A meta-analysis of cohort studies including dose-response relationship between shift work and the risk of diabetes mellitus


Previous reviews have suggested that shift work is associated with an increased risk of diabetes mellitus (DM); however, the results should be interpreted with caution due to differences in study designs and non-comprehensive literature searches. In addition, the quantitative dose-response relationship between years of shift work and DM risk is still unknown. We aimed to conduct an updated meta-analysis with cohort studies and to evaluate the relationship between the duration of shift work and the risk of DM in a dose-dependent manner. The PubMed and Web of Science databases were searched through 15 August 2019, and multivariate-adjusted relative risks (RRs) were pooled using random-effects models. Restricted cubic spline analysis with three knots was used to explore the relationship of years of shift work and risk of DM. Twelve cohort studies with 28 independent reports involving 244,266 participants and 15,906 DM cases were included. The summarized adjusted RR for the relationship between shift work and DM risk was 1.14 (95% CI 1.10 to 1.19; I2 = 38.9%, P = 0.028). The summary RR of a 5-year increase in shift work was 1.07 (95% CI 1.04 to 1.09), without heterogeneity (I2= 0.0%, P = 0.829) for the female population. Shift work is associated with an increased risk of DM, and a strong and highly significant linear dose-response relationship between the duration of shift work and the risk of DM in women was observed. Further studies are needed to confirm the results, establish causality and elucidate the underlying mechanisms.

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  1. 1.

    Wang XS, Armstrong ME, Cairns BJ, Key TJ, Travis RC. Shift work and chronic disease: the epidemiological evidence. Occup Med. 2011;61(2):78–89. https://doi.org/10.1093/occmed/kqr001.

    Article  Google Scholar 

  2. 2.

    Szosland D. Shift work and metabolic syndrome, diabetes mellitus and ischaemic heart disease. Int J Occup Med Environ Health. 2010;23(3):287–91. https://doi.org/10.2478/v10001-010-0032-5.

    Article  PubMed  Google Scholar 

  3. 3.

    Papantoniou K, Devore EE, Massa J, et al. Rotating night shift work and colorectal cancer risk in the nurses’ health studies. Int J Cancer. 2018;143(11):2709–17. https://doi.org/10.1002/ijc.31655.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Cordina-Duverger E, Menegaux F, Popa A, et al. Night shift work and breast cancer: a pooled analysis of population-based case-control studies with complete work history. Eur J Epidemiol. 2018;33(4):369–79. https://doi.org/10.1007/s10654-018-0368-x.

    Article  PubMed  Google Scholar 

  5. 5.

    Wang D, Ruan W, Chen Z, Peng Y, Li W. Shift work and risk of cardiovascular disease morbidity and mortality: a dose-response meta-analysis of cohort studies. Eur J Prevent Cardiol. 2018;25(12):1293–302. https://doi.org/10.1177/2047487318783892.

    Article  Google Scholar 

  6. 6.

    Esquirol Y, Bongard V, Mabile L, Jonnier B, Soulat JM, Perret B. Shift work and metabolic syndrome: respective impacts of job strain, physical activity, and dietary rhythms. Chronobiol Int. 2009;26(3):544–59. https://doi.org/10.1080/07420520902821176.

    Article  PubMed  Google Scholar 

  7. 7.

    Bokenberger K, Sjolander A, Dahl Aslan AK, Karlsson IK, Akerstedt T, Pedersen NL. Shift work and risk of incident dementia: a study of two population-based cohorts. Eur J Epidemiol. 2018;33(10):977–87. https://doi.org/10.1007/s10654-018-0430-8.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Knutsson A, Kempe A. Shift work and diabetes–a systematic review. Chronobiol Int. 2014;31(10):1146–51. https://doi.org/10.3109/07420528.2014.957308.

    Article  PubMed  Google Scholar 

  9. 9.

    Gan Y, Yang C, Tong X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med. 2015;72(1):72–8. https://doi.org/10.1136/oemed-2014-102150.

    Article  PubMed  Google Scholar 

  10. 10.

    Teratani T, Morimoto H, Sakata K, et al. Dose-response relationship between tobacco or alcohol consumption and the development of diabetes mellitus in Japanese male workers. Drug Alcohol Depend. 2012;125(3):276–82. https://doi.org/10.1016/j.drugalcdep.2012.03.002.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Oberlinner C, Ott MG, Nasterlack M, et al. Medical program for shift workers–impacts on chronic disease and mortality outcomes. Scand J Work Environ Health. 2009;35(4):309–18.

    Article  Google Scholar 

  12. 12.

    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group. Jama. 2008;283(15):2008–12.

    Article  Google Scholar 

  13. 13.

    Wells G, Shea B, O’Connell J, et al. The newcastle-ottawa scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Oxford, Ottawa, ON: Ottawa Health Research Institute; 2014.

    Google Scholar 

  14. 14.

    Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557–60. https://doi.org/10.1136/bmj.327.7414.557.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Lau J, Ioannidis JP, Schmid CH. Quantitative synthesis in systematic reviews. Ann Int Med. 1997;127(9):820–6.

    CAS  Article  Google Scholar 

  16. 16.

    Greenland S, Longnecker MP. Methods for trend estimation from summarized dose-response data, with applications to meta-analysis. Am J Epidemiol. 1992;135(11):1301–9.

    CAS  Article  Google Scholar 

  17. 17.

    Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629–34.

    CAS  Article  Google Scholar 

  18. 18.

    Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50(4):1088–101.

    CAS  Article  Google Scholar 

  19. 19.

    Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Performance of the trim and fill method in the presence of publication bias and between-study heterogeneity. Stat Med. 2007;26(25):4544–62. https://doi.org/10.1002/sim.2889.

    Article  PubMed  Google Scholar 

  20. 20.

    Kroenke CH, Spiegelman D, Manson J, Schernhammer ES, Colditz GA, Kawachi I. Work characteristics and incidence of type 2 diabetes in women. Am J Epidemiol. 2007;165(2):175–83. https://doi.org/10.1093/aje/kwj355.

    Article  PubMed  Google Scholar 

  21. 21.

    Pan A, Schernhammer ES, Sun Q, Hu FB. Rotating night shift work and risk of type 2 diabetes: two prospective cohort studies in women. PLoS Med. 2011;8(12):e1001141. https://doi.org/10.1371/journal.pmed.1001141.

    Article  PubMed  PubMed Central  Google Scholar 

  22. 22.

    Jorgensen JT, Karlsen S, Stayner L, Andersen J, Andersen ZJ. Shift work and overall and cause-specific mortality in the Danish nurse cohort. Scand J Work Environ Health. 2017;43(2):117–26. https://doi.org/10.5271/sjweh.3612.

    Article  PubMed  Google Scholar 

  23. 23.

    Bannai A, Yoshioka E, Saijo Y, Sasaki S, Kishi R, Tamakoshi A. The risk of developing diabetes in association with long working hours differs by shift work schedules. J Epidemiol. 2016;26(9):481–7. https://doi.org/10.2188/jea.JE20150155.

    Article  PubMed  Google Scholar 

  24. 24.

    Monk TH, Buysse DJ. Exposure to shift work as a risk factor for diabetes. J Biol Rhythms. 2013;28(5):356–9. https://doi.org/10.1177/0748730413506557.

    Article  PubMed  PubMed Central  Google Scholar 

  25. 25.

    Eriksson AK, van den Donk M, Hilding A, Ostenson CG. Work stress, sense of coherence, and risk of type 2 diabetes in a prospective study of middle-aged Swedish men and women. Diabetes Care. 2013;36(9):2683–9. https://doi.org/10.2337/dc12-1738.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Karlsson B, Alfredsson L, Knutsson A, Andersson E, Toren K. Total mortality and cause-specific mortality of Swedish shift- and dayworkers in the pulp and paper industry in 1952–2001. Scand J Work Environ Health. 2005;31(1):30–5.

    Article  Google Scholar 

  27. 27.

    Suwazono Y, Sakata K, Okubo Y, et al. Long-term longitudinal study on the relationship between alternating shift work and the onset of diabetes mellitus in male Japanese workers. J Occup Environ Med. 2006;48(5):455–61. https://doi.org/10.1097/01.jom.0000214355.69182.fa.

    Article  PubMed  Google Scholar 

  28. 28.

    Kawakami N, Araki S, Takatsuka N, Shimizu H, Ishibashi H. Overtime, psychosocial working conditions, and occurrence of non-insulin dependent diabetes mellitus in Japanese men. J Epidemiol Commun Health. 1999;53(6):359–63.

    CAS  Article  Google Scholar 

  29. 29.

    Morikawa Y, Nakagawa H, Miura K, et al. Shift work and the risk of diabetes mellitus among Japanese male factory workers. Scand J Work Environ Health. 2005;31(3):179–83.

    Article  Google Scholar 

  30. 30.

    De Bacquer D, Van Risseghem M, Clays E, Kittel F, De Backer G, Braeckman L. Rotating shift work and the metabolic syndrome: a prospective study. Int J Epidemiol. 2009;38(3):848–54. https://doi.org/10.1093/ije/dyn360.

    Article  PubMed  Google Scholar 

  31. 31.

    Vimalananda VG, Palmer JR, Gerlovin H, et al. Night-shift work and incident diabetes among African–American women. Diabetologia. 2015;58(4):699–706. https://doi.org/10.1007/s00125-014-3480-9.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Shan Z, Li Y, Zong G, et al. Rotating night shift work and adherence to unhealthy lifestyle in predicting risk of type 2 diabetes: results from two large US cohorts of female nurses. BMJ. 2018;363:k4641. https://doi.org/10.1136/bmj.k4641.

    Article  PubMed  PubMed Central  Google Scholar 

  33. 33.

    Hansen AB, Stayner L, Hansen J, Andersen ZJ. Night shift work and incidence of diabetes in the Danish Nurse Cohort. Occup Environ Med. 2016;73(4):262–8. https://doi.org/10.1136/oemed-2015-103342.

    Article  PubMed  Google Scholar 

  34. 34.

    Poulsen K, Cleal B, Clausen T, Andersen LL. Work, diabetes and obesity: a seven year follow-up study among Danish health care workers. PLoS ONE. 2014;9(7):e103425. https://doi.org/10.1371/journal.pone.0103425.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Costa G. Shift work and health: current problems and preventive actions. Saf Health Work. 2010;1(2):112–23. https://doi.org/10.5491/shaw.2010.1.2.112.

    Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    James SM, Honn KA, Gaddameedhi S, Van Dongen HPA. Shift work: disrupted circadian rhythms and sleep-implications for health and well-being. Curr Sleep Med Rep. 2017;3(2):104–12. https://doi.org/10.1007/s40675-017-0071-6.

    Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Schernhammer ES, Rosner B, Willett WC, Laden F, Colditz GA, Hankinson SE. Epidemiology of urinary melatonin in women and its relation to other hormones and night work. Cancer Epidemiol Biomark Prevent A Publ Am Assoc Cancer Res Cosponsored Am Soc Prevent Oncol. 2004;13(6):936–43.

    CAS  Google Scholar 

  38. 38.

    Bekkers MB, Koppes LL, Rodenburg W, van Steeg H, Proper KI. Relationship of night and shift work with weight change and lifestyle behaviors. J Occup Environ Med. 2015;57(4):e37–44. https://doi.org/10.1097/jom.0000000000000426.

    Article  PubMed  Google Scholar 

  39. 39.

    Lin PC, Chen CH, Pan SM, et al. The association between rotating shift work and increased occupational stress in nurses. J Occup Health. 2015;57(4):307–15. https://doi.org/10.1539/joh.13-0284-OA.

    Article  PubMed  Google Scholar 

  40. 40.

    Najafian J, Mohamadifard N, Siadat ZD, Sadri G, Rahmati MR. Association between sleep duration and diabetes mellitus: isfahan healthy heart program. Niger J Clin Pract. 2013;16(1):59–62.

    CAS  Article  Google Scholar 

  41. 41.

    Van Cauter E. Sleep disturbances and insulin resistance. Diabet Med A J Br Diabet Assoc. 2011;28(12):1455–62. https://doi.org/10.1111/j.1464-5491.2011.03459.x.

    CAS  Article  Google Scholar 

  42. 42.

    Tsatsoulis A, Fountoulakis S. The protective role of exercise on stress system dysregulation and comorbidities. Ann N Y Acad Sci. 2006;1083:196–213. https://doi.org/10.1196/annals.1367.020.

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Ulhoa MA, Marqueze EC, Burgos LG, Moreno CR. Shift work and endocrine disorders. Int J Endocrinol. 2015;2015:826249. https://doi.org/10.1155/2015/826249.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  44. 44.

    Bonham MP, Bonnell EK, Huggins CE. Energy intake of shift workers compared to fixed day workers: a systematic review and meta-analysis. Chronobiol Int. 2016;33(8):1086–100. https://doi.org/10.1080/07420528.2016.1192188.

    Article  PubMed  Google Scholar 

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The study was supported by the Young Scientists Fund of the National Natural Science Foundation of China (81903291), the Fundamental Research Funds for the Central Universities (2019kfyXJJS032), China Postdoctoral Science Foundation (2019T120666), and Key project of Wuhan Municipal Health Committee (WG16B08). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Author information




WZL proposed the study. WZL, DMW and WYR performed the searching, data extraction, and quality assessment. ZXL helped to develop search strategies. WZL analyzed the data. WZL wrote the first manuscript; DMW, ZLC and GLY revised the draft. All authors contributed to reviewing or revising the paper and read and approved the final version.

Corresponding authors

Correspondence to Dongming Wang or Zuxun Lu.

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The authors declare no conflict of interest.


Data for the present meta-analysis were acquired through previously published articles, and the study did not involve participants or patients.

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Li, W., Chen, Z., Ruan, W. et al. A meta-analysis of cohort studies including dose-response relationship between shift work and the risk of diabetes mellitus. Eur J Epidemiol 34, 1013–1024 (2019). https://doi.org/10.1007/s10654-019-00561-y

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  • Shift work
  • Diabetes mellitus
  • Cohort
  • Meta-analysis
  • Dose-response relationship