Chronobiology International

The Journal of Biological and Medical Rhythm Research

ISSN: 0742-0528 (Print) 1525-6073 (Online) Journal homepage: https://www.tandfonline.com/loi/icbi20

Relationships between chronotype, social jetlag,

sleep, obesity and blood pressure in healthy young
adults

Daria M. McMahon, James B. Burch, Shawn D. Youngstedt, Michael D. Wirth,

James W. Hardin, Thomas G. Hurley, Steven N. Blair, Gregory A. Hand, Robin
P. Shook, Clemens Drenowatz, Stephanie Burgess & James R. Hebert

To cite this article: Daria M. McMahon, James B. Burch, Shawn D. Youngstedt, Michael D.
Wirth, James W. Hardin, Thomas G. Hurley, Steven N. Blair, Gregory A. Hand, Robin P. Shook,
Clemens Drenowatz, Stephanie Burgess & James R. Hebert (2019): Relationships between
chronotype, social jetlag, sleep, obesity and blood pressure in healthy young adults, Chronobiology
International, DOI: 10.1080/07420528.2018.1563094

To link to this article: https://doi.org/10.1080/07420528.2018.1563094

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CHRONOBIOLOGY INTERNATIONAL
https://doi.org/10.1080/07420528.2018.1563094

Relationships between chronotype, social jetlag, sleep, obesity and blood

pressure in healthy young adults
Daria M. McMahona, James B. Burcha,b,c, Shawn D. Youngstedtd,e, Michael D. Wirtha,b,f, James W. Hardina,
Thomas G. Hurleyb, Steven N. Blaira,g, Gregory A. Handh, Robin P. Shooki, Clemens Drenowatzg,j,
Stephanie Burgessf, and James R. Heberta,b
a
Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA; bCancer Prevention and Control
Program, University of South Carolina, Columbia, South Carolina, USA; cWJB Dorn Department of Veterans Affairs Medical Center Research
Department, Columbia, South Carolina, USA; dCollege of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA;
e
Department of Veterans Affairs, Phoenix Health Care System Research Department, Phoenix, Arizona, USA; fCollege of Nursing, University of
South Carolina, Columbia, South Carolina, USA; gDepartment of Exercise Science, University of South Carolina, Columbia, South Carolina,
USA; hSchool of Public Health, West Virginia University, Morgantown, West Virginia, USA; iDepartment of Pediatrics, Center for Healthy
Lifestyles and Nutrition, Children’s Mercy Hospital, Kansas City, Missouri, USA; jDivision of Physical Education, University of Education Upper
Austria, Linz, Austria

ABSTRACT ARTICLE HISTORY

Sleep disturbances, chronotype and social jetlag (SJL) have been associated with increased risks Received 28 September 2018
for major chronic diseases that take decades to develop, such as obesity, metabolic syndrome and Revised 17 December 2018
cardiovascular disease. Potential relationships between poor sleep, chronotype and SJL as they Accepted 20 December 2018
relate to metabolic risk factors for chronic disease have not been extensively investigated. This KEYWORDS
prospective study examined chronotype, SJL and poor sleep in relation to both obesity and Actigraphy; body mass
elevated blood pressure among healthy young adults. index; chronotype; repeated
SJL and objective sleep measures (total sleep time, sleep onset latency, wake after sleep onset measures latent class
and sleep efficiency) were derived from personal rest/activity monitoring (armband actigraphy) analysis; sleep efficiency;
among 390 healthy adults 21–35 years old. Participants wore the device for 6–10 days at 6-month social jetlag
intervals over a 2-year period (n = 1431 repeated observations). Chronotypes were categorized
into morning, intermediate and evening groups using repeated measures latent class analysis.
Means of SJL and sleep measures among latent chronotype groups were compared using partial
F-tests in generalized linear mixed models. Generalized linear mixed models also were used to
generate odds ratios (ORs) with 95% confidence intervals (CIs) examining the relationship
between repeated measures of chronotype, SJL, sleep and concurrent anthropometric outcome
measures (body mass index, percentage of body fat, waist-to-hip ratio, waist-to-height ratio),
systolic blood pressure and diastolic blood pressure.
Sleep latency ≥12 min was associated with increased odds of a high waist-to-height ratio
(OR = 1.37; CI: 1.03–1.84). Neither chronotype nor SJL was independently associated with anthro-
pometric outcomes or with blood pressure. Relationships between poor sleep and anthropometric
outcomes or blood pressure varied by chronotype. Morning types with total sleep time <6 h, sleep
efficiency <85% or wake after sleep onset ≥60 min were more likely to have an increased
percentage of body fat, waist-to-hip ratio and waist-to-height ratio relative to those with an
intermediate chronotype. Similarly, sleep latency ≥12 min was associated with increased odds of
elevated systolic blood pressure (OR = 1.90; CI: 1.15–3.16, pinteraction = 0.02) among morning versus
intermediate chronotypes. No relationships between poor sleep and obesity or elevated blood
pressure were observed among evening chronotypes.
The results from this study among healthy young adults suggest that poor sleep among
morning types may be more strongly associated with obesity and elevated blood pressure relative
to those with an intermediate (neutral) chronotype. Sleep-related metabolic alterations among
different chronotypes warrant further investigation.

CONTACT James B. Burch burch@mailbox.sc.edu Department of Epidemiology and Biostatistics, Cancer Prevention & Control Program, University of
South Carolina, 915 Greene St, Room 229, Columbia, SC 29208, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/icbi.
Supplemental data for this article can be accessed here.
© 2019 Taylor & Francis Group, LLC
2 D. M. MCMAHON ET AL.

Introduction intermediate chronotype (Culnan et al. 2013; Wang

2014). However, not all studies have confirmed this
In 2013–2014, almost 38% of adults in the United
association; in one study, morning rather than evening
States were obese (Flegal et al. 2016). Obesity is
chronotype was associated with increased risk of
associated with many serious complications such
weight gain (Roenneberg et al. 2012), while in two
as metabolic syndrome, type 2 diabetes mellitus,
others body mass index (BMI) did not differ by chron-
arterial hypertension, cardiovascular disease and
otype (Maukonen et al. 2017; Pabst et al. 2009).
cancer (Malnick and Knobler 2006). Some of
Chronotype in combination with social schedule
these conditions begin to develop early in child-
can elicit an increase in SJL, particularly among
hood (Ogden et al. 2016).
those with an evening chronotype (Roenneberg et al.
One modifiable risk factor for weight gain,
2012; Wittmann et al. 2006). Thus, it is reasonable to
obesity and metabolic syndrome is short, dis-
hypothesize that SJL may mediate the relationship
rupted or inefficient sleep (Bailey et al. 2014;
between chronotype and obesity. One study that
Hasler et al. 2004; Vgontzas et al. 2014). Poor
tested this hypothesis produced conflicting results
sleep also has been associated with an increased
(Culnan and Kloss 2013), whereas other studies have
risk of hypertension and cardiovascular disease
assumed that chronotype, SJL and sleep duration may
(Gottlieb et al. 2006), diabetes (Cespedes et al.
confound each other’s association with anthropo-
2016) and cancer (Gu et al. 2016). Moreover,
metric indices of metabolic syndrome (Parsons et al.
sleep disturbances are prevalent and persistent
2015; Roenneberg et al. 2012).
in young adults (Hasler et al. 2004; McMahon
This study was originally designed to examine the
et al. 2018; Vgontzas et al. 2014).
effects of energy intake and expenditure on changes in
Modern life often causes persistent misalignment in
weight and body composition (Hand et al. 2013). In
sleep/wake timing between weekdays and weekends,
a cross-sectional analysis, relationships between sleep
a phenomenon referred to as “social jetlag” (SJL)
disturbances, BMI and percentage of body fat (BF%)
(Wittmann et al. 2006). SJL can start in teenage years
were evaluated at baseline (Wirth et al. 2015), although
and continue throughout working years until retire-
chronotype and SJL were not considered. More
ment, and thus may affect millions of people in indus-
recently, temporal patterns of sleep, chronotype and
trialized countries over long periods of time
SJL were characterized (McMahon et al. 2018),
(Roenneberg et al. 2012). SJL has been associated
although relationships between these factors and obe-
with sleep loss (Roenneberg et al. 2007; Wittmann
sity or elevated blood pressure were not evaluated.
et al. 2006), as well as increases in obesity and meta-
Young adults ~21–35 years of age are at risk for
bolic syndrome, biomarkers of systemic inflammation
developing metabolic changes that may predispose
and with mood disturbances (Levandovski et al. 2011;
them to an increased risk of chronic disease later in
Parsons et al. 2015; Roenneberg et al. 2012; Rutters
life (Ogden et al. 2016).
et al. 2014).
During the last decade, prevalence of obesity has
Preferred sleep timing and sleep efficiency (SE)
remained high (30%) in this age group in the United
are related to an individual’s diurnal preference or
States (Flegal et al. 2016). Adults in this age range also
chronotype (Juda et al. 2013; Roenneberg et al.
may experience SJL and have persistently poor sleep
2007). Individuals with an evening chronotype
(Hasler et al. 2004; McMahon et al. 2018; Vgontzas
tend to accumulate sleep debt during the week,
et al. 2014). The present analysis prospectively exam-
for which they often try to compensate with longer
ined independent associations between sleep, chron-
sleep and delayed sleep onset during the weekend
otype or SJL and measures of obesity and elevated
(Roenneberg et al. 2007; Valdez et al. 1996).
blood pressure among healthy young adults 21–-
Morning chronotypes, by contrast, are more likely
35 years of age. In addition to these direct associa-
to develop a sleep debt during the weekend
tions, this analysis also evaluated the potential
(Roenneberg et al. 2007; Valdez et al. 1996).
interactions between chronotype, sleep and SJL. It
Some studies suggest that individuals with an eve-
also was hypothesized that SJL may act as
ning chronotype are more likely to be overweight or
a mediator of the relationship between chronotype
obese compared to those with a morning or
and obesity or elevated blood pressure. In this

Figure 1. Analyses of the relationships between chronotype, social jetlag, sleep measures, obesity and elevated blood pressure. The
dashed lines represent relationships for which chronotype was assessed as a potential effect modifier.
manner, both the independent and combined effects
of chronotype, SJL and sleep on obesity and elevated
blood pressure were evaluated in a single study (see
Figure 1).
Methods
Study population
The population characteristics and recruitment pro-
cedures have been previously described (Hand et al.
2013). Briefly, eligible individuals were 21–35 years
of age, with a BMI of 20–35 kg/m2, no major health
conditions or large changes in body composition
during the previous 6 months and no pregnancy or
childbirth during the past 12 months (Hand et al.
2013). Individuals with major depression, anxiety
disorder or panic attacks (including those who took
selective serotonin reuptake inhibitors) were
excluded. Those who met diagnostic criteria for
arterial hypertension or diabetes – systolic blood
pressure (SBP) ≥150 mmHg and/or diastolic blood
pressure (DBP) ≥90 mmHg, or a blood glucose level
>145 mg/dl – also were excluded (Hand et al. 2013).
Potential participants provided demographic
and health characteristics via the internet, followed
by a telephone interview to establish eligibility.
Those considered eligible were invited for an
orientation session and three baseline screenings.
Out of 1831 persons contacted, 1116 were
CHRONOBIOLOGY INTERNATIONAL 3
considered ineligible, 66 declined to participate
and 169 did not attend the baseline clinic and
therefore did not enter the study (Hand et al.
2013). Thus, a total of 430 healthy men and
women residing in the Columbia, SC, region
were enrolled. The study was approved by the
Institutional Review Board at the University of
South Carolina, and all study participants pro-
vided informed consent. The Energy Balance
Study was originally planned for 1 year; however,
as additional funding was obtained, participants
were asked if they wished to continue for
another year.
After a comprehensive baseline assessment
(demographics, health history, anthropometric
measurements, diet, actigraphy), participants
were re-examined every 6 months to characterize:
anthropometric outcomes, blood pressure, sleep/
wake patterns via armband actigraphy and diet.
During the 2-year study period (2011–2013),
each participant completed between 1 and 5
assessments.
Chronotype, SJL and sleep characteristics
Sleep characteristics were derived from the data
collected using a SenseWear® Mini
Armband (BodyMedia Inc, Pittsburgh, PA) worn
by participants over the triceps muscle of the left
arm (Sharif and Bahammam 2013). An armband
4 D. M. MCMAHON ET AL.
sensor records limb movements at a frequency of
32 times per second and data are averaged over
1-min intervals. Participants wore the armband for
6–10 days (minimum of three weekdays and one
weekend day, 81% had ≥10 days) and kept a log of
their activities during non-wear periods.
Participants wore armbands with different serial
numbers during different assessment periods.
Prior to calculating summary measures, infor-
mation on sleep and physical activity from
a personal log was used to estimate activity during
non-wear periods (Hand et al. 2013). Activities
reported on the log were assigned Metabolic
Equivalent of Task (MET) values from the 2011
Compendium of Physical Activities (Ainsworth
et al. 2011) and used with measured resting meta-
bolic rate to calculate energy expenditure.
Analogously, periods of sleep or lying down for
the non-wear periods were assigned either a 0 or
a 1 in the minute-by-minute data. A compliant day
was defined as having verifiable wear time (actual
wear plus data from the log) for at least 80% of the
24-h day, and observations with wear time <80%
were excluded.
Minute-by-minute armband data were used to
calculate sleep characteristics. The following aver-
age night-time sleep measures for work- and free
days were calculated for every 6–10-day period of
armband wear: sleep onset and wake-up times,
total sleep time (TST), sleep onset latency (SOL),
wake after sleep onset (WASO) and SE (Wirth
et al. 2015).
The sleep onset time was defined as the first of 3
minutes asleep that coincided with ≥10 minutes
lying down. SOL was defined as the time between
lying down and sleep onset. Morning wake-up
time was defined by the first out of 90 consecutive
minutes awake. TST was defined as the sum of all
minutes asleep from initiation of the sleep period
until wake-up. WASO was calculated as the sum of
wake periods of at least 2 minutes duration
between sleep onset and the final wake-up time.
SE was calculated as a proportion of TST relative
to total time in bed.
Chronotype was calculated as the time of mid-sleep
on free days (i.e. weekends) corrected for “make-up
sleep” on free days (weekends) (Roenneberg et al.
2012). SJL was defined as the difference between
unadjusted midpoints of sleep on a weekend and
week day (Roenneberg et al. 2012; Wittmann et al.
2006). Absolute values of SJL were used for all ana-
lyses (hereafter referred to as SJL). Information on
work schedule was not available, and it was assumed
that free days occurred only on weekends.
Observations were excluded from statistical
analyses if armband data had any of the following
characteristics: missing bed- or wake-time (n = 40
observations), <4 days of data in a given assess-
ment period (n = 51 observations), missing sleep
data on the weekend (n = 38 observations),
extreme or implausible TST values (<4 h either
on a weekday, free day or on average) (n = 71
observations), TST >11 h on a work day or on
average (n = 1 observation) or mid-sleep on a
free day occurring in the afternoon (n = 2 obser-
vations) (Levandovski et al. 2011; Roenneberg
et al. 2012) (Note: ‘observation’ refers to one 6–10-
day period of armband use for a single participant;
Fischer et al. 2017.) Due to a lack of information
about work schedules, an average TST <4 h on
a week day, weekend or total for a given week,
and/or mid-sleep occurring in the afternoon on
a week day or weekend, were used as criteria for
excluding those potentially involved in shift work.
Participants also were excluded if they regularly
used prescription or over-the-counter sleep-
promoting medications (≥3 times per week,
n = 22), self-reported working nights (n = 2) or
traveled across time zones during periods of arm-
band use (n = 1) (Levandovski et al. 2011;
McMahon et al. 2018; Roenneberg et al. 2012).
After exclusions, only five observations (0.35% of
all observations) were based on six consecutive days
of armband wear, which is below a reliability
threshold of ≥7 days for actigraphy-derived sleep
and circadian measures (van Someren 2007); the
remainder wore the armbands for 7 days (N = 26,
1.8%); 8 days (N = 57, 4.0%); 9 days (N = 191,
13.3%) or ≥10 days (N = 1157, 80.6%).
Anthropometric outcomes and blood pressure
Height and weight were measured using tradi-
tional stadiometer and electronic scales with
a precision of 0.1 cm and 0.1 kg, respectively
(Hand et al. 2013). The average of three measure-
ments was used to calculate an individual’s BMI
(weight [kg]/height [m]2).

Waist and hip circumferences were measured
with a calibrated, spring-loaded tape measure.
Waist circumference was measured at midpoint
between costal margin and iliac crest on the axillary
line on both sides of the trunk and 2 cm above the
umbilicus (Hand et al. 2013). Hip circumference was
measured at the level of the greater trochanter, at the
widest point. The average of three measurements,
each rounded to 0.1 cm, was recorded and used to
calculate waist-to-hip ratio (WHR) and waist-to-
height ratio (WHtR). BF% was estimated based on
body composition measurements with dual x-ray
absorptiometry full-body Lunar fan-beam scanner
(GE Healthcare model 8743, Waukesha, WI).
Resting blood pressure was measured on the arm
of a subject’s preference using Baumanometer® with
Calibrated® V-Lok® Complete Inflation System (W.
A. Baum Co., Inc., NY) and a Littmann Classic II S.
E. stethoscope (Hand et al. 2013). All readings were
taken and reported to the nearest even digit,
according to the top of the meniscus. Typically,
two measurements were taken with the interval of
1 min between them. If the measurements differed
by more than 10 mmHg for SBP or more than
5 mmHg for DBP, the third measurement was
taken. Average value of two measurements was
used for each time point in the statistical analyses.
When three measurements were taken, two values
with the difference equal to or less than 10 mmHg
for SBP or 5 mmHg for DBP were averaged. If all
three measurements exceeded the limit of differ-
ence between them, the summary value was set to
missing. All available anthropometric and blood
pressure measures (1–5 time points) were used in
the analyses.
Covariates
Estimates of total daily physical activity were
obtained from armband data. Information for the
periods of non-wear was supplemented with values
for matching activity from the 2011 Compendium
of Physical Activity (Ainsworth et al. 2011). Total
daily hours of physical activity were defined as
a sum of all activities of at least 3 MET.
Estimates of dietary intake were derived from
random 24-h dietary recall interviews (24HR), col-
lected on non-consecutive days by telephone inter-
view. Up to three interviews (>97% completed at
CHRONOBIOLOGY INTERNATIONAL 5
least two interviews) were conducted by trained,
registered dietitians, two interviews for weekday
and one for weekend day consumption (Hand
et al. 2013). The 24HR is the method with the lowest
overall variance and, therefore, total error (Hebert
et al. 1998) and 3 days is the optimal number of days
needed to compute total caloric intake (Ma et al.
2009). The Nutrient Data System for Research (ver-
sion 2012: Nutrition Coordinating Center,
University of Minnesota, Minneapolis, Minnesota)
was used to estimate nutrient and individual food
intakes from the dietary recalls. Forty-three food
parameters (including whole foods and nutrients)
were used to calculate the dietary inflammatory
index (DII)™ score, which expresses the inflamma-
tory potential of each individual’s diet (Shivappa
et al. 2014). Lower DII scores are more anti-
inflammatory while the higher scores are more
proinflammatory (maximum theoretical range is
−8.87 to 7.98). To account for individual differences
in energy intake, the DII scores were calculated per
1000 kcal (4184 kJ) (E-DII).
Statistical analyses
All statistical analyses were performed using SAS®
9.4 software (Cary, NC). Continuous actigraphy
variables were categorized using previously estab-
lished cut-points: TST (<6, 6 to <7, ≥7 h) (Gottlieb
et al. 2006), SOL (≥12 vs. <12 min) (Natale et al.
2009), WASO (≥60 vs. <60 min) (Kim 2015) and
SE (<85 vs. ≥85%) (Kim 2015).
Relationships between SJL, chronotype, sleep
measures (TST, SOL, WASO, SE), obesity mea-
sures and elevated blood pressure were analyzed
using generalized linear mixed models for repeated
measures (GLMMs) with an unstructured covar-
iance matrix, binary distribution and logit link
function (Figure 1, paths 1–3). Separate models
were fit for each predictor (SJL, chronotype, TST,
SOL, WASO, SE). BMI was categorized into two
groups: underweight/normal weight (<25 kg/m2)
and overweight/obese (≥25 kg/m2). Sex-specific
cut-points were used to categorize BF% and
WHR. Obesity was defined as BF% ≥25% in men
and ≥30% in women (Shah and Braverman 2012).
WHR was dichotomized: <0.95 vs. ≥0.95 in men
and <0.80 vs. ≥0.80 in women (Lean et al. 1995).
WHtR was dichotomized as <0.5 vs. ≥0.5
6 D. M. MCMAHON ET AL.
(Browning et al. 2010). SBP was dichotomized
using cut-points for prehypertension ≥120 vs.
<120 mmHg, and DBP ≥80 vs.<80 mmHg since
only a few participants met clinical criteria for
hypertension (SBP ≥ 140 mmHg, 11%; DBP ≥
90 mmHg, 4%) (Chobanian et al. 2003).
Potential covariates included age, sex, race
(European American [EA], African American
[AA], Other [Hispanic, Asian, Native American
and mixed race]), education, annual income,
employment, marital status, having children (yes/
no), physical activity (hours/day), caffeine intake
(g/day), napping (yes [>0 min/day]/no [0 min/
day]), season (winter [November–January], spring
[February–April], summer [May–July], autumn
[August–October]) and current dieting (yes/no).
The assessment sequence number (1–5 at
6-month intervals) was treated as a categorical
variable and included in crude and adjusted statis-
tical models. To select potential covariates, bivari-
ate relationships between each sleep measure and
the anthropometric outcomes were presented as
odds ratios (OR) and 95% confidence intervals
(95% CI), and variables with a p value <0.20
were selected for further evaluation in multivari-
able statistical models. Final variable selection was
performed by identifying covariates that changed
an estimate of the main exposure variable by
>10%. The final model included only covariates
that were identified using the 10% rule or if they
were statistically significant (p ≤ 0.05).
Repeated measures latent class analysis
(RMLCA) was performed to identify latent groups
for chronotype (morning, intermediate and eve-
ning) using PROC TRAJ in SAS® (Jones et al.
2001; McMahon et al. 2018). This analysis assumes
a mixture model to define the trajectories of
unique subgroups within a population that does
not change group membership over time (Jones
and Nagin 2007; Nagin 2005). The best-fitting
model was selected using the Bayesian
Information Criterion (Jones and Nagin 2007)
and a priori minimum group sizes containing
≥10% of the study population (McMahon et al.
2018). RMLCAs were adjusted for race (EA vs.
AA/other) and sex, which were assumed not to
change over time. Because the group trajectories
for all three latent chronotype groups were linear,
other potential covariates that change over time
were not used to adjust group trajectories.
Participants with complete armband data for all
available time points (1–5) were included in these
analyses (N = 390, 1431 observations). GLMMs
were estimated to compare means of SJL, sleep or
chronotype among latent chronotype groups using
the F-tests in PROC GLIMMIX and the intermedi-
ate chronotype group as the referent (Figure 1,
paths 4–5). The p value was penalized for multiple
comparisons using the Bonferroni method.
Because chronotype may influence anthropo-
metric measures and blood pressure in several
ways, additional analyses were conducted using
chronotype as either a continuous or categorical
(i.e. latent group identified using RMLCA) vari-
able. When examining relationships between SJL,
sleep measures, obesity measures and blood pres-
sure, chronotype (continuous) was considered as
a potential confounder along with other covariates
(Figure 1, paths 1, 3). It was not included in the
final models because tests for confounding (10%
rule) were negative. The potential role of chrono-
type as an effect modifier was tested using two
approaches (Figure 1). In the first approach, an
interaction term between chronotype and a main
independent variable (e.g. each sleep measure) was
added to the multivariable statistical model, and its
significance was assessed using the Wald test. The
continuous or categorical version of chronotype
that was used for the interaction term was chosen
to match the form of the other independent vari-
able. The second approach examined the relation-
ship between absolute SJL or sleep characteristics
and each outcome after stratification by latent
chronotype group (Figure 1). Neither chronotype
nor SJL was directly associated with obesity mea-
sures or elevated blood pressure; thus, a potential
mediating role of SJL in these relationships was
not evaluated.
Results
The final analytical data set consisted of 390 parti-
cipants with a total of 1431 repeated observations.
Complete data were available at other time points
as follows: 6 months (n = 341), 12 months
(n = 317), 18 months (n = 206) and 24 months
(n = 177). Note that the 18- and 24-month mea-
surements were beyond the initial design of this
 CHRONOBIOLOGY INTERNATIONAL 7

study. Subjects measured at those time points (BMI≥30 kg/m2, 14%) at baseline (Table 2).
agreed to additional involvement after the study Among males, 37% had BF% ≥25% and 3% had
was extended. A majority of the participants had at high WHR (≥0.95). Among females, 71% had BF%
least three repeated assessments (79%), including ≥30% and 15% had high WHR (≥0.80). Twenty-
those who had four (15%) and five (39%). Only two percent of participants of both sexes had high
10% of participants had two, and 11% had only WHtR (≥0.50).
one assessment. The average age at baseline was SBP was elevated (≥120 mmHg) among 59% of
28 ± 4 years, and the distribution of sex was participants (Table 2), including those who met
approximately equal (51% women, Table 1). Most a criterion for hypertension (≥140 mmHg, 11%,
participants were EA (68%) and had at least not shown). Only 23% had elevated DBP
4 years of college education (84%). Fifty-five per- (≥80 mmHg) (Table 2), including those with hyper-
cent of participants were employed, and 45% were tension (≥90 mmHg, 4%, not shown) at baseline. By
college students (19% undergraduate, 81% gradu- the end of 2-year follow-up, there were negligible to
ate). A majority of participants (71%) had an moderate increases in the proportion of obese par-
annual income <$60,000. Thirty-two percent of ticipants (Table 2). Alternatively, the proportion of
participants were married, and 14% had children. those with elevated SBP decreased after 2 years of
Forty-five percent of participants were over- follow-up (Table 2).
weight (BMI 25–29.9 kg/m2, 31%) or obese At baseline, chronotype was normally distribu-
ted and moderately correlated with SJL (Pearson
r = 0.46, p < 0.001; Spearman r = 0.43, p < 0.001).
Table 1. Characteristics of the participants at baseline, Energy When analyzed as a continuous variable, chrono-
Balance Study, Columbia, SC, 2011–2014. type was not associated with any of the outcomes
All participants Women Men (Table 3). The RMLCA identified three latent
Variable (n = 390) (n = 198) (n = 192)
Age (years, mean±SD) 27.6 ± 3.8 27.7 ± 3.7 27.4 ± 3.9
chronotype groups: morning (mean ± SE:
Race, n (%) 3.0 ± 0.04 h, 32.5% of participants), intermediate
European American 264 (68) 131 (66) 133 (70) (4.4 ± 0.03 h, 53%) and evening (6.1 ± 0.1 h,
African American 47 (12) 31 (16) 16 (8)
Hispanic/Latino 11 (3) 7 (3) 4 (2) 14.5%) (McMahon et al. 2018). Based on the base-
Asian 42 (11) 15 (8) 27 (14) line data, the cut-points between chronotype
Native American 12 (3) 8 (4) 4 (2)
Mixed race 14 (3) 6 (3) 8 (4)
groups were approximately at 2:40 a.m. and 4:20
Education, n (%) a.m. Chronotype defined by latent group member-
HS graduate/GED 62 (16) 18 (9) 44 (23) ship was not associated with any of the outcomes
Some college
College (4+ years) 328 (84) 180 (91) 148 (77) (Table 3).
Income ($), n (%) Each sleep measure except SOL was associated
<20 000 65 (17) 34 (17) 31 (16)
20 000 to <40 000 137 (35) 76 (39) 61 (32)
with chronotype (Table 4). Participants with an
40 000 to <60 000 74 (19) 37 (19) 37 (19) evening chronotype had shorter TST, lower SE
60 000 to <80 000 50 (13) 23 (12) 27 (14) and larger WASO than those with an intermediate
≥80 000 62 (16) 26 (13) 36 (19)
Employment, n (%) chronotype.
Employed and self- 214 (55) 113 (57) 101 (53) Approximately 50% of participants had more
employed
Student/othera 176 (45) 85 (43) 91 (47)
than 1 h of SJL at baseline (>1 to <2 h: 33%; ≥2 h:
Marital status, n 17%). Morning types had less SJL (0.9 ± 0.04,
Marriedb 178 (46) 90 (45) 88 (46) p< 0.001), whereas those with an evening chrono-
Singlec 212 (54) 108 (55) 104 (54)
Children, age type had more SJL (1.5 ± 0.1 h, p < 0.001) compared
<18 years, n (%) to intermediate chronotypes (1.2 ± 0.03 h). SJL was
0 336 (86) 173 (88) 163 (85) not associated with any of the outcome measures
1 29 (7) 13 (7) 16 (8)
≥2 24 (7) 11 (5) 13 (7) (Table 5).
Source: McMahon et al. (2018), doi: 10.1080/07420528.2017.1405014. Among the sleep measures, SOL ≥12 min was
a
Out of work (<1 year), homemaker, unable to work (n = 4, 1%). associated with an increased odds of elevated WHtR
b
Includes members of unmarried couples (n = 55, 14%).
c
Includes divorced and separated (n = 7, 1.7%). (OR: 1.37, 95% CI: 1.03–1.84, Table 6). Stratification
SD: standard deviation. by latent chronotype group indicated that morning
8 D. M. MCMAHON ET AL.

Table 2. Descriptive outcomes at baseline and after 2 years of follow-up, Energy Balance Study, Columbia, SC, 2011–2014.
Baseline 24 months
All participants Women Men All participants Women Men
(n = 390) (n = 198) (n = 192) (n = 177) (n = 82) (n = 95)
Outcome
measure Category n (%) n (%) n (%) n (%) n (%) n (%)
Body mass index Overweight/obese 175 (45) 84 (42) 91 (47) 90 (51) 39 (48) 51 (54)
(kg/m2) Normal 215 (55) 114 (58) 101 (53) 87 (49) 43 (52) 44 (46)
Percent body fat
Obese 210 (54) 140 (71) 70 (37) 110 (62) 65 (79) 45 (47)
Non-obese 179 (46) 58 (29) 121 (63) 67 (38) 17 (21) 50 (53)
Waist-to-hip ratio
Obese 34 (9) 29 (15) 5 (3) 20 (11) 17 (21) 3 (3)
Non-obese 356 (91) 169 (85) 187 (97) 157 (89) 65 (79) 92 (97)
Waist-to-height Ratio
Obese 87 (22) 47 (24) 40 (21) 48 (27) 22 (27) 26 (27)
Non-obese 303 (78) 151 (76) 152 (79) 129 (73) 60 (73) 69 (73)
Systolic blood pressure (mmHg)
Elevated 232 (59) 93 (47) 139 (72) 58 (33) 12 (15) 46 (48)
Normal 158 (41) 105 (53) 53 (28) 119 (67) 70 (85) 49 (52)
Diastolic blood pressure (mmHg)
Elevated 91 (23) 23 (12) 68 (35) 47 (27) 11 (13) 36 (38)
Normal 299 (77) 175 (88) 124 (65) 130 (73) 71 (87) 59 (62)
Cut-points for outcomes: body mass index (≥25 vs. <25 kg/m2), percent body fat (males ≥0.25 vs. <0.25, females ≥30 vs. <30), waist-to-hip ratio
(males ≥0.95 vs. <0.95, females ≥0.8 vs. <0.8), waist-to-height ratio (≥0.5 vs. <0.5), systolic blood pressure (≥120 vs. <120 mmHg) and diastolic
blood pressure (≥80 vs. <80 mmHg).

Table 3. Relationship between chronotype and outcome measures, Energy Balance Study, Columbia, SC, 2011–2014.
Chronotype Chronotype group
(continuous, hours) (referent: intermediate)
Outcome Morning Evening
measure Model OR (95% CI) p Value OR (95% CI) OR (95% CI) p value
Body mass index Crude 0.91 (0.79–1.06) 0.24 1.56 (0.81–2.98) 0.95 (0.39–2.28) 0.36
(kg/m2) Adjusteda 0.86 (0.76–1.03) 0.12 1.49 (0.80–2.78)c 1.22 (0.50–2.97)c 0.45
Percent body fat Crude 1.01 (0.86–1.17) 0.94 0.67 (0.35–1.30) 0.45 (0.18–1.12) 0.17
Adjusteda 1.11 (0.94–1.31) 0.22 0.77 (0.40–1.50)c 1.41 (0.54–3.69)d 0.48
Waist-to-hip ratio Crude 0.83 (0.68–1.01) 0.07 1.24 (0.64–2.44) 0.58 (0.20–1.66) 0.38
Adjustedb 0.86 (0.69–1.07) 0.17 1.18 (0.56–2.48)e 1.66 (0.46–6.06)e 0.71
Waist-to-height ratio Crude 0.96 (0.82–1.13) 0.64 1.30 (0.67–2.52) 0.70 (0.30–1.98) 0.55
Adjustedb 0.98 (0.83–1.17) 0.86 1.38 (0.70–2.73)b 1.36 (0.50–3.72)b 0.60
Systolic blood Crude 1.00 (0.90–1.11) 0.90 1.21 (0.81–1.81) 1.81 (1.04–3.13) 0.10
pressure (mmHg) Adjusteda 0.96 (0.87–1.07) 0.47 1.16 (0.79–1.72)a 1.10 (0.63–1.90)a 0.74
Diastolic blood Crude 1.07 (0.96–1.20) 0.22 0.95 (0.62–1.44) 1.83 (1.06–3.16) 0.07
pressure (mmHg) Adjusteda 1.04 (0.93–1.16) 0.49 0.89 (0.59–1.34)a 1.19 (0.68–2.07)a 0.61
Cut-points for outcomes: body mass index (≥25 vs. <25 kg/m2), percent body fat (males ≥0.25 vs. <0.25, females ≥30 vs. <30), waist-to-hip ratio
(males ≥0.95 vs. <0.95, females ≥0.8 vs. <0.8), waist-to-height ratio (≥0.5 vs. <0.5), systolic blood pressure (≥120 vs. <120 mmHg) and diastolic
blood pressure (≥80 vs.<80 mmHg).
a
Adjusted for time, sex and physical activity.
b
Adjusted for time, age, sex and physical activity.
c
Adjusted for time, sex, physical activity and income.
d
Adjusted for time, sex, race and physical activity.
e
Adjusted for time, age, sex, race, physical activity and employment status.
OR: odds ratio; 95% CI: 95% confidence interval.

types who also had short TST (<6 h), elevated WASO
(≥60 min) or low SE (<85%) were more likely to have
increased BF%, WHR or WHtR (Table 7).
Participants with both morning chronotype and
sleep latency ≥12 min were 1.90 times more likely to
have elevated SBP (95% CI: 1.15–3.16,
pinteraction = 0.02, Table 7). Elevated WASO
(≥60 min) was associated with increased odds of
elevated DBP among those with an intermediate
chronotype (OR = 1.68, 95% CI: 1.05–2.71,
 CHRONOBIOLOGY INTERNATIONAL 9

Table 4. Relationship between sleep characteristics and latent chronotype group (n = 390, 1431 observations), Energy
Balance Study, Columbia, SC, 2011–2014.
Morning Intermediate Evening
(32.5%) (53%) (14.5%) F-test,
Variable Mean±SE Mean±SE Mean±SE p value†
Chronotype (h)a 3.0 ± 0.05* 4.4 ± 0.04 6.1 ± 0.08* <0.01
Total sleep time (h)b 6.5 ± 0.13 6.5 ± 0.13 6.1 ± 0.16* 0.01
Total sleep time, work days (h)c 6.2 ± 0.14 6.3 ± 0.13 6.0 ± 0.17* 0.04
Sleep onset latency (min)c 11.1 ± 0.04 11.6 ± 0.03 10.6 ± 0.10 0.35
Sleep efficiency (%)d 81.4 ± 0.50 81.3 ± 0.50 78.8 ± 0.80* 0.02
WASO (min)e 49.6 ± 2.41 52.3 ± 2.36 62.9 ± 4.20* 0.01
Absolute SJL (h)f 1.0 ± 0.10* 1.3 ± 0.09 1.6 ± 0.11* <0.01
*p <0.025 vs. intermediate chronotype, with Bonferroni adjustment for multiple comparisons.
†Partial F-test in generalized linear mixed models with repeated measures and unstructured covariance matrix.
a
Adjusted for time.
b
Adjusted for time, sex, race, having children, employment status, physical activity and caffeine intake.
c
Adjusted for time, sex, race, employment status and physical activity.
d
Adjusted for time, sex, race, employment status and caffeine intake.
e
Adjusted for time, sex and having children.
f
Adjusted for time and employment status.
SE: standard error of the mean.

Table 5. Relationship between absolute social jetlag (continu-

ous, hours) and outcome measures, Energy Balance Study, Discussion
Columbia, SC, 2011–2014.
To the authors’ knowledge, this is the first study to use
Outcome F-test,
measure OR (95% CI) p value† repeated actigraphy measures to examine relation-
Body mass indexa (kg/m2) 0.93 (0.73–1.16) 0.71 ships between chronotype, SJL, sleep and measures
Percent body fata 0.90 (0.70–1.15) 0.41 of obesity and elevated blood pressure. The results
Waist-to-hip ratioa 0.81 (0.59–1.12) 0.20
Waist-to-height ratiob 1.00 (0.77–1.29) 0.98 suggest that disrupted sleep was associated with mod-
Systolic blood pressurea (mmHg) 1.12 (0.95–1.31) 0.19 est increases in total and abdominal obesity, as well as
Diastolic blood pressurea (mmHg) 1.02 (0.86–1.21) 0.83 with elevated blood pressure, particularly among
Cut-points for outcomes: body mass index (≥25 vs. <25 kg/m2), percent
body fat (males ≥0.25 vs. <0.25, females ≥30 vs. <30), waist-to-hip
morning types. These observations are consistent
ratio (males ≥0.95 vs. <0.95, females ≥0.8 vs. <0.8), waist-to-height with some previous studies that found an association
ratio (≥0.5 vs. <0.5), systolic BP (≥120 vs. <120 mmHg) and diastolic between sleep disruption and weight gain or obesity in
BP (≥80 vs.<80 mmHg).
†Partial F-test in generalized linear mixed models with repeated mea- young adults (Bailey et al. 2014; Hasler et al. 2004;
a
sures and an unstructured covariance matrix. Lauderdale et al. 2009; Theorell-Haglow et al. 2012;
Adjusted for time, sex and physical activity.
b
Adjusted for time, age, sex and physical activity.
Vgontzas et al. 2014). However, none of the men-
OR: odds ratio; CI: confidence interval. tioned studies considered individual chronotype.
One relatively novel aspect of this study was the
inclusion of both the independent effects of chron-
pinteraction = 0.10, Table 7). No statistically significant otype, SJL and sleep, as well as their combined
association was detected between evening chrono- effects. Most previous studies investigated only the
type and any sleep measure (Table 7). separate effects of chronotype or sleep on obesity
Results obtained when the data were ana- (Bailey et al. 2014; Culnan et al. 2013; Hasler et al.
lyzed using sleep measures as continuous vari- 2004; Lauderdale et al. 2009; Theorell-Haglow et al.
ables were generally consistent with those 2012; Vgontzas et al. 2014; Wang 2014), whereas
obtained using categorical sleep variables. For a minority of studies adjusted for the effects of
example, among morning types, the odds of chronotype and sleep duration while examining the
a high WHR increased per 1% decrease in SE relationship between absolute SJL and BMI, percent
(OR = 1.11; 95% CI: 1.03–1.20, pinteraction fat mass, waist circumference or obesity (Parsons
= 0.01, data not shown). et al. 2015; Roenneberg et al. 2012). Some previous
10 D. M. MCMAHON ET AL.

Table 6. Relationship between sleep characteristics and outcome measures, Energy Balance Study, Columbia, SC, 2011–2014.
Total sleep time
(referent: 6 to <7 h) Sleep efficiency Sleep onset latency Wake after sleep onset
Outcome
measure Model OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Body mass index <6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
(kg/m2) Crude 1.28 (0.77–2.10) 1.01 (0.65–1.57) 1.03 (0.68–1.54) 1.06 (0.72–1.55) 1.04 (0.67–1.60)
Adjusted 1.30 (0.77–2.19)a 0.87 (0.55–1.37)a 0.96 (0.64–1.48)a 0.99 (0.67–1.45)b 0.97 (0.63–1.51)b
Continuous Continuous† Continuous Continuous
Crude 0.88 (0.67–1.14) 1.00 (0.97–1.04) 1.01 (0.98–1.05) 1.00 (0.99–1.01)
Adjusted 0.81 (0.62–1.06)a 1.00 (0.96–1.03)a 1.00 (0.97–1.04)b 1.00 (0.99–1.01)a
<6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Crude 0.88 (0.53–1.49) 1.02 (0.64–1.64) 0.98 (0.65–1.48) 1.41 (0.94–2.10) 1.35 (0.86–2.14)
Percent body fat Adjusted 1.00 (0.57–1.77)c 0.75 (0.45–1.24)c 0.95 (0.60–1.51)d 1.41 (0.91–2.16)c 1.31 (0.80–2.14)c
Continuous Continuous† Continuous Continuous
Crude 1.07 (0.81–1.41) 1.03 (0.99–1.07) 1.04 (1.00–1.07) 1.01 (1.00–1.02)
Adjusted 0.83 (0.62–1.12)c 1.04 (1.00–1.08)e 1.03 (1.00–1.07)c 1.01 (1.00–1.02)c
<6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Crude 1.16 (0.62–2.18) 1.17 (0.66–2.09) 1.22 (0.72–2.08) 1.25 (0.76–2.06) 1.31 (0.76–2.24)
Waist-to-hip ratio Adjusted 1.34 (0.68–2.63)e 0.98 (0.53–1.80)e 1.20 (0.68–2.12)e 1.23 (0.73–2.08)e 1.23 (0.69–2.18)c
Continuous Continuous† Continuous Continuous
Crude 1.09 (0.79–1.52) 1.02 (0.98–1.06) 1.00 (0.96–1.04) 1.00 (1.00–1.01)
Adjusted 0.93 (0.63–1.31)e 1.02 (0.98–1.06)e 0.97 (0.94–1.03)e 1.00 (0.99–1.01)c
<6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Crude 1.16 (0.62–2.18) 1.17 (0.66–2.09) 1.14 (0.89–1.47) 1.29 (1.01–1.65) 1.15 (0.71–1.87)
Waist-to-height Adjusted 1.58 (0.88–2.83)e 0.76 (0.45–1.30)e 1.16 (0.86–1.55)e 1.37 (1.03–1.84)f 1.30 (0.96–1.75)e
ratio Continuous Continuous† Continuous Continuous
Crude 0.83 (0.62–1.12) 1.02 (0.98–1.06) 1.03 (1.01–1.04) 1.00 (1.00–1.01)
Adjusted 0.76 (0.56–1.04)e 1.02 (0.99–1.06)f 1.02 (1.00–1.04)f 1.00 (1.00–1.01)e
<6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Systolic blood Crude 1.36 (0.95–1.96) 0.90 (0.64–1.25) 0.98 (0.96–1.01) 1.13 (0.85–1.50) 1.32 (0.96–1.82)
pressure (mmHg) Adjusted 1.26 (0.87–1.81)c 0.95 (0.68–1.33)c 1.15 (0.85–1.55)c 1.05 (0.79–1.40)c 1.31 (0.95–1.79)e
Continuous Continuous† Continuous Continuous
Crude 0.80 (0.66–0.97) 1.03 (1.00–1.05) 1.02 (0.99–1.04) 1.00 (1.00–1.01)
Adjusted 0.86 (0.71–1.04)c 1.02 (0.99–1.04)c 1.01 (0.98–1.03)c 1.00 (1.00–1.01)e
<6 h ≥7 h <85 vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Crude 1.26 (0.85–1.86) 1.18 (0.83–1.70) 1.12 (0.81–1.54) 1.16 (0.86–1.58) 1.24 (0.89–1.73)
Diastolic blood Adjusted 1.18 (0.80–1.75)c 1.28 (0.89–1.84)c 1.04 (0.75–1.43)c 1.08 (0.79–1.46)c 1.23 (0.88–1.73)e
pressure (mmHg) Continuous Continuous† Continuous Continuous
Crude 0.86 (0.70–1.05) 1.03 (1.00–1.05) 1.02 (0.99–1.04) 1.00 (1.00–1.01)
Adjusted 0.92 (0.75–1.12)c 1.02 (0.99–1.05)c 1.01 (0.98–1.03)c 1.00 (1.00–1.01)e
Cut-points for outcomes: body mass index (≥25 vs. <25 kg/m2), percent body fat (males ≥25 vs. <25%, females ≥30 vs. <30%), waist-to-hip ratio
(males ≥0.95 vs. <0.95, females ≥0.8 vs. <0.8), waist-to-height ratio (≥0.5 vs. <0.5), systolic blood pressure (≥120 vs. <120 mmHg) and diastolic
blood pressure (≥80 vs. <80 mmHg).
† - OR per 1 unit decrease in sleep efficiency.
a
Adjusted for time, sex, income and physical activity.
b
Adjusted for time, sex, employment status and physical activity.
c
Adjusted for time, sex and physical activity.
d
Adjusted for time, sex, physical activity and sleep latency.
e
Adjusted for time, age, sex and physical activity.
f
Adjusted for time, age, sex, race and physical activity.

studies have reported associations between anthro-
pometric indicators of obesity and either sleep, SJL
or chronotype, although inconsistencies in both the
analytical approaches and the results are apparent
(Parsons et al. 2015; Roenneberg et al. 2012). It has
been suggested that SJL may partially mediate the
relationships between chronotype and BMI (Culnan
and Kloss 2013). Adjustment for an intermediate
variable on a causal path, or adjustment for
confounders correlated with a main predictor, may
lead to overadjustment bias (Breslow 1982). Thus, in
the present analysis, relationships between chrono-
type, SJL or sleep measures and the outcomes were
first examined independently. Chronotype was asso-
ciated with sleep measures, but not with obesity or
elevated blood pressure; thus, it did not meet criteria
for confounding. Instead, relationships between
sleep and outcomes were modified by chronotype.
 CHRONOBIOLOGY INTERNATIONAL 11

Table 7. Relationships between sleep characteristics and outcomes measures stratified by latent chronotype group, Energy Balance
Study, Columbia, SC, 2011–2014.
Total sleep time
(referent: 6 to <7 h) Sleep efficiency Sleep onset latency Wake after sleep onset
<6 h ≥7 h <85% vs. ≥85% ≥12 vs. <12 min ≥60 vs. <60 min
Outcome Chronotype
measure group OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)
Body mass index Morning 0.98 (0.34–2.82)a 1.01 (0.42–2.44)b 1.12 (0.52–2.43)b 1.17 (0.55–2.51)c 0.88 (0.37–2.10)a
(kg/m2) Intermediate 1.63 (0.79–3.37)a 0.81 (0.45–1.47)a 0.99 (0.57–1.71)b 1.04 (0.62–1.75)c 1.26 (0.69–2.29)a
Evening 1.31 (0.33–5.27)a 1.77 (0.28–11.18)a 0.60 (0.17–2.11)b 1.26 (0.43–3.74)c 1.38 (0.39–4.86)a
pinteraction† 0.99 0.69 0.97 0.32
Percent body fat Morning 0.88 (0.30–2.57)b 0.69 (0.27–1.73)b 1.22 (0.53–2.84)d 1.73 (0.81–3.72)b 3.43 (1.35–8.72)b
Intermediate 0.83 (0.37–1.86)b 0.79 (0.40–1.56)b 0.80 (0.43–1.50)d 1.33 (0.73–2.41)b 0.71 (0.37–1.38)b
Evening 1.23 (0.28–5.48)b 0.59 (0.09–3.79)b 0.68 (0.14–3.30)d 1.18 (0.29–4.82)b 1.38 (0.30–6.26)b
pinteraction 0.92 0.64 0.84 0.03
Waist-to-hip ratio Morning 3.91 (1.19–12.84)e 1.39 (0.42–4.54)e 3.38 (1.07–10.69)e 2.13 (0.83–5.47)b 3.72 (1.38–10.07)b
Intermediate 0.66 (0.25–1.78)e 0.82 (0.37–1.80)e 0.95 (0.46–1.95)e 1.06 (0.54–2.10)b 0.67 (0.30–1.51)b
Evening 2.01 (0.19–21.28) 1.36 (0.16–11.59)e
e
0.20 (0.03–1.30)e 0.19 (0.03–1.20)b 0.42 (0.06–2.90)b
pinteraction 0.15 0.03 0.27 0.01
Waist-to-height Morning 1.59 (0.47–5.39)e 0.60 (0.21–1.72)e 1.89 (1.10–3.25)e 1.63 (0.94–2.84)f 2.21 (1.27–3.84)e
ratio Intermediate 1.76 (0.79–3.84)e 0.85 (0.42–1.70)e 0.87 (0.58–1.30)e 1.44 (0.96–2.18)f 0.81 (0.53–1.24)e
e
Evening 1.05 (0.22–5.09) 1.65 (0.26–10.31)e 0.95 (0.39–2.32)e 0.87 (0.37–2.09)f 1.28 (0.55–2.94)e
pinteraction 0.74 0.05 0.13 0.01
Systolic blood Morning 0.70 (0.36–1.38)e 0.65 (0.37–1.16)e 1.05 (0.63–1.75)b 1.90 (1.15–3.16)b 1.19 (0.67–2.09)e
pressure (mmHg) Intermediate 1.45 (0.85–2.46)e 1.09 (0.68–1.75)e 1.24 (0.81–1.89)b 0.90 (0.59–1.35)b 1.38 (0.87–2.18)e
e
Evening 2.51 (0.99–6.38) 2.31 (0.74–7.27)e 0.96 (0.41–2.22)b 0.63 (0.29–1.35)b 1.21 (0.55–2.66)e
pinteraction 0.17 0.95 0.02 0.93
Diastolic blood Morning 0.83 (0.38–1.81)b 1.51 (0.79–2.90)b 0.67 (0.38–1.20)b 0.83 (0.47–1.45)b 0.94 (0.50–1.78)e
pressure (mmHg) Intermediate 1.44 (0.81–2.54)b 1.46 (0.88–2.40)b 1.41 (0.90–2.22)b 1.40 (0.90–2.16)b 1.68 (1.05–2.71)e
Evening 1.15 (0.49–2.72)b 0.63 (0.20–2.01)b 0.72 (0.30–1.74)b 0.79 (0.36–1.73)b 0.73 (0.32–1.64)e
pinteraction 0.50 0.13 0.33 0.10
Cut-points for outcomes: body mass index (≥25 vs. <25 kg/m2), percent body fat (males ≥0.25 vs. <0.25, females ≥30 vs. <30), waist-to-hip ratio
(males ≥0.95 vs. <0.95, females ≥0.8 vs. <0.8), waist-to-height ratio (≥0.5 vs. <0.5), systolic blood pressure (≥120 vs. <120 mmHg) and diastolic
blood pressure (≥80 vs.<80 mmHg).
†pinteraction: p value for the interaction term between a sleep variable and chronotype group in adjusted statistical model.
a
Adjusted for time, sex, income and physical activity.
b
Adjusted for time, sex, physical activity.
c
Adjusted for time, sex, employment status and physical activity.
d
Adjusted for time, sex, physical activity and sleep latency.
e
Adjusted for time, age, sex and physical activity.
f
Adjusted for time, age, sex, race and physical activity.
OR: odds ratio; CI: confidence interval.

Since SJL was not associated with obesity or elevated
blood pressure, the potential mediating role of SJL
was not assessed.
A lack of association between chronotype and
BMI in the current study is consistent with find-
ings reported by others (Maukonen et al. 2017;
Parsons et al. 2015). Most other studies investigat-
ing relationships between circadian preference and
obesity found that evening types were more likely
to be obese compared to morning types (Culnan
et al. 2013; Wang 2014). However, in one large
cross-sectional study, morning circadian prefer-
ence was associated with increased BMI
(Roenneberg et al. 2012).
Similarly, SJL was not associated with any
anthropometric indices of obesity in the current
analysis. In prior cross-sectional studies, SJL was
associated with elevated BMI, fat mass and waist
circumference (Roenneberg et al. 2012; Valdez et al.
1996; Wong et al. 2015). In another study, SJL
predicted increases in BMI only among those who
were already overweight or obese (Roenneberg et al.
2012).
The present study used quantitative actigraphic
armband data to characterize SJL, whereas others
typically used self-report information to ascertain
sleep/wake timing. The present study had fewer
individuals with elevated absolute SJL relative to
other studies (≤1 h 49% vs. 31–37%, >1 h 51% vs.
63–69%, ≥2 h 16% vs. 26–30%, respectively)
(Roenneberg et al. 2012; Rutters et al. 2014).
Thus, it is possible that the 2-year study duration
12 D. M. MCMAHON ET AL.
was insufficient to detect changes in outcomes that
may have been related to SJL or chronotype.
In this population of relatively young healthy
adults, the increase in the proportion of those with
obesity relative to baseline was modest (~10%–
15% or less), while the proportion of participants
with elevated SBP decreased. Participants in the
present study gained an average of ~3 lbs over two
years, consistent with the Centers for Disease
Control and National Longitudinal Survey of
Youth 1979 (1990–2008), which reported that
young adults gain, on average, 1–2 lbs each year
(Fryar et al. 2012; Malhotra et al. 2013).
Discrepancies between this and other studies may
have been due to unexplained methodological dif-
ferences, residual confounding, differences in the
age distribution, or other population characteris-
tics. For example, young adults tend to have an
increased tolerance to shift work (Saksvik et al.
2011). Reasons for the discrepancies between this
analysis and some other studies also may have
been due in part to the accuracy of the indicators.
For example, BMI likely underestimates obesity
among those with BMI <30 kg/m2, particularly
among white and Hispanic women (Frankenfield
et al. 2001; Rahman and Berenson 2010), while it
also can overestimate obesity among some popula-
tions relative to percent body fat (Ode et al. 2007).
In a prior analysis of this population at baseline,
measures of sleep disturbance (lower SE, higher
WASO, longer TST) were associated with elevated
mean BMI (Wirth et al. 2015). The present analy-
sis employed conventional BMI categories widely
used to diagnose obesity along with sex-specific
cut-points for %BF and WHR, and the effects of
chronotype and SJL also were considered. The
repeated measures design used data from the
entire 2-year period and provided greater statisti-
cal power, although only modest increases in BF%
or WHtR were observed among those with sleep
disturbances (increased SOL, or decreased SE).
When an individual’s chronotype was incorpo-
rated into the analysis, relationships between poor
sleep and anthropometric measures were accentu-
ated among morning types; and those with dis-
rupted sleep had increased odds of total or
abdominal obesity. Morning types with a SOL
≥12 min also had increased odds of elevated SBP.
No increases in obesity or blood pressure were
observed among evening chronotypes despite pre-
vious evidence that poor sleep was more common
among evening types compared to others
(McMahon et al. 2018; Merikanto et al. 2012;
Patterson et al. 2018). The results are similar to
those from a recent population-based study where
morning types who had short or long sleep dura-
tion had an increased odds of being overweight or
obese relative to morning types with normal sleep
(7–8 h) (Patterson et al. 2018). However, increased
odds of being overweight or obese also were
observed among evening types with long sleep
durations (Patterson et al. 2018). Participants in
that study were older (mean age = 56.5,
SD = 8.1 years) and the cut-point for long sleep
was ≥9 h vs. ≥7 h in the current study (Patterson
et al. 2018).
Increased vulnerability to the detrimental effects
of sleep among morning types may be mediated by
physiological mechanisms controlling stress and
fat deposition. It has been reported that morning
chronotypes had higher baseline and postprandial
total cholesterol, lower low-density lipoprotein
and a higher adiponectin compared to intermedi-
ate or evening chronotypes (Merikanto et al.
2013). In the same study, participants with a
morning chronotype also had higher baseline glu-
cose levels and greater increases in postprandial
blood glucose levels compared to other chrono-
types (Merikanto et al. 2013). Others have
observed that morning chronotypes had a higher
cortisol awakening response relative to evening
types (Bailey and Heitkemper 2001; Kudielka
et al. 2006; Randler and Schaal 2010).
Short or fragmented sleep may initiate
a neuroendocrine stress response leading to
increased activity of the sympathoadrenal and
hypothalamic-pituitary axes, which in turn can
lead to increased blood pressure, impaired glucose
metabolism and abdominal obesity (Meerlo et al.
2008; Spiegel et al. 1999). People with disrupted or
short sleep had increased cortisol levels at night,
delayed cortisol response in the morning and
increased cortisol levels the following evening
(Meerlo et al. 2008; Spiegel et al. 1999). Based on
these observations, it is plausible that people with
a morning chronotype who also experience poor
sleep may have augmented cortisol secretion with
its accompanying metabolic consequences (e.g.

greater fat deposition) relative to those with only
one or the other of these conditions.
Recent research shows that various lifestyle fac-
tors such as diet composition, meal timing and
physical activity may differ by chronotype
(Maukonen et al. 2017; Mota et al. 2016; Munoz
et al. 2017). Evening types were less likely to
adhere to healthy diet, preferred energy-dense
foods over fruit and consumed significantly higher
amounts of energy, sucrose and saturated fat later
in a day relative to morning types (Maukonen
et al. 2017; Munoz et al. 2017). On weekends,
these differences were even more pronounced
with evening types having more frequent meals
at irregular times (Maukonen et al. 2017). In one
study, differences in meal content and timing
between chronotypes were modified by an indivi-
dual’s BMI (Munoz et al. 2017). Overweight or
obese participants with a morning chronotype
consumed high-calorie meals for dinner while eve-
ning types consumed them at breakfast and lunch,
a pattern opposite to that observed in the normal
weight stratum (Munoz et al. 2017). In the current
study, E-DII scores among morning types were
lower (anti-inflammatory) than in intermediate
and evening types, although among overweight
and obese participants, they were higher (more
pro-inflammatory) than among those with
a normal BMI. Obesity among morning chrono-
types may result from complex interactions
between several factors including diet, meal timing
and sleep disturbances.
This study had a few noteworthy limitations.
Participants’ work schedules and alarm clock use
were not available; thus, it was assumed that they
worked only on weekdays and were free on week-
ends. This assumption also was used in a recent,
nationally representative, cross-sectional study of
chronotype in US population (Fischer et al. 2017),
but it may have led to non-differential misclassifi-
cation of chronotype and SJL and likely biased
measures of association toward the null.
Approximately 45% of the participants in the cur-
rent study were graduate students who typically
attend classes and work part-time during the day.
Regular night work in this population is less likely
since it could potentially interfere with course-
work. Approximately 5–7% of the study sample
may have used an alarm clock on a weekend
CHRONOBIOLOGY INTERNATIONAL 13
(McMahon et al. 2018). To diminish the possible
influence of shift or weekend work on the study
results, participants with extreme or implausible
sleep schedules (TST values <4 h either on week
days, free days, or on average, or mid-sleep time in
the afternoon) were excluded (Levandovski et al.
2011; McMahon et al. 2018; Merikanto et al. 2012;
Roenneberg et al. 2012).
There is a possibility that objectively measured
wake-up time could have led to some overestima-
tion of morningness among those who woke up
earlier relative to their preferred time due to
insomnia. However, prevalence of morning and
evening chronotypes in this study population was
consistent with several populations in Europe and
in the United States within the same age range
(Allebrandt et al. 2014; Fischer et al. 2017;
McMahon et al. 2018). Also, participants of the
current study did not have any major acute or
chronic health conditions that could potentially
affect sleep, and those who regularly used sleep
promoting medications, both over the counter
and prescription, were excluded. Therefore, con-
founding by somatic conditions or sleep disorders
was unlikely to bias the results.
The generalizability of these results is limited to
healthy adults ages 21–35 years, half of whom were
college or graduate students with relatively low
incomes (<$40 000). Loss to follow-up by the end
of 2 years (19% and 44% during the first
and second years, respectively) may have intro-
duced selection bias. However, those who ended
the study early did not differ from those who
completed all five assessments with respect to sev-
eral demographic characteristics (Table S1). It is
possible that some individuals who were excluded
from the study, such as those with BMI >35 kg/m2
or who had arterial hypertension, had evening
chronotypes and poor sleep. This may explain, at
least partially, why no increased risk for obesity or
elevated blood pressure was observed among eve-
ning chronotypes. The study population was rela-
tively young and healthy, thus they also may have
been more resilient to the potential effects of poor
sleep or changes in sleep/wake timing on the study
outcomes.
One strength of this study was the use of acti-
graphic measurements to define SJL, chronotype
and sleep disruption, which avoids issues inherent
14 D. M. MCMAHON ET AL.
to self-reported data. Armband actigraphy is
a convenient, non-invasive and relatively inexpen-
sive method for quantifying sleep relative to the
“gold standard” method of polysomnography
(PSG) (Soric et al. 2013). Research suggests that
armband actigraphy is comparable with PSG at the
group level and at least as accurate as other acti-
graphic devices including
Motionlogger® (Ambulatory Monitoring, Inc.
Ardsley, NY) and Actiwatch2 (Philips Respironics,
Murrysville, PA) (O’Driscoll et al. 2013; Roane et al.
2015; Sharif and Bahammam 2013; Shin et al. 2015).
Compared to PSG, the armband underestimated
SOL while Actiwatch2 overestimated WASO at
ambient temperatures (17 °C and 22 °C) (Shin
et al. 2015). At the individual level, armband-
derived sleep measures may deviate from PSG
(Roane et al. 2015; Soric et al. 2013). The misclassi-
fication bias resulting from armband inaccuracy
would likely have been non-differential, leading to
an underestimation of the observed associations;
this also may have contributed to the null findings.
Nonetheless, associations between some actigraphic
measures and several outcomes were identified.
In this study, the armband measurements over
6–10 days were obtained, and information for non-
wear periods was augmented using logs completed
by participants. Only days with at least 80% of
verifiable time (based on data from armband and
activity logs) were included (McMahon et al. 2018),
thus minimizing potential measurement error. In
addition, use of repeated sleep measures throughout
the study increases their reliability within partici-
pants. Armbands with different serial numbers
were worn during different assessment periods.
Therefore, it is plausible that the measurement
error varied between time points within a given
participant. A previous analysis in this sample indi-
cated that sleep characteristics overall remained
stable within 2 years, and that participants did not
switch between distinct subgroups with different
sleep quality characteristics (McMahon et al. 2018),
suggesting that measurement error did not result in
significant misclassification.
Other study strengths included the use of gen-
der-specific cut-points for obesity, which decreases
potential misclassification of outcomes (Browning
et al. 2010; Lean et al. 1995; Shah and Braverman
2012), and a statistical modeling strategy that
accounted for correlated data within individuals
and bolstered statistical power. The RMLCA was
used to categorize participants into latent chron-
otype groups based on individual trajectories over
time. This “data-driven” approach provided clear
contrasts among those with different chronotypes.
In summary, results from this study indicated
that disrupted sleep had a modest association with
anthropometric measures of obesity and arterial
hypertension in a population of healthy, young
adults over a 2-year period, predominantly
among those with a morning chronotype. The
complex relationships between sleep, chronotype,
SJL, obesity and arterial hypertension deserve care-
ful examination in future studies.
Acknowledgment
The authors thank the study participants and the Energy
Balance Study team.
Disclosure statement
J.B.B. was supported by a Dept. of Veterans Affairs Office of
Research and Development grant (Merit Award: I01CX001182-
01A1). J.R.H. was supported by an Established Investigator
Award in Cancer Prevention and Control from the Cancer
Training Branch of the National Cancer Institute (K05
CA136975). M.D.W. and J.R.H. were supported by grant num-
ber R44DK103377 [N. Shivappa and M.D. Wirth, Multiple PIs]
from the National Institute of Diabetes and Digestive and
Kidney Diseases. S.D.Y. was supported by an NIH grant
(R01HL095799) and a Dept. of Veterans Affairs Office
ofResearch and Development grant (Merit Award:
5I01CX000898). S.N.B. serves on the scientific advisory boards
of Technogym, Clarity, and Santech. He has received research
funding from BodyMedia, Technogym, the U.S. Department of
Defense, and the NIH, and he receives book royalties from
Human Kinetics. G.A.H. has no disclosures. The Energy
Balance Study was funded by an unrestricted grant from Coca-
Cola Company. Coca-Cola representatives did not participate
in the data analyses, interpretation of the results or manuscript
preparation.
Funding
This work was supported by the National Institute of
Diabetes and Digestive and Kidney Diseases
[R44DK103377]; National Institutes of Health
[R01HL095799]; VA Merit [5I01CX000898]; Established
Investigator Award in Cancer Prevention and Control from
the Cancer Training Branch of the National Cancer Institute
[K05 CA136975]; Dept. of Veterans Affairs Office of

Research and Development grant [Merit Award:
I01CX001182-01A1].
References
Ainsworth BE, Haskell WL, Herrmann SD, Meckes N,
Bassett DR, Tudor-Locke C, Greer JL, Vezina J, Whitt-
Glover MC, Leon AS. 2011. 2011 compendium of physical
activities: a second update of codes and MET values. Med
Sci Sports Exerc. 43:1575–81.
Allebrandt KV, Teder-Laving M, Kantermann T, Peters A,
Campbell H, Rudan I, Wilson JF, Metspalu A,
Roenneberg T. 2014. Chronotype and sleep duration: the
influence of season of assessment. Chronobiol Int.
31:731–40.
Bailey BW, Allen MD, LeCheminant JD, Tucker LA,
Errico WK, Christensen WF, Hill MD. 2014. Objectively
measured sleep patterns in young adult women and the
relationship to adiposity. Am J Health Promot. 29:46–54.
Bailey SL, Heitkemper MM. 2001. Circadian rhythmicity of
cortisol and body temperature: morningness-eveningness
effects. Chronobiol Int. 18:249–61.
Breslow N. 1982. Design and analysis of case-control studies.
Annu Rev Publ Health. 3:29–54.
Browning LM, Hsieh SD, Ashwell M. 2010. A systematic review
of waist-to-height ratio as a screening tool for the prediction
of cardiovascular disease and diabetes: 0.5 could be a suitable
global boundary value. Nutr Res Rev. 23:247–69.
Cespedes EM, Dudley KA, Sotres-Alvarez D, Zee PC,
Daviglus ML, Shah NA, Talavera GA, Gallo LC, Mattei J,
Qi Q, et al. 2016. Joint associations of insomnia and sleep
duration with prevalent diabetes: the Hispanic Community
Health Study/Study of Latinos (HCHS/SOL). J Diabetes.
8:387–97.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA,
Izzo JL, Jones DW, Materson BJ, Oparil S, Wright JT, et al.
2003. The seventh report of the joint national committee on
prevention, detection, evaluation, and treatment of high
blood pressure: the jnc 7 report. JAMA. 289:2560–71.
Culnan E, Kloss JD (2013). Social jetlag as a mediator of the
relationship between chronotype and body mass index
[PhD diss.]. College of Arts and Sciences, Drexel
University, p. 103.
Culnan E, Kloss JD, Grandner M. 2013. A prospective study
of weight gain associated with chronotype among college
freshmen. Chronobiol Int. 30:682–90.
Fischer D, Lombardi DA, Marucci-Wellman H,
Roenneberg T, Tosini G. 2017. Chronotypes in the US–
influence of age and sex. PLoS One. 12:e0178782.
Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD,
Ogden CL. 2016. Trends in obesity among adults in the
United States, 2005 to 2014. JAMA. 315:2284–91.
Frankenfield DC, Rowe WA, Cooney RN, Smith JS, Becker D.
2001. Limits of body mass index to detect obesity and
predict body composition. Nutrition. 17:26–30.
CHRONOBIOLOGY INTERNATIONAL 15
Fryar CD, Gu Q, Ogden CL. 2012. Anthropometric reference
data for children and adults: United States, 2007-2010. In:
Vital and Health Statistics Series, Number 11. Data from
the National Health Survey. Washington DC: US
Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for
Health Statistics, p. 1–48. Available at: https://www.cdc.
gov/nchs/data/series/sr_11/sr11_252.pdf.
Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB,
Resnick HE, Punjabi NM. 2006. Association of usual sleep
duration with hypertension: the Sleep Heart Health Study.
Sleep. 29:1009–14.
Gu F, Xiao Q, Chu LW, Yu K, Matthews CE, Hsing AW,
Caporaso NE, Chang JS. 2016. Sleep duration and cancer
in the NIH-AARP diet and health study cohort. PLoS One.
11:e0161561.
Hand GA, Shook RP, Paluch AE, Baruth M, Crowley EP,
Jaggers JR, Prasad VK, Hurley TG, Hebert JR,
O’Connor DP, et al. 2013. The Energy Balance Study: the
design and baseline results for a longitudinal study of
energy balance. Res Q Exerc Sport. 84:275–86.
Hasler G, Buysse DJ, Klaghofer R, Gamma A, Ajdacic V,
Eich D, Rössler W, Angst J. 2004. The association between
short sleep duration and obesity in young adults: a 13-year
prospective study. Sleep. 27:661–66.
Hebert JR, Hurley TG, Chiriboga DE, Barone J. 1998.
A comparison of selected nutrient intakes derived from
three diet assessment methods used in a low-fat mainte-
nance trial. Public Health Nutr. 1:207–14.
Jones BL, Nagin DS. 2007. Advances in group-based trajec-
tory modeling and an SAS procedure for estimating them.
Sociol Method Res. 35:542–71.
Jones BL, Nagin DS, Roeder K. 2001. A SAS procedure based
on mixture models for estimating developmental
trajectories. Sociol Methods Res. 29:374–93.
Juda M, Vetter C, Roenneberg T. 2013. Chronotype modu-
lates sleep duration, sleep quality, and social jet lag in
shift-workers. J Biol Rhythms. 28:141–51.
Kim M. 2015. Association between objectively measured
sleep quality and obesity in community-dwelling adults
aged 80 years or older: a cross-sectional study. J Korean
Med Sci. 30:199–206.
Kudielka BM, Federenko IS, Hellhammer DH, Wüst S. 2006.
Morningness and eveningness: the free cortisol rise after
awakening in “early birds” and “night owls”. Biol Psychol.
72:141–46.
Lauderdale DS, Knutson KL, Rathouz PJ, Yan LL, Hulley SB,
Liu K. 2009. Cross-sectional and longitudinal associations
between objectively measured sleep duration and body mass
index: the CARDIA sleep study. Am J Epidemiol. 170:805–13.
Lean ME, Han TS, Morrison CE. 1995. Waist circumference
as a measure for indicating need for weight management.
BMJ. 311:158–61.
Levandovski R, Dantas G, Fernandes LC, Caumo W, Torres I,
Roenneberg T, Hidalgo MPL, Allebrandt KV. 2011.
Depression scores associate with chronotype and social
jetlag in a rural population. Chronobiol Int. 28:771–78.
16 D. M. MCMAHON ET AL.
Ma Y, Olendzki BC, Pagoto SL, Hurley TG, Magner RP,
Ockene IS, Schneider KL, Merriam PA, Hébert JR. 2009.
Number of 24-hour diet recalls needed to estimate energy
intake. Ann Epidemiol. 19:553–59.
Malhotra R, Ostbye T, Riley CM, Finkelstein EA. 2013.
Young adult weight trajectories through midlife by body
mass category. Obesity. 21:1923–34.
Malnick SD, Knobler H. 2006. The medical complications of
obesity. Qjm. 99:565–79.
Maukonen M, Kanerva N, Partonen T, Kronholm E,
Tapanainen H, Kontto J, Männistö S. 2017. Chronotype
differences in timing of energy and macronutrient intakes:
A population-based study in adults. Obesity. 25:608–15.
McMahon DM, Burch JB, Wirth MD, Youngstedt SD, Hardin
JW, Hurley TG, Blair SN, Hand GA, Shook RP, Drenowatz
C, et al. 2018. Persistence of social jetlag and sleep disruption in
healthy young adults. Chronobiol Int. 35:312–328.
Meerlo P, Sgoifo A, Suchecki D. 2008. Restricted and disrupted
sleep: effects on autonomic function, neuroendocrine stress
systems and stress responsivity. Sleep Med Rev. 12:197–210.
Merikanto I, Kronholm E, Peltonen M, Laatikainen T,
Lahti T, Partonen T. 2012. Relation of chronotype to
sleep complaints in the general Finnish population.
Chronobiol Int. 29:311–17.
Merikanto I, Lahti T, Puolijoki H, Vanhala M, Peltonen M,
Laatikainen T, Vartiainen E, Salomaa V, Kronholm E,
Partonen T. 2013. Associations of chronotype and sleep with
cardiovascular diseases and type 2 diabetes. Chronobiol Int.
30:470–77.
Mota MC, Waterhouse J, De-Souza DA, Rossato LT, Silva CM,
Araújo MBJ, Tufik S, de Mello MT, Crispim CA. 2016.
Association between chronotype, food intake and physical
activity in medical residents. Chronobiol Int. 33:730–39.
Munoz JSG, Canavate R, Hernandez CM, Cara-Salmerón V,
Morante JJH. 2017. The association among chronotype,
timing of food intake and food preferences depends on
body mass status. Eur J Clin Nutr. 71:736–42.
Nagin D. 2005. Group-based modeling of development.
Cambridge (MA): Harvard University Press.
Natale V, Plazzi G, Martoni M. 2009. Actigraphy in the assess-
ment of insomnia: a quantitative approach. Sleep. 32:767–71.
O’Driscoll DM, Turton AR, Copland JM, Strauss BJ,
Hamilton GS. 2013. Energy expenditure in obstructive sleep
apnea: validation of a multiple physiological sensor for deter-
mination of sleep and wake. Sleep Breath. 17:139–46.
Ode JJ, Pivarnik JM, Reeves MJ, Knous JL. 2007. Body mass
index as a predictor of percent fat in college athletes and
nonathletes. Med Sci Sports Exerc. 39:403–09.
Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-
Moran D, Kit BK, Flegal KM. 2016. Trends in obesity
prevalence among children and adolescents in the United
States, 1988-1994 through 2013-2014. JAMA. 315:2292–99.
Pabst SR, Negriff S, Dorn LD, Susman EJ, Huang B. 2009.
Depression and anxiety in adolescent females: the impact of
sleep preference and body mass index. J Adolesc Health.
44:554–60.
Parsons MJ, Moffitt TE, Gregory AM, Goldman-Mellor S,
Nolan PM, Poulton R, Caspi A. 2015. Social jetlag, obesity
and metabolic disorder: investigation in a cohort study.
Int J Obes (Lond). 39:842–48.
Patterson F, Malone SK, Grandner MA, Lozano A, Perkett M,
Hanlon A. 2018. Interactive effects of sleep duration and
morning/evening preference on cardiovascular risk factors.
Eur J Public Health. 28:155–61.
Rahman M, Berenson AB. 2010. Accuracy of current body mass
index obesity classification for white, black, and Hispanic
reproductive-age women. Obstet Gynecol. 115:982–88.
Randler C, Schaal S. 2010. Morningness-eveningness, habi-
tual sleep-wake variables and cortisol level. Biol Psychol.
85:14–18.
Roane BM, Van Reen E, Hart CN, Wing R, Carskadon MA.
2015. Estimating sleep from multisensory armband mea-
surements: validity and reliability in teens. J Sleep Res.
24:714–21.
Roenneberg T, Allebrandt KV, Merrow M, Vetter C. 2012.
Social jetlag and obesity. Curr Biol. 22:939–43.
Roenneberg T, Kuehnle T, Juda M, Kantermann T,
Allebrandt K, Gordijn M, Merrow M. 2007.
Epidemiology of the human circadian clock. Sleep Med
Rev. 11:429–38.
Rutters F, Lemmens SG, Adam TC, Bremmer MA, Elders PJ,
Nijpels G, Dekker JM. 2014. Is social jetlag associated with
an adverse endocrine, behavioral, and cardiovascular risk
profile? J Biol Rhythms. 29:377–83.
Saksvik IB, Bjorvatn B, Hetland H, Sandal GM, Pallesen S.
2011. Individual differences in tolerance to shift work–a
systematic review. Sleep Med Rev. 15:221–35.
Shah NR, Braverman ER. 2012. Measuring adiposity in
patients: the utility of body mass index (BMI), percent
body fat, and leptin. PLoS One. 7:e33308.
Sharif MM, Bahammam AS. 2013. Sleep estimation using
BodyMedia’s SenseWear armband in patients with
obstructive sleep apnea. Ann Thorac Med. 8:53–57.
Shin M, Swan P, Chow CM. 2015. The validity of Actiwatch2 and
SenseWear armband compared against polysomnography at
different ambient temperature conditions. Sleep Sci. 8:9–15.
Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert JR.
2014. Designing and developing a literature-derived,
population-based dietary inflammatory index. Public
Health Nutr. 17:1689–96.
Soric M, Turkalj M, Kucic D, Marusic I, Plavec D, Misigoj-
Durakovic M. 2013. Validation of a multi-sensor activity
monitor for assessing sleep in children and adolescents.
Sleep Med. 14:201–05.
Spiegel K, Leproult R, Van Cauter E. 1999. Impact of sleep debt
on metabolic and endocrine function. Lancet. 354:1435–39.
Theorell-Haglow J, Berglund L, Janson C, Lindberg E. 2012. Sleep
duration and central obesity in women - differences between
short sleepers and long sleepers. Sleep Med. 13:1079–85.
Valdez P, Ramirez C, Garcia A. 1996. Delaying and extending
sleep during weekends: sleep recovery or circadian effect?
Chronobiol Int. 13:191–98.

van Someren EJW. 2007. Improving actigraphic sleep esti-
mates in insomnia and dementia: how many nights?
J Sleep Res. 16:269–75.
Vgontzas AN, Fernandez-Mendoza J, Miksiewicz T,
Kritikou I, Shaffer ML, Liao D, Basta M, Bixler EO.
2014. Unveiling the longitudinal association between
short sleep duration and the incidence of obesity: the
Penn State Cohort. Int J Obes (Lond). 38:825–32.
Wang LL. 2014. Body mass index, obesity, and self-control:
a comparison of chronotypes. Soc Behav Personal. 42:313–20.
CHRONOBIOLOGY INTERNATIONAL 17
Wirth MD, Hebert JR, Hand GA, Youngstedt SD, Hurley TG,
Shook RP, Paluch AE, Sui X, James SL, Blair SN. 2015.
Association between actigraphic sleep metrics and body
composition. Ann Epidemiol. 25:773–78.
Wittmann M, Dinich J, Merrow M, Roenneberg T. 2006. Social
jetlag: misalignment of biological and social time. Chronobiol
Int. 23:497–509.
Wong PM, Hasler BP, Kamarck TW, Muldoon MF,
Manuck SB. 2015. Social jetlag, chronotype, and cardio-
metabolic risk. J Clin Endocrinol Metab. 100:4612–20.