Is ADHD Sabotaging Your Weight Management Efforts?

Are you an impulsive eater? Do you have a hard time meal planning or keeping a food journal? Do you find it hard to remember if you had breakfast or not (never mind what you actually ate)? Do you start every new diet or exercise program with super enthusiasm, only to lose interest a few days later? Does your day lack a routine (for no good reason)? These are just some of the ways in which Attention Deficit Hypertactivity or just Attention Deficit Disorder (ADHD/ADD) can sabotage your efforts to control your weight. Now, an article by Philip Asherson and colleagues from Kings College London, UK, published in The Lancet Psychiatry discuss important conceptual issues regarding the diagnosis and management of ADHD/ADD in adults. Although ADHD/ADD is largely thought to be a problem in kids and youth, it remains a considerable and often undiagnosed issue in adults. Thus, as the authors point out, “…treatment of adult ADHD in Europe and many other regions of the world is not yet common practice, and diagnostic services are often unavailable or restricted to a few specialist centres.” This is all the more surprising (and disappointing) given that adult patients respond similarly to current drug and psychosocial interventions, with the same benefits seen in children and adolescents. With regard to diagnosis it is important to note that, “Symptoms of ADHD cluster together into two key dimensions of inattention and hyperactivity-impulsivity, are reliably measured, and are strong predictors of functional impairments, but they reflect continuous traits rather than a categorical disorder.” “Of particular relevance to adult ADHD is the relative persistence of inattention and improvements in hyperactive-impulsive symptoms during development, so that many patients who had the combined type presentation of ADHD as children present with predominantly inattentive symptoms as adults.”  “In clinical practice, the continuous nature of ADHD should not present diagnostic difficulties in moderate-to-severe cases, but might cause difficulties in mild cases with more subtle forms of impairment. Careful attention is needed to assess the effect of ADHD symptoms on impairment and quality of life, including an understanding of the broader range of problems linked to ADHD (eg, executive function [self-regulation] impairments, sleep problems, irritability, and internal restlessness), in addition to functional impairments such as traffic accidents and occupational underachievement. Therefore, some individuals, who seem to function well, might nevertheless suffer from a substantial mental health problem related to ADHD.” Key criteria according to… Read More »

All Obese Patients Should Be Screened For ADHD

Regular readers will recall previous posts on the association between attention deficit disorder (ADD) and obesity. As this condition significantly affects impulse control, ability to plan, perseverance, time management, and many other factors and skills essential for weight management, this relationship should be no surprise. In our own clinical experience (as suggested in several recent publications from others), managing ADD can often be the key step to managing weight gain. Once you start systematically screening patients for ADD in an obesity clinic, it seems to be present in a surprisingly large number – almost 20-30%. This number is consistent with the findings of another study, this time by Bruno Palazzo Nazar and colleagues from the Federal University of Rio de Janeiro, Brazil, published in the Journal of Attention Disorders. The study sample consisted of women seeking nonsurgical treatment of obesity at a public endocrinology hospital with an eating disorders and obesity clinic, in Rio de Janeiro. One hundred and fify-five consecutive patients presenting in the clinic were approached for this study. Exclusion criteria included less than 5 years of schooling/inability to read and fill out forms and questionnaires; current alcohol or drug abuse, history of bipolar or psychotic disorder; current treatment with psychoactive drugs; and presence of uncontrolled clinical, neurological, or endocrine disorders, especially if they interfere with weight, appetite, and attention; and patients older than 60 years. Based on a battery of validated questionnaires and semi-structured interviews, 28.3% of patients were diagnosed with ADD, which, in turn, was significantly correlated with more severe binge eating, bulimic behaviors, and depressive symptoms. As the authors note, this rate of almost 30% is far higher than the expected rate of less than 5% in the general population. In fact, given the rather rigorous exclusion criteria, the actual prevalence of ADHD in this patient set may actually be even higher. As a clinician, I’d certainly support the notion that we should be aware of the high prevalence of ADHD in patients presenting in obesity programs. Making this diagnosis and managing this issue, may make all the difference in long-term outcomes. AMS Cambridge, UK photo credit: Peter Vidrine via photo pin cc Nazar BP, Pinna CM, Suwwan R, Duchesne M, Freitas SR, Sergeant J, & Mattos P (2012). ADHD Rate in Obese Women With Binge Eating and Bulimic Behaviors From a Weight-Loss Clinic. Journal of attention disorders PMID: 22930790 .

Energy Expenditure in ADHD Kids

I have repeatedly posted on the relationship between Attention Hyperactivity Deficit Disorder (ADHD) and obesity. We see a remarkable number of adults with this disorder in our bariatric clinic and, as blogged before, treating this disorder is often a key step in helping these patients manage their weight. In kids, this disorder is often characterized by substantial hyperactivity, which would be expected to burn more calories. But what about the impact of ADHD on resting energy expenditure (REE) and the thermogenic effect of food (together accounting for about 60% if not more of the daily calories burnt)? This question was addressed by my colleague Thomas Mueller and other researchers from the University of Alberta in a paper just published online in Eating and Weight Disorders. Mueller and his team studied 12 pre-pubertal boys with untreated ADHD of the hyperactive-impulsive type and 12 control boys without ADHD. In addition, they examined an independent group of 60 boys with ADHD. On average, REE was 6.5 kcal/kg fat free mass/day higher in the ADHD compared to the control group. However, there was no difference in the thermogenic effect of food between groups. Neither age nor restlessness explained the differences in REE. Despite the higher REE (and likely higher activity energy expenditiure due to the innate restlessness that comes with this condition), boys with ADHD had similar BMI levels compared to non-ADHD reference groups. Thus, this paper shows that despite a notably greater energy expenditure, ADHD kids are not generally leaner, clearly suggesting that they manage to make up for their greater energy needs through higher caloric intake. One may well speculate that as these kids become older and their REEs (and activity expenditures?) decrease, persistence of a higher caloric intake than their non-ADHD peers may well make them more prone to obesity as adults. How and why REE is elevated in ADHD clearly deserves further study. I’d certainly appreciate hearing from any of my readers, who have experience with the ingestive behaviour of ADHD kids. AMS Burlington, Ontario

Still More on ADHD and Obesity

In response to yesterday’s post on ADHD and obesity, I was made aware of two recent studies, both relevant to this topic. In the first, A psycho-genetic study by Caroline Davis and colleagues from York University, Toronto, Ontario, Canada, published in the Journal of Psychiatric Research, the researchers examined whether ADHD symptoms were more pronounced in adults with symptoms of binge eating disorder (BE) than in their non-binging obese counterparts, and whether the links were stronger with inattentive vs impulsive/hyperactive symptoms. They also assessed the role of the dopamine D3 receptor in ADHD symptoms since the DRD3 gene has been associated with impulsivity and drug addiction – both relevant features of ADHD. In the study that involved 60 cases and 120 controls (60 obese and 60 normal weight), childhood and adults ADHD symptoms were assessed and genotying was performed. While all of the four ADHD symptom scales were significantly elevated in the BE and obese groups compared to the normal weight group, bearers of three DRD3 genotypes had significantly elevated scores on the hyperactive/impulsive symptom scale. These results suggest that symptoms of ADHD are more common in obese individuals (irrespective of BED status) and that the D3 receptor may play a role in the manifestation of the hyperactive/impulsive symptoms of ADHD. In another study, published in this month’s issue of OBESITY by Lance Levy and colleagues from the Nutritional Disorders Clinic, also in Toronto, Ontario, Canada, they describe their success in treating refractory obesity in severely obese adults following the management of newly diagnosed attention deficit hyperactivity disorder. 78 subjects out of 242 consecutively referred severely obese, weight loss refractory individuals were diagnosed as having ADHD, of which 65 received ADHD treatment and 13 remained as controls. After an average of 466 days of continuous ADHD pharmacotherapy, weight change in treated subjects was -12% of initial weight versus a 3% weight gain in controls. This study not only confirms that ADHD is a highly prevalent condition in severely obese patients, but that the treatment of ADHD is associated with significant long-term weight loss in individuals with a lengthy history of weight loss failure. Levy suggests, as I did in earlier postings on this topic, that ADHD should be considered as a primary cause of weight loss failure in obese patients. As he points out, this finding may also be important for patients seeking obesity surgery, as surgical patients with unmanaged… Read More »

ADHD, BED and Obesity in US Adults

In my clinical practice I remain impressed by the surprisingly high incidence of attention deficit hyperactivity disorder (ADHD) in my obese patients. Many have had symptoms all their lives, many have kids diagnosed and treated for ADHD, but have never considered that they may have this condition themselves. Long-time readers of this blog will recall several previous postings on this issue – there is little doubt that ADHD is a major handicap in dealing with a weight problem. Lack of impulse control, difficulty planning and following through on lifestyle changes, compliance problems – all make it difficult for someone with ADHD to tackle their weight problem. But how close is the relationship between ADHD and obesity in the general population? Based on previous observations that while ADHD affects ~2.9-4.7% of US adults, this condition is reported to be present in 26-61% of patients seeking weight loss treatment, Sherry Pagoto and colleagues from the University of Massachusetts, MA, USA, revisited this issue in a paper published in this month’s issue of OBESITY. Using cross-sectional data from the Collaborative Psychiatric Epidemiology Surveys, which includes data from 6,735 US residents (63.9% white; 51.6% female) aged 18-44 years, a retrospective assessment of childhood ADHD and a self-report assessment of adult ADHD were administered. The prevalence of overweight and obesity was 33.9 and 29.4%, respectively, among adults with ADHD, and 28.8 and 21.6%, respectively, among persons with no history of ADHD. Thus, adult ADHD was associated with a 58% greater likelihood of overweight and 81% greater likelihood of obesity. Further analyses suggested that binge eating disorder (BED), but not depression, partially mediates the associations between ADHD and excess weight. This is not surprising, given that poor impulse control is likely to affect binge-eating behaviour. The study underlines what I have long proposed: assessment for ADHD should be part of routine work up for obesity and weight-related health problems. When present, ADHD can pose a major barrier to obesity management and should be addressed by CBT and/or medications. AMS Edmonton, Alberta