Chronobiology International

The Journal of Biological and Medical Rhythm Research

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Vitamin D supply in shift working nurses

Martin Lehnert, Alexandra Beine, Katarzyna Burek, Simone Putzke, Stephan

Schlösser, Dirk Pallapies, Thomas Brüning, Thomas Behrens & Sylvia
Rabstein

To cite this article: Martin Lehnert, Alexandra Beine, Katarzyna Burek, Simone Putzke, Stephan
Schlösser, Dirk Pallapies, Thomas Brüning, Thomas Behrens & Sylvia Rabstein (2018): Vitamin D
supply in shift working nurses, Chronobiology International, DOI: 10.1080/07420528.2018.1424719

To link to this article: https://doi.org/10.1080/07420528.2018.1424719

Published online: 11 Apr 2018.

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CHRONOBIOLOGY INTERNATIONAL
https://doi.org/10.1080/07420528.2018.1424719

Vitamin D supply in shift working nurses

Martin Lehnerta, Alexandra Beineb, Katarzyna Bureka, Simone Putzkea, Stephan Schlösserc, Dirk Pallapiesa,
Thomas Brüningd, Thomas Behrensa, and Sylvia Rabsteina
a
Center for Epidemiology, Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr-
Universität Bochum (IPA), Bochum, Germany; bCenter for Medicine, Institute for Prevention and Occupational Medicine of the German Social
Accident Insurance, Institute of the Ruhr-Universität Bochum (IPA), Bochum, Germany; cOccupational physician at BG University Hospital
Bergmannsheil, Bochum, Germany; dDirector of the Institute for Prevention and Occupational Medicine of the German Social Accident
Insurance, Institute of the Ruhr-Universität Bochum (IPA), Bochum, Germany

ABSTRACT ARTICLE HISTORY

We studied determinants of Vitamin D in serum of 67 female health care workers (aged Received 20 December 2017
25–60 years), including age, body mass index, physical activity, and shift work. Overall, vitamin Accepted 4 January 2018
D levels were low, ranging from 6 to 51 ng/mL (median: 20 ng/mL). Lower serum levels were KEYWORDS
found in samples drawn in winter and spring and in obese subjects. Shift work had only small Night work; cohort;
effects on vitamin D levels. biomarker; calciferol; cross
The high prevalence of vitamin D undersupply is in line with observations from the German sectional study
general population. Vitamin D supply particularly in winter and spring should be ensured to avoid
health problems.

Introduction rickets. Levels below 20 ng/mL are considered

deficient and supplementation is recommended
The main source of bodily vitamin D is the synth-
(National Institutes of Health 2016; German
esis in deeper layers of the skin under the impact
Nutrition Society 2012). Hypercalcemia is respon-
of ultraviolet radiation with a wavelength of
sible for most symptoms of vitamin D intoxication
280–320 nm (UVB). Its active form 1,25-hydroxy-
due to prolonged high dosage intake (Alshahrani
vitamin D regulates calcium homeostasis, intest-
and Aljohani 2013). As the US Institute of
inal absorption of calcium and phosphorus, and
Medicine stated in 2010, serum concentrations
bone mineralization. While negative effects to
above 50 ng/mL (150 nmol/L) can be associated
bone health due to vitamin D deficiency are widely
with adverse effects.
acknowledged, associations with cardiovascular
Most populations studied presented a high pre-
disease, cancer, or mental health disturbances
valence of 25[OH]D serum levels below the
were described in the literature with inconsistent
recommended level of 20 ng/mL. According to
findings (Bolland et al. 2014; Autier et al. 2014). In
the 13th Nutrition Report of the German
this regard, vitamin D is discussed to be rather a
Nutrition Society, almost 30% of adult women in
general marker of bad health instead of being
Germany are estimated to be vitamin D deficient
causal to these chronic diseases (Harvey and
(Rabenberg and Mensink 2016).
Cooper 2012; Schöttker et al. 2014). Furthermore,
Serum levels of 25[OH]D are known to show a
it was reported that vitamin D body storage may
high inter-individual and intra-individual
influence sleep quality and duration, although the
variation.
evidence was considered weak (McCarty et al.
Physical activity is associated with increased
2014).
vitamin D status (Looker 2007), whereas over-
Independent health authorities recommend a
weight is associated with decreased vitamin D
total 25-hydroxyvitamin D (25[OH]D) serum
serum levels (Skaaby et al. 2016), which may be
level of at least 20 ng/mL (50 nmol/L) to prevent
attributed to the storage of more cutaneous

CONTACT Martin Lehnert lehnert@ipa-dguv.de Institute for Prevention and Occupational Medicine of the German Social Accident Insurance,
Institute of the Ruhr-Universität Bochum (IPA), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, Germany.
© 2018 Taylor & Francis Group, LLC
2 M. LEHNERT ET AL.

synthesized vitamin D in subcutaneous fat tissue Ethics

and altered circulation of metabolites (Wortsman
Participation was voluntary and required a signed
et al. 2000). Women appear to have lower levels of
informed consent. Personal data were handled and
vitamin D than men which might be attributed to
stored anonymously. The study was approved by
higher body fat (van Dam et al. 2007; Scragg et al.
the ethic review committee of the medical faculty
2004). Age appears to be negatively associated with
at Ruhr University Bochum (No. 3840-10).
vitamin D in all seasons, whereas the effect of
smoking on vitamin D status remains controver-
sial (Scharla 1998). Vitamin D measurements
Duration of sun exposure, latitude, skin pig- The determination of 25[OH]D in 14 serum sam-
mentation, and use of sunscreen are affecting ples was performed by immunoassay on a Roche
UVB intensity and are proven determinants of Elecsys System 2010. Due to a change of laboratory
vitamin D synthesis (Osmancevic et al. 2015; equipment on the 1st March 2014 the later 53
Armas et al. 2007; Engelsen et al. 2005). It is samples were analyzed employing an immunoas-
hypothesized that night work could alter levels of say on a Beckman Coulter System DxI800. All
circulating vitamin D due to a reduction of expo- samples were drawn between 11th June 2013 and
sure to direct sunlight because of day sleep 26th March 2015 and analyzed on the day of
(Fritschi et al. 2011). drawing. Accounting for variations over the year
Therefore we assessed the vitamin D blood sta- we assigned dates of sample drawing to the calend-
tus and studied interfering factors in female health rical seasons.
care workers.
Potential predictors of serum 25[OH]D
Additionally, age, body mass index (BMI) and
Material and methods smoking status were assessed as potential predic-
tors at baseline. If diary entries reflected any sport-
We analyzed 25[OH]D serum levels in 67 female
ing activity during the observation periods, a
subjects comprising 44 professional nurses, 17
subject was classified as physically active.
medical assistants and 6 other health workers.
The age ranged between 25 and 60 years with a
median of 38 years (Table 1). Forty seven subjects
were working in a forward rotating roster with Statistical analyses
early, late, and night shifts. Subjects of this group In case of categorical parameters (obesity,
served between 2 and 9 night shifts per month. smoking, sport activities, season) the medians
Most of them worked four nights in each month. of 25[OH]D serum levels were compared
Five or more monthly night shifts were performed group-wise including the calculation of non-
by 15 subjects within this group. Twenty other parametric t-tests. Correlations to linear para-
subjects had regular worktimes only at daytime meters (age, BMI) were studied based on
starting earliest at 6 a.m. Spearman’s rank correlation coefficients.
P-values less than 0.05 (2-sided test) were con-
sidered statistically significant.
Table 1. Characteristics of the study population of female Linear multivariable models were used to
health care workers. analyze log transformed vitamin D concentra-
Variable N % tions. The final model included age, BMI,
Subjects (female) 67 100 smoking status, and season of sample draw
Shift work 47 70
Physically active 41 61 and physical activity. Regarding BMI, subjects
Current smoker 18 27 were assigned to a group with BMI below
Former smoker 12 18
Median Range
30 kg/m2 or BMI of 30 kg/m2 or above. Effect
Age [years] 38 (25–60) estimates for age were calculated per 10 years.
BMI [kg/m2] 24.8 (17.9–41.2) Statistical analyses were performed with SAS
 CHRONOBIOLOGY INTERNATIONAL 3

software, version 9.4 (SAS Institute Inc., Cary,

NC, USA) and Graph Pad Prism 7.3.

Results
Serum levels of 25[OH]D ranged from 6 to 51 ng/
mL with a median of 20 ng/mL (95%-CI:
15–23 ng/mL). Fifteen out of 67 subjects (22%)
showed levels <12 ng/mL. Although there was no
significant correlation of 25[OH]D levels and BMI
(rs: −0.089; p: 0.47), the median Vitamin D level in
obese subjects (BMI >30) was slightly lower at Figure 3. Vitamin D status in physically active (N = 41) and
inactive subjects (N = 24); four subjects under supplementation
13 ng/mL (Figure 1). (open symbols).
There was no correlation of 25[OH]D serum
levels with age (rs: −0.067; p: 0.59). As shown in
Table 2. Linear regression model for determinants of serum
Figure 2 the median of 25[OH]D of day workers level of the 25[OH]D, orally supplemented subjects excluded
was higher than that of shift workers (23 vs. 20 ng/ (N = 63).
25[OH]D in serum
Variable N Reference NExp(β) 95%-CI
Intercept 29.0 (16.4–51.2)
Age (10 years) 0.94 (0.83–1.06)
Day group 17 Shift group 46 1.24 (0.91–1.69)
Winter/Spring* 36 Summer/Fall* 27 0.77 (0.60–0.99)
BMI (≥ 30 kg/m2) 13 BMI (< 30) 50 0.72 (0.52–0.99)
Smoker 18 Nonsmoker 45 0.90 (0.66–1.22)
Physically active 37 Not active 26 0.97 (0.73–1.29)
*Season of sampling

mL), although the difference did not reach the

Figure 1. Vitamin D status versus body mass index (N = 67);
four subjects under supplementation (open symbols).
Figure 2. Vitamin D status in the day working group (N = 20)
and the shift working group with occasional night shifts
(N = 47); four women under supplementation (open symbols).
level of statistical significance (p = 0.18).
Vitamin D serum levels in physical active subjects
ranged from 6 to 51 ng/mL (median: 22 ng/mL) and
in inactive persons from 8 to 44 ng/mL (median:
19 ng/mL) as shown in Figure 3. Again, this differ-
ence was not statistically significant (p = 0.43).
Blood samples drawn in winter or spring
time presented significantly lower concentra-
tions of 25[OH]D than samples from summer
or autumn (medians: 16 vs. 23 ng/mL;
p = 0.032).
The results of multivariable log linear regres-
sion modeling (Table 2) confirmed no signifi-
cant effects of age, physical activity on vitamin
D levels. Dayworkers had slightly higher vita-
min D levels than nurses in shift work,
although this difference did not reach the
level of formal statistical significance. BMI
above 30 kg/m2 was associated with reduced
vitamin D levels (eβ = 0.72; 95% CI: 0.52–
4 M. LEHNERT ET AL.
0.99). Sampling in winter and spring time was
associated with lower blood levels of vitamin D
than sampling in summer and autumn (eβ = 0.77
(95% CI: 0.60–0.99).
Discussion
Half of the studied female health care workers in
the Ruhr-Area in western Germany (50°N latitude)
presented vitamin D levels below the recom-
mended 20 ng/mL in blood serum. A substantial
deficiency (<12 ng/mL) was verified in 22% of
these workers. Low serum levels were associated
with winter and spring season as well as with
obesity. Multivariate modeling revealed slightly
lower vitamin D concentrations in female shift
workers, although this difference was not statisti-
cally significant. We did not observe a statistically
significant effect of age or physical activity on
vitamin D levels.
The small size of our population limited the
power to detect small differences or effects. We
observed a higher percentage of subjects with
severe vitamin D deficiency in shift workers. A
similar pattern appeared for women who were
physical inactive. However, physical activity was
extracted from the subjects’ diary entries which
may provide limited reliability.
As recently discussed, immunoassays to deter-
mine 25[OH]D serum levels may be inaccurate
(Schottker et al. 2012). Compared to tandem
mass spectrometry DiaSorin Liaison chemilumi-
nescence assay measured substantially lower con-
centrations of total 25[OH]D in plasma (Koning
et al. 2013). Both, the Beckman Coulter System
DxI800 and Roche Elecsys System 2010 applied
in this study are well established in commercial
clinical routine. The distribution of the measured
values does not point to any kind of batch effect
(data not shown).
The high prevalence of undersupply with vita-
min D is in line with observations from other
studies. High prevalence rates were observed in
the general population of Western countries
(Scharla 1998). The German Health monitoring
at Robert Koch Institute reported almost 30% of
adult women in Germany presenting a deficient
vitamin D status (Rabenberg and Mensink 2016).
A population-based cohort from the same area
than this study showed median vitamin D concen-
trations of 15.3 ng/mL among male study subjects
(Behrens et al., 2017).
Other studies also reported similar seasonal pat-
terns with lower vitamin D levels in winter and
spring (Wallingford et al. 2014). A seasonal effect
with peak vitamin D levels in late summer and
autumn is plausible because effective UVB radia-
tion in summer is high and vitamin D can be
stockpiled. Accordingly, the lowest levels are
found at the beginning of spring. More UVB pene-
trates the atmosphere at low latitudes, hence solar
exposure is considered insufficient from
November to March at high latitudes of 40–50°N
and beyond (Kimlin 2008).
Studies assessing shift work as independent
risk factor for vitamin D undersupply are con-
tradictory. In contrast to our findings, an
Italian cross-sectional study of voluntary parti-
cipants observed reduced vitamin D levels in
shift workers compared with day workers
(Romano et al. 2015). This is in line with the
association of shift work and increased risk for
vitamin D deficiency (< 20 ng/mL) in shift
working versus non shift working wageworkers
revealed in the 5th Korea National Health and
Nutrition Examination Study (KNHANES).
Adjusted odds ratios in women were 1.3 (95%
CI 0.9–2.0) and 1.5 (95%CI 1.1–1.9) in men
(Jeong et al. 2014).
In contrast, a cross-sectional study within the
British birth cohort found that night work was
associated with increased vitamin D status in
mid-life women (Ward et al. 2011). A small
study on Japanese male indoor workers did not
observe differences between fixed day workers,
shift workers and night workers (Itoh et al.
2011). Indoor work may reduce exposure to sun-
light of day workers as well as of shift workers
(Harb et al. 2015). Accordingly, spare time in day-
light could stimulate vitamin D synthesis of night
works.
In summary, according to a recommended
threshold of 20 ng/mL (50 nmol/mL) our findings
point to a distinct under-supply with cholecalci-
ferol also in nurses with an emphasis on winter
and spring time. Occasional night work seems to
have only a small (if any) impact on vitamin D
levels. We suggest following recommendations of

the national health authorities to counter health
problems due to inappropriate vitamin D supply.
Conflict of interest
The authors do not declare any conflict of interest. As staff
of the Institute for Prevention and Occupational Medicine
(IPA), authors are employed at the “Berufsgenossenschaft
Rohstoffe und chemische Industrie” (BG RCI), a public
body, which is a member of the study’s main sponsor,
the German Social Accident Insurance. IPA is an indepen-
dent research institute of the Ruhr-Universität Bochum.
The authors are independent from the German Social
Accident Insurance in study design, access to the collected
data, responsibility for data analysis and interpretation,
and the right to publish. The views expressed in this
paper are those of the authors and not necessarily those
of the sponsor.
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