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
In Obesity Variety is Bad
Humans are omnivores and apparently our hunter-gatherer ancestors ate an extraordinary range of plant and animal foods. The advent of culinary skills and use of spices and seasonings further enhanced the variety, taste, flavour, appearance, texture and consistency of foods. Today, the apparently limitless choice of foods in our supermarkets, restaurants and homes is a sure sign of the importance we place on variety and variation when it comes to eating. When trying to manage your weight, however, variety may be your downfall. This at least is the gist of a recent study by Ramona Guerrieri and colleagues from the Department of Experimental Psychology, Maastricht University, in The Netherlands, who examined the interaction between impulsivity and a varied food environment and its influence on on food intake and overweight, published in the International Journal of Obesity. The study is based on two observations: 1) Our current food environment offers a large variety of cheap and easily available sweet and fatty foods and 2) Impulsive people may be reward sensitive and are generally less successful at inhibiting prepotent responses (i.e. a response that is or has been previously associated with positive reinforcement) Using a rather complicated experimental design masquerading as a taste test, Guerrieri and colleagues studied 78 healthy primary school children (age: 8-10 years) regarding two aspects of impulsivity: reward sensitivity and deficient response inhibition. The kids were studied in two groups: one was offered rather monotonous foods; the other was offered foods varied in colour, form, taste and texture. As expected, reward sensitivity interacted with variety. In the “monotony group” there was no difference in food intake between the less and more reward-sensitive children (183 kcal+/-23 s.d. versus 180 kcal+/-21 s.d.). However, in the “variety group” the more reward-sensitive children ate almost 70% more calories than the less reward-sensitive children (237 kcal+/-30 s.d. versus 141 kcal+/-19 s.d.). While reward sensitivity in itself was not linked to overweight, deficient response inhibition (a measure of impulsivity) was. Clearly, the kids with poor impulse control were handicapped when it came to dealing with variety. Why is this important? What the data suggest is that kids (and adults?) who have poor impulse control are more likely to overeat when faced with variety. Therefore, the incredible variety and choices of food that we have available to us, may indeed be a major factor in the problem of overeating. As blogged previously, attention deficit disorders… Read More »
Does Maternal Obesity Promote ADHD?
Regular readers of my blog know about the risk of increased pre-pregnancy weight and pregnancy-induced weight gain for mother and child. Readers may also recall my posting on the potential importance of recognizing attention deficit disorder (ADD) as a common and important barrier to obesity treatment. This month, a new study by Alina Rodriguez and colleagues from the University of Upsalla, Sweden, published in the International Journal of Obesity, may help bring it all together. Rodriguez and colleagues examined whether pregnancy weight (pre-pregnancy body mass index (BMI) and/or weight gain) is related to core symptoms of attention deficit hyperactivity disorder (ADHD) in school-age offspring. They analyzed data from three separate prospective pregnancy cohorts from Sweden, Denmark and Finland within the Nordic Network on ADHD. Maternal pregnancy and delivery data were collected prospectively. Teachers rated inattention and hyperactivity symptoms 12 556 school-aged offspring in relationship to maternal weight measures. While gestational weight gain was unrelated to ADHD rate, the researchers found significant associations between pre-pregnancy overweight or obesity and a high ADHD symptom score in offspring, ORs ranged between 1.4 and 1.9 fold higher despite adjustment for gestational age, birth weight, weight gain, pregnancy smoking, maternal age, maternal education, child gender, family structure and cohort country of origin. Children of women who were both overweight and gained a large amount of weight during gestation had a 2-fold risk of ADHD symptoms compared to normal-weight women. Although the authors carefully note that associations do not prove causality, they do point out that if future studies prove causality, then we may need to add ADHD to the list of deleterious outcomes related to maternal overweight and obesity in the prenatal period. It would certainly explain why ADHD is so common in patients battling overweight and obesity. AMSEdmonton, Alberta
Please Pay Attention – You May be Obese
There are over 50 recent publications in PubMed on the possible link between Attention Deficit Disorder (ADD) and obesity. In my own anecdotal experience I continue to be surprised on how many patients presenting with obesity have clear signs of this disorder. They are usually the patients who show up late for appointments because they locked their keys in their cars, did not fill the last prescription for their metformin because they lost it, started filling out food records but never got past the first day, used their new bike only once because they never got around to fixing the flat tire from their first ride, take a packed lunch to work but forget to eat it, enthusiastically start a new diet but lose interest three days later because weight loss is too slow – I could go on forever – you probably get the picture. In my practice I have come to recognize that ADD is probably one of the most common and frustrating barriers to obesity management. By definition, individuals with ADD lack the ability to plan ahead and to follow through on their plans, easily lose interest, and are constantly sabotaged by their impulsiveness when it comes to making healthy choices. There is now evidence to support the notion that alterations in the dopaminergic reward system may be common to both ADD and hedonistic hyperphagia. Not surprisingly there is some work showing that methylphenidate (ritalin) can sometimes reduce cravings for sweet and fatty foods. It does not surprise me that someone with ADD is probably more prone to “mindless eating” and thus more likely to gain weight than someone with proper impulse control. One of the most remarkable cases I recall was a patient, who after being started on ritalin, at his next visit for the first time brought in and proudly presented meticulously completed food records (he was also a couple of pounds lighter). In medicine it is always easiest to blame the patient – not motivated, not interested, not focused, not following instructions, not compliant, not adherent, etc. Recognizing that this behavior may be due to ADD and providing proper treatment for this condition may in these cases be the first step to obesity management. AMS
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