Knutsson A
National Institute for Psychosocial Factors and Health, Karolinska Institutet, Stockholm.
Scand J Soc Med Suppl. 1989;44:1-36.
Previous research on the medical consequences of shift work has mainly been concerned with sleep disorders and gastrointestinal disturbances. Cardiovascular disease has not been clearly implicated. The objective of the present study was to investigate a possible association between shift work and Coronary Heart Disease (CHD), which is the most common cause of death in industrialized countries. Previous research is reviewed and criticized for using simple approaches with little ability to quantify exposure and to control for selection. Two longitudinal and two cross-sectional studies have been carried out. One study has measured incidence of CHD in 504 male day and shiftworkers from 1968 to 1982/83. The results indicate that shift work is associated with CHD. Our result has demonstrated a dose-response relationship between years of shift work and CHD. Our findings on increased risk of CHD in shift workers are consistent with recent epidemiological studies from Sweden which have used register data. The cross-sectional studies in which two different cohorts of male blue-collar workers were investigated did show a higher percentage of smokers among shift workers. In addition, the shift workers had higher serum concentrations of serum triglycerides. The difference in serum triglyceride levels between day and shift workers could not be explained by obesity, smoking or alcohol intake in the statistical analyses. These results suggest that the prevalence of risk factors for CHD is higher among shift workers. A prospective study of 25 male shift and day workers, who were followed for six months, indicated that the diet of shift workers might be responsible for changes in the ratio between apoB and apoA-1, a ratio which is related to risk of coronary disease. The analyses of spontaneous changes in the diet showed that the shift workers tended to decrease the intake of dietary fibre and increase the intake of sacharose. The change in the ratio between apoB and apoA-1 correlated inversely with the change in intake of dietary fibre. It is concluded that spontaneous changes in the diet of shift workers might be responsible for changes in serum lipoproteins. Three major disease pathways from shift work to CHD are proposed: (i) disturbed physiological rhythm and/or a collision between the circadian rhythm and myocardial performance, (ii) changes in behaviour, and (iii) disturbed sociotemporal rhythmicity, which might lead to distress reactions.
以往关于轮班工作对健康影响的研究主要集中在睡眠障碍和胃肠道紊乱方面。心血管疾病与轮班工作的关联尚未明确。本研究的目的是调查轮班工作与冠心病（CHD）之间可能存在的关联，冠心病是工业化国家最常见的死亡原因。以往的研究因采用简单方法，几乎没有能力量化暴露因素和控制选择因素而受到审查和批评。我们进行了两项纵向研究和两项横断面研究。其中一项研究测量了1968年至1982/83年期间504名男性日班和轮班工人的冠心病发病率。结果表明，轮班工作与冠心病有关。我们的研究结果显示了轮班工作年限与冠心病之间的剂量反应关系。我们关于轮班工人患冠心病风险增加的研究结果与瑞典最近使用登记数据进行的流行病学研究一致。在对两组不同男性蓝领工人进行调查的横断面研究中，确实发现轮班工人中的吸烟者比例较高。此外，轮班工人的血清甘油三酯浓度较高。在统计分析中，日班和轮班工人之间血清甘油三酯水平的差异无法用肥胖、吸烟或饮酒来解释。这些结果表明，轮班工人中冠心病危险因素的患病率较高。一项对25名男性轮班和日班工人进行的为期六个月的前瞻性研究表明，轮班工人的饮食可能是导致载脂蛋白B与载脂蛋白A-1比例变化的原因，该比例与冠心病风险相关。对饮食自发变化的分析表明，轮班工人倾向于减少膳食纤维的摄入量，增加蔗糖的摄入量。载脂蛋白B与载脂蛋白A-1比例的变化与膳食纤维摄入量的变化呈负相关。研究得出结论，轮班工人饮食的自发变化可能是血清脂蛋白变化的原因。本文提出了从轮班工作到冠心病的三条主要疾病途径：（i）生理节律紊乱和/或昼夜节律与心肌功能之间的冲突，（ii）行为变化，以及（iii）社会时间节律紊乱，这可能导致应激反应。
