Article - Paper Answers

Read the article attach and aswer the following

1. From the description in the Methods section, how were the participants chosen for inclusion into the study? What were the criteria for exclusion? What was the final sample size for this study?

2. In the References, can you spot the citation “CDC, 2013”? What are the letters a, b, c for? Do you know if that’s also an APA formatting requirement (to use letters a, b, etc after the year)?

D
a U
b Y

International Journal of Nursing Studies 57 (2016) 60–69

Art

Sch

fax

htt

ccupational factors associated with obesity and leisure-time
hysical activity among nurses: A cross sectional study

al Lae Chin a, Soohyun Nam b, Soo-Jeong Lee a,*

niversity of California San Francisco, School of Nursing, San Francisco, CA, USA

ale University, School of Nursing, Orange, CT, USA

hat is already known about the topic?

The increasing prevalence of obesity is a major public
health problem in the U.S. and worldwide.

* The vast majority of U.S. adults does not engage in
regular physical activity.

* Research shows adverse working conditions contribute
to obesity and physical inactivity.

What this paper adds

* Nurses are faced with the high prevalence of over-
weight/obesity and their leisure-time physical activities
are far from optimal.

R T I C L E I N F O

icle history:

ceived 19 July 2015

ceived in revised form 25 January 2016

cepted 27 January 2016

ywords:

dy mass

index

rses

esi

cupational characteristics

ysical activity

A B S T R A C

Background and objective: Adverse working conditions contribute to obesity and physical

inactivity. The purpose of this study was to examine the associations of occupational

factors with obesity and leisure-time physical activity among nurses.

Methods: This study used cross-sectional data of 394 nurses (mean age 48 years, 91%

females, 61% white) randomly selected from the California Board of Registered Nursing list.

Data on demographic and employment characteristics, musculoskeletal symptom

comorbidity, physical and psychosocial occupational factors, body mass index (BMI), an

physical activity were collected using postal and on-line surveys from January to July in 2013.

Results: Of the participants, 31% were overweight and 18% were obese; 41% engaged in

regular aerobic physical activity (�150 min/week) and 57% performed regular muscle-
strengthening activity (�2 days/week). In multivariable logistic regression models,
overweight/obesity (BMI � 25 kg/m2) was significantly more common among nurse
managers/supervisors (OR = 2.54, 95% CI: 1.16–5.59) and nurses who worked full-time

(OR = 2.18, 95% CI: 1.29–3.70) or worked �40 h per week (OR = 2.53, 95% CI: 1.58–4.05).
Regular aerobic physical activity was significantly associated with high job demand

(OR = 1.63, 95% CI: 1.06–2.51). Nurses with passive jobs (low job demand combined with

low job control) were significantly less likely to perform aerobic

physical activity

(OR = 0.49, 95% CI: 0.26–0.93). Regular muscle-strengthening physical activity was

significantly less common among nurses working on non-day shifts (OR = 0.55, 95% CI:

0.34–0.89). Physical workload was not associated with obesity and physical activity.

Conclusions: Our study findings suggest that occupational factors significantly contribute

to obesity and physical inactivity among nurses. Occupational characteristics in the work

environment should be considered in designing effective workplace health promotion

programs targeting physical activity and obesity among nurses.

Corresponding author at: Department of Community Health Systems,

ool of Nursing University of California, San Francisco, 2 Koret Way,

ite N505, San Francisco, CA 94143-0608, USA. Tel.: +1 415 476 3221;

: +1 415 476 6042.

E-mail address: soo-jeong.lee@nursing.ucsf.edu (S.-J. Lee).

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

p://dx.doi.org/10.1016/j.ijnurstu.2016.01.009

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2016.01.009&domain=pdf

http://dx.doi.org/10.1016/j.ijnurstu.2016.01.009

mailto:soo-jeong.lee@nursing.ucsf.edu

http://www.sciencedirect.com/science/journal/00207489

http://dx.doi.org/10.1016/j.ijnurstu.2016.01.009

h
(F
O
2
S
o
to
d
ti
In
S
o
d
b
2
in
v
o
r
D
S
e
fo
e
n
r
s

to
c
a
c
la
h
le
2
a
s
a
to
2

s
o
h
o
5
w
e
w
s
p
ti

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–69 61

Overweight/obesity and leisure-time physical inactivity
among nurses were associated with occupational
factors, such as job title, full-time work, long work
hours, shift work, and high job demand.

. Introduction

The increasing prevalence of obesity is a major public
ealth problem in the United States (U.S.) and worldwi

legal et al., 2012; Ogden and Carroll, 2010; World Health
rganization, 2004). According to a recent study using
011–2012 National Health and Nutrition Examination
urvey data, two out of three adults in the U.S. a

verweight or obese (Ogden et al., 2014). Obesity is linked

type 2 diabetes, mental health, and cardiovascular
isease morbidity and mortality, which result in substan-
al health care costs (National Heart Lung and Blood
stitute, 2003; U.S. Department of Health and Human

ervices (USDHHS), 2001; Wang et al., 2008). The cause of
besity is multifactorial, including unhealthy eating, sleep
eprivation, psychological, genetic, environmental, and
ehavioral factors (Institute of Medicine, 2006; USDHHS,
001). Physical activity is one of the major factors targeted

obesity prevention and management and also produces
arious health benefits. Engaging in physical activity
ffsets the adverse health effects of overweight or obesity,
educing the risk of cardiovascular disease (Centers for
isease Control and Prevention [CDC], 2011; Li et al., 2006;
ofi et al., 2008; Thompson et al., 2003), and the protective
ffects of physical activity hold true even after controlling
r body mass index (BMI) (Kriska et al., 1993; Wareham

t al., 2000). However, the vast majority of U.S. adults do
ot engage in regular physical activity, and only 21% meet
ecommended levels for both aerobic and muscle-
trengthening physical activity (CDC, 2013a).

Research suggests that occupational factors contribute
obesity and physical inactivity. Adverse working

onditions such as long work hours, high job demands,
nd exposure to hostile work environments are signifi-
antly associated with obesity (Han et al., 2011; Jaaske-
inen et al., 2015; Luckhaupt et al., 2014). Individuals with
ighly stressful jobs require more recovery time and are
ss likely to engage in physical activity (Fransson et al.,
012; Lallukka et al., 2008a,b; McVicar, 2003; Sveinsdottir
nd Gunnarsdottir, 2008). Furthermore, studies demon-
trated that obesity is associated with high absenteeism
nd low workplace productivity, which lead to rising costs

businesses and society (Goetzel et al., 2010; Thompson,
007; Zapka et al., 2009).

In a recent study, health care employment was
ignificantly associated with increased prevalence of
besity (Luckhaupt et al., 2014). Nurses are the largest
ealth care occupation group, and the prevalence of
verweight/obesity among U.S. nurses ranges from 30% to
5% depending on geographical area, race and ethnicity, and
ork settings (Han et al., 2011; Miller et al., 2008; Tucker

t al., 2010; Zapka et al., 2009). Nursing jobs involve shift
ork and long work hours and are often reported as highly

tressful from physically and psychologically demanding
atient care (McVicar, 2003; Sveinsdottir and Gunnarsdot-
r, 2008). Also, work-related musculoskeletal injuries and

pain are common among nurses due to patient handling (Lee
et al., 2013). Such factors may be associated with reduced
leisure-time physical activity, which, in turn, contributes to
overweight/obesity among nurses (Atkinson et al., 2008;
Keller, 2009; Lallukka et al., 2008a,b; Zhao et al., 2012).

Previous studies of obesity among nurses have often
focused on the relationship between shift work and
irregular meal or disrupted sleep patterns (Field et al.,
2007; Geiger-Brown et al., 2011). There is limited research
on the effect of occupational factors other than shift work
on obesity among nurses. Also, little is known about
leisure-time physical activity among nurses and associated
occupational risk factors. The purpose of this study was to
describe the prevalence of overweight/obesity and leisure-
time physical activity among nurses and to examine the
relationships of occupational factors with obesity and
physical activity.

2. Methods

2.1. Study design and participants

This study analyzed cross-sectional survey data of
394 California registered nurses. The survey data were
collected through mail and internet from January to July in
2013. The study initially invited 2000 nurses randomly
selected from a list of actively licensed nurses by the
California Board of Registered Nursing by sending mail
surveys. Respondents were given an alternative response
option of on-line completion following log-on information
provided in the study information letter. A total of 526
nurses responded, and 394 nurses were eligible for the
analysis in the present study. Excluded were 102 retired or
not working, 14 currently on disability leave, and
11 employed less than one year. Additionally, three
subjects with more than 50% missing data, and two
subjects with missing data on both BMI and physical
activity were excluded.

2.2. Measures

2.2.1. Outcomes

2.2.1.1. Overweight/obesity. Overweight and obesity were
determined by using BMI, which is calculated by weight in
kilograms divided by height in meters squared (kg/m2).
BMI was categorized as underweight (<18.5 kg/m2), normal (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), and obese (�30 kg/m2) (CDC, 2012). We divided the categories into two groups as follows: underweight/ normal (<25 kg/m2) and overweight/obese (�25 kg/m2).

2.2.1.2. Leisure-time physical activity. Leisure-time aerobic
physical activity and muscle-strengthening physical activ-
ity were measured by questions from the Behavioral Risk
Factor Surveillance System (CDC, 2013b).

Aerobic physical activity was measured by the following
two questions: ‘‘During the past month, other than your
regular job, how many times per week did you take part in
any physical activities or exercises such as running,
calisthenics, golf, gardening, or walking for exercise?’’

Th
‘‘W
di
to
ac
ph
on
Gu
ph
pe

as
jo
ph
cle
str
(U

2.2

ty
2.2

th
tin
in
pr

2.2

w
(e
(e
w

lo
w
of
ha
lo
co
1 (
ca
et

qu
co
ite
de
lev
re
ra
co
sk
di
co
jo
(h
jo

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–6962

ose who reported at least one time were then asked
hen you took part in this activity, for how many minutes

d you usually keep at it?’’ Using the two questions, the
tal number of minutes per week of aerobic physical
tivity was calculated by multiplying the frequency of
ysical activity per week by the number of minutes spent
physical activity. Based on the 2008 Physical Activity
idelines for Americans (USDHHS, 2008), regular aerobic
ysical activity was defined as engaging in at least 150 min
r week of aerobic physical activity.
Muscle-strengthening physical activity was measured by

king, ‘‘During the past month, other than your regular
b, how many times per week or per month did you do
ysical activities or exercises to strengthen your mus-
s?’’ Regular activity was defined as performing muscle-
engthening physical activity 2 or more days a week
SDHHS, 2008).

.2. Sociodemographics

Sociodemographics included age, gender, race/ethnici-
, and education.

.3.

Musculoskeletal pain

Musculoskeletal pain was assessed by asking whether
ey had pain, aching, stiffness, burning, numbness, or
gling in the low back, neck, shoulders, and hands/wrists

the past 12 months (Lee et al., 2013). Pictograms were
ovided for each body region on the questionnaire.

.4. Occupational factors

Workplace and employment factors included type of
orkplace (e.g., hospital), work setting (e.g., rural), job title
.g., staff nurse), work status (e.g., full-time), work shift
.g., day), hours worked per shift, and hours worked per
eek.

Physical workload was assessed by the Physical Work-
ad Index Questionnaire (PWIQ) (Hollmann et al., 1999),
hich includes 19 items assessing the average frequency

specific body postures (trunk, arms, and legs) and
ndling weights (lifting, pushing, pulling, or carrying of

ads) during ordinary daily work. All responses were
nstructed using a 5-point Likert-type scale ranging from
never) to 5 (very often). The physical workload index was
lculated by summing weighted item scores (Hollmann

al., 1999).
Psychosocial work factors were assessed using the Job

ntent Questionnaire (Karasek et al., 1998). Job stress
estions included five items assessing job demand (e.g.,
nflicting job demands, excessive amount of work); three
ms assessing decision authority (e.g., little freedom to
cide); and six items assessing skill discretion (e.g., a high
el of skill, opportunity to develop special abilities). All

sponses were constructed using a 4-point Likert scale
nging from 1 (strongly disagree) to 4 (strongly agree). Job
ntrol was created as the sum of decision authority and
ill discretion subscales. Job demand and job control were
chotomized at the median. The two variables were
mbined and classified into four categories: (a) high-strain
bs (high job demand and low job control); (b) active jobs
igh job demand and high job control); (c) low-strain

jobs (low job demand and low job control).

Job satisfaction

was measured by a single question, ‘‘How satisfied are you
with your job?’’ on a 4-point Likert-type scale (1 = not at all
satisfied to 4 = very satisfied).

2.3. Data analysis

Data were analyzed using SPSS version 20 (SPSS, Chicago,
IL). Descriptive statistics were used to summarize the study
variables. Values for continuous variables were presented as
means and standard deviations, and categorical variables
were summarized by frequencies and percentages. Preva-
lence rates of overweight/obesity and aerobic physical
activity and muscle-strengthening physical activity were
described by sociodemographics, musculoskeletal symp-
tom comorbidity, and occupational factors. Bivariate
analysis was conducted to examine differences in over-
weight/obesity, aerobic physical activity, and muscle-
strengthening physical activity by study variables, using
chi-square tests. Multivariable logistic regression analysis
was conducted to examine the relationships of occupational
factors with overweight/obesity, aerobic physical activity,
and muscle-strengthening physical activity. Sociodemo-
graphics and musculoskeletal pain were adjusted in the
multivariable logistic regression analyses. Odds ratios (ORs)
and 95% confidence intervals (CIs) were calculated. A value
of p < .05 was considered to be significant.

3. Results

3.1. Participant characteristics

Table 1 summarizes the characteristics of the study
participants. Participants were predominantly middle-
aged (mean 48.4 years), women (90.6%), non-Hispanic
white (61.2%), and 65.5% had bachelor’s degrees or higher
education. The majority of the participants (81.2%)
experienced musculoskeletal pain in the past 12 months,
most commonly in the lower back (61.8%). The majority of
participants were employed in hospital settings (67.5%) as
staff nurses (52.2%), working full-time (73.3%) on day shifts
(69.4%). About 43% of the participants worked more than
12 h per shift (mean 10 h), and 46.5% worked more than
40 h per week (mean 37.6 h). About half of the participants
(44.9%) were very satisfied with their job.

3.2. Overweight/obesity and regular physical activity:

prevalence and bivariate analysis

Of the participants, 31.1% were overweight and 17.6%
were obese. For physical activity, 41.3% engaged in regular
aerobic physical activity and 56.6% performed muscle-
strengthening activity 2 or more days a week (see Table 1).
Significant associations were found between BMI and
physical activity: the proportion of obese nurses was
significantly higher among nurses who did not participate
in regular aerobic physical activity (23.7% vs. 9.5%, p = .004)
and in regular muscle-strengthening activity (23.6% vs.
13.4%, p = .040), compared to nurses performing regular

ysical activity (see Table 2).

bs (low job demand and high job control); and (d) passive ph

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–69 63

Table 3 presents the prevalence of obesity and regular
physical activity by sociodemographics, musculoskeletal
symptom comorbidity, and occupational factors. Nurses
who were older, men, non-Hispanic white, and had a
diploma or associate degree were significantly more likely
to be overweight or obese (p < .05). No sociodemographic factors were significantly associated with regular physical activity, but the proportion of regular muscle-strengthen- ing physical activity tended to decrease with increased age (p = .084). Nurses reporting musculoskeletal

symptoms

tended to have a higher prevalence of overweight/obese
and lower prevalence of regular aerobic physical activity
compared to those without any musculoskeletal symp-
toms, but the findings were not statistically significant
(p > .05).

The prevalence of overweight/obesity was significantly
higher among nurses who worked full-time compared to
part-time or per-diem nurses (52.1% vs. 37.8%, p = .015)
and among nurses who worked �40 h per week compared
to those who worked <40 h per week (58.9% vs. 39.9%, p < .001). The prevalence of regular aerobic physical activity was significantly higher among nurses who perceived high job demand (47.4% vs. 36.5%, p = .003) while nurses in the passive job category had the lowest prevalence of regular aerobic physical activity (29.3%, p = .033). Nurses with low physical workload tended to

able 1

haracteristics of the study participants (N = 394).a

Characteristics Mean � SD
(range) or n (%)

Age (years) 48.4 � 12.1 (23–81)

Gender

Men 37 (9.4)

Women 356 (90.6)

Race/ethnicity

Hispanic 28 (7.1)

White, Non-Hispanic 241 (61.2)

Asian or Pacific Islander 89 (22.6)

Otherb 36 (9.1)

Education

Diploma or associate 135 (34.4)

Bachelor 180 (45.9)

Master or doctoral 77 (19.6)

Comorbidity: musculoskeletal

symptoms

Low back pain 241 (61.8)

Neck pain 191 (49.0)

Shoulder pain 164 (42.2)

Hand/wrist pain 163 (42.1)

Musculoskeletal pain

(any region)

319 (81.2)

Body mass index (kg/m2) 25.7 � 4.8 (16.0–41.6)
Underweight (<18.5) 5 (1.3)

Normal (18.5–24.9) 193 (50.0)

Overweight (25–29.9) 120 (31.1)

Obese (�30) 68 (17.6)

Aerobic physical activity

(minutes a week)

148.9 � 128.2 (0–900)

No activity 37 (9.5)

<150 min a week 192 (49.2)

150–300 min a week 109 (28.0)

�300 min a week 52 (13.3)

Muscle strengthening

physical activity

None 126 (32.7)

1 day a week 41 (10.6)

�2 days a week 218 (56.6)

Type of workplace

Hospital 266 (67.5)

Ambulatory

outpatient clinic

52 (13.2)

Long term care/

home health

agency

/hospice

29 (7.4)

Other 47 (11.9)

Type of work setting

Rural 50 (14.0)

Suburban 125 (34.9)

Urban 183 (51.1)

Job title

Staff nurse 205 (52.2)

Charge nurse 40 (10.2)

Nurse manager/supervisor 40 (10.2)

Other 108 (27.5)

Work status

Full-time 272 (73.3)

Part-time/per-diem 99 (26.7)

Work hours per shift 10.0 � 2.2 (0–15)
<8 h 17 (4.7)

8–11 h 191 (52.5)

�12 h 156 (42.9)

Work hours per week 37.6 � 11.7 (0–85)

Table1 (Continued )

Characteristics Mean � SD
(range) or n (%)

<40 h 197 (53.5)

�40 h 171 (46.5)

Shift

Day 258 (69.4)

Evening 23 (6.2)

Night 76 (20.4)

Rotating 15 (4.0)

Physical workload index 35.0 � 13.3 (14.0–70.2)

Job demand 34.1 � 6.4 (18–48)

Job control 70.0 � 10.0 (42–94)

Job strainc

Low strain (low demand

and high control)

113 (29.0)

Passive job (low demand

and low control)

101(25.9)

Active job (high demand

and high control)

90 (23.1)

High strain (high demand

and low control)

86 (22.1)

Job satisfaction

Not at all or not

too satisfied

36 (9.2)

Somewhat satisfied 179 (45.9)

Very satisfied 175 (44.9)

a Sample sizes for variables may not add up the total due to missing

data.
b Other: African-American, American Indian or Alaskan Native, and

Other.
c Low vs. high of psychological demand and job control were

dichotomized at median.

ha
pr
w

3.3

w
sig
sig
lin
m
sh
ob
in
m
be
W
w
w
ob
<4 ph re an 95 no ca str w pe (O to CI

lei
w
be
co
oc
ac
of
m

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–6964

ve a higher prevalence of overweight/obesity and lower
evalence of regular physical activity, but the findings
ere not statistically significant (p > .05).

. Associations of occupational factors with obesity and

gular physical activity

Table 4 presents the associations of occupational factors
ith overweight/obesity and regular physical activity. All
nificant variables in bivariate analysis maintained
nificant associations in multivariable analysis, control-
g for age, gender, race/ethnicity, education, and

usculoskeletal pain. Additionally, job title and work
ift showed significant associations with overweight/
esity or regular muscle-strengthening physical activity

multivariable analysis. Compared to staff nurses,
anagers/supervisors were significantly more likely to

overweight or obese (OR = 2.54, 95% CI: 1.16–5.59).
orking full-time (OR = 2.18, 95% CI: 1.29–3.70) and
orking �40 h per week (OR = 2.53, 95% CI: 1.58–4.05)
ere associated with 2–3 fold odds of being overweight or
ese, compared to working part-time/per-diem and
0 h per week, respectively. The odds of regular aerobic
ysical activity were 1.6 times greater among nurses

porting high job demand (OR = 1.63, 95% CI: 1.06–2.51)
d 51% lower among nurses on passive jobs (OR = 0.49,
% CI: 0.26–0.93). Compared to day shifts, working on
n-day shifts (OR = 0.55, 95% CI: 0.34–0.89) was signifi-
ntly associated with 45% lower odds of regular muscle-
engthening physical activity. In particular, nurses who

orked on night shifts were significantly less likely to
rform regular muscle-strengthening physical activity
R = 0.44, 95% CI: 0.25–0.77) and tended to be less likely

perform aerobic physical activity (OR = 0.59, 95%
= 0.33–1.05; data not shown in Table 4).

Discussion

Nurses are at high risk of both overweight/obesity and
sure-time physical inactivity, which may be associated

ith occupational and work environment factors. To the
st of our knowledge, this study is the first study that
mprehensively investigated the relationships among
cupational factors, obesity and leisure-time physical
tivity among nurses. This study found that increased risk

overweight/obesity was associated with being nurse

more than 40 h per week and that physical activity was
associated with working on day shifts and experiencing
high job demand.

4.1.

Overweight/obesity

In our study sample of California registered nurses,
about half (48.7%) were overweight or obese; this
prevalence is similar to or lower than the reports of
previous studies of nurses (Han et al., 2011; Miller et al.,
2008; Tucker et al., 2010; Zapka et al., 2009). This finding
may be explained from the fact that our study was based in
California, which presents a lower obesity prevalence in
the U.S. (CDC, 2013c). Therefore, the obesity prevalence
reported in the study is likely an underestimate of the
prevalence among U.S. nurses.

This study found a significant association between
job title and overweight/obesity. Nurse managers/super-
visors presented a significantly higher prevalence of
overweight/obesity than staff nurses. A possible expla-
nation would be that nurse managers/supervisors tend
to be more sedentary at work during their shift, while
staff nurses, in general, perform more physically active
and demanding tasks by delivering direct patient care
(Trinkoff et al., 2001, 2003). Indeed, we found that nurse
managers/supervisors had a significantly lower physical
workload (PWIQ score: 30.1 vs. 38.5 score, p < .001). Previous research suggested that more sedentary work and low physical job demand were associated with increased risk of total and central obesity in workers (Choi et al., 2010b). A multinational study of nurses and midwives in Australia, New Zealand and the United Kingdom reported that those employed in administra- tion and management positions were at increased risk of overweight or obesity due to sedentary work practices (Bogossian et al., 2012). In that respect, this high-risk group of nurses should be targeted specifically for health promotion interventions, enabling positive lifestyle changes.

Another important finding of our study is the impact of
work status and work hours as risk factors of obesity.
Working full-time and working �40 h per week were
associated with increased risk of obesity. Similarly,
previous research showed that full-time workers had a
significantly higher prevalence of overweight and obesity
than workers with part-time or casual working status

ble 2

robic and muscle strengthening physical activity by body mass index among California nurses.

Aerobic physical activity Muscle strengthening physical activity

<150 min/week

(n = 229)

�150 min/week
(n = 161)

<2 days/week

(n = 167)

�2 days/week
(n = 218)

n (%) n (%) p n (%) n (%) p

ody mass index (kg/m2) .004 .040

Underweight (<18.5) 2 (0.9) 3 (1.9) 3 (1.9) 2 (0.9)

Normal (18.5–24.9) 105 (46.9) 87 (55.1) 70 (43.5) 118 (54.6)

Overweight (25–29.9) 64 (28.6) 53 (33.5) 50 (31.1) 67 (31.0)

Obese (�30) 53 (23.7) 15 (9.5) 38 (23.6) 29 (13.4)

mple sizes for variables may not add up the total due to missing data.

ong nurses and midwives (Bogossian et al., 2012;

anagers/supervisors, working full-time, and working am

Table 3

Prevalence (%) of overweight/obesity and regular physical activity by sociodemographics and occupational factors among California nurses (N = 394).a

Overweight/obesity

(BMI � 25 kg/m2)
Regular aerobic physical

activity (�150 min/week)
Regular muscle

strengthening physical

activity (�2 days/week)

n (%)* p n (%)* p n (%)* p

Total 188 (48.7) 161 (41.3) 218 (56.6)

Age (years) .014 .818 .084

<30 9 (31.0) 12 (41.4) 19 (65.5)

30–39 31 (40.8) 28 (36.4) 50 (64.9)

40–49 34 (48.6) 29 (42.6) 43 (62.3)

50–59 66 (47.8) 62 (44.6) 74 (54.0)

�60 44 (64.7) 28 (39.4) 30 (44.8)

Gender .006 .945 .365

Men 26 (70.3) 15 (41.7) 23 (63.9)

Women 162 (46.4) 145 (41.1) 195 (56.0)

Race/ethnicity .001 .223 .865

Hispanic 15 (53.6) 11 (39.3) 17 (60.7)

White, Non-Hispanic 127 (53.8) 105 (43.8) 135 (57.2)

Asian or Pacific Islander 26 (29.9) 28 (32.2) 45 (52.9)

Otherb 20 (57.1) 17 (48.6) 21 (58.3)

Education .006 .388 .923

Diploma or associate 77 (58.8) 51 (37.8) 75 (56.8)

Bachelor 72 (40.4) 80 (45.2) 101 (57.4)

Master or doctoral 37 (49.3) 30 (39.5) 41 (54.7)

Musculoskeletal symptoms c .299 .090 .471

Yes 156 (49.8) 124 (39.1) 173 (55.6)

No 31 (43.1) 36 (50.0) 44 (60.3)

Type of workplace .880 .438 .669

Hospital 126 (48.1) 101 (38.5) 145 (55.8)

Ambulatory/outpatient clinic 27 (54.0) 23 (44.2) 30 (57.7)

Long term care/home

health agency/hospice

13 (46.4) 14 (48.3) 13 (50.0)

Other 22 (47.8) 23 (48.9) 30 (63.8)

Type of work setting .811 .930 .530

Rural 25 (50.0) 19 (38.8) 29 (60.4)

Suburban 63 (50.8) 52 (41.9) 64 (52.0)

Urban 83 (47.2) 74 (40.9) 103 (57.2)

Job title .106 .265 .281

Staff nurse 89 (44.3) 74 (36.6) 115 (56.9)

Charge nurse 19 (50.0) 18 (45.0) 22 (59.5)

Nurse Manager/supervisor 25 (65.8) 19 (47.5) 16 (42.1)

Other 54 (50.0) 50 (46.7) 64 (59.8)

Work status .015 .210 .293

Full-time 138 (52.1) 104 (38.7) 147 (55.3)

Part-time/Per-diem 37 (37.8) 45 (45.9) 59 (61.5)

Work hours per shift

<12 h 104 (51.5) .135 89 (43.2) .190 115 (56.9) .934

�12 h 67 (43.5) 56 (36.4) 87 (56.5)

Work hours per week <.001 .895 .160

<40 h 77 (39.9) 78 (39.8) 104 (53.3)

�40 h 99 (58.9) 68 (40.5) 100 (60.6)

Shift

Day shift 120 (47.6) .675 108 (42.4) .274 150 (59.5) .108

Non-day shift d 56 (50.0) 41 (36.3) 56 (50.5)

Physical workload index .055 .531 .229

Low 95 (54.6) 70 (39.1) 93 (53.8)

High 79 (44.4) 75 (42.4) 107 (60.1)

Job demand .282 .003 .247

Low 107 (51.2) 77 (36.5) 112 (54.1)

High 79 (45.7) 83 (47.4) 105 (60.0)

Job control .252 .195 .293

Low 84 (45.7) 70 (38.0) 100 (54.1)

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–69 65

Ne
lo
tw
ob
Lu
ve
ob
ob
ov
pe
in
ho
be
in

a
th
w
nu
sk
m
to
in

4.2

be
no
On
ph
51
str
m
m
W
m
as

*
a

b
c
d
e
de

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–6966

lson et al., 2014). Also, several cross-sectional and
ngitudinal studies found significant associations be-
een long work hours and weight gain, overweight or
esity (Han et al., 2011; Lallukka et al., 2008a,b;
ckhaupt et al., 2014; Solovieva et al., 2013). In the same
in, we expected that a 12-h shift might be a risk factor for
esity, but found no supporting evidence. Conversely, we
served the opposite pattern with lower prevalence of
erweight/obesity among nurses working more than 12 h
r day. Although our study results on work hours were
consistent, it appears that full-time nurses working long
urs may encounter more barriers in engaging in healthy
haviors such as regular physical activity. Further
vestigation is warranted to elucidate this relationship.

In regard to musculoskeletal symptoms, we did not find
significant association with overweight/obesity, but
ere was a tendency of higher prevalence of over-
eight/obesity as well as lower physical activity among
rses with musculoskeletal symptoms. Having musculo-
eletal symptoms may reduce physical activity engage-
ent and contribute to obesity. Therefore, it is warranted
emphasize workplace prevention of musculoskeletal
juries or disorders.

. Physical activity

For physical activity, despite its substantial health
nefits (CDC, 2011), most of the nurses in this study did
t perform recommended amounts of physical activities.
ly 41.3% met the recommended level for aerobic
ysical activity, which is lower than the prevalence of
.6% among U.S. adults (CDC, 2013a). For muscle-
engthening physical activity, 56.6% met the recom-

ended level and 32.8% did not meet both aerobic and
uscle-strengthening physical activity recommendations.
e also found that the low levels of both aerobic and
uscle-strengthening physical activities were strongly
sociated with obesity, consistent with a recent national

analysis (CDC, 2013a). The findings clearly indicate a need
to help nurses to achieve regular physical activity during
their leisure time. This need has a significant public health
implication because nurses are in a good position to
educate and motivate patients about healthy lifestyle
behaviors.

We found slightly different sets of risk factors among
occupational factors. Regular muscle-strengthening phys-
ical activity was associated with only shift work. Our
findings indicate that nurses on non-day shifts, especially
night shifts, are less likely to engage in regular muscle-
strengthening physical activity. Studies show that night-
shift work is associated with insufficient sleep quality and
quantity and chronic fatigue (Geiger-Brown et al., 2011; Han
et al., 2014; Huth et al., 2013). Also, shift workers generally
have fewer resources or opportunities for leisure-time
physical activity (Atkinson and Davenne, 2007; van
Amelsvoort et al., 2004). All of these factors may negatively
influence nurses working night or other shifts in performing
regular physical activity (Atkinson et al., 2008; Lallukka
et al., 2004; Persson and Martensson, 2006).

We also found significant associations between job
demand and aerobic physical activity. Interestingly, high
job demand was associated with increased regular aerobic
physical activity, whereas passive job, defined as low job
demand combined with low job control, was significantly
associated with less engagement in regular aerobic
physical activity. Previous studies have found relatively
consistent inverse associations between leisure-time
physical activity and passive jobs, but not with job
demands, and the relationship slightly varied by gender
and education level (Choi et al., 2010a; Fransson et al.,
2012; Gimeno et al., 2009; Kouvonen et al., 2005). For
example, in a prospective cohort study of British civil
servants (Gimeno et al., 2009), men who worked on passive
jobs over 5 years performed less leisure-time physical
activity than those who had never worked on passive jobs,
but the difference was not significant in women. According

ble3 (Continued )

Overweight/obesity
(BMI � 25 kg/m2)
Regular aerobic physical
activity (�150 min/week)
Regular muscle
strengthening physical
activity (�2 days/week)
n (%)* p n (%)* p n (%)* p

High 102 (51.5) 90 (44.6) 117 (59.4)

ob straine .303 .033 .284

Low strain 62 (56.4) 48 (42.9) 64 (59.3)

Passive job 45 (45.5) 29 (29.3) 48 (48.5)

Active job 40 (45.5) 42 (46.7) 53 (59.6)

High strain 39 (45.9) 41 (48.2) 52 (60.5)

ob satisfaction .671 .433 .165

Not at all or not too satisfied 15 (41.7) 12 (33.3) 17 (47.2)

Somewhat satisfied 86 (49.7) 72 (40.7) 96 (54.2)

Very satisfied 85 (49.1) 77 (44.5) 104 (61.9)

I (body mass index).

Row percentages by each category.

Due to missing data, the sample size was 386 for BMI, 390 for aerobic physical activity, and 385 for muscle strengthening physical activity.

Other: African-American, American Indian or Alaskan Native, and Other.

Any symptom in the low back, neck, shoulders, hands or wrists in the past 12 months.

Non-day shift: evening, night or rotating shift.

Low strain (low demand and high control); passive job (low demand and low control); active job (high demand and high control); high strain job (high

mand and low control).

Table 4

Associations of occupational factors with overweight/obesity and regular physical activity among California nurses (N = 394).

Characteristics Overweight/obesity (BMI � 25 kg/m2) Regular aerobic physical activity
(�150 min/week)

Regular muscle strengthening physical

activity (�2 days/week)

Unadjusted OR

(95% CI)

Adjusted ORa

(95% CI)
Unadjusted OR
(95% CI)
Adjusted ORa
(95% CI)
Unadjusted OR
(95% CI)
Adjusted ORa
(95% CI)
Type of workplace

Hospital 1.00 1.00 1.00 1.00 1.00 1.00

Ambulatory/

outpatient clinic

1.27 (0.69–2.32) 1.26 (0.64–2.47) 1.26 (0.69–2.31) 1.10 (0.58–2.11) 1.08 (0.59–1.97) 1.44 (0.75–2.75)

Long term care/

home health

agency

/hospice

0.94 (0.43–2.04) 0.88 (0.36–2.16) 1.49 (0.69–3.21) 1.55 (0.68–3.54) 0.79 (0.35–1.78) 0.99 (0.42–2.33)

Other 0.99 (0.53–1.85) 1.00 (0.51–1.96) 1.53 (0.82–2.85) 1.47 (0.77–2.83) 1.40 (0.74–2.66) 1.66 (0.85–3.24)

Type of work setting

Urban 1.00 1.00 1.00 1.00 1.00 1.00

Rural 1.12 (0.60–2.10) 0.89 (0.45–1.76) 0.92 (0.48–1.75) 0.90 (0.46–1.77) 1.14 (0.60–2.18) 1.02 (0.52–2.00)

Suburban 1.16 (0.73–1.83) 1.10 (0.66–1.83) 1.04 (0.66–1.66) 0.94 (0.57–1.54) 0.81 (0.51–1.29) 0.76 (0.47–1.24)

Job title

Staff nurse 1.00 1.00 1.00 1.00 1.00 1.00

Charge nurse 1.26 (0.63–2.52) 0.77 (0.35–1.69) 1.42 (0.71–2.81) 1.38 (0.67–2.87) 1.11 (0.54–2.26) 1.37 (0.64–2.93)

Nurse Manager

/supervisor

2.42 (1.17–5.00)* 2.54 (1.16–5.59)* 1.56 (0.79–3.10) 1.33 (0.64–2.78) 0.55 (0.27–1.11) y 0.63 (0.30–1.33)

Other 1.26 (0.79–2.01) 1.15 (0.66–1.99) 1.52 (0.94–2.44)y 1.41 (0.83–2.40) 1.13 (0.70–1.81) 1.39 (0.82–2.36)

Work status

Part-time/per-diem 1.00 1.00 1.00 1.00 1.00 1.00

Full-time 1.79 (1.11–2.88)* 2.18 (1.29–3.70)** 0.74 (0.47–1.18) 0.67 (0.41–1.10) 0.77 (0.48–1.25) 0.64 (0.39–1.06)y

Work hours per shift

<12 h 1.00 1.00 1.00 1.00 1.00 1.00

�12 h 0.73 (0.48–1.11) 0.81 (0.50–1.31) 0.75 (0.49–1.15) 0.74 (0.46–1.20) 0.98 (0.64–1.50) 0.78 (0.49–1.25)

Work hours per week

<40 h 1.00 1.00 1.00 1.00 1.00 1.00

�40 h 2.16 (1.42–3.29)*** 2.53 (1.58–4.05)*** 1.03 (0.68–1.57) 0.98 (0.63–1.54) 1.35 (0.88–2.05) 1.43 (0.92–2.24)

Shift

Day shift 1.00 1.00 1.00 1.00 1.00 1.00

Non-day shiftb 1.10 (0.70–1.72) 1.19 (0.73–1.93) 0.78 (0.49–1.22) 0.70 (0.43–1.13) 0.69 (0.44–1.08) 0.55 (0.34–0.89)*

Physical workload

index

Low 1.00 1.00 1.00 1.00 1.00 1.00

High 0.66 (0.44–1.01)y 0.70 (0.43–1.16) 1.14 (0.75–1.75) 1.31 (0.81–2.11) 1.30 (0.85–1.98) 1.10 (0.69–1.75)

Job demand

Low 1.00 1.00 1.00 1.00 1.00 1.00

High 0.80 (0.53–1.20) 0.83 (0.53–1.29) 1.57 (1.04–2.36)* 1.63 (1.06–2.51)* 1.27 (0.85–1.91) 1.24 (0.81–1.90)

Job control

Low 1.00 1.00 1.00 1.00 1.00 1.00

High 1.26 (0.85–1.89) 1.24 (0.80–1.93) 1.31 (0.87–1.97) 1.23 (0.81–1.89) 1.24 (0.83–1.86) 1.35 (0.88–2.07)

Job strainc

High strain 1.00 1.00 1.00 1.00 1.00 1.00

Active job 0.98 (0.54–1.79) 1.09 (0.58–2.08) 0.94 (0.52–1.70) 1.01 (0.54–1.86) 0.96 (0.53–1.76) 1.01 (0.54–1.89)

Passive job 0.98 (0.55–1.76) 1.06 (0.56–2.01) 0.44 (0.24–0.82)** 0.49 (0.26–0.93)* 0.62 (0.34–1.10) 0.61 (0.33–1.13)

Low strain 1.52 (0.86–2.69) 1.48 (0.79–2.75) 0.80 (0.46–1.42) 0.74(0.41–1.36) 0.95 (0.53–1.70) 1.06 (0.58–1.96)

Job satisfaction

Very satisfied 1.00 1.00 1.00 1.00 1.00 1.00

Somewhat satisfied 1.02 (0.67–1.56) 0.98 (0.62–1.54) 0.85 (0.56–1.31) 0.95 (0.61–1.47) 0.73 (0.47–1.12) 0.71 (0.45–1.12)

Not at all or not
too satisfied

0.74 (0.36–1.53) 0.81 (0.37–1.78) 0.62 (0.29–1.33) 0.69 (0.31–1.51) 0.55 (0.27–1.14) 0.48 (0.23–1.03)y

BMI (body mass index).
a Multivariable logistic regression analyses adjusted for age, gender, race/ethnicity, educational background, and musculoskeletal pain
b Non-day shift: evening, night or rotating shift.
c Low strain (low demand and high control); passive job (low demand and low control); active job (high demand and high control); High strain job (high

demand and low control).
y p < .10.

* p < .0

** p < .01.

*** p < .001.

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–69 67

to
stu
w
be
w
ag
pe
ed
ph
M
as
ac

4.3

se
fa
m
fo
re
un
So
ac
alt
sm
in
se
ab
co
di
sm
un
of

po
he
nu
ov
tie
oc
ho
ac
to
de
gr
co
gi
de
co
di
ob

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–6968

pooled data from 14 European prospective cohort
dies (n = 170,162) (Fransson et al., 2012), employees

orking on high-strain and passive jobs were less likely to
physically active during their leisure time, compared
ith those on low-strain jobs. Also, in a study of middle-
ed U.S. workers, higher educated men with passive jobs
rformed less leisure-time physical activity, while less
ucated women with passive jobs were less likely to be
ysically active during leisure time (Choi et al., 2010a).

ore research is needed to confirm the independent
sociations between job strain components and physical
tivity among nurses.

. Limitations

The study has several limitations. First, due to the cross-
ctional design, causal directions among occupational
ctors, obesity, and physical activity cannot be deter-
ined. Second, this study relied upon self-reported data
r BMI and physical activity; thus, there may have been
call or reporting bias, which may result in either the
derestimation or overestimation of the true prevalence.
cial desirability may lead to overreporting of physical
tivity and underreporting of body weight. Third,
hough this study used a random sample, a relatively
all sample size and low response rate (26.3%) may have

troduced selection bias. Along with this, a study sample
lected from one state in the U.S. limits the generaliz-
ility of the study findings. Finally, some potential
nfounders were not collected in this study, such as
etary habits, sleep patterns, other lifestyle factors (e.g.,
oking and alcohol use), and social support. These
measured or unknown factors may raise the possibility

residual confounding effect.

Conclusion

Nurses are a major health care workforce and are well
sitioned to promote healthy lifestyle behaviors for the
alth of the population. However, our study shows that
rses are also faced with the high prevalence of
erweight/obesity and their leisure-time physical activi-
s are far from optimal. Our findings suggest that
cupational factors, such as job title, work status, work
urs, shift work, and job demand, may affect physical
tivity or BMI. Accordingly, the findings indicate the need

consider the influence of working conditions in
veloping effective workplace health promotion pro-
ams targeting obesity prevention and physical activity in
mbination with individual-focused intervention strate-
es. Future research is needed to validate the findings and
termine causal relationships in a large prospective
hort of U.S. nurses and to further explore the longitu-
nal effect of occupational factors in work environment on
esity and physical activity.

nflict of interests: The authors declare no conflict of interest.

nding: This research was funded by the Southern California

tional Institute for Occupational Safety and Health

(NIOSH) Education and Research Center Pilot Project Re-

search Training Grant (Grant number: 2 T42 OH008412-08).

Ethical approval:The study was approved by the Committee of

Human Research of the University of California San Francisco.

References

Atkinson, G., Davenne, D., 2007. Relationships between sleep, physical
activity and human health. Physiol. Behav. 90 (2–3), 229–235.

Atkinson, G., Fullick, S., Grindey, C., Maclaren, D., 2008. Exercise, energy
balance and the shift worker. Sports Med. 38 (8), 671–685.

Bogossian, F.E., Hepworth, J., Leong, G.M., Flaws, D.F., Gibbons, K.S.,
Benefer, C.A., et al., 2012. A cross-sectional analysis of patterns of
obesity in a cohort of working nurses and midwives in Australia, New
Zealand, and the United Kingdom. Int. J. Nurs. Stud. 49 (6), 727–738.

CDC, 2012. Adult Overweight and Obesity. Defining Overweight and
Obesity. http://www.cdc.gov/obesity/adult/defining.html.

CDC, 2013a. Adult participation in aerobic and muscle-strengthening
physical activities – United States, 2011. MMWR Morb. Mortal. Wkly.
Rep. 62 (17), 326–330.

CDC, 2013b. Behavioral Risk Factor Surveillance System Questionnaires.
http://www.cdc.gov/brfss/questionnaires/index.htm.

CDC, 2013c. Obesity Prevalence Maps. Prevalence of Self-Reported Obe-
sity Among U.S. Adults by State and Territory, BRFSS. http://www.cdc.
gov/obesity/data/table-adults.html.

CDC, 2011. Physical Activity and Health The Benefits of Physical Activity.
http://www.cdc.gov/physicalactivity/everyone/health/index.
html?s_cid=cs_284.

Choi, B., Schnall, P.L., Yang, H., Dobson, M., Landsbergis, P., Israel, L., et al.,
2010. Psychosocial working conditions and active leisure-time phys-
ical activity in middle-aged us workers. Int. J. Occup. Med. Environ.
Health 23 (3), 239–253.

Choi, B., Schnall, P.L., Yang, H., Dobson, M., Landsbergis, P., Israel, L., et al.,
2010. Sedentary work, low physical job demand, and obesity in US
workers. Am. J. Ind. Med. 53 (11), 1088–1101.

Field, A.E., Willett, W.C., Lissner, L., Colditz, G.A., 2007. Dietary fat and
weight gain among women in the Nurses’ Health Study. Obesity
(Silver Spring) 15 (4), 967–976.

Flegal, K.M., Carroll, M.D., Kit, B.K., Ogden, C.L., 2012. Prevalence of obesity
and trends in the distribution of body mass index among US adults,
1999–2010. J. Am. Med. Assoc. 307 (5), 491–497.

Fransson, E.I., Heikkila, K., Nyberg, S.T., Zins, M., Westerlund, H., Wester-
holm, P., et al., 2012. Job strain as a risk factor for leisure-time
physical inactivity: an individual-participant meta-analysis of up to
170,000 men and women: the IPD-Work Consortium. Am. J. Epide-
miol. 176 (12), 1078–1089.

Geiger-Brown, J., Trinkoff, A., Rogers, V.E., 2011. The impact of work
schedules, home, and work demands on self-reported sleep in regis-
tered nurses. J. Occup. Environ. Med. 53 (3), 303–307.

Gimeno, D., Elovainio, M., Jokela, M., De Vogli, R., Marmot, M.G., Kivimaki,
M., 2009. Association between passive jobs and low levels of leisure-
time physical activity: the Whitehall II cohort study. Occup. Environ.
Med. 66 (11), 772–776.

Goetzel, R.Z., Gibson, T.B., Short, M.E., Chu, B.C., Waddell, J., Bowen, J.,
et al., 2010. A multi-worksite analysis of the relationships among
body mass index, medical utilization, and worker productivity. J.
Occup. Environ. Med. 52 (Suppl. 1), S52–S58.

Han, K., Trinkoff, A.M., Geiger-Brown, J., 2014. Factors associated with
work-related fatigue and recovery in hospital nurses working 12-
hour shifts. Workplace Health Saf. 62 (10), 409–414.

Han, K., Trinkoff, A.M., Storr, C.L., Geiger-Brown, J., 2011. Job stress and
work schedules in relation to nurse obesity. J. Nurs. Adm. 41 (11),
488–495.

Hollmann, S., Klimmer, F., Schmidt, K.H., Kylian, H., 1999. Validation of a
questionnaire for assessing physical work load. Scand. J. Work Envi-
ron. Health 25 (2), 105–114.

Huth, J.J., Eliades, A., Handwork, C., Englehart, J.L., Messenger, J., 2013.
Shift worked, quality of sleep, and elevated body mass index in
pediatric nurses. J. Pediatr. Nurs. 28 (6), e64–e73.

Institute of Medicine, 2006. Committee on Assessing Interactions Among
Social Behavioral, and Genetic Factors in Health.

Jaaskelainen, A., Kaila-Kangas, L., Leino-Arjas, P., Lindbohm, M.L., Nevan-
pera, N., Remes, J., et al., 2015. Psychosocial factors at work and
obesity among young Finnish adults: a cohort study. J. Occup. Envi-
ron. Med. 57 (5), 485–492.

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0005

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0010

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0015

http://www.cdc.gov/obesity/adult/defining.html

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0025

http://www.cdc.gov/brfss/questionnaires/index.htm

http://www.cdc.gov/obesity/data/table-adults.html

http://www.cdc.gov/physicalactivity/everyone/health/index.html?s_cid=cs_284

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0045

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0050

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0055

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0060

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0065

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0070

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0075

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0080

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0085

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0090

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0095

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0100

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0105

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0110

K
K
K

L
L
L
L
L
M
M

N
O
O

D.L. Chin et al. / International Journal of Nursing Studies 57 (2016) 60–69 69

arasek, R., Brisson, C., Kawakami, N., Houtman, I., Bongers, P., Amick, B.,
1998. The Job Content Questionnaire (JCQ): an instrument for inter-
nationally comparative assessments of psychosocial job characteris-
tics. J. Occup. Health Psychol. 3 (4), 322–355.

eller, S.M., 2009. Effects of extended work shifts and shift work on
patient safety, productivity, and employee health. AAOHN J. 57 (12),
497–502.

ouvonen, A., Kivimaki, M., Elovainio, M., Virtanen, M., Linna, A., Vahtera,
J., 2005. Job strain and leisure-time physical activity in female and
male public sector employees. Prev. Med. 41 (2), 532–539.

riska, A.M., LaPorte, R.E., Pettitt, D.J., Charles, M.A., Nelson, R.G., Kuller,
L.H., et al., 1993. The association of physical activity with obesity, fat
distribution and glucose intolerance in Pima Indians. Diabetologia 36
(9), 863–869.

allukka, T., Lahelma, E., Rahkonen, O., Roos, E., Laaksonen, E., Martikai-
nen, P., et al., 2008. Associations of job strain and working overtime
with adverse health behaviors and obesity: evidence from the White-
hall II Study, Helsinki Health Study, and the Japanese Civil Servants
Study. Soc. Sci. Med. 66 (8), 1681–1698.

allukka, T., Sarlio-Lahteenkorva, S., Kaila-Kangas, L., Pitkaniemi, J., Luuk-
konen, R., Leino-Arjas, P., 2008. Working conditions and weight gain:
a 28-year follow-up study of industrial employees. Eur. J. Epidemiol.
23 (4), 303–310.

allukka, T., Sarlio-Lahteenkorva, S., Roos, E., Laaksonen, M., Rahkonen, O.,
Lahelma, E., 2004. Working conditions and health behaviours among
employed women and men: the Helsinki Health Study. Prev. Med. 38
(1), 48–56.

ee, S.J., Faucett, J., Gillen, M., Krause, N., 2013. Musculoskeletal pain
among critical-care nurses by availability and use of patient lifting
equipment: an analysis of cross-sectional survey data. Int. J. Nurs.
Stud. 50 (12), 1648–1657.

i, T.Y., Rana, J.S., Manson, J.E., Willett, W.C., Stampfer, M.J., Colditz, G.A.,
et al., 2006. Obesity as compared with physical activity in predicting
risk of coronary heart disease in women. Circulation 113 (4), 499–506.

uckhaupt, S.E., Cohen, M.A., Li, J., Calvert, G.M., 2014. Prevalence of
obesity among U.S. workers and associations with occupational fac-
tors. Am. J. Prev. Med. 46 (3), 237–248.

cVicar, A., 2003. Workplace stress in nursing: a literature review. J. Adv.
Nurs. 44 (6), 633–642.

iller, S.K., Alpert, P.T., Cross, C.L., 2008. Overweight and obesity in
nurses, advanced practice nurses, and nurse educators. J. Am. Acad.
Nurse Pract. 20 (5), 259–265.

elson, C.C., Wagner, G.R., Caban-Martinez, A.J., Buxton, O.M., Kenwood,
C.T., Sabbath, E.L., et al., 2014. Physical activity and body mass index:
the contribution of age and workplace characteristics. Am. J. Prev.
Med. 46 (3), S42–S51.

ational Heart Lung and Blood Institute, 2003. Seventh report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treat-
ment of High Blood Pressure (JNC 7) Express (NIH Publication No.
5233) National Institutes of Health, Bethesda, MD.

gden, C.L., Carroll, M.D., 2010. Prevalence of overweight, obesity, and
extreme obesity among adults: United States, trends 1960–1962
through 2007–2008. NCHS Health E-Stat. National Center for Health
Statistics, Hyattsville, MD.

gden, C.L., Carroll, M.D., Kit, B.K., Flegal, K.M., 2014. Prevalence of
childhood and adult obesity in the United States, 2011–2012. J.
Am. Med. Assoc. 311 (8), 806–814.

Persson, M., Martensson, J., 2006. Situations influencing habits in diet and
exercise among nurses working night shift. J. Nurs. Manag. 14 (5),
414–423.

Sofi, F., Capalbo, A., Cesari, F., Abbate, R., Gensini, G.F., 2008. Physical
activity during leisure time and primary prevention of coronary heart
disease: an updated meta-analysis of cohort studies. Eur. J. Cardio-
vasc. Prev. Rehabil. 15 (3), 247–257.

Solovieva, S., Lallukka, T., Virtanen, M., Viikari-Juntura, E., 2013. Psycho-
social factors at work, long work hours, and obesity: a systematic
review. Scand. J. Work Environ. Health 39 (3), 241–258.

Sveinsdottir, H., Gunnarsdottir, H.K., 2008. Predictors of self-assessed
physical and mental health of Icelandic nurses: results from a na-
tional survey. Int. J. Nurs. Stud. 45 (10), 1479–1489.

Thompson, D.L., 2007. The costs of obesity: what occupational health
nurses need to know. AAOHN J. 55 (7), 265–270.

Thompson, P.D., Buchner, D., Pina, I.L., Balady, G.J., Williams, M.A., Marcus,
B.H., et al., 2003. Exercise and physical activity in the prevention and
treatment of atherosclerotic cardiovascular disease: a statement from
the Council on Clinical Cardiology (Subcommittee on Exercise, Reha-
bilitation, and Prevention) and the Council on Nutrition, Physical
Activity, and Metabolism (Subcommittee on Physical Activity). Cir-
culation 107 (24), 3109–3116.

Trinkoff, A.M., Lipscomb, J.A., Geiger-Brown, J., Storr, C.L., Brady, B.A.,
2003. Perceived physical demands and reported musculoskeletal
problems in registered nurses. Am. J. Prev. Med. 24 (3), 270–275.

Trinkoff, A.M., Storr, C.L., Lipscomb, J.A., 2001. Physically demanding work
and inadequate sleep, pain medication use, and absenteeism in
registered nurses. J. Occup. Environ. Med. 43 (4), 355–363.

Tucker, S.J., Harris, M.R., Pipe, T.B., Stevens, S.R., 2010. Nurses’ ratings of
their health and professional work environments. AAOHN J. 58 (6),
253–267.

USDHHS, 2008. Physical Activity Guidelines for Americans. US Depart-
ment of Health and Human Services, Hyattsville, MD.

USDHHS, 2001. The Surgeon General’s call to action to prevent and
decrease overweight and obesity. U.S. Department of Health and
Human Services, Public Health Service, Office of the Surgeon General,
Rockville, MD.

van Amelsvoort, L.G., Schouten, E.G., Kok, F.J., 2004. Impact of one year of
shift work on cardiovascular disease risk factors. J. Occup. Environ.
Med. 46 (7), 699–706.

Wang, Y., Beydoun, M.A., Liang, L., Caballero, B., Kumanyika, S.K., 2008.
Will all Americans become overweight or obese? Estimating the
progression and cost of the US obesity epidemic. Obesity (Silver
Spring) 16 (10), 2323–2330.

Wareham, N.J., Wong, M.Y., Hennings, S., Mitchell, J., Rennie, K., Cruick-
shank, K., et al., 2000. Quantifying the association between habitual
energy expenditure and blood pressure. Int. J. Epidemiol. 29 (4),
655–660.

World Health Organization, 2004. Obesity: Preventing and Managing the
Global Epidemic. Report of a WHO Consultation, Geneva.

Zapka, J.M., Lemon, S.C., Magner, R.P., Hale, J., 2009. Lifestyle behaviours
and weight among hospital-based nurses. J. Nurs. Manag. 17 (7),
853–860.

Zhao, I., Bogossian, F., Turner, C., 2012. The effects of shift work and
interaction between shift work and overweight/obesity on low back
pain in nurses: results from a longitudinal study. J. Occup. Environ.
Med. 54 (7), 820–825.

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0115

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0120

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0125

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0130

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0135

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0140

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0145

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0150

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0155

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0160

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0165

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0170

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0175

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0180

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0185

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0190

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0195

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0200

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0205

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0210

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0215

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0220

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0225

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0230

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0235

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0240

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0245

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0250

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0255

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0260

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0265

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0270

http://refhub.elsevier.com/S0020-7489(16)00010-9/sbref0275

Occupational factors associated with obesity and leisure-time physical activity among nurses: A cross sectional study

1 Introduction
2 Methods
2.1 Study design and participants
2.2 Measures
2.2.1 Outcomes
2.2.1.1 Overweight/obesity
2.2.1.2 Leisure-time physical activity
2.2.2 Sociodemographics
2.2.3 Musculoskeletal pain
2.2.4 Occupational factors
2.3 Data analysis
3 Results
3.1 Participant characteristics
3.2 Overweight/obesity and regular physical activity: prevalence and bivariate analysis
3.3 Associations of occupational factors with obesity and regular physical activity
4 Discussion
4.1 Overweight/obesity
4.2 Physical activity
4.3 Limitations
5 Conclusion
References

Turn in your highest-quality paper
Get a qualified writer to help you with

“ Article ”

Get high-quality paper

NEW! AI matching with writer

Order an Essay Now & Get These Features For Free:

Turnitin Report

Formatting

Title Page

Citation

Outline

Place an Order