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

Can Diabetologists Take On Obesity Care?

For the past 30 years or so, I have given countless talks to diabetologists urging them to pay more attention to obesity management – all to little avail.  Interestingly enough, now, that we have new effective medications for obesity, which come with loads of pharma funding for research, education and conferences and as we near the end of significant new pharmacological developments in diabetes care, we are witnessing a sudden surge in interest amongst diabetologists and their professional organisations in taking on obesity as part of their “portfolio”. This is good!  Not only is there considerable overlap between patients with type 2 diabetes (T2DM) and those with obesity (indeed, it is hard to find a T2DM patient without obesity), effective treatment of obesity can lead to substantial improvements in glycemic control (and even complete remission of T2DM), and the incretin-based medications for obesity are also of use for managing T2DM.  Moreover, given the sheer number of diabetologists out there, together with the rather extensive and well-established infrastructures for diabetes care, expanding their mandate to also managing obesity appears a logical and long-overdue step. However, there are some important caveats.  For one, the majority of people with obesity do not have diabetes and will probably never get it. For these individuals, going to  a diabetes centre would seem strange, given that glycemic control is the least of their worries.  Anyone who has any experience with obesity medicine knows that people presenting at obesity and bariatric centres are rarely there because they are concerned about their HbA1c levels. Their problems are chronic pain, sleep apnea, infertility, polycystic ovary syndrome, fatty liver disease, urinary stress incontinence, osteoarthritis, GERD, migraines, and a host of other issues that have nothing to do with glycemic control.  Furthermore, a substantial proportion of patients presenting at bariatric centres have depression, anxiety, ADHD, BED, history of trauma, chronic grief, addictions, internalised weight bias, and plain old emotional eating, all of which need to be properly diagnosed and managed as part of obesity care.  Finally, no one can claim to have expertise in obesity medicine, who is also not comfortable with the pre- and post-surgical management of patients undergoing bariatric surgery (so far, despite strong evidence, diabetologists have rarely referred a patient for bariatric surgery never mind getting involved in their post-surgical care). While there is no reason why diabetologists should not be able to learn about and attend to… Read More »

Is Obesity Best Managed by Generalists?

Obesity is complex and few medical professionals have any formal background or training in obesity management. Furthermore, the range of problems that patients can present with (potentially affecting every organ system and mental health as well as socio-ecomonic aspects), is rather broad, thus requiring expertise across a wide range of disciplines.  These circumstances have of course fostered the notion that obesity is best managed by specialists – ideally working in a multidisciplinary team that includes dietitians, exercise specialists and clinical psychologists. While there is little doubt that health care providers, who have undergone specific training in obesity medicine, will likely do a much better job of managing patients with obesity that a doctor with no such experience or training, it is quite unrealistic to expect that we will ever have enough obesity specialists to address the needs of the millions of patients living with this chronic disease.  Indeed, the vast number of people living with obesity means that it would be entirely unrealistic to expect that any speciality, be it endocrinology or cardiology, will ever have the capacity to handle this vast demand.  Thus, as with other common chronic diseases (such as hypertension or diabetes), the vast majority of patients with obesity will have to be managed by their family doctor in primary care.  As it turns out, this may not be a bad thing. In fact, given the broad nature of medical and psychosocial challenges presented by these patients, the fact that it can occur throughout the lifespan, and the need for life-long management, one may well argue that family medicine is indeed the discipline best suited to managing the vast majority of patients living with obesity.   In contrast to specialists, who by nature tend to focus their care on their respective specialty, family doctors tend to be generalists who are just as comfortable managing hypertension or diabetes as they are managing depression, anxiety, chronic pain, or any of the other multitude of issues that can make obesity management challenging.  Thus, while a cardiologist may primarily focus on controlling hypertension, a diabetologist may focus on optimising glycemic control, a pulmonologist may focus on sleep apnea, a hepatologist may focus on NAFLD, and a psychiatrist may focus on depression or ADHD, a family doctor would probably step back and look at the “big picture” thereby prioritising and integrating the various aspects of care across disciplines, while also taking into consideration… Read More »

Setting Up an Obesity Program: Importance of Having a Diagnostic and Consultant Network

Irrespective of what services you can integrate into your obesity clinic, there will always be issues that require consultation with other specialists or require diagnostic procedures outside your clinic. Or, as I learnt early in my medical practice, the two most important skills of being a good doctor are knowing when to consult a colleague and knowing who to consult.  Areas in which any obesity clinic will most likely need regular consult services include psychiatry, sleep medicine, gastrointestinal medicine and hepatology, thrombosis, uro-gynaecology, respiratory medicine, cardiology, orthopaedic surgery, plastic surgery and a few others. Common diagnostic requirements will include ultrasounds, cardiac testing, CTs, MRIs, etc.  In all cases, you will find colleagues who are happy to see patients with obesity and those who are not. You will also find that certain diagnostic procedures have technical or weight limitations for patients with obesity. Ideally you would be able to identify at least one colleague in each of these disciplines who will welcome patients with obesity into their clinics and are willing to work closely with you in helping your patients deal with these issues.  Be aware that it may take time for colleagues to recognise and adapt to the special needs of this population. Not everyone is comfortable practicing bariatric psychiatry, bariatric cardiology, or bariatric plastic surgery. Over time, hopefully, these colleagues will come to appreciate the issues specific to patients with obesity.  A good source of determining whether or not your patients with obesity are welcomed and well treated are your patients themselves. Sometimes patients will complain about a specific consultant or practice and in my experience it is often worthwhile bringing this to their attention, as they may be unaware of how their attitude or statements are being received. Sometimes the complaints may not be about the colleagues themselves but rather about their clinic personnel or even just about the ambience and infrastructure.  Many colleagues will thank you for this feedback and many will change their practice. In cases where patients continue to complain, you may be better off looking for a new consultant for that specific issue.  One important reason for having competent consultants at hand is, because patients presenting at an obesity centre may often have problems that need to be dealt with before you can have any hope of helping them manage their obesity. This includes patients with unmanaged or uncontrolled psychiatric issues like depression, anxiety, or… Read More »

Setting Up An Obesity Program: Medical Expertise and Leadership

Now that we’ve looked at some of the issues around gathering administrative support for setting up an obesity program, we must turn our attention to the next key step, i.e. finding personnel to staff the program. This of course starts with finding appropriate leadership for the program – be it medical or surgical.  Today, thanks to the proliferation of bariatric surgery, finding surgical leadership for a bariatric program is in many ways far less challenging than finding medical leadership. Indeed no one would today consider hiring a bariatric surgeon who has never performed such operations to run a program. Bariatric procedures are now increasingly listed in many licensing catalogues for general abdominal surgery. There are also an increasing number of surgical bariatric centres, which regularly train residents and fellows. Thus, finding a trained bariatric surgeon to establish and lead a bariatric surgery program is rather straightforward.  In contrast, finding experienced and qualified medical leadership for an obesity centre is far more challenging. For one, while you would require a surgeon to have performed a certain number of bariatric procedures (hopefully in the hundreds) before claiming expertise in the area, no such requirements exist for other health professionals.  Thus, there is currently no accepted pathway or minimal requirement that would stop any medical professional who takes an interest in this field from setting up their own “weight-management” program.  As in my case, when I embarked on running my first obesity clinic two decades ago, I had no specific training or experience in obesity medicine – in fact the term “obesity medicine” was not even around yet. All I had was a bunch of, what I then thought were, good ideas, an interest in the field, and strong administrative support to do something in this area.  My story is by no means unusual. Most of my colleagues in this field had little, if any, formal training in obesity medicine and had little more than good intentions and a lot of hope and determination when they set out to work in this area. Many were guided by their own personal “weight-loss-success” stories, their strong interest in “preventive medicine”, or simply their fascination with healthy eating and/or exercise. Few had ever worked in an actual obesity program. Even fewer had completed a formal fellowship or had any kind of training or certification in this field.  Given that there is no accepted pathway to obesity medicine,… Read More »