August/September 2025 Issue
Navigating Diabetes Management in Shift Work
By Janelle Eligon-Ketchum, RD, LDN, CDCES
Today’s Dietitian
Vol. 27 No. 7 P. 20
Insights Into a Challenging Demographic
As the global burden of diabetes escalates, health care professionals, especially dietitians, must lead the way in addressing the lifestyle demands for these populations. Among those disproportionately impacted are shift workers, an occupational category encompassing millions worldwide, including truck drivers, pilots, firefighters, public transit employees, correction officers, traffic controllers, physicians, nurses, restaurant staff, and many others.
These individuals face unique physiological and environmental stressors that heighten their risk for metabolic disorders, including type 2 diabetes mellitus (T2DM).1 Managing diabetes in these populations requires an evidence-based, personalized approach that considers erratic schedules, heightened stress levels, and individual environmental constraints. RDs can address these challenges by offering practical strategies, including collaborative problem solving, for patients and clients to support the nutrition and overall health of shift workers.
Ngozi Onuoha, MD, MBA-HCM, CEO of Health4Naija, LLC, speaks to the benefits of collaborating with RDs on the care team. “Shift workers often struggle to manage chronic conditions because their irregular schedules disrupt key health routines, such as consistent mealtimes, quality sleep, and regular physical activity,” she says. “Effectively managing health as a shift worker requires extra effort and support. Partnering with knowledgeable health professionals, such as dietitians, can provide the tailored guidance needed to address these unique challenges. Additionally, improving access to care outside traditional office hours is essential for addressing chronic health concerns in this population.”
The Unique Challenges
Shift work, defined as employment outside the traditional 9-to-5 workday, disrupts circadian rhythms and has been associated with increased risk for T2DM. Epidemiological data suggests that night shift workers have a 9% increased risk of developing diabetes compared with daytime workers.2 Disruptions in sleep-wake cycles alter glucose metabolism, reduce insulin sensitivity, and impair hormonal regulation, contributing to the onset and progression of T2DM.3
Transit employees and correction officers, for example, often work in high-stress, high-vigilance environments with rotating shifts. The inconsistent timing of meals and sleep, limited access to nutritious food, and occupational stressors contribute to poor glycemic control and health outcomes. Tailored diabetes management strategies are essential for these populations.
Shift workers who strive for improved management of T2DM are confronted with multiple barriers. For an individual without proper support, these obstacles may seem overwhelming. RDs should work in conjunction with the interdisciplinary team to help patients make steady progress over time.
Circadian Misalignment
Circadian rhythms help coordinate the timing of many physiological processes beyond glucose metabolism, including hormone and neurotransmitter regulation, sleep-wake cycles, and many aspects of digestion and nutrient absorption. Circadian misalignment occurs when there is a mismatch between internal biological clocks and external environmental cues.4
When activities like eating occur at biologically inappropriate times, metabolic regulation becomes impaired with far-reaching consequences. Shift workers often eat during the biological night, when insulin sensitivity is naturally at its lowest. Studies indicate that meal timing, independent of caloric intake, significantly affects glycemic response and overall metabolic health.3 For example, high carbohydrate nighttime eating when melatonin is high leads to reduced insulin sensitivity and lower pancreatic beta cell responsiveness. Experimental and clinical evidence shows that consuming a given food late at night produces higher blood glucose levels than eating that same food during daytime hours.4
Those working the night shift may also frequently rely on convenience foods high in high glycemic carbohydrates, sodium, and saturated fats, exacerbating dysglycemia and cardiovascular risk. The lack of refrigeration or kitchen facilities can further limit healthy meal preparation. The combination of disrupted meal timing and lower diet quality accentuates glucose excursions and increases long-term risk for CVD.5-7
Furthermore, eating low fiber, carbohydrate-rich foods late at night may affect daily recurring patterns of appetite regulation by hormones such as leptin and ghrelin, contributing to increased hunger the following day and difficulty maintaining healthy weight over time.7,8
A Note About Metabolic Health
Metabolic health is a term some have used to loosely refer to glucose control, when in fact, metabolism encompasses all chemical reactions needed to sustain life.9 These include not only glucose metabolism but also lipid metabolism, protein synthesis and turnover, micronutrient metabolism, hormone production, and detoxification processes, among countless others.9 Health goals for shift work employees should include a comprehensive appreciation for the many facets of metabolism, with lower levels of oxidative stress and improved cardiometabolic and inflammatory biomarkers and symptoms.
Psychosocial Stress and Sleep Deprivation
In addition to the chronic physiological stress of poor glucose regulation, potential nutritional imbalances, and sleep-wake cycle disruption, many shift workers, such as prison officers, transit workers, and health care providers, are exposed to chronic psychosocial stress, which collectively may contribute to elevated cortisol levels and further exacerbate insulin resistance. Sleep deprivation impairs glucose regulation all on its own. Research shows that even short-term sleep restriction can lead to decreased insulin sensitivity and impaired beta-cell function.10
Chronic stress may negatively impact other hormones, such as thyroid hormone, which plays a central role in regulating basal metabolic rate and influences nearly every organ system. Both hypothyroidism and hyperthyroidism can disrupt glucose homeostasis. In hypothyroid states, slowed glucose uptake and reduced insulin clearance can contribute to insulin resistance. Hyperthyroidism, by contrast, often increases hepatic glucose production and accelerates carbohydrate absorption, sometimes mimicking the glycemic variability seen in early T2DM.11
Limited Bathroom Access
Limited access to and ability to use the restroom is an underappreciated factor that may influence fiber and fluid intake as well as medication compliance. Bus operators are particularly at risk for limited bathroom access. In order to take regular bathroom breaks, drivers would have to park their buses and either ask nearby businesses to use their bathroom facilities or have specific bathrooms that they can use mapped out in advance. Then, taking those bathroom breaks might make them late on their route, which would negatively affect their passengers, coworkers, and potentially their ability to keep their jobs. Would you choose a diet or take medication that sent you to the bathroom if you had limited access to one? The answer to this for most shift workers in this position is no.
Medication Noncompliance
Shift workers often avoid taking medications if they are likely to cause frequent urination or digestive upset. Many shift workers may not share that they are not taking their medication or let their medical providers know that they will not take certain medications due to their side effects.
Evidence-Based Strategies and Solutions
For RDs working with shift workers, understanding the physiological and logistical
realities of nontraditional work hours is essential to developing sustainable, evidence-based nutrition strategies. Targeted MNT can help shift workers improve their blood sugar and lipid levels and lower their risk of diabetes-related complications.
Structured Meal Planning
Irregular schedules, disrupted circadian rhythms, and workplace constraints all intersect to influence meal timing, nutrient intake, and ultimately, glycemic control.
Emphasizing timing meals with adequate protein, higher fiber, and lower carbohydrates at the end of the shift can work well for some.12 Since some night shift workers may not get a designated meal break, smaller snacks rich in protein and healthy fats such as nuts with low glycemic fruit or a low-sugar protein bar may work well.
Studies suggest that eating meals at consistent intervals improves insulin sensitivity and supports more stable postprandial glucose responses, particularly in individuals with T2DM.13 In practice, RDs should encourage clients to establish predictable eating patterns, ideally every four to five hours, and align these patterns with scheduled work breaks, regardless of shift timing.
Transit employees working overnight shifts often attempt to maintain daytime eating schedules, consuming meals during their biological sleep window and avoiding food during active work hours. This may backfire, as the misalignment between altered sleep-wake cycles and food intake can lead to increased hunger, disordered eating patterns, and reliance on calorie-dense, nutrient-poor convenience foods.13 Clients trying this strategy often express guilt or frustration after consuming late-night snacks such as potato chips or fried food items commonly available at 24-hour convenience stores or fast-food outlets.
Providing shift workers with portable, nutrient-dense meals and snacks can reduce reliance on vending machines and fast food. Encouraging the use of balanced meal replacements, such as high-protein blood sugar-friendly shakes or bars with at least 10 g of protein, less than 30 g of carbohydrates, and 1 to 3 g fiber, can support glycemic control and satiety in environments with limited refrigeration, heating, or bathroom access.12 Prepping meals during days off and storing them in grab-and-go containers helps ensure adherence during chaotic or long shifts.
RDs can guide clients to anchor smaller meals or snacks around known break times and adjust their intake based on energy needs and work demands in ways that won’t impair alertness or digestion.
Personalized Nutrition Plans
Nutrition counseling for shift workers with T2DM must integrate empathy, practicality, and a deep understanding of the metabolic and occupational challenges these clients face. When done well, it empowers clients to make sustainable changes that improve glycemic control, energy levels, and overall health regardless of the hour on the clock.
Encouraging high-fiber foods at the end of shifts or on long breaks helps reduce postprandial blood glucose spikes and addresses limited bathroom access. Suitable options may include legumes, whole grains, nonstarchy vegetables, and low glycemic fruits. Incorporating protein or healthy fat with carbohydrates can further modulate glycemic response.
Dietitians must assess individual health status, work schedules, cultural preferences, income, bathroom access, and readiness for change. Motivational interviewing techniques during MNT sessions can help uncover barriers and enhance engagement. For example, a correctional officer working alternating night and day shifts may benefit from separate designated mealtimes tailored to each schedule.
Mindful Snacking
Shift workers often rely on snacks to maintain energy levels. RDs can recommend nutrient-dense, lower glycemic options such as nuts, plain yogurt and fruit, hummus with vegetables, or hardboiled eggs. Limiting snacks that are high in added sugars, sodium, and caffeine near the end of a shift can also promote better sleep quality. Planning a meal at the end of the shift that follows the diabetes plate method and includes individualized calculations for macronutrients is a helpful starting approach.
Hydration Awareness
Dehydration can mimic symptoms of hyperglycemia, such as fatigue and dizziness. RDs should emphasize the importance of meeting fluid needs and timing hydration intake to coordinate with break times and bathroom access.
For correctional officers, hydration presents unique challenges. Many intentionally restrict fluid intake due to safety concerns. For instance, if a correctional officer is on a diuretic or other medication that increases urination and causes them to frequently leave their post for the restroom, they will likely stop taking the medication. Chronic underhydration can exacerbate fatigue, impair concentration, and influence appetite cues. RDs must assess fluid intake behaviors and collaborate with clients to develop tailored hydration strategies that consider worksite realities and medication timing. Suggestions might include taking the diuretic at bedtime and drinking most fluids toward the end of shifts and drinking small amounts during working hours.
Cultural and Environmental Adaptations
Considering cultural food preferences, work nutrition culture, and workplace environments may enhance dietary compliance. For instance, an RD might suggest ways to alter portions while adding beneficial nutrients to a cheesesteak (something consumed regularly by transit employees in Philadelphia), instead of suggesting total avoidance, by eating a half portion and adding some carrot sticks sold at convenience stores. Encouraging nourishing cultural meals by providing appropriate food lists and storage solutions (eg, insulated lunch boxes) can further improve meal accessibility.
Alexis Newman, RD, LDN, says, “Many of my shift work clients feel that their African or Latin heritage foods are not healthy and cause weight gain. First, I take the time to dismantle food myths, such as cultural foods are what caused their diabetes. We then work together to create realistic meal plans that include their cultural foods with customized carbohydrate and fiber portions while planning out the timing of their meals according to their unique schedule and bathroom accessibility.”
Medication Adherence
While RDs are well versed in discussing drug-nutrient interactions, many hesitate to explore medication adherence in clinical practice. Yet, noncompliance with prescribed medications, particularly those managing chronic conditions such as T2DM, hypertension, and hyperlipidemia, remains a significant barrier to achieving desirable health outcomes.13 Incorporating medication adherence conversations into routine counseling sessions can uncover root causes of therapeutic failure and provide critical opportunities for interdisciplinary intervention.
Clients are often more forthcoming about their medication habits once trust and rapport have been established. In such cases, an honest question like, “How many days in the week do you forget or not take your medications?” can elicit valuable insights. Many individuals reveal that they skip doses, alter timing, or stop medications altogether due to side effects, cost, or lack of perceived benefit. Studies suggest that nearly 50% of patients with chronic disease do not take their medications as prescribed, with gastrointestinal side effects being a leading contributor to nonadherence with drugs like metformin.13
RDs are not expected to prescribe or alter medications, but they can play a pivotal role in identifying adherence barriers and initiating productive conversations with their clients and prescribing providers. In a real-world clinical example, a client who was a train operator reported not taking his metformin as prescribed due to experiencing bloating, diarrhea, or gas after taking metformin. After discussing with the RD the option of an extended-release (ER) version to reduce symptoms, he wrote a note to his prescribing provider through his EMR, and the prescription was updated. Now, the client takes his metformin as prescribed without side effects. Clinical evidence supports that metformin ER is associated with significantly improved gastrointestinal tolerability while maintaining glycemic efficacy.14
Group or Peer Support
Group counseling or peer-led support groups within workplaces can foster a sense of community and shared accountability. Studies show peer support positively affects adherence to dietary and medical recommendations in populations with diabetes.15
In Conclusion: RDs as Advocates and Educators
Dietitians are uniquely positioned to lead interdisciplinary efforts in managing diabetes among shift workers. Collaborating with employer medical centers, groups, and medical providers, they can do the following:
• conduct workplace wellness, nutrition, and diabetes workshops;
• advocate for healthier vending, food truck, and cafeteria options;
• offer personalized MNT and diabetes education during convenient hours; and
• provide accountability with MNT and diabetes education goals.
Managing diabetes among shift workers requires an integrative, personalized, and flexible approach rooted in science and empathy. RDs must leverage their expertise to navigate this complex landscape, using innovative technologies and long-term MNT to drive and support sustainable change. By tailoring interventions to align with occupational realities, RDs can significantly improve both glycemic outcomes and quality of life for these underserved populations.
— Janelle Eligon-Ketchum, RD, LDN, CDCES, is a certified diabetes care and education specialist with over 20 years of experience. She is the CEO of Nutrition Unlimited, and, along with her team of RDNs, provides culturally responsive MNT. Based in Philadelphia, Eligon-Ketchum is a national spokesperson for the Association of Diabetes Care & Education Specialists and is passionate about health equity, food access, and mentoring future nutrition professionals.
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