|Year : 2021 | Volume
| Issue : 2 | Page : 92-97
Prevalence of eveningness and its association with cardiometabolic risk factors, risky sexual behavior, and alcohol use in adolescents and young adult males with ADHD
Shankar Kumar1, Sneha Venkatakrishna2, Karthik Ambalavana3, Shruthi Nayak3
1 Assistant Professor, Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
2 Senior Resident, Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
3 House-Surgeon, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||21-Nov-2020|
|Date of Acceptance||04-May-2021|
|Date of Web Publication||31-Aug-2021|
Dr. Shankar Kumar
Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Individuals with eveningness chronotype may be at a higher risk for developing unhealthy lifestyle and cardiovascular risk factors. Screening with traditional biomarkers may not help in detecting children and young adults with such a risk. There is paucity of literature studying novel biomarkers such as Apo B/ApoA1 ratio and highly sensitive C reactive protein (hs CRP) in predicting cardiometabolic risk in this population.
Objectives: To study the prevalence of eveningness chronotype in attention-deficit/hyperactivity disorder (ADHD) and to know its association with metabolic risk factors that predict cardiometabolic consequences.
Materials and Methods: This cross-sectional study consisted of thirty consenting adolescents and young adults who were on treatment for ADHD. Sociodemographic details were collected and the Morningness-eveningness questionnaire, alcohol use disorders identification test, HIV risk-taking behavior scale-sexual behavior subsection were used to determine eveningness, alcohol use, and risky sexual behavior, respectively. Body mass index (BMI) was measured. Blood investigations high-density lipoprotein, low-density lipoprotein, total cholesterol, triglycerides, Apo B/A1 ratio, lipoprotein A, and hsCRP were sent.
Results: The prevalence of eveningness in our study participants was 30% (n = 9). Risky sexual behavior was more among those with eveningness (P = 0.03). Those with eveningness had significantly earlier sexual experience (P = 0.05). Alcohol use was also significantly more in those with eveningness (P = 0.02). There was no significant difference in traditional markers such as BMI, lipid profile for cardiometabolic risk among study participants with or without eveningness. However, Apo B/A1 ratio was significantly more in those with eveningness (P = 0.01).
Conclusion: Eveningness chronotype is common in ADHD which could indicate risk for future cardiometabolic consequences in addition to behavioral issues. There is a need for large-scale cohort studies studying cardiometabolic risk and the clinical utility of novel biomarkers such as ApoB/ApoA1 in this population.
Keywords: Attention-deficit/hyperactivity disorder, behavioral problems, cardiometabolic risk, chronotype, eveningness
|How to cite this article:|
Kumar S, Venkatakrishna S, Ambalavana K, Nayak S. Prevalence of eveningness and its association with cardiometabolic risk factors, risky sexual behavior, and alcohol use in adolescents and young adult males with ADHD. Arch Ment Health 2021;22:92-7
|How to cite this URL:|
Kumar S, Venkatakrishna S, Ambalavana K, Nayak S. Prevalence of eveningness and its association with cardiometabolic risk factors, risky sexual behavior, and alcohol use in adolescents and young adult males with ADHD. Arch Ment Health [serial online] 2021 [cited 2022 May 23];22:92-7. Available from: https://www.amhonline.org/text.asp?2021/22/2/92/325048
| Introduction|| |
Circadian and sleep disorders are often present in attention-deficit/hyperactivity disorder (ADHD). Genetic susceptibility to circadian rhythm disorders attributed to the CLOCK gene may play an important role in ADHD. Recent systematic reviews have shown that there is an association between ADHD and both subjective and objective sleep disturbances in both children and in adults., Studies have found association between single nucleotide polymorphisms in circadian genes and core ADHD symptoms, increased evening orientation, and frequent sleep problems.
Chronotype refers to individual differences in sleep timing and preferences for a given time of day. Morning types prefer to get up and go to bed early, while evening types get up and go to bed later. Some people are known as typical “morning” or “evening” people, but most people fall in between these chronotypes which are typically genetically determined. Of all sleep problems associated with ADHD, a delayed sleep-wake cycle/circadian rhythm is the most common with an objectively measured prevalence of 73%–78% in both children and adults with ADHD.
The delayed circadian rhythm and ADHD have genetic associations and shared environmental factors, and may also have a shared etiology. Sleep problems are also known to contribute to the severity of ADHD symptoms.
A study by Bijlenga et al. on sleep patterns reported significantly increased frequency of self-reported cardiovascular disease among adults with ADHD compared with controls.
Adults with ADHD are at higher risk for developing unhealthy lifestyle and cardiovascular risk factors, such as smoking and obesity, and have a greater probability of chronic substance misuse. Studies suggest that these patients are more likely to experiment with licit and illicit substances, especially at earlier ages, and exhibit risky substance use patterns and subsequently develop substance use disorders.
Studies have shown that ADHD patients with eveningness chronotype are at higher risk for developing some metabolic complications later on in life. There is a need to systematically study if eveningness chronotype in ADHD is associated with cardiometabolic complications.
Routine screening with body mass index (BMI) and lipid profile may not help in detecting children and young adults with risk for future cardiovascular complications. Thus, it may necessitate screening using novel markers which detect future risk for metabolic and cardiovascular disorders. Studies have shown that markers such as Apo B/ApoA1 ratio and highly sensitive C reactive protein (hs CRP) are useful in predicting cardiometabolic risk., There is paucity of studies that involve the measurement of these risk markers in patients with ADHD, especially among those who have eveningness chronotype which is known to be associated with cardiometabolic risk.
In this study, we aim to study the prevalence of eveningness chronotype in ADHD and to know its association with metabolic risk factors (BMI, Routine lipid profile, novel markers including ApoB/Apo A1 ratio, hsCRP that predict cardiometabolic consequences in later life.
Aims and objectives of the study
- To study the prevalence of eveningness in ADHD using morningness-eveningness questionnaire (MEQ)
- To study the differences between cardiometabolic risk markers (BMI, Routine lipid profile, novel markers including ApoB/Apo A1 ratio, hsCRP) in those with and without eveningness in ADHD.
| Materials and Methods|| |
This was a cross-sectional study which was conducted in a tertiary care out-patient department in a general hospital psychiatry setting for a period of one month. Institutional ethical committee clearance was obtained for the study. Convenience sampling was used and thirty consenting adolescents and young adults (12–25 years) diagnosed with ADHD and who were on treatment from a clinician were included in the study. Those on psychotropics for any other psychiatric condition were excluded since psychotropics are known to be independently associated with metabolic abnormalities. Those with prior history of diabetes mellitus and other metabolic disorders were also excluded from the study.
Morningness eveningness questionnaire
This questionnaire contains 19 questions. Scores can range from 16 to 86. Scores of 41 and below indicate “evening types.” Scores of 59 and above indicate “morning types.” Scores between 42-58 indicate “intermediate types.”
Alcohol use disorders identification test
Alcohol use disorders identification test (AUDIT) provides a framework for intervention to help those with unhealthy alcohol use reduce or cease alcohol consumption and thereby avoid the harmful consequences of alcohol. The AUDIT can also help identify alcohol dependence and specific consequences of harmful drinking. Scores 0–3 indicate low risk, 4–9 risky, 10–13 harmful, and 14 and above indicate severe risk.
HIV risk-taking behavior scale [HRBS] – It is a brief 11 item questionnaire developed to measure the behavior that puts at risk of either contracting or passing on HIV. Sexual behavior section of this scales was used to check if the study subjects have risky sexual behavior. Few additional questions regarding sexual behavior were also included in the sociodemographic proforma which included age of initiation of sexual activity and number of sexual partners.
- Lipid profile – low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol
- ApoB/A1 ratio
- hs CRP.
Study participants who were diagnosed with ADHD and were on treatment in the age group of 12–25 years were enrolled into the study after informed consent. For children <18 years of age, informed consent was obtained from parents. Sociodemographic details were collected. MEQ was applied. BMI was measured. AUDIT questionnaire was applied to screen and know the pattern of alcohol intake. HRBS-sexual behavior subsection was applied. Anyone question answered positively was taken as risky sexual behavior present. Blood investigationsHDL, LDL, total cholesterol, triglycerides, Apo B/A1 ratio, lipoprotein A, and hsCRP were sent. Data obtained were entered on MS Excel sheet and statistical analysis was done using SPSSv20 Statistical Product and Service Solutions version 20.
For statistical analysis, those without eveningness were taken as controls. 't'-test was used for comparison of sociodemographic data, risky sexual behavior, and cardiometabolic risk markers among the two groups. Fisher's exact test was used for the comparison of alcohol use among the two groups.
| Results|| |
The prevalence of eveningness in our study participants was 30% (n = 9).
Mean age of study participants with eveningness was 19.25 years and those without eveningness was 23.42 years. Mean years of education was 8.12 years for those with eveningness and 10.1 years for those without. Mean MEQ score was 37.66 for those with eveningness and 52.1 for the rest. Five of the nine people with eveningness had sexual experience before 18 years of age as compared to 3 out of 21 without eveningness. Four out of 9 with eveningness had multiple sexual partners compared to 2 out of 21 without.
Risky sexual behavior among study participants
Those with eveningness had mean HRBS score of 4.53 and those without had mean score of 3.45.
Alcohol use among study participants
Six out of nine participants with eveningness had alcohol use as compared to eight out of 21 without eveningness.
Risk markers for cardiometabolic risk among study participants
There was no significant difference in traditional biomarkers for cardiometabolic risk between the two groups. However, novel biomarker Apo B/A1 ratio was significantly more in those with eveningness.
| Discussion|| |
This study was undertaken to study the prevalence of eveningness chronotype in ADHD and to study the differences between cardiometabolic risk markers (BMI, routine lipid profile, novel markers including ApoB/Apo A1 ratio, and hsCRP) in those with or without eveningness in ADHD.
The prevalence of eveningness in the study was 30% (n = 9) which is significantly higher than that of general population, wherein, a prevalence of 5.6% was described as per a study done by Paine et al. A study conducted by Whittier et al. found that the prevalence of eveningness chronotype was 10% among undergraduate students with no medical comorbidities. Previous studies have shown that the prevalence of eveningness in ADHD is about 73%–78%. Our study also is in line with existing literature which describes a higher prevalence of eveningness chronotype among individuals with ADHD. This higher prevalence is probably explained by the CLOCK polymorphisms which are commonly seen in individuals with ADHD.
In our study, those with eveningness were significantly younger [Table 1]. This could probably be because those with eveningness tend to have more behavioral issues as described by previous studies thus making them more likely to come to clinical attention earlier.
Those with eveningness had earlier sexual experience which was statistically significant. Risky sexual behaviors were also higher among those with eveningness [Table 2]. This is in concordance with existing literature which states that those with eveningness chronotype tend to have higher behavioral problems such as impulsiveness, substance use, and risk-taking behaviors. Impulsiveness is known to be associated with risky sexual behaviors.
Alcohol use was also significantly higher among those with eveningness [Table 3]. This finding of higher substance use correlates with earlier studies where associations between eveningness and anxious/depressive symptoms, emotional/behavioral problems such as inattention, conduct problems, rule-breaking behaviors, substance abuse, suicidal behavior, and social problems have been described.,, However, there was no significant difference between alcohol dependence status in the two groups [Table 4]. This lack of statistical significance for dependence could probably be due to the fact that dependence takes more time to establish. Thus, follow-up studies could help in determining if dependence is actually more in this population or otherwise.
|Table 4: Alcohol use disorders identification test scores among study participants|
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There was no significant difference in traditional markers such as BMI, lipid profile for cardiometabolic risk among study participants with or without eveningness [Table 5]. However, Apo B/A1 ratio was significantly more in those with eveningness [Table 6]. Measurement of BMI and lipid profile represents a snapshot view of cardiometabolic status and may not indicate future risk. Apo B presents as a single molecule in all potentially atherogenic lipoprotein particles, i.e., very LDL, intermediate-density lipoprotein, and LDL. Apo A1 is the major lipoprotein associated with HDL. Previous studies have indicated that higher Apo B/A1 ratio is a powerful marker of risk for future cardiovascular disease. Apolipoproteins significantly predict cardiovascular death, independently of conventional lipids and other cardiovascular risk factors such as smoking, dyslipidemia, hypertension, obesity, diabetes, and CRP., This is an important finding in our study where we have found an association between ApoB/ApoA1 ratio and eveningness chronotype in individuals with ADHD which could represent high cardiometabolic risk in this population.,
|Table 5: Traditional risk markers for cardiometabolic risk among study participants|
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|Table 6: Novel biomarkers for cardiovascular risk among study participants|
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There is a need for longitudinal studies looking at these novel risk markers in ADHD and study the occurrence of clinical cardiometabolic complications which arise in this population as a better proof of the hypothesis. Clinical collaboration between clinicians and basic researchers to study the underlying mechanisms of this association is needed.
Limitations and strengths of the study
This was a cross-sectional study which was statistically underpowered, thus only associations could be determined. Sample size was inadequate and no randomization was done. Other factors such as lifestyle factors, psychiatric comorbidities in ADHD, and genetic vulnerability for cardiometabolic risk which may independently be associated with metabolic risk were not measured. Nevertheless, this was one of the first studies to describe an association between eveningness chronotype in ADHD and novel markers for cardiometabolic risk such as ApoB/Apo A1 ratio. We also excluded those who were already on psychotropics and metabolic disorders.
Implications of the study
This study adds to the existing literature of association of eveningness chronotype in ADHD which is a risk factor for later life cardiometabolic risk. We have in addition been able to describe an association between eveningness chronotype and novel biomarkers such as ApoB/ApoA1 ratio which indicate cardiometabolic risk. This finding, if replicated in future large-scale studies, may help in early clinical and laboratory detection of cardiometabolic risk in this population. This could also pave way for studies describing mechanisms linking this association which can help us in understanding the etiological basis for this comorbidity.
| Conclusion|| |
Eveningness chronotype is common in ADHD which could indicate risk for future cardio-metabolic consequences in addition to behavioral issues. There is a need for large-scale cohort studies studying cardiometabolic risk in this population taking into account factors such as psychiatric comorbidities and other metabolic risk factors. There is also a need for studying the sensitivity and specificity, positive predictive value, and clinical utility of these novel biomarkers indicating cardiometabolic risk which can help in clinical management and risk assessment of these patients.
Dr. Chandrashekar Hongally, Professor and HOD, Department of Psychiatry, Bangalore Medical College and Research Institute.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]