Association of Endocrine-Metabolic Disorders with Depression and Anxiety in Nurses: A Prospective Cohort Study

Association of Endocrine-Metabolic Disorders with Depression and Anxiety in Nurses: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association of Endocrine-Metabolic Disorders with Depression and Anxiety in Nurses: A Prospective Cohort Study Zhihui LU, Zijing HUANG, Xiaobei GUO, Mengying CUI, Ying WANG This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9070647/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The association between various endocrine-metabolic disorders and symptoms of depression and anxiety has been established in the general population. However, longitudinal evidence regarding these associations within nurse populations remains limited. Objective Aimed to identify specific endocrine and metabolic diseases associated with an increased risk of depression and anxiety, and to delineate relevant occupational, behavioral, and physiological susceptibility factors within the nursing population. Methods We conducted a prospective cohort study among registered nurses from a tertiary hospital in Hubei Province. Eligible participants were those without depressive or anxiety symptoms at baseline (January 2024). Baseline data on sociodemographic characteristics, lifestyle factors, disease history, and psychological scale scores were collected via questionnaires. The primary exposures were predefined endocrine-metabolic disorders (thyroid disease, polycystic ovary syndrome(POCS), gastric/duodenal ulcer, and diabetes), ascertained through a self-reported disease history questionnaire. The primary outcomes were the 12-month incidence of depressive symptoms and anxiety symptoms, assessed at follow-up using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) scale, respectively. Logistic regression models were used to analyze the longitudinal associations between endocrine-metabolic disorders and the incidence of depressive or anxiety symptoms. Stratified analyses were performed to evaluate potential effect modification by selected covariates. Results A total of 2,888 participants contributed complete data at both baseline and follow-up. At baseline, depressive symptoms were present in 1577 nurses (54.61%) and anxiety symptoms in 940 (34.42%). In adjusted analyses, hypothyroidism was significantly associated with an increased risk of incident depressive symptoms (adjusted odds ratio [aOR] = 2.004,95%CI: 1.159 ~ 3.463). For incident anxiety symptoms, hypothyroidism, gastric/duodenal ulcer, and PCOS were significant independent predictors. The corresponding aORs were1.631(95%CI:1.012 ~ 2.629) for hypothyroidism, 1.707(95%CI:1.085 ~ 2.685) for gastric/duodenal ulcer, and 2.058(95%CI:1.350 ~ 3.136) for PCOS. A sleep duration of ≤ 7 hours per day was associated with a higher risk of incident depressive symptoms, while sleep duration ≤ 6 hours and night shift work were associated with an increased risk of incident anxiety symptoms (all P < 0.05). Furthermore, stratified analyses indicated that the risk of anxiety associated with hypothyroidism was significantly higher among nurses who did not engage in regular exercise compared to those who did ( P for interaction = 0.010). In contrast, no significant effect modification was observed for gender, age, night shift work, smoking status, alcohol use, or sleep duration on the associations between endocrine-metabolic disorders and either depressive or anxiety outcomes (all P for interaction > 0.05). Conclusion This prospective cohort study identified hypothyroidism as a significant longitudinal risk factor for both incident depressive and anxiety symptoms. Gastric/duodenal ulcer and PCOS were also independently associated with an increased risk of incident anxiety symptoms. Furthermore, night shift work and insufficient sleep duration were confirmed as independent risk factors for these mental health outcomes. Nurses Endocrine and Metabolic Diseases Depression Anxiety Night Shift Work Figures Figure 1 Figure 2 Figure 3 Introduction Nurses are a core workforce sustaining continuity of clinical care and the quality of health services worldwide. However, accumulating evidence indicates that nurses are experiencing a growing burden of mental health problems[ 1 , 2 ]. Long-term exposure to high work demands, irregular shift schedules, emotional labor, and occupational burnout places nurses at substantially higher risk of depressive and anxiety symptoms than the general population[ 3 , 4 ]. Persistent psychological distress not only undermines nurses’ physical and mental well-being and shortens their professional longevity, but may also reduce work engagement, impair clinical judgment and communication,and ultimately threaten care quality and patient safety[ 5 , 6 ]. Identifying biological susceptibility factors for mental health problems in nurses therefore has important implications for occupational health management and early prevention of mental disorders. Physiological dysregulation induced by chronic occupational stress, especially disruptions in the endocrine and metabolic systems, is regarded as a crucial biological pathway connecting job stress to psychopathology[ 7 ]. Previous research has demonstrated that several chronic conditions, such as thyroid dysfunction[ 8 ], polycystic ovary syndrome (PCOS)[ 9 ], peptic ulcer disease[ 10 ], and abnormalities in glucose metabolism[ 11 ], are closely associated with depressive and anxiety symptoms. These associations may stem from multi - system interactions. Dysregulation of neuroendocrine axes, including the hypothalamic-pituitary-thyroid (HPT) axis and hypothalamic-pituitary-adrenal (HPA) axis, can modify neurotransmitter systems involved in mood regulation and disrupt physiological adaptation to stress[ 12 , 13 ]. Chronic low - grade inflammation and proinflammatory cytokines may influence central nervous system function via neuroimmune pathways[ 14 ]. Additionally, disruptions in the gut–brain axis have been implicated. Gastrointestinal and metabolic disorders may affect emotional regulation through alterations in gut microbiota, neural signaling, and the production of neuroactive metabolites[ 15 , 16 ]. Collectively, these findings support a complex endocrine-neuro-immune interaction network that provides a biological basis for the link between physical disorders and emotional disturbances. Lifestyle and behavioral factors, such as sleep patterns and physical activity, may further modulate the psychological impact of endocrine and metabolic dysregulation[ 17 ]. Although these associations have been partly documented in the general population, important gaps remain when focusing on nurses, a group characterized by sustained exposure to high occupational stress. First, most previous studies have used cross-sectional designs[ 18 , 19 ], which limit inference about temporal sequence and causality. It remains unclear whether endocrine disorders increase the risk of emotional symptoms, or whether psychological stress exacerbates physical illness through behavioral changes or neuroendocrine pathways. Second, many existing studies are based on community or general clinical samples and rarely incorporate nurse-specific occupational exposures in a systematic manner[ 20 , 21 ]. Circadian disruption caused by shift work has been shown to affect cortisol rhythms, melatonin secretion, and metabolic homeostasis. These changes may lead to adverse effects on mental health[ 22 , 23 ], yet longitudinal evidence on such interactions is still limited. Third, prior research has often focused on a single endocrine disorder. Few studies have conducted integrated analyses of multiple endocrine conditions within a homogeneous occupational cohort, which restricts the applicability of findings to occupational health screening and intervention. To address these gaps, we conducted a one-year prospective cohort study among nurses to examine the longitudinal associations between multiple endocrine conditions and the onset of depressive and anxiety symptoms. We further explored whether occupational and behavioral factors modified these associations. Our aims were to identify specific endocrine disorders that are closely linked to mental health risk and to identify specific occupational, behavioral, and physiological susceptibility factors. By providing longitudinal evidence from a nursing population, this study contributes to an integrated framework linking occupational stress, physiological dysregulation, and mental health. In addition, by quantifying biological and behavioral indicators that can be obtained in routine occupational health practice, our findings may inform the development of risk-stratified screening tools and targeted prevention strategies. This approach may help hospitals identify high-risk nurses earlier and integrate physical health management with psychological support, thereby promoting nurse well-being and improving the quality and safety of clinical care. METHODS Study Design and Participants This prospective cohort study examines the longitudinal associations between endocrine-metabolic disorders and symptoms of depression and anxiety among nurses. Baseline assessments were conducted in January 2024. Participants completed a baseline questionnaire collecting sociodemographic data, lifestyle factors, disease history, and psychological scale scores. A 12-month follow-up was subsequently performed to reassess depression and anxiety symptoms. The study protocol was approved by the Ethics Review Committee (ethics number: LYF20230048), and all participants provided written informed consent prior to enrollment. Participants comprised registered nurses from a tertiary hospital in Hubei Province. Inclusion criteria were: age ≥ 18 years, current employment in a clinical position, and voluntary participation with completion of the baseline survey. Exclusion criteria included: a pre-existing diagnosis of depression or anxiety at baseline, pregnancy or lactation, and inability to complete the follow-up. Exposures The primary exposures were endocrine-metabolic disorders. Presence of the following conditions was assessed using self-reported questionnaires: thyroid disease (including hyperthyroidism and hypothyroidism), polycystic ovary syndrome (PCOS), gastric/duodenal ulcer, and diabetes. Disease status was dichotomized (yes/no). Outcomes Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), with each item rated on a 4-point Likert scale. A total score of ≥ 5 was used to define the presence of clinically relevant depressive symptoms. The instrument demonstrated good internal consistency, with a Cronbach's α of 0.80[ 24 ]. Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, with each item also scored on a 4-point Likert scale. A total score of ≥ 5 indicated clinically relevant anxiety symptoms. The scale showed good internal consistency (Cronbach's α = 0.92)[ 25 ]. The primary outcome was defined as the first documented occurrence of either set of symptoms during the follow-up period. Participants who reported depressive or anxiety symptoms at any point prior to baseline were excluded from the longitudinal analysis. Covariates Potential confounders were selected for inclusion in the analysis based on their established associations with mental health and endocrine-metabolic disorders in the existing literature. These covariates encompassed demographic characteristics (age, gender, educational level, marital status), lifestyle factors (smoking status, alcohol use, physical activity frequency, sleep duration), and work-related factors (night shift, job position). Variables found to be associated with the onset of depressive or anxiety symptoms in univariate analyses were subsequently entered into a multivariable logistic regression model. Static Analysis All analyses were performed using complete cases. Data were analyzed with SPSS 26.0 statistical software. Continuous variables are presented as mean ± standard deviation, and categorical variables as frequency (percentage). Participants were stratified by the presence of incident depressive or anxiety symptoms, and intergroup differences were assessed using the chi-square test. P < 0.05 was considered statistically significant. Binary logistic regression models were employed to examine the associations between endocrine-metabolic disorders and the incidence of depressive and anxiety symptoms. To assess the robustness of the findings, two or three sequential models were constructed: Model 1 included only the exposure variables; Model 2 was further adjusted for key lifestyle factors (sleep duration); Model 3 additionally incorporated clinical and occupational factors (night shift). Stratified analyses were conducted to examine potential effect modification. Participants were stratified by the following variables: gender (male, female), age group (18–29, 30–34, 35–44, ≥ 45 years), night shift work (yes, no), smoking status (yes, no), alcohol use (yes, no), exercise frequency (none, ≤ 1 time/week, ≥ 2 times/week), and sleep duration (≤ 5, 6, 7, 8, 9, ≥ 10 hours per day). RESULTS A total of 4,539 nurses completed the baseline survey. Among them, 2,888 participants provided complete data at both baseline and follow-up (see Fig. 1 ). At baseline, depressive symptoms were present in 1,577 nurses (54.61%), and anxiety symptoms in 994 nurses (34.42%). Collinearity diagnostics indicated no serious multicollinearity among independent variables, as all variance inflation factor (VIF) values were below 5. For the analysis with incident depression as the outcome, 1,311 participants were eligible, of whom 369 (28.15%) developed new depressive symptoms at the 12-month follow-up. For the analysis with incident anxiety as the outcome, 1,894 participants were eligible, of whom 346 (18.27%) developed new anxiety symptoms at the 12-month follow-up. The baseline characteristics of the participants and the results of univariate analyses with outcome variables are presented in Table 1 . In the univariate analysis for incident depression, a diagnosis of hypothyroidism and sleep duration were significantly associated with the outcome ( P < 0.05). For incident anxiety, hypothyroidism, gastric/duodenal ulcer, polycystic ovary syndrome, sleep duration, and night shift work showed significant associations ( P < 0.05). Table 1 Baseline characteristics and univariate associations with incident depression and anxiety symptoms during follow-up Characteristic No Depression(n = 942) Incident Depression(n = 369) χ 2 P No Anxiety (n = 1548) Incident Anxiety (n = 346) χ 2 P Gender Male 46 15 0.400 0.527 62 16 0.275 0.600 Female 896 354 1486 330 Age, years 18 ~ 29 148 49 1.997 0.573 246 49 3.057 0.383 30 ~ 34 266 112 455 97 35 ~ 44 403 164 658 164 ≥ 45 125 44 189 36 Marital Status Unmarried 209 77 0.283 0.868 361 79 0.068 0.967 Married 712 284 1149 259 Divorced/Widowed 21 8 38 8 Smoking Status No 929 365 - 0.792 1528 341 - 0.795 Yes 13 4 20 5 Alcohol Use No 665 271 3.288 0.193 1090 252 4.361 0.113 ≤ 1 time/month 257 86 423 81 ≥ 2 times/month 20 12 35 13 Exercise Frequency None 342 125 2.837 0.417 574 140 3.626 0.305 ≤ 1 time/week 443 191 733 164 2–3 times/week 128 45 194 36 ≥ 4 times/week 29 8 47 6 Sleep Duration, hours/day ≤ 5h 36 19 12.424 0.026 95 30 12.853 0.021 6h 349 154 628 162 7h 397 157 613 125 8h 141 31 181 26 9h 12 6 22 3 ≥ 10h 7 2 9 0 Professional Title Staff Nurse 873 341 0.027 0.870 1441 326 0.579 0.447 Head Nurse or above 69 28 107 20 Education Level Secondary/Junior College 6 0 1.962 0.414 7 0 1.288 0.497 Undergraduate 876 346 1454 324 Master's degree or above 60 23 87 22 Night Shift Work No 225 83 0.286 0.593 339 58 4.503 0.034 Yes 717 286 1209 288 Diabetes No 935 363 - 0.210 1535 344 - 1.000 Yes 7 6 13 2 Hyperthyroidism No 919 364 1.498 0.221 1517 337 0.490 0.484 Yes 23 5 31 9 Hypothyroidism No 910 345 6.260 0.012 1477 321 4.093 0.043 Yes 32 24 71 25 Gastric/Duodenal Ulcer No 900 348 0.880 0.348 1474 317 7.131 0.008 Yes 42 21 74 29 Polycystic Ovary Syndrome No 894 353 0.329 0.566 1469 311 12.559 <0.001 Yes 48 16 79 35 Binary logistic regression analyses revealed significant associations between endocrine-metabolic disorders and incident psychological symptoms. Regarding incident depressive symptoms, hypothyroidism was identified as a significant risk factor. In the model 2, hypothyroidism remained associated with an elevated risk of depressive symptoms (OR = 2.004, 95% CI: 1.159 ~ 3.463). Furthermore, compared to a sleep duration of 8 hours, sleeping ≤ 7 hours per day was associated with a higher risk of depressive symptoms (see Fig. 2 ). For incident anxiety symptoms, hypothyroidism, gastric/duodenal ulcer, and PCOS were significant predictors in the fully adjusted model (Model 3). The corresponding adjusted odds ratios were 1.631 (95% CI: 1.012 ~ 2.629) for hypothyroidism, 1.707 (95% CI: 1.085 ~ 2.685) for gastric/duodenal ulcer, and 2.058 (95% CI: 1.350 ~ 3.136) for PCOS. Additionally, sleep duration ≤ 6 hours and engagement in night shift work were associated with an increased risk of anxiety symptoms (see Fig. 3 ). Subgroup analyses revealed that the association between hypothyroidism and incident anxiety symptoms was significantly modified by exercise frequency. Specifically, the increased risk of anxiety associated with hypothyroidism was more pronounced among nurses who did not exercise, compared to those who exercised ( P for interaction = 0.010). No significant effect modification was observed for gender, age, night shift work, smoking status, alcohol use, or sleep duration on the associations between endocrine/metabolic diseases and depression & anxiety outcomes ( P for interaction>0.05). Detailed results of the subgroup analyses are provided in Appendix A . DISCUSSION In this one-year prospective cohort study of nurses, we systematically investigated the longitudinal associations between various endocrine and metabolic conditions and the onset of depressive and anxiety symptoms. Our findings indicate that hypothyroidism is significantly associated with an elevated risk of developing depressive symptoms. Additionally, hypothyroidism, gastric/duodenal ulcer disease, and PCOS were significantly linked to an increased risk of anxiety symptoms. Furthermore, night shift work and reduced sleep duration (≤ 6 hours, particularly < 5 hours) demonstrated independent longitudinal associations with both depressive and anxiety symptoms. These findings suggest that occupational factors and sleep patterns may directly contribute to mental health risks. Collectively, the results underscore the presence of endocrine-psychiatric comorbidity in a population subjected to high occupational stress. They also suggest that sleep deprivation and career-related occupational factors may interact with biological vulnerabilities in the development of mental health symptoms. In addition, subgroup analyses indicated that the association between hypothyroidism and incident anxiety symptoms varied by exercise frequency, with a stronger association observed among nurses who did not engage in regular physical activity. This study provides novel evidence for risk stratification among nurses and may inform more targeted prevention and intervention strategies. The relationship between hypothyroidism and depressive or anxiety symptoms has been documented within the general population[ 26 – 28 ]. This study builds upon existing literature by highlighting the longitudinal significance of this association in nurses subjected to elevated occupational stress. Findings indicate that nurses with hypothyroidism exhibit a markedly increased risk of developing depressive and anxiety symptoms over the follow-up period. These associations persisted even after controlling for demographic factors, lifestyle variables, and work-related conditions. The results align with findings from extensive studies utilizing community samples and biobank data[ 8 , 29 , 30 ]. From a mechanistic standpoint, thyroid hormones are integral to the central nervous system, extending their influence beyond mere metabolic regulation[ 31 ]. Triiodothyronine (T3) and thyroxine (T4) exert direct effects on monoaminergic neurotransmitter systems, including serotonin and norepinephrine, by modulating their synthesis, transport, and receptor expression. Additionally, these hormones regulate neurotrophic factors such as brain-derived neurotrophic factor (BDNF), thereby impacting neuroplasticity and emotional stability[ 32 , 33 ]. Chronic hypothyroidism may lead to diminished functional activity in prefrontal-limbic circuits and altered amygdala plasticity[ 34 ], potentially impairing the regulation of negative emotional stimuli[ 35 ]. Furthermore, hypothyroidism is frequently associated with chronic low-grade inflammation. Proinflammatory cytokines can influence the central neuroimmune environment via the blood-brain barrier or vagal pathways, thereby disrupting mood-related neural circuits[ 14 , 36 ]. In the context of nursing professionals, prolonged shift work, sleep deprivation, and high psychological demands may further perturb the rhythmic regulation of the HPT axis[ 37 ]. These factors may synergistically interact with pre-existing thyroid dysfunction, thereby elevating the risk of emotional dysregulation. Our subgroup findings further suggest that lack of regular physical activity may exacerbate the association between hypothyroidism and anxiety symptoms, highlighting the potential role of behavioral resilience factors in modulating endocrine-related mental health risk. Previous research has indicated that subclinical hypothyroidism, characterized by elevated thyroid-stimulating hormone (TSH) levels while maintaining normal thyroid hormone concentrations, may be linked to an increased risk of depression[ 38 , 39 ]. This suggests that even minor disruptions in HPT axis function could have significant implications for mental health, particularly in populations subjected to chronic stress. Future research should employ continuous biomarkers to investigate potential dose–response relationships. It may also be important to consider modifiable lifestyle factors such as physical activity, which could influence the mental health impact of subtle thyroid dysfunction. Additionally, we identified a longitudinal correlation between gastric/duodenal ulcer disease and the onset of anxiety symptoms. This finding underscores the potential role of gastrointestinal disorders in the etiology of anxiety, which can be understood through the lens of gut-brain axis dysregulation[ 15 ]. Gastric mucosal damage and the resultant inflammation may compromise intestinal barrier integrity, leading to increased gut permeability. This condition permits the translocation of bacterial metabolites and proinflammatory factors into the systemic circulation, thereby activating both peripheral and central immune responses and affecting brain regions involved in emotional regulation[ 40 ]. Gastrointestinal dysfunction is intricately associated with imbalances in the autonomic nervous system. Persistent disruptions in the sympathetic-parasympathetic balance have been identified as a significant physiological foundation for anxiety[ 10 , 41 ]. A prospective study has demonstrated that gastrointestinal symptoms, such as constipation, may precede the onset of depression or anxiety, indicating that disturbances in gut homeostasis could serve as early indicators of risk for mental disorders[ 42 ]. Among nurses, irregular meal patterns, night shift work, and continuous psychological stress may further impede gastrointestinal recovery. Concurrently, our study found that night shifts and sleep deprivation were independently linked to an increased risk of anxiety[ 43 ]. These factors may collectively impose an additional burden within the same occupational setting, where physiological vulnerability and work-related stress are present. This combined vulnerability necessitates heightened attention in the management of occupational health. Our study revealed a significant association between PCOS and an elevated risk of developing anxiety symptoms. PCOS is characterized by disruptions in reproductive endocrine, metabolic, and immune systems, with its link to anxiety potentially mediated through multiple biological pathways[ 44 ]. Elevated androgen levels in PCOS may directly impact the central nervous system, modify GABAergic neurotransmission, and influence stress responses via the HPA axis. Additionally, insulin resistance and compensatory hyperinsulinemia may interfere with cerebral energy metabolism and insulin signaling, thereby affecting emotional regulation[ 9 , 45 ]. Chronic low-grade inflammation and oxidative stress, frequently observed in PCOS, have also been implicated in the neurobiological mechanisms underlying anxiety. Under conditions of elevated occupational stress, these endocrine and metabolic disturbances may reduce resilience to psychological stress, increasing the likelihood of anxiety symptoms. Our findings suggest that gastrointestinal disorders and PCOS could serve as clinically relevant indicators for anxiety risk stratification, particularly within predominantly female nursing populations. Night shift work and limited sleep duration (≤ 6 hours, particularly < 5 hours) have been independently linked to the development of anxiety symptoms, while sleep restriction has also been independently associated with the onset of depressive symptoms. These findings suggest that sleep deprivation and circadian disruption may serve as significant occupational risk factors that directly contribute to the emergence of mental health symptoms. Night shift work and chronic sleep restriction can lead to a desynchronization of endogenous circadian rhythms from the external light-dark cycle. This persistent circadian misalignment has been demonstrated to impact the homeostasis of the HPA and HPT axes, alter cortisol rhythms, and disrupt thyroid hormone metabolism, thereby compromising neuroendocrine stability[ 22 , 37 ]. Sleep deprivation itself can impair prefrontal regulation of emotional responses, increase amygdala reactivity to threat-related stimuli, and promote systemic inflammation, collectively undermining emotional stability[ 17 , 46 ]. Consequently, night shift work and inadequate sleep may function through independent yet overlapping biological pathways and, in conjunction with endocrine abnormalities, shape the overall mental health risk profile in nurses. Despite the strengths of employing a prospective design, extensive adjustments for potential confounders, and the robustness of the main associations observed in subgroup analyses, several limitations warrant consideration. Firstly, the identification of endocrine and metabolic conditions was primarily based on self-reports and medical history, which did not account for incident cases or changes in disease status during the follow-up period. This limitation may have resulted in exposure misclassification. Future research should incorporate repeated laboratory measurements to facilitate more precise dose–response analyses. Secondly, depressive and anxiety symptoms were assessed using self-report scales. Although these instruments demonstrate good validity and reliability, the possibility of information bias cannot be excluded. Additionally, residual confounding factors, such as genetic susceptibility and early-life stress, may persist. Lastly, the sample was drawn from nurses at a single center and was predominantly composed of women, which limits the generalizability of the findings to other occupations or to men. In addition, although a significant interaction with exercise frequency was observed for the association between hypothyroidism and anxiety symptoms, subgroup analyses may be subject to limited statistical power and should be interpreted with caution. As this is an observational study, the underlying mechanisms require further validation through experimental and interventional research. The findings of this study have important implications for clinical care and occupational health management in healthcare settings. Endocrine and metabolic disorders, such as hypothyroidism, peptic ulcer disease, and polycystic ovary syndrome, are common in clinical practice and can be identified through routine medical assessments. Healthcare professionals with these conditions may benefit from closer mental health monitoring, particularly in high-stress environments such as nursing. Risk-stratified interventions could be incorporated into occupational health programs. Nurses with a history of endocrine disorders, long-term night shift work, chronic sleep deprivation, or low levels of physical activity may warrant prioritized psychological surveillance and supportive resources. Optimizing shift schedules to reduce chronic sleep restriction, promoting regular physical activity, improving access to mental health services, and providing targeted stress-management support may help mitigate the cumulative burden of physiological and occupational risk factors. Although interventional studies are still needed, these findings support a more integrated approach to monitoring physical and mental health among healthcare workers, where routine clinical information can inform early identification and prevention of common mental health symptoms. CONCLUSION In this cohort of nurses experiencing high levels of occupational stress, we identified longitudinal associations between hypothyroidism and symptoms of depression and anxiety, as well as between gastric/duodenal ulcer disease, PCOS, and symptoms of anxiety. Furthermore, our study demonstrated that night shift work and insufficient sleep function as independent risk factors for the onset of mental health symptoms. These findings underscore the multifaceted pathways through which endocrine-metabolic dysregulation, occupational exposures, and sleep behaviors collectively contribute to the risk of mental health issues. The observed variation in the hypothyroidism–anxiety association by exercise frequency further suggests that modifiable lifestyle factors may influence vulnerability to mental health symptoms. Future strategies ought to encompass a synthesis of biological, behavioral, and occupational interventions to formulate comprehensive and individualized mental health promotion programs tailored for nurses. In evaluating mental health risks among healthcare workers, it is imperative to concurrently consider physical health status, sleep patterns, and occupational stressors. The integration of routinely accessible clinical data into occupational mental health surveillance systems may facilitate the identification of high-risk individuals and inform targeted preventive measures. Enhancing collaboration among clinical care, occupational health services, and mental health support systems could potentially enable the earlier detection and more efficacious prevention of prevalent mental health symptoms within the nursing workforce. Declarations Acknowledgements The authors extend their deepest gratitude to all the nurses who generously participated in this study by sharing their time, experiences, and insights through the survey questionnaire. Authors’ Contributions ZL: Conceptualization, Methodology and Writing-Original draft preparation. ZH: Data collection, Investigation, Writing-Original draft preparation. XG: Data analysis, Data interpretation and Validation. MC: Data analysis, Data interpretation. YW: Supervision, Writing-Reviewing and Editing. All authors reviewed the manuscript and approved the final manuscript. Funding This work was supported by the Chinese Nursing Association Research Project [ZHKY202306]. Data Availability The data presented in this study are available on request from the corresponding author. (the data are not publicly available due to privacy or ethical restrictions.) Ethics approval and consent to participate This study forms part of the All-China Psychological Cohort Study and has been granted approval by the ethics committee of the Second Xiangya Hospital of Central South University (ethics number: LYF20230048). The entire procedure adhered to the ethical guidelines outlined in the Helsinki Declaration, guaranteeing the anonymity and confidentiality of all respondents. The study has been registered in the Chinese Clinical Trial Registry (No: ChiCTR2300072142). Prior to the implementation of the program, consents were obtained from the participants, and they were provided with a detailed explanation of the study objectives, procedure, and ethical issues. Consent for publication Not applicable. Competing interests The authors declare that there is no conflict of interests in this study. References Li X, Tian Y, Yang J, et al. Network of job demands-resources and depressive symptoms in critical care nurses: a nationwide cross-sectional study. 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Validation of Patient Health Questionnaire for depression screening among primary care patients in Taiwan. Compr Psychiatry. 2011;52:96–101. https://doi.org/10.1016/j.comppsych.2010.04.013 . Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166:1092–7. https://doi.org/10.1001/archinte.166.10.1092 . Siegmann EM, Müller H, Luecke C, et al. Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis: A Systematic Review and Meta-analysis. Jama Psychiat. 2018;75:577–84. https://doi.org/10.1001/jamapsychiatry.2018.0190 . Rehman UL, Khalid M, Fatima M, et al. Anxiety and depression among adolescents and young adults with thyroid function disorders: a cross-sectional study. Expert Rev Endocrinol Metab. 2025;20:279–89. https://doi.org/10.1080/17446651.2025.2480693 . Yang R, Zhu F, Yue Y, et al. Association between thyroid function and psychotic symptoms in adolescents with major depressive disorder: A large sample sized cross-sectional study in China. Heliyon. 2023;9:e16770. https://doi.org/10.1016/j.heliyon.2023.e16770 . Dehesh T, Mosleh-Shirazi MA, Dehesh P. Prevalence and associated factors of anxiety and depression among patients with hypothyroidism in Southern Iran. BMC Psychiatry. 2025;25:54. https://doi.org/10.1186/s12888-025-06490-3 . Li M, Wang XW, Wang XQ, et al. Prevalence and risk factors for subclinical hypothyroidism in older patients with major depressive disorder. Bmc Geriatr. 2024;24:15. https://doi.org/10.1186/s12877-023-04584-9 . Yen PM. Physiological and molecular basis of thyroid hormone action. Physiol Rev. 2001;81:1097–142. https://doi.org/10.1152/physrev.2001.81.3.1097 . Montero-Pedrazuela A, Venero C, Lavado-Autric R, et al. Modulation of adult hippocampal neurogenesis by thyroid hormones: implications in depressive-like behavior. Mol Psychiatry. 2006;11:361–71. https://doi.org/10.1038/sj.mp.4001802 . Da CR, Laureano-Melo R, Oliveira KC, et al. Antidepressant behavior in thyroidectomized Wistar rats is induced by hippocampal hypothyroidism. Physiol Behav. 2016;157:158–64. https://doi.org/10.1016/j.physbeh.2016.02.005 . Głombik K, Detka J, Bobula B, et al. Contribution of Hypothyroidism to Cognitive Impairment and Hippocampal Synaptic Plasticity Regulation in an Animal Model of Depression. Int J Mol Sci. 2021;22. https://doi.org/10.3390/ijms22041599 . Maddox SA, Ponomareva OY, Zaleski CE, et al. Evidence for thyroid hormone regulation of amygdala-dependent fear-relevant memory and plasticity. Mol Psychiatry. 2025;30:201–12. https://doi.org/10.1038/s41380-024-02679-2 . Cheng YW, Zou ZH, Lou CL, et al. Hippocampal NLRP1 inflammasome mediates anxiety-like behavior in mice with hypothyroidism. Sci Rep. 2025;15:16176. https://doi.org/10.1038/s41598-025-00979-3 . Khosravipour M, Gharagozlou F, Kakavandi MG, et al. Association of prolonged occupational co-exposures to electromagnetic fields, noise, and rotating shift work with thyroid hormone levels. Ecotoxicol Environ Saf. 2024;270:115837. https://doi.org/10.1016/j.ecoenv.2023.115837 . Wang H, Jia M. Analysis of thyroid function and related factors in narcolepsy patients. Sci Rep. 2023;13:18494. https://doi.org/10.1038/s41598-023-45321-x . Dai W, Liu J, Xie H, et al. Association between subclinical hypothyroidism and psychotic features in Chinese young adults with first-episode and untreated major depressive disorder. J Affect Disord. 2023;333:209–15. https://doi.org/10.1016/j.jad.2023.04.067 . Rutsch A, Kantsjö JB, Ronchi F. The Gut-Brain Axis: How Microbiota and Host Inflammasome Influence Brain Physiology and Pathology. Front Immunol. 2020;11:604179. https://doi.org/10.3389/fimmu.2020.604179 . Ancona A, Petito C, Iavarone I, et al. The gut-brain axis in irritable bowel syndrome and inflammatory bowel disease. Dig Liver Dis. 2021;53:298–305. https://doi.org/10.1016/j.dld.2020.11.026 . Yun Q, Wang S, Chen S, et al. Constipation preceding depression: a population-based cohort study. EClinicalMedicine. 2024;67:102371. https://doi.org/10.1016/j.eclinm.2023.102371 . Yasmin A, Roychoudhury S, Sengupta P, et al. Prevalence of polycystic ovary syndrome (PCOS) and its associated hormonal and comorbid risk factors in Northeast India: a cross-sectional comparative study. Ther Adv Reprod Health. 2025;19:1383609219. https://doi.org/10.1177/26334941251384195 . Zhao W, Zhou J, Song Y, et al. Polycystic Ovary Syndrome Revisited: Novel Insights and Updates. Int J Med Sci. 2026;23:271–82. https://doi.org/10.7150/ijms.119968 . Stefanaki K, Karagiannakis DS, Raftopoulou M, et al. Obesity and hyperandrogenism are implicated with anxiety, depression and food cravings in women with polycystic ovary syndrome. Endocrine. 2023;82:201–8. https://doi.org/10.1007/s12020-023-03436-1 . Stenson AR, Kurinec CA, Hinson JM, et al. Total sleep deprivation reduces top-down regulation of emotion without altering bottom-up affective processing. PLoS ONE. 2021;16:e256983. https://doi.org/10.1371/journal.pone.0256983 . Additional Declarations No competing interests reported. Supplementary Files Supplementalmaterial.docx AppendixA.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 31 Mar, 2026 Editor assigned by journal 11 Mar, 2026 Editor invited by journal 11 Mar, 2026 Submission checks completed at journal 11 Mar, 2026 First submitted to journal 11 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9070647","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":615331772,"identity":"9748ecbb-26e9-4d31-9016-8bf716b1aca6","order_by":0,"name":"Zhihui LU","email":"","orcid":"","institution":"Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Zhihui","middleName":"","lastName":"LU","suffix":""},{"id":615331773,"identity":"be8df3b5-2f80-4d0e-9341-e8f76203b54b","order_by":1,"name":"Zijing HUANG","email":"","orcid":"","institution":"Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Zijing","middleName":"","lastName":"HUANG","suffix":""},{"id":615331774,"identity":"7426b9d6-9557-4291-8a20-936c24fd21b2","order_by":2,"name":"Xiaobei GUO","email":"","orcid":"","institution":"Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Xiaobei","middleName":"","lastName":"GUO","suffix":""},{"id":615331775,"identity":"d1c76770-ed19-42a7-8fcb-5064198202f6","order_by":3,"name":"Mengying CUI","email":"","orcid":"","institution":"Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Mengying","middleName":"","lastName":"CUI","suffix":""},{"id":615331776,"identity":"a5bd4ae2-76d9-455d-b222-301fd0bdb727","order_by":4,"name":"Ying WANG","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYBAC+/uHDxh8MJCob2NvIFbPDbaEwhkVFoz9PAeI1sJj8JnjTAXjzBkJROpgnN1guJmxTYLZ4ObjjTcYamyiCWphljmQbFzYJsFmcDut2ILhWFpuAyEtbAwJx4xntknwGNzOMZNgbDhMWAsPQ2L7b942CQmDm2eI1CIhkcxgzHNGwkByBg+RWgx4jjEYzqiQSODnAfolgRi/GLD3fwBGZV0CG/vhjTc+1NgQ1oKiXSKBFOUQLaTqGAWjYBSMgpEBALDLP5ksbTyXAAAAAElFTkSuQmCC","orcid":"","institution":"Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"WANG","suffix":""}],"badges":[],"createdAt":"2026-03-09 08:53:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9070647/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9070647/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106190116,"identity":"f8a2bde1-b9dd-4fee-ba95-3c5f8c1f93c9","added_by":"auto","created_at":"2026-04-05 17:13:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":82428,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of participant screening\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/65e323a017926e4a05cb34c6.png"},{"id":106402484,"identity":"4fd01d2d-c787-4adb-a5a6-86d02d37580e","added_by":"auto","created_at":"2026-04-08 09:12:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":90853,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between hypothyroidism and incident depressive symptoms. Model 1: unadjusted (crude); Model 2: adjusted for sleep duration.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/cc5888b44bce9e37431f66f8.png"},{"id":106402203,"identity":"31827ff0-493e-4bbf-997b-441cd74b62e2","added_by":"auto","created_at":"2026-04-08 09:11:26","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":174616,"visible":true,"origin":"","legend":"\u003cp\u003eAssociations between hypothyroidism, gastric/duodenal ulcer, and incident anxiety symptoms. Model 1: unadjusted (crude); Model 2: adjusted for sleep duration; Model 3: additionally adjusted for night shift work.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/7b04dc98c939b0ecfb3bafa9.png"},{"id":106405613,"identity":"cf58658c-8fd8-49b8-bc00-52b6db2c75ed","added_by":"auto","created_at":"2026-04-08 09:27:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1019210,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/5e451a7c-84fc-4a1a-bb80-d1c2f41d81cd.pdf"},{"id":106402810,"identity":"5a93b58e-647f-42fc-a0d2-c7a0b359b257","added_by":"auto","created_at":"2026-04-08 09:12:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":14066,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementalmaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/4cf5bda1cb21ac4de384ebfb.docx"},{"id":106190118,"identity":"469f68c2-a5c2-4ceb-8f6b-c1cd0e334841","added_by":"auto","created_at":"2026-04-05 17:13:39","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32335,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9070647/v1/db475abac23d704f55481fc9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of Endocrine-Metabolic Disorders with Depression and Anxiety in Nurses: A Prospective Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eNurses are a core workforce sustaining continuity of clinical care and the quality of health services worldwide. However, accumulating evidence indicates that nurses are experiencing a growing burden of mental health problems[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Long-term exposure to high work demands, irregular shift schedules, emotional labor, and occupational burnout places nurses at substantially higher risk of depressive and anxiety symptoms than the general population[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Persistent psychological distress not only undermines nurses\u0026rsquo; physical and mental well-being and shortens their professional longevity, but may also reduce work engagement, impair clinical judgment and communication,and ultimately threaten care quality and patient safety[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Identifying biological susceptibility factors for mental health problems in nurses therefore has important implications for occupational health management and early prevention of mental disorders.\u003c/p\u003e \u003cp\u003ePhysiological dysregulation induced by chronic occupational stress, especially disruptions in the endocrine and metabolic systems, is regarded as a crucial biological pathway connecting job stress to psychopathology[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Previous research has demonstrated that several chronic conditions, such as thyroid dysfunction[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], polycystic ovary syndrome (PCOS)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], peptic ulcer disease[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and abnormalities in glucose metabolism[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], are closely associated with depressive and anxiety symptoms. These associations may stem from multi - system interactions. Dysregulation of neuroendocrine axes, including the hypothalamic-pituitary-thyroid (HPT) axis and hypothalamic-pituitary-adrenal (HPA) axis, can modify neurotransmitter systems involved in mood regulation and disrupt physiological adaptation to stress[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Chronic low - grade inflammation and proinflammatory cytokines may influence central nervous system function via neuroimmune pathways[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, disruptions in the gut\u0026ndash;brain axis have been implicated. Gastrointestinal and metabolic disorders may affect emotional regulation through alterations in gut microbiota, neural signaling, and the production of neuroactive metabolites[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Collectively, these findings support a complex endocrine-neuro-immune interaction network that provides a biological basis for the link between physical disorders and emotional disturbances. Lifestyle and behavioral factors, such as sleep patterns and physical activity, may further modulate the psychological impact of endocrine and metabolic dysregulation[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough these associations have been partly documented in the general population, important gaps remain when focusing on nurses, a group characterized by sustained exposure to high occupational stress. First, most previous studies have used cross-sectional designs[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], which limit inference about temporal sequence and causality. It remains unclear whether endocrine disorders increase the risk of emotional symptoms, or whether psychological stress exacerbates physical illness through behavioral changes or neuroendocrine pathways. Second, many existing studies are based on community or general clinical samples and rarely incorporate nurse-specific occupational exposures in a systematic manner[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Circadian disruption caused by shift work has been shown to affect cortisol rhythms, melatonin secretion, and metabolic homeostasis. These changes may lead to adverse effects on mental health[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], yet longitudinal evidence on such interactions is still limited. Third, prior research has often focused on a single endocrine disorder. Few studies have conducted integrated analyses of multiple endocrine conditions within a homogeneous occupational cohort, which restricts the applicability of findings to occupational health screening and intervention.\u003c/p\u003e \u003cp\u003eTo address these gaps, we conducted a one-year prospective cohort study among nurses to examine the longitudinal associations between multiple endocrine conditions and the onset of depressive and anxiety symptoms. We further explored whether occupational and behavioral factors modified these associations. Our aims were to identify specific endocrine disorders that are closely linked to mental health risk and to identify specific occupational, behavioral, and physiological susceptibility factors. By providing longitudinal evidence from a nursing population, this study contributes to an integrated framework linking occupational stress, physiological dysregulation, and mental health. In addition, by quantifying biological and behavioral indicators that can be obtained in routine occupational health practice, our findings may inform the development of risk-stratified screening tools and targeted prevention strategies. This approach may help hospitals identify high-risk nurses earlier and integrate physical health management with psychological support, thereby promoting nurse well-being and improving the quality and safety of clinical care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Participants\u003c/h2\u003e \u003cp\u003eThis prospective cohort study examines the longitudinal associations between endocrine-metabolic disorders and symptoms of depression and anxiety among nurses. Baseline assessments were conducted in January 2024. Participants completed a baseline questionnaire collecting sociodemographic data, lifestyle factors, disease history, and psychological scale scores. A 12-month follow-up was subsequently performed to reassess depression and anxiety symptoms. The study protocol was approved by the Ethics Review Committee (ethics number: LYF20230048), and all participants provided written informed consent prior to enrollment.\u003c/p\u003e \u003cp\u003eParticipants comprised registered nurses from a tertiary hospital in Hubei Province. Inclusion criteria were: age\u0026thinsp;\u0026ge;\u0026thinsp;18 years, current employment in a clinical position, and voluntary participation with completion of the baseline survey. Exclusion criteria included: a pre-existing diagnosis of depression or anxiety at baseline, pregnancy or lactation, and inability to complete the follow-up.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExposures\u003c/h3\u003e\n\u003cp\u003eThe primary exposures were endocrine-metabolic disorders. Presence of the following conditions was assessed using self-reported questionnaires: thyroid disease (including hyperthyroidism and hypothyroidism), polycystic ovary syndrome (PCOS), gastric/duodenal ulcer, and diabetes. Disease status was dichotomized (yes/no).\u003c/p\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003eDepressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9), with each item rated on a 4-point Likert scale. A total score of \u0026ge;\u0026thinsp;5 was used to define the presence of clinically relevant depressive symptoms. The instrument demonstrated good internal consistency, with a Cronbach's \u003cem\u003eα\u003c/em\u003e of 0.80[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Anxiety symptoms were assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, with each item also scored on a 4-point Likert scale. A total score of \u0026ge;\u0026thinsp;5 indicated clinically relevant anxiety symptoms. The scale showed good internal consistency (Cronbach's \u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.92)[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The primary outcome was defined as the first documented occurrence of either set of symptoms during the follow-up period. Participants who reported depressive or anxiety symptoms at any point prior to baseline were excluded from the longitudinal analysis.\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003ePotential confounders were selected for inclusion in the analysis based on their established associations with mental health and endocrine-metabolic disorders in the existing literature. These covariates encompassed demographic characteristics (age, gender, educational level, marital status), lifestyle factors (smoking status, alcohol use, physical activity frequency, sleep duration), and work-related factors (night shift, job position). Variables found to be associated with the onset of depressive or anxiety symptoms in univariate analyses were subsequently entered into a multivariable logistic regression model.\u003c/p\u003e\n\u003ch3\u003eStatic Analysis\u003c/h3\u003e\n\u003cp\u003eAll analyses were performed using complete cases. Data were analyzed with SPSS 26.0 statistical software. Continuous variables are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables as frequency (percentage). Participants were stratified by the presence of incident depressive or anxiety symptoms, and intergroup differences were assessed using the chi-square test. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Binary logistic regression models were employed to examine the associations between endocrine-metabolic disorders and the incidence of depressive and anxiety symptoms. To assess the robustness of the findings, two or three sequential models were constructed: Model 1 included only the exposure variables; Model 2 was further adjusted for key lifestyle factors (sleep duration); Model 3 additionally incorporated clinical and occupational factors (night shift). Stratified analyses were conducted to examine potential effect modification. Participants were stratified by the following variables: gender (male, female), age group (18\u0026ndash;29, 30\u0026ndash;34, 35\u0026ndash;44, \u0026ge;\u0026thinsp;45 years), night shift work (yes, no), smoking status (yes, no), alcohol use (yes, no), exercise frequency (none, \u0026le;\u0026thinsp;1 time/week, \u0026ge;\u0026thinsp;2 times/week), and sleep duration (\u0026le;\u0026thinsp;5, 6, 7, 8, 9, \u0026ge;\u0026thinsp;10 hours per day).\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 4,539 nurses completed the baseline survey. Among them, 2,888 participants provided complete data at both baseline and follow-up (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At baseline, depressive symptoms were present in 1,577 nurses (54.61%), and anxiety symptoms in 994 nurses (34.42%). Collinearity diagnostics indicated no serious multicollinearity among independent variables, as all variance inflation factor (VIF) values were below 5. For the analysis with incident depression as the outcome, 1,311 participants were eligible, of whom 369 (28.15%) developed new depressive symptoms at the 12-month follow-up. For the analysis with incident anxiety as the outcome, 1,894 participants were eligible, of whom 346 (18.27%) developed new anxiety symptoms at the 12-month follow-up.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe baseline characteristics of the participants and the results of univariate analyses with outcome variables are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In the univariate analysis for incident depression, a diagnosis of hypothyroidism and sleep duration were significantly associated with the outcome (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). For incident anxiety, hypothyroidism, gastric/duodenal ulcer, polycystic ovary syndrome, sleep duration, and night shift work showed significant associations (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics and univariate associations with incident depression and anxiety symptoms during follow-up\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Depression(n\u0026thinsp;=\u0026thinsp;942)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncident Depression(n\u0026thinsp;=\u0026thinsp;369)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo Anxiety\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1548)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIncident Anxiety\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;346)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.600\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e896\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1486\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e330\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026thinsp;~\u0026thinsp;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.997\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.573\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e246\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026thinsp;~\u0026thinsp;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e455\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e35\u0026thinsp;~\u0026thinsp;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e403\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e658\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.283\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.868\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e712\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e259\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced/Widowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e929\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.792\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.795\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlcohol Use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e665\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e271\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.361\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 time/month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e257\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e423\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;2 times/month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise Frequency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.837\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.417\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e574\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;1 time/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e443\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e733\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026ndash;3 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e194\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4 times/week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep Duration, hours/day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;5h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.853\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e157\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e613\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;10h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional Title\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStaff Nurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e873\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e341\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e326\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.447\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead Nurse or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary/Junior College\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e1.962\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e876\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1454\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e324\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaster's degree or above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNight Shift Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e225\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e717\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e935\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.210\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1535\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHyperthyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e919\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.498\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.490\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypothyroidism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e910\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e345\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1477\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastric/Duodenal Ulcer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.348\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolycystic Ovary Syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e894\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.566\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e311\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12.559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBinary logistic regression analyses revealed significant associations between endocrine-metabolic disorders and incident psychological symptoms. Regarding incident depressive symptoms, hypothyroidism was identified as a significant risk factor. In the model 2, hypothyroidism remained associated with an elevated risk of depressive symptoms (OR\u0026thinsp;=\u0026thinsp;2.004, 95% CI: 1.159\u0026thinsp;~\u0026thinsp;3.463). Furthermore, compared to a sleep duration of 8 hours, sleeping\u0026thinsp;\u0026le;\u0026thinsp;7 hours per day was associated with a higher risk of depressive symptoms (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFor incident anxiety symptoms, hypothyroidism, gastric/duodenal ulcer, and PCOS were significant predictors in the fully adjusted model (Model 3). The corresponding adjusted odds ratios were 1.631 (95% CI: 1.012\u0026thinsp;~\u0026thinsp;2.629) for hypothyroidism, 1.707 (95% CI: 1.085\u0026thinsp;~\u0026thinsp;2.685) for gastric/duodenal ulcer, and 2.058 (95% CI: 1.350\u0026thinsp;~\u0026thinsp;3.136) for PCOS. Additionally, sleep duration\u0026thinsp;\u0026le;\u0026thinsp;6 hours and engagement in night shift work were associated with an increased risk of anxiety symptoms (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubgroup analyses revealed that the association between hypothyroidism and incident anxiety symptoms was significantly modified by exercise frequency. Specifically, the increased risk of anxiety associated with hypothyroidism was more pronounced among nurses who did not exercise, compared to those who exercised (\u003cem\u003eP\u003c/em\u003e for interaction\u0026thinsp;=\u0026thinsp;0.010). No significant effect modification was observed for gender, age, night shift work, smoking status, alcohol use, or sleep duration on the associations between endocrine/metabolic diseases and depression \u0026amp; anxiety outcomes (\u003cem\u003eP\u003c/em\u003e for interaction\u0026gt;0.05). Detailed results of the subgroup analyses are provided in \u003cem\u003eAppendix A\u003c/em\u003e.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this one-year prospective cohort study of nurses, we systematically investigated the longitudinal associations between various endocrine and metabolic conditions and the onset of depressive and anxiety symptoms. Our findings indicate that hypothyroidism is significantly associated with an elevated risk of developing depressive symptoms. Additionally, hypothyroidism, gastric/duodenal ulcer disease, and PCOS were significantly linked to an increased risk of anxiety symptoms. Furthermore, night shift work and reduced sleep duration (\u0026le;\u0026thinsp;6 hours, particularly\u0026thinsp;\u0026lt;\u0026thinsp;5 hours) demonstrated independent longitudinal associations with both depressive and anxiety symptoms. These findings suggest that occupational factors and sleep patterns may directly contribute to mental health risks. Collectively, the results underscore the presence of endocrine-psychiatric comorbidity in a population subjected to high occupational stress. They also suggest that sleep deprivation and career-related occupational factors may interact with biological vulnerabilities in the development of mental health symptoms. In addition, subgroup analyses indicated that the association between hypothyroidism and incident anxiety symptoms varied by exercise frequency, with a stronger association observed among nurses who did not engage in regular physical activity. This study provides novel evidence for risk stratification among nurses and may inform more targeted prevention and intervention strategies.\u003c/p\u003e \u003cp\u003eThe relationship between hypothyroidism and depressive or anxiety symptoms has been documented within the general population[\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This study builds upon existing literature by highlighting the longitudinal significance of this association in nurses subjected to elevated occupational stress. Findings indicate that nurses with hypothyroidism exhibit a markedly increased risk of developing depressive and anxiety symptoms over the follow-up period. These associations persisted even after controlling for demographic factors, lifestyle variables, and work-related conditions. The results align with findings from extensive studies utilizing community samples and biobank data[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom a mechanistic standpoint, thyroid hormones are integral to the central nervous system, extending their influence beyond mere metabolic regulation[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Triiodothyronine (T3) and thyroxine (T4) exert direct effects on monoaminergic neurotransmitter systems, including serotonin and norepinephrine, by modulating their synthesis, transport, and receptor expression. Additionally, these hormones regulate neurotrophic factors such as brain-derived neurotrophic factor (BDNF), thereby impacting neuroplasticity and emotional stability[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Chronic hypothyroidism may lead to diminished functional activity in prefrontal-limbic circuits and altered amygdala plasticity[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], potentially impairing the regulation of negative emotional stimuli[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Furthermore, hypothyroidism is frequently associated with chronic low-grade inflammation. Proinflammatory cytokines can influence the central neuroimmune environment via the blood-brain barrier or vagal pathways, thereby disrupting mood-related neural circuits[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In the context of nursing professionals, prolonged shift work, sleep deprivation, and high psychological demands may further perturb the rhythmic regulation of the HPT axis[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These factors may synergistically interact with pre-existing thyroid dysfunction, thereby elevating the risk of emotional dysregulation. Our subgroup findings further suggest that lack of regular physical activity may exacerbate the association between hypothyroidism and anxiety symptoms, highlighting the potential role of behavioral resilience factors in modulating endocrine-related mental health risk.\u003c/p\u003e \u003cp\u003ePrevious research has indicated that subclinical hypothyroidism, characterized by elevated thyroid-stimulating hormone (TSH) levels while maintaining normal thyroid hormone concentrations, may be linked to an increased risk of depression[\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. This suggests that even minor disruptions in HPT axis function could have significant implications for mental health, particularly in populations subjected to chronic stress. Future research should employ continuous biomarkers to investigate potential dose\u0026ndash;response relationships. It may also be important to consider modifiable lifestyle factors such as physical activity, which could influence the mental health impact of subtle thyroid dysfunction.\u003c/p\u003e \u003cp\u003eAdditionally, we identified a longitudinal correlation between gastric/duodenal ulcer disease and the onset of anxiety symptoms. This finding underscores the potential role of gastrointestinal disorders in the etiology of anxiety, which can be understood through the lens of gut-brain axis dysregulation[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Gastric mucosal damage and the resultant inflammation may compromise intestinal barrier integrity, leading to increased gut permeability. This condition permits the translocation of bacterial metabolites and proinflammatory factors into the systemic circulation, thereby activating both peripheral and central immune responses and affecting brain regions involved in emotional regulation[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGastrointestinal dysfunction is intricately associated with imbalances in the autonomic nervous system. Persistent disruptions in the sympathetic-parasympathetic balance have been identified as a significant physiological foundation for anxiety[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. A prospective study has demonstrated that gastrointestinal symptoms, such as constipation, may precede the onset of depression or anxiety, indicating that disturbances in gut homeostasis could serve as early indicators of risk for mental disorders[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Among nurses, irregular meal patterns, night shift work, and continuous psychological stress may further impede gastrointestinal recovery. Concurrently, our study found that night shifts and sleep deprivation were independently linked to an increased risk of anxiety[\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. These factors may collectively impose an additional burden within the same occupational setting, where physiological vulnerability and work-related stress are present. This combined vulnerability necessitates heightened attention in the management of occupational health.\u003c/p\u003e \u003cp\u003eOur study revealed a significant association between PCOS and an elevated risk of developing anxiety symptoms. PCOS is characterized by disruptions in reproductive endocrine, metabolic, and immune systems, with its link to anxiety potentially mediated through multiple biological pathways[\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Elevated androgen levels in PCOS may directly impact the central nervous system, modify GABAergic neurotransmission, and influence stress responses via the HPA axis. Additionally, insulin resistance and compensatory hyperinsulinemia may interfere with cerebral energy metabolism and insulin signaling, thereby affecting emotional regulation[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Chronic low-grade inflammation and oxidative stress, frequently observed in PCOS, have also been implicated in the neurobiological mechanisms underlying anxiety. Under conditions of elevated occupational stress, these endocrine and metabolic disturbances may reduce resilience to psychological stress, increasing the likelihood of anxiety symptoms. Our findings suggest that gastrointestinal disorders and PCOS could serve as clinically relevant indicators for anxiety risk stratification, particularly within predominantly female nursing populations.\u003c/p\u003e \u003cp\u003eNight shift work and limited sleep duration (\u0026le;\u0026thinsp;6 hours, particularly\u0026thinsp;\u0026lt;\u0026thinsp;5 hours) have been independently linked to the development of anxiety symptoms, while sleep restriction has also been independently associated with the onset of depressive symptoms. These findings suggest that sleep deprivation and circadian disruption may serve as significant occupational risk factors that directly contribute to the emergence of mental health symptoms. Night shift work and chronic sleep restriction can lead to a desynchronization of endogenous circadian rhythms from the external light-dark cycle. This persistent circadian misalignment has been demonstrated to impact the homeostasis of the HPA and HPT axes, alter cortisol rhythms, and disrupt thyroid hormone metabolism, thereby compromising neuroendocrine stability[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Sleep deprivation itself can impair prefrontal regulation of emotional responses, increase amygdala reactivity to threat-related stimuli, and promote systemic inflammation, collectively undermining emotional stability[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Consequently, night shift work and inadequate sleep may function through independent yet overlapping biological pathways and, in conjunction with endocrine abnormalities, shape the overall mental health risk profile in nurses.\u003c/p\u003e \u003cp\u003eDespite the strengths of employing a prospective design, extensive adjustments for potential confounders, and the robustness of the main associations observed in subgroup analyses, several limitations warrant consideration. Firstly, the identification of endocrine and metabolic conditions was primarily based on self-reports and medical history, which did not account for incident cases or changes in disease status during the follow-up period. This limitation may have resulted in exposure misclassification. Future research should incorporate repeated laboratory measurements to facilitate more precise dose\u0026ndash;response analyses. Secondly, depressive and anxiety symptoms were assessed using self-report scales. Although these instruments demonstrate good validity and reliability, the possibility of information bias cannot be excluded. Additionally, residual confounding factors, such as genetic susceptibility and early-life stress, may persist. Lastly, the sample was drawn from nurses at a single center and was predominantly composed of women, which limits the generalizability of the findings to other occupations or to men. In addition, although a significant interaction with exercise frequency was observed for the association between hypothyroidism and anxiety symptoms, subgroup analyses may be subject to limited statistical power and should be interpreted with caution. As this is an observational study, the underlying mechanisms require further validation through experimental and interventional research.\u003c/p\u003e \u003cp\u003eThe findings of this study have important implications for clinical care and occupational health management in healthcare settings. Endocrine and metabolic disorders, such as hypothyroidism, peptic ulcer disease, and polycystic ovary syndrome, are common in clinical practice and can be identified through routine medical assessments. Healthcare professionals with these conditions may benefit from closer mental health monitoring, particularly in high-stress environments such as nursing.\u003c/p\u003e \u003cp\u003eRisk-stratified interventions could be incorporated into occupational health programs. Nurses with a history of endocrine disorders, long-term night shift work, chronic sleep deprivation, or low levels of physical activity may warrant prioritized psychological surveillance and supportive resources. Optimizing shift schedules to reduce chronic sleep restriction, promoting regular physical activity, improving access to mental health services, and providing targeted stress-management support may help mitigate the cumulative burden of physiological and occupational risk factors.\u003c/p\u003e \u003cp\u003eAlthough interventional studies are still needed, these findings support a more integrated approach to monitoring physical and mental health among healthcare workers, where routine clinical information can inform early identification and prevention of common mental health symptoms.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn this cohort of nurses experiencing high levels of occupational stress, we identified longitudinal associations between hypothyroidism and symptoms of depression and anxiety, as well as between gastric/duodenal ulcer disease, PCOS, and symptoms of anxiety. Furthermore, our study demonstrated that night shift work and insufficient sleep function as independent risk factors for the onset of mental health symptoms. These findings underscore the multifaceted pathways through which endocrine-metabolic dysregulation, occupational exposures, and sleep behaviors collectively contribute to the risk of mental health issues. The observed variation in the hypothyroidism\u0026ndash;anxiety association by exercise frequency further suggests that modifiable lifestyle factors may influence vulnerability to mental health symptoms.\u003c/p\u003e \u003cp\u003eFuture strategies ought to encompass a synthesis of biological, behavioral, and occupational interventions to formulate comprehensive and individualized mental health promotion programs tailored for nurses. In evaluating mental health risks among healthcare workers, it is imperative to concurrently consider physical health status, sleep patterns, and occupational stressors. The integration of routinely accessible clinical data into occupational mental health surveillance systems may facilitate the identification of high-risk individuals and inform targeted preventive measures. Enhancing collaboration among clinical care, occupational health services, and mental health support systems could potentially enable the earlier detection and more efficacious prevention of prevalent mental health symptoms within the nursing workforce.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors extend their deepest gratitude to all the nurses who generously participated in this study by sharing their time, experiences, and insights through the survey questionnaire.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; Contributions\u003c/p\u003e\n\u003cp\u003eZL: Conceptualization, Methodology and Writing-Original draft preparation. ZH: Data collection, Investigation, Writing-Original draft preparation. XG: Data analysis, Data interpretation and Validation. MC: Data analysis, Data interpretation. YW: Supervision, Writing-Reviewing and Editing. All authors reviewed the manuscript and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Chinese Nursing Association Research Project [ZHKY202306].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Availability\u003c/p\u003e\n\u003cp\u003eThe data presented in this study are available on request from the corresponding author. (the data are not publicly available due to privacy or ethical restrictions.)\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eThis study forms part of the All-China Psychological Cohort Study and has been granted approval by the ethics committee of the Second Xiangya Hospital of Central South University (ethics number: LYF20230048). The entire procedure adhered to the ethical guidelines outlined in the Helsinki Declaration, guaranteeing the anonymity and confidentiality of all respondents. The study has been registered in the Chinese Clinical Trial Registry (No: ChiCTR2300072142). Prior to the implementation of the program, consents were obtained from the participants, and they were provided with a detailed explanation of the study objectives, procedure, and ethical issues.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interests in this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLi X, Tian Y, Yang J, et al. Network of job demands-resources and depressive symptoms in critical care nurses: a nationwide cross-sectional study. 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PLoS ONE. 2021;16:e256983. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1371/journal.pone.0256983\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0256983\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nurses, Endocrine and Metabolic Diseases, Depression, Anxiety, Night Shift Work","lastPublishedDoi":"10.21203/rs.3.rs-9070647/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9070647/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe association between various endocrine-metabolic disorders and symptoms of depression and anxiety has been established in the general population. However, longitudinal evidence regarding these associations within nurse populations remains limited.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eAimed to identify specific endocrine and metabolic diseases associated with an increased risk of depression and anxiety, and to delineate relevant occupational, behavioral, and physiological susceptibility factors within the nursing population.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a prospective cohort study among registered nurses from a tertiary hospital in Hubei Province. Eligible participants were those without depressive or anxiety symptoms at baseline (January 2024). Baseline data on sociodemographic characteristics, lifestyle factors, disease history, and psychological scale scores were collected via questionnaires. The primary exposures were predefined endocrine-metabolic disorders (thyroid disease, polycystic ovary syndrome(POCS), gastric/duodenal ulcer, and diabetes), ascertained through a self-reported disease history questionnaire. The primary outcomes were the 12-month incidence of depressive symptoms and anxiety symptoms, assessed at follow-up using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) scale, respectively. Logistic regression models were used to analyze the longitudinal associations between endocrine-metabolic disorders and the incidence of depressive or anxiety symptoms. Stratified analyses were performed to evaluate potential effect modification by selected covariates.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 2,888 participants contributed complete data at both baseline and follow-up. At baseline, depressive symptoms were present in 1577 nurses (54.61%) and anxiety symptoms in 940 (34.42%). In adjusted analyses, hypothyroidism was significantly associated with an increased risk of incident depressive symptoms (adjusted odds ratio [aOR]\u0026thinsp;=\u0026thinsp;2.004,95%CI: 1.159\u0026thinsp;~\u0026thinsp;3.463). For incident anxiety symptoms, hypothyroidism, gastric/duodenal ulcer, and PCOS were significant independent predictors. The corresponding aORs were1.631(95%CI:1.012\u0026thinsp;~\u0026thinsp;2.629) for hypothyroidism, 1.707(95%CI:1.085\u0026thinsp;~\u0026thinsp;2.685) for gastric/duodenal ulcer, and 2.058(95%CI:1.350\u0026thinsp;~\u0026thinsp;3.136) for PCOS. A sleep duration of \u0026le;\u0026thinsp;7 hours per day was associated with a higher risk of incident depressive symptoms, while sleep duration\u0026thinsp;\u0026le;\u0026thinsp;6 hours and night shift work were associated with an increased risk of incident anxiety symptoms (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, stratified analyses indicated that the risk of anxiety associated with hypothyroidism was significantly higher among nurses who did not engage in regular exercise compared to those who did (\u003cem\u003eP\u003c/em\u003e for interaction\u0026thinsp;=\u0026thinsp;0.010). In contrast, no significant effect modification was observed for gender, age, night shift work, smoking status, alcohol use, or sleep duration on the associations between endocrine-metabolic disorders and either depressive or anxiety outcomes (all \u003cem\u003eP\u003c/em\u003e for interaction\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis prospective cohort study identified hypothyroidism as a significant longitudinal risk factor for both incident depressive and anxiety symptoms. Gastric/duodenal ulcer and PCOS were also independently associated with an increased risk of incident anxiety symptoms. Furthermore, night shift work and insufficient sleep duration were confirmed as independent risk factors for these mental health outcomes.\u003c/p\u003e","manuscriptTitle":"Association of Endocrine-Metabolic Disorders with Depression and Anxiety in Nurses: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-05 17:13:35","doi":"10.21203/rs.3.rs-9070647/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-03-31T13:07:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-11T12:47:53+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-11T12:26:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-11T11:43:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychology","date":"2026-03-11T08:01:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"psyo","sideBox":"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)","snPcode":"","submissionUrl":"","title":"BMC Psychology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3dabda27-4261-4b8e-82e9-f98596bae251","owner":[],"postedDate":"April 5th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-05T17:13:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-05 17:13:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9070647","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9070647","identity":"rs-9070647","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}