 25 26 5 Vegetables 15, 18, 24 26 4 Sweetened beverages 18 1 Salt 15 18, 26 3

Number of main meals 23

(number of meals at work – 18) 9, 10, 13 4

Number of snacks 10, 13, 25 9 4

Meals regularity 16, 25 2

Time of the last meal 9 (later), 21 2

Eating at night 10, 21, 23 3

Diet quality 21, 22

(worse) 12, 20, 26 5

Dietary habits change since

the start of shift work (meals intake increase)9 1

a Among shift workers with longer shift work duration. * In the subgroup of emotional eating.

“+” – greater consumption compared to the reference group. “–” – lower consumption compared to the reference group.

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