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ORIGINAL ARTICLE
Association between attention-deficit/hyperactivity
disorder symptoms and obesity and hypertension in
early adulthood: a population-based study
BF Fuemmeler1, T Østbye1,4, C Yang2, FJ McClernon3 and SH Kollins3
1
Community and Family Medicine, Duke University Medical Center, Durham, NC, USA; 2Social Science Research Institute,
Duke University, Durham, NC, USA; 3Department of Psychiatry, Duke University, Durham, NC, USA and 4Duke-NUS
Graduate Medical School, Singapore
Objective: To examine the associations between attention-deficit/hyperactivity disorder (ADHD) symptoms, obesity and
hypertension in young adults in a large population-based cohort.
Design, Setting and Participants: The study population consisted of 15 197 respondents from the National Longitudinal Study
of Adolescent Health, a nationally representative sample of adolescents followed from 1995 to 2009 in the United States.
Multinomial logistic and logistic models examined the odds of overweight, obesity and hypertension in adulthood in relation to
retrospectively reported ADHD symptoms. Latent curve modeling was used to assess the association between symptoms and
naturally occurring changes in body mass index (BMI) from adolescence to adulthood.
Results: Linear association was identified between the number of inattentive (IN) and hyperactive/impulsive (HI) symptoms and
waist circumference, BMI, diastolic blood pressure and systolic blood pressure (all P-values for trend o0.05). Controlling for
demographic variables, physical activity, alcohol use, smoking and depressive symptoms, those with three or more HI or IN
symptoms had the highest odds of obesity (HI 3 þ , odds ratio (OR) ¼ 1.50, 95% confidence interval (CI) ¼ 1.222.83; IN 3 þ ,
OR ¼ 1.21, 95% CI ¼ 1.021.44) compared with those with no HI or IN symptoms. HI symptoms at the 3 þ level were
significantly associated with a higher OR of hypertension (HI 3 þ , OR ¼ 1.24, 95% CI ¼ 1.011.51; HI continuous, OR ¼ 1.04,
95% CI ¼ 1.001.09), but associations were nonsignificant when models were adjusted for BMI. Latent growth modeling results
indicated that compared with those reporting no HI or IN symptoms, those reporting 3 or more symptoms had higher initial
levels of BMI during adolescence. Only HI symptoms were associated with change in BMI.
Conclusion: Self-reported ADHD symptoms were associated with adult BMI and change in BMI from adolescence to adulthood,
providing further evidence of a link between ADHD symptoms and obesity.
International Journal of Obesity (2011) 35, 852–862; doi:10.1038/ijo.2010.214; published online 26 October 2010
a a
Age (years) 28.8 (0.12) 28.6 (0.12) 28.8 (0.12) 28.9 (0.12) 28.7 (0.12) 29.0 (0.14)a
Body mass index (BMI) 29.1 (0.15) 22.0 (0.04) 27.4 (0.03)a 36.9 (0.15)a 28.4 (0.13) 33.5 (0.34)a
Gender
Male 51.0 45.3 59.0 49.9 49.5 60.2
Female 49.0 54.7 41.0 50.1b 50.5 39.8b
Race/ethnicity
Hispanic 11.6 8.3 13.4 13.4 11.7 11.0
Black 15.3 11.9 14.7 18.8 14.8 18.8
Other 6.7 7.9 6.7 5.8 6.8 6.4
White 66.3 71.9 65.3 62.0b 66.7 63.8b
Education
High school or less 25.9 22.0 26.3 29.1 25.3 29.6
Vocational or some college 42.9 39.1 39.8 48.8 42.6 44.8
College degree or higher 31.2 38.9 33.9 22.1b 32.1 25.6b
Physical activity
None 57.4 53.3 54.6 63.4 56.5 64.0
Once in last week 42.6 46.7 45.4 36.6b 43.6 36.0b
Alcohol consumption
Abstinent 37.5 33.3 34.1 44.0 36.7 42.8
Moderate 45.7 51.7 47.7 38.7 47.0 37.5
Heavy 16.8 15.0 18.2 17.3b 16.3 19.8b
Overweight (%) Obese (%) (%) Mean (s.e.) Mean (s.e.) Mean (s.e.) Mean (s.e.)
Hyperactive-Impulsive
None 29.1 34.2 12.4 96.6 (0.50) 28.6 (0.22) 79.2 (0.23) 124.8 (0.30)
1 symptom 28.4 36.0 12.9 97.7 (0.46) 29.0 (0.21) 79.3 (0.26) 124.7 (0.39)
2 symptoms 29.4 37.7 12.6 98.9 (0.69)a 29.3 (0.31)a 79.4 (0.34) 125.0 (0.50)
3+symptoms 29.5 41.1b 15.8b 100.3 (0.58)a 29.7 (0.24)a,c 80.3 (0.29)a,c 126.6 (0.35)a,c
Inattentive
None 29.4 35.1 12.4 97.0 (0.40) 28.7 (0.17) 79.2 (0.21) 124.6 (0.28)
1 symptom 27.9 37.9 13.6 98.6 (0.61)a 29.3 (0.28) 79.7 (0.34) 125.1 (0.43)
2 symptoms 31.4 35.7 14.0 99.0 (0.82)a 29.1 (0.35) 79.7 (0.43) 125.7 (0.60)
3+symptoms 28.2 41.9b 15.9 100.8 (0.65)a,c 29.8 (0.28)a,c 80.4 (0.31)a,c 127.0 (0.41)a,c
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; BMI, body mass index; DBP, diastolic blood pressure; HI, hyperactive/impulsive; IN, inattentive; SBP,
systolic blood pressure. aPo0.05 for t-tests from mean comparisons (subclinical ADHD, HI none and IN none as referent). bPp0.05 for comparison from w2-test
(categorical variables). cP for trend o0.01.
Mean values for waist circumference, BMI, DBP and SBP IN symptoms, when measured on a continuous scale, were
by ADHD symptoms not statistically significantly associated with overweight or
Mean waist circumference was higher among those in the obesity (OR overweight ¼ 1.00, 95% CI ¼ 0.97–1.04; OR
ADHD clinically relevant categories compared with those obese ¼ 1.03, 95% CI ¼ 0.99–1.07) (data not shown).
with subclinical ADHD symptoms (Table 2). Mean DBP and In addition, HI symptoms at the 3 þ level or measured
SBP were higher, but not statistically significantly higher on a continuous scale were significantly associated with
among those in the ADHD clinically relevant categories higher relative odds for hypertension (HI 3 þ , OR ¼ 1.24,
compared with those with subclinical ADHD symptoms. 95% CI ¼ 1.01–1.51; HI continuous, OR ¼ 1.04, 95%
In general, means for waist circumference, BMI, DBP and SBP CI ¼ 1.00–1.09). These associations were attenuated so that
increased with increasing HI and IN symptoms. no significant associations were observed when models were
adjusted for BMI (HI 3 þ , OR ¼ 1.16, 95% CI ¼ 0.92–1.45;
HI continuous, OR ¼ 1.03, 95% CI ¼ 0.98–1.07). IN symptoms,
Multivariate-adjusted odds of overweight, obesity and when measured on a continuous scale, were not statis-
hypertension tically significantly associated with hypertension, regardless
Table 3 presents the odds ratio (OR) and 95% CIs from the of whether BMI was included in the models (OR
multinomial logistic and logistic regression analyses. Com- hypertension ¼ 1.03, 95% CI ¼ 0.99–1.07; OR hypertension
pared with those in the subclinical ADHD category (o6 HI adjusted for BMI ¼ 1.02, 95% CI ¼ 0.98–1.07) (data not
and o6 IN symptoms), those in the HI only category had the shown).
highest odds of obesity (OR ¼ 01.63; 95% CI ¼ 1.11–2.39). When both the HI and IN continuous symptoms were
The relative odds of hypertension among those in clinically entered together in a model, the OR was attenuated for IN
relevant categories (IN only, HI only or combined) were not symptoms, but not for HI symptoms (OR overweight for
significantly higher than among those in the subclinical HI ¼ 1.08, 95% CI ¼ 1.03–1.13; OR overweight for IN ¼ 0.96,
ADHD category. 95% CI ¼ 0.91–1.00 and OR obese for HI ¼ 1.11, 95%
Compared with those with no HI or IN symptoms, those CI ¼ 1.06–1.17; OR obese for IN ¼ 0.96, 95% CI ¼ 0.93–1.01)
with 3 or more symptoms had the highest odds of obesity (data not shown). There was no association between HI or IN
(HI 3 þ , OR ¼ 1.50, 95% CI ¼ 1.22–2.83; IN 3 þ , OR ¼ 1.21, symptoms and hypertension when both symptoms were
95% CI ¼ 1.02–1.44). In models that included the conti- entered into these models simultaneously.
nuous variable of HI and IN (0–8 HI symptoms and 0–9 IN
symptoms), one additional HI symptom was associated
with a 5% increase in the odds of overweight and a 9% Longitudinal associations between ADHD symptoms and BMI
increase in the odds of obesity (OR overweight ¼ 1.05, 95% The change in BMI was best described by a quadratic growth
CI ¼ 1.01–1.09; OR obese ¼ 1.09, 95% CI ¼ 1.04–1.14). function with a homoscedastic residual structure (d.f. ¼ 4;
38
improved (data not shown). Models included the quadratic
36 function, but none of the ADHD variables were related to the
curvature, thus the data are not shown. There were no
34 statistically significant associations between the clinically
relevant ADHD categories and overall BMI intercept or slope.
32 HI symptoms assessed as either a categorical variable or on a
continuous scale were associated with BMI intercept and
30
0 1 2 3+ slope. Compared with having no HI symptoms, having 3 þ
HI symptoms was associated with a 0.36 unit higher initial
Number of symptoms
BMI above the age/sex/race-adjusted mean intercept of 22.32
IN HI (that is, 22.68). From Wave I to Wave IV, the slope in BMI
among those with 3 þ HI symptoms was 0.12 units higher
b Prevalence of stage II hypertension compared with those with no HI symptoms (0.85 vs the
18
age/sex/race-adjusted mean slope of 0.73). A similar effect
was observed for the continuous 0 to 8 HI variable with
higher HI symptoms associated with a higher initial BMI and
16 steeper slope over time (gintercept ¼ 0.08, s.e. ¼ 0.04, Po0.05;
gslope ¼ 0.02, s.e. ¼ 0.01, Po0.05) (data not shown).
Compared with the effect of the HI symptoms, IN
Percent
Model Overweight Obesity Hypertension (stage II) Hypertension (stage II) adjusted for BMI
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
HI
None F F F F
1 symptom 1.02 (0.85–1.23) 1.11 (0.93–1.33) 1.05 (0.83–1.34) 1.07 (0.83–1.39)
2 symptoms 1.16 (0.94–1.43) 1.26 (1.03–1.55) 1.02 (0.81–1.29) 0.97 (0.74–1.27)
3+symptoms 1.24 (1.04–1.48) 1.50 (1.22–1.83) 1.24 (1.01–1.51) 1.16 (0.92–1.45)
P for trend 0.01 0.00 0.04 0.26
Inattentive
None F F F F
1 symptom 0.91 (0.75–1.10) 0.98 (0.81–1.18) 0.99 (0.79–1.26) 0.98 (0.78–1.23)
2 symptoms 1.05 (0.85–1.30) 0.98 (0.78–1.23) 1.02 (0.76–1.36) 1.00 (0.74–1.35)
3+symptoms 1.02 (0.86–1.22) 1.21 (1.02–1.44) 1.09 (0.87–1.36) 1.03 (0.82–1.31)
P for trend 0.73 0.07 0.47 0.81
Abbreviations: ADHD, attention-deficit/hyperactivity disorder; BMI, body mass index; CI, confidence interval; HI, hyperactive/impulsive; IN, inattentive; OR, odds
ratio. All models include age, sex, race/ethnicity, education achieved, past or current depression, alcohol use, current smoking and current physical activity.
Table 4 Standardized regression coefficients, s.e. and P-values for effect of a Inattention
ADHD symptoms on BMI intercept and slope adjusted for age, sex and race 23.5
Model Intercept Slope
a b c d
Categories of ADHD 22.47 19.39 0.80 1.04
symptoms
Subclinical ADHD 22.5
IN only 0.75 (0.35) 0.03 0.05 (0.12) 0.68
HI only 0.25 (0.35) 0.48 0.09 (0.08) 0.27
Combined 0.46 (0.34) 0.18 0.11 (0.11) 0.34
22
HI 22.32 a
19.38 b
0.73 c
1.03 d 1 2 3 4
None Wave
1 symptom 0.12 (0.16) 0.44 0.07 (0.04) 0.10
IN 0 IN 1 IN 2 IN 3+
2 symptoms 0.40 (0.19) 0.04 0.10 (0.05) 0.05
3+ symptoms 0.36 (0.17) 0.03 0.12 (0.05) 0.01
b Hyperactive-Impulsive
Inattentive 22.29a 19.38b 0.76c 1.04d 25.5
None 25
1 symptom 0.25 (0.19) 0.19 0.06 (0.05) 0.27
2 symptoms 0.41 (0.23) 0.07 0.03 (0.06) 0.58 24.5
3+ symptoms 0.44 (0.16) 0.01 0.08 (0.06) 0.16
24
BMI
Conclusions
Acknowledgements
Evidence from smaller community-based samples and at
least one other population-based representative sample have This research uses data from Add Health, a program project
found an association between ADHD and adult obesity. Our directed by Kathleen Mullan Harris and designed by
findings show a dose–response increase in risk of obesity J Richard Udry, Peter S Bearman and Kathleen Mullan Harris
associated with increasing ADHD symptoms, especially HI at the University of North Carolina at Chapel Hill, and
symptoms. Indicators of hypertension also increased with funded by Grant P01-HD31921 from the Eunice Kennedy
increasing HI symptoms; however, this relationship was Shriver National Institute of Child Health and Human
attenuated when accounting for BMI. If our findings are Development, with cooperative funding from 23 other
confirmed in other samples, they could have relevant federal agencies and foundations. We acknowledge Ronald
clinical implications both for the treatment of ADHD and R Rindfuss and Barbara Entwisle for assistance in the original
for obesity. As has been suggested, it may be clinically design. Information on how to obtain the Add Health
relevant to screen patients with ADHD who are at risk for data files is available on the Add Health website (http://
obesity to develop appropriate treatment strategies.7,59,60 www.cpc.unc.edu/addhealth). No direct support was
Medications for ADHD often suppress appetite, and in received from Grant P01-HD31921 for this analysis. Support
children decelerated growth velocity has typically been a to complete this study was funded in part by the following
concern. It may become necessary for clinicians to monitor grants from NIH: NCI 1K07CA124905 awarded to BFF; R01
weight more carefully among their child and adolescent DA024838 awarded to FJM; K24 DA023464 awarded to SHK.
patients with ADHD, especially when they come off This research was supported in part by National Institute on
medications or in developmental transitions where weight Drug Abuse (NIDA) Grant P30 DA023026. Its contents are
gain is common. Treatment for obesity may also be affected solely the responsibility of the author(s) and do not
among individuals with ADHD symptoms. Treatment necessarily represent the official views of NIDA.