• Users Online: 1001
  • Print this page
  • Email this page

ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Prevalence of eveningness and its association with cardiometabolic risk factors, risky sexual behavior, and alcohol use in adolescents and young adult males with ADHD


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

Click here for correspondence address and email

Date of Submission21-Nov-2020
Date of Acceptance04-May-2021
Date of Web Publication31-Aug-2021
 

  Abstract 


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 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 [Epub ahead of print] [cited 2021 Dec 7]. Available from: https://www.amhonline.org/preprintarticle.asp?id=325048





  Introduction Top


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.[1] 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.[2],[3] Studies have found association between single nucleotide polymorphisms in circadian genes and core ADHD symptoms, increased evening orientation, and frequent sleep problems.[4]

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.[5] 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.[6]

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.[6]

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.[7]

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.[8]

Studies have shown that ADHD patients with eveningness chronotype are at higher risk for developing some metabolic complications later on in life.[9] 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.[10],[11] 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

  1. To study the prevalence of eveningness in ADHD using morningness-eveningness questionnaire (MEQ)
  2. 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 Top


Study design

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.

Study tools

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.

Biomarkers

  • BMI
  • Lipid profile – low-density lipoprotein (LDL), high-density lipoprotein (HDL), and total cholesterol
  • ApoB/A1 ratio
  • hs CRP.


Method

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 Top


The prevalence of eveningness in our study participants was 30% (n = 9).

Sociodemographic data

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 Top


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.[12] A study conducted by Whittier et al. found that the prevalence of eveningness chronotype was 10% among undergraduate students with no medical comorbidities.[13] Previous studies have shown that the prevalence of eveningness in ADHD is about 73%–78%.[6] 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.[1]

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.[8]
Table 1: Sociodemographic data of the study participants

Click here to view


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.[6] Impulsiveness is known to be associated with risky sexual behaviors.
Table 2: Risky sexual behavior scores among study participants

Click here to view


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.[14],[15],[16] 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 3: Alcohol use among study participants

Click here to view
Table 4: Alcohol use disorders identification test scores among study participants

Click here to view


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.[14] 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.[17],[18] 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.[10],[11]
Table 5: Traditional risk markers for cardiometabolic risk among study participants

Click here to view
Table 6: Novel biomarkers for cardiovascular risk among study participants

Click here to view


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 Top


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.

Acknowledgments

Dr. Chandrashekar Hongally, Professor and HOD, Department of Psychiatry, Bangalore Medical College and Research Institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carpena MX, Hutz MH, Salatino-Oliveira A, Polanczyk GV, Zeni C, Schmitz M, et al. CLOCK Polymorphisms in Attention-Deficit/Hyperactivity Disorder (ADHD): Further evidence linking sleep and circadian Disturbances and ADHD. Genes (Basel). 2019;10:88.  Back to cited text no. 1
    
2.
Díaz-Román A, Hita-Yáñez E, Buela-Casal G. Sleep characteristics in children with attention deficit hyperactivity disorder: Systematic review and meta-analyses. J Clin Sleep Med 2016;12:747-56.  Back to cited text no. 2
    
3.
Diaz-Roman A, Mitchell R, Cortese S. Sleep in adults with ADHD: Systematic review and meta-analysis of subjective andobjective studies. Neuro Sci Biobehav Rev 2018;89:61-71.  Back to cited text no. 3
    
4.
Korman M, Palm D, Uzoni A, Faltraco F, Tucha O, Thome J, et al. ADHD 24/7: Circadian clock genes, chronotherapy and sleep/wake cycle insufficiencies in ADHD. World J Biol Psychiatry 2020;21:156-71.  Back to cited text no. 4
    
5.
Randler C, Schredl M, Goritz AS. Chronotype, Sleep Behavior, and the Big Five Personality Factors; 2017. Available from: https://doi.org/10.1177/2158244017728321. [Last accessed on 2021 May 29].  Back to cited text no. 5
    
6.
BijlengaD, Vollebregt MA, Kooij JJ, Arns M. The role of the circadian system in the etiology and pathophysiologyof ADHD: Time to redefine ADHD? Atten Defcit Hyperact Dis 2019;11:5-19.  Back to cited text no. 6
    
7.
Bijlenga D, van der Heijden KB, Breuk M, van Someren EJ, Lie ME, Boonstra AM, et al. Associations between sleep characteristics, seasonal depressive symptoms, lifestyle, and ADHD symptoms in adults. J Atten Disord 2013;17:261-75.  Back to cited text no. 7
    
8.
Sinha A, Lewis O, Kumar R, Yeruva SL, Curry BH. Adult ADHD medications and their cardiovascular implications. Case Rep Cardiol 2016;2016:2343691.  Back to cited text no. 8
    
9.
Türkoğlu S, Çetin FH. The relationship between chronotype and obesity in children and adolescent with attention deficit hyperactivity disorder. Chronobiol Int 2019;36:1138-47.  Back to cited text no. 9
    
10.
Savas Erdeve S, Simsek E, Dallar Y, Biyikli Z. Utility of ApoB/ApoA1 ratio for the prediction of cardiovascular risk in children with metabolic syndrome. Indian J Pediatr 2010;77:1261-5.  Back to cited text no. 10
    
11.
Suhett LG, Hermsdorff HH, Rocha NP, Silva MA, Filgueiras MS, Milagres LC, et al. Increased C-reactive protein in brazilian children: Association with cardiometabolic risk and metabolic syndrome components (PASE Study). Cardiol Res Pract 2019;2019: 3904568.  Back to cited text no. 11
    
12.
Paine SJ, Gander PH, Travier N. The epidemiology of morningness/eveningness: Influence of age, gender, ethnicity, and socioeconomic factors in adults (30-49 years). J Biol Rhythms 2006;21:68-76.  Back to cited text no. 12
    
13.
Whittier A, Sanchez S, Castañeda B, Sanchez E, Gelaye B, Yanez D, et al. Eveningness chronotype, daytime sleepiness, caffeine consumption, and use of other stimulants among peruvian University students. J Caff Res 2014;4:21-7.  Back to cited text no. 13
    
14.
Gau SS, Kessler RC, Tseng WL, Wu YY, Chiu YN, Yeh CB, et al. Association between sleep problems and symptoms of attention-deficit/hyperactivity disorder in young adults. Sleep 2007;30:195-201.  Back to cited text no. 14
    
15.
Selvi Y, Aydin A, Atli A, Boysan M, Selvi F, Besiroglu L. Chronotype differences in suicidal behavior and impulsivity among suicide attempters. Chronobiol Int 2011;28:170-5.  Back to cited text no. 15
    
16.
Selvi Y, Aydin A, Boysan M, Atli A, Agargun MY, Besiroglu L. Associations between chronotype, sleep quality, suicidality, and depressive symptoms in patients with major depression and healthy controls. Chronobiol Int 2010;27:1813-28.  Back to cited text no. 16
    
17.
Lu M, Lu Q, Zhang Y, Tian G. Apo B/A1 is an effective predictor of coronary heart disease risk in overweight and obesity. J Biomed Res 2011;25:266-73.  Back to cited text no. 17
    
18.
Sierra-Johnson J, Fisher RM, Romero-Corral A, Somers VK, Lopez-Jimenez F, Ohrvik J, et al. Concentration of apolipoprotein B is comparable with the apolipoprotein B/apolipoprotein A1 ratio and better than routine clinical lipid measurements in predicting coronary heart disease mortality: Findings from a multi-ethnic US population. Eur Heart J 2009;30:710-7.  Back to cited text no. 18
    

Top
Correspondence Address:
Shankar Kumar,
Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru - 560 002, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMH.AMH_61_20




 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
  Search
 
   Ahead Of Print
  
 Article in PDF
     Search Pubmed for
 
    -  Kumar S
    -  Venkatakrishna S
    -  Ambalavana K
    -  Nayak S


   Abstract
  Introduction
   Materials and Me...
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed212    
    PDF Downloaded6    

Recommend this journal