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Mismatch of Sleep and Work Timing and Risk of Type 2 Diabetes

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Mismatch of Sleep and Work Timing and Risk of Type 2 Diabetes Diabetes Care Volume 38, September 2015 1707 Celine´ Vetter,1 Elizabeth E. Devore,1 Mismatch of Sleep and Work Cody A. Ramin,2 Frank E. Speizer,1,3 Walter C. Willett,4,5 and Timing and Risk of Type 2 Diabetes Eva S. Schernhammer 1,4 Diabetes Care 2015;38:1707–1713 | DOI: 10.2337/dc15-0302 EPIDEMIOLOGY/HEALTH SERVICES RESEARCH OBJECTIVE To examine whether a mismatch between chronotype (i.e., preferred sleep tim- ing) and work schedule is associated with type 2 diabetes risk. RESEARCH DESIGN AND METHODS In the Nurses’ Health Study 2, we followed 64,615 women from 2005 to 2011. Newly developed type 2 diabetes was the outcome measure (n =1,452).Aques- tion on diurnal preference ascertained chronotype in 2009; rotating night shift work exposure was assessed regularly since 1989. RESULTS Compared with intermediate chronotypes, early chronotypes had a slightly de- creased diabetes risk after multivariable adjustment (odds ratio 0.87 [95% CI 0.77– 0.98]), whereas no significant association was observed for late chronotypes (1.04 [0.89–1.21]). Among early chronotypes, risk of type 2 diabetes was modestly re- duced when working daytime schedules (0.81 [0.63–1.04]) and remained similarly reduced in women working <10 years of rotating night shifts (0.84 [0.72–0.98]). After ‡10 years of shift work exposure, early chronotypes had a nonsignificant elevated diabetes risk (1.15 [0.81–1.63], Ptrend = 0.014). By contrast, among late chronotypes, the significantly increased diabetes risk observed among day work- ers (1.51 [1.13–2.02]) appeared largely attenuated if their work schedules in- 1 cluded night shifts (<10 years: 0.93 [0.76–1.13]; ‡10 years: 0.87 [0.56–1.34]; Channing Division of Network Medicine, De- ’ P partment of Medicine, Brigham and Women s trend = 0.14). The interaction between chronotype and shift work exposure was Hospital and Harvard Medical School, Boston, significant (Pinteraction = 0.0004). Analyses restricting to incident cases revealed MA similar patterns. 2Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, CONCLUSIONS MD 3Department of Environmental Health, Harvard In early chronotypes, type 2 diabetes risk increased with increasing duration of T.H. Chan School of Public Health, Boston, MA shift work exposure, whereas late types had the highest diabetes risk working 4Department of Epidemiology, Harvard T.H. daytime schedules. These data add to the growing body of evidence that workers Chan School of Public Health, Boston, MA 5 could benefit from shift schedules minimizing interference with chronotype- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA dependent sleep timing. Corresponding author: Celine´ Vetter, celine. [email protected]. Laboratory studies have shown that sleep loss results in altered glucose metabolism, Received 10 February 2015 and accepted 30 May and large observational studies have shown that short and long sleep durations are 2015. associated with type 2 diabetes risk, supporting the link between sleep and metab- This article contains Supplementary Data online olism (1,2). Sleep, however, is multidimensional. In addition to sleep duration and at http://care.diabetesjournals.org/lookup/ suppl/doi:10.2337/dc15-0302/-/DC1. quality, sleep timing may be critical for metabolic processes (3). For example, stud- © 2015 by the American Diabetes Association. ies have shown that late chronotypes (also referred to as owls), who generally tend Readers may use this article as long as the work to fall asleep and wake up later than earlier chronotypes (or larks) (4,5), exhibit is properly cited, the use is educational and not higher HbA1c levels (6), are at higher risk for the metabolic syndrome (7), and have a for profit, and the work is not altered. 1708 Chronotype, Shift Work, and Type 2 Diabetes Diabetes Care Volume 38, September 2015 significantly higher risk for type 2 diabe- nurses aged 25–42 years responded urination, weight loss, hunger) in addition tes compared with early or intermediate to a baseline questionnaire. Participants to fasting plasma glucose levels of at least chronotypes (8). complete biennial follow-up question- 7.8 mmol/L or random plasma glucose Sleep timing is largely regulated by naires to update information on medical levels of at least 11.1 mmol/L, 2)twoor the circadian clock (together with the history, lifestyle factors, and newly di- more measures of elevated plasma glu- sleep homeostat) (9); however, in our agnosed diseases. Follow-up rates are cose concentrations at separate occa- 24/7 society, it also heavily depends on high, with ;90% participation at each sionsintheabsenceofsymptoms($7.8 work schedules: In a cross-sectional 2-year cycle (16). This study was ap- mmol/L fastening, $11.1 mmol/L ran- study, we showed that early chrono- proved by the Brigham and Women’s dom plasma glucose, or oral glucose tol- types sleep worse and less and display Institutional Review Board. Answering erance test of $11.1 mmol/L after 2 h), or the highest levels of circadian misalign- the self-administered questionnaire im- 3) hypoglycemia treatment (insulin or ment during night shift work, whereas plies informed consent. oral hypoglycemic agent). In line with late chronotypes’ sleep and circadian American Diabetes Association recom- system are most adversely affected by Chronotype Assessment mendations (21), a level of 7.0 mmol/L early morning shifts (10). Furthermore, In 2009, we queried chronotype with a was considered the threshold for fasting among .60,000 day-working partici- single question on the NHS2 main ques- plasma glucose levels from 1998 onward. fi pants, work schedules constraining indi- tionnaire, speci cally, question 19 from Validation studies showed extremely vidual sleep timing were associated with the Morningness-Eveningness Ques- high reliability of self-reported diabetes “ ‘ obesity (11), suggesting that chronotype tionnaire (17): One hears about morn- diagnoses in the NHS cohorts. Of 62 ’ ‘ ’ may interact with working times and ing and evening types of people. cases in the NHS, 61 were verified by thereby modulate sleep and ultimately Which one of these types do you con- medical records (22). A substudy evalu- ” health (12). sider yourself to be? Response catego- ated the prevalence of undiagnosed di- fi Experimental studies support inde- ries comprised de nitely a morning abetes by measuring plasma glucose pendent effects of sleep timing and du- type, rather more a morning than an and fructosamine in a random sample ration. When systematically varying evening type, rather more an evening of nurses who had not reported diabe- fi sleep/wake episodes across the biologi- than a morning type, de nitely an even- tes previously. Only one woman (0.5%) cal day and night in a laboratory setting ing type, and neither. This single-item had levels within the diabetic range, (i.e., similar to what shift workers expe- measure of chronotype relates well with suggesting a very low level of false-positive rience), Scheer et al. (13) observed that the overall score of the Morningness- findings in this highly medically trained greater circadian misalignment is asso- Eveningness Questionnaire (r = 0.72) (18) population of nurses. ciated with impaired glucose metabo- and has previously been associated with lism, decreased insulin sensitivity, and sleep timing (19). Assessment of Covariates From 1989 onward, women were asked reduced leptin levels. Taking this ap- Night Shift Work Assessment every 2 years to provide updated infor- proach one step farther, Buxton et al. The assessment of night shift work his- mation on risk factors for chronic dis- (14) mimicked shift schedule constraints tory in NHS2 has been described in de- eases, such as body weight, cigarette on sleep in the laboratory, imposing tail elsewhere (16). Briefly, women smoking, family history of diabetes, both partial sleep deprivation and circa- indicated in 1989 how many years of physical activity, menopausal status, dian misalignment on participants. They rotating night shift work (at least three and hormone intake. Census 2005 and found that metabolic rates decreased night shifts per month in addition to 2009 data were used to assign median and plasma glucose levels increased, days and evenings) they had worked un- annual household income at the census suggesting inadequate insulin secretion. til then, with updates in 1991, 1993, tract level. Alcohol consumption and the We have previously demonstrated in 1997, 2001, 2005, and 2009, and retro- Alternative Healthy Eating Index (AHEI) the Nurses’ Health Study 2 (NHS2) that spective rotating night shift work as- (23) were calculated based on food fre- type 2 diabetes risk increases monoton- sessments for 1997–1999 (in 2001), quency questionnaire data collected in ically with increasing years of shift work 2001–2003 (in 2005), and 2005–2007 2007. Average sleep duration was ascer- (15). In the current study, we first exam- (in 2009) were included in the next bi- tained in 2009. Participants repeatedly ined the association of chronotype with ennial questionnaire, respectively. answered questions regarding antide- type 2 diabetes risk and then tested how pressant medication use (1993, 1997, rotating night shift work may modulate Ascertainment of Type 2 Diabetes 1999, 2001, 2003, 2005, 2007, and these associations. We hypothesized Type 2 diabetes has been queried bienni- 2009) as well as indicated whether that night shift work adversely affects ally since 1989 in the NHS2. All women they had a diagnosis of depression theriskoftype2diabetesinearlychro- reporting the diagnosis of diabetes on any (2001–2009). We combined this infor- notypes but not in late chronotypes be- questionnaire received a supplemental mation to account for potential depres- cause night shifts interfere less with questionnaire regarding symptoms, diag- sive symptoms. their sleep timing. nostic tests, and hypoglycemic therapy. A case of type 2 diabetes was considered Population for Analysis RESEARCH DESIGN AND METHODS confirmed if one of the following National A total of 85,362 women completed the The NHS2 is a large prospective cohort Diabetes Data Group criteria (20) applied: NHS2 questionnaire in 2005.
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