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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 »

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What Smoking Cessation Does To Your Metabolism

One of the most pervasive problems with quitting cigarettes, is the accompanying weight gain – in fact, post-cessation weight gain is reportedly the number one reason why smokers, especially women, fail to stop smoking or relapse after stopping. But what exactly happens when you stop smoking? This is the topic of a comprehensive review article by Kindred Harris and colleagues published in Nature Reviews Endocrinology. The paper begins by examining the magnitude of weight gain generally experienced after smoking cessation – an amount that can vary considerably between individuals. As for mechanisms, the authors note that, “Several theories have been proposed to explain increased food intake after smoking cessation. One theory is that the ability of nicotine to suppress appetite is reversed. Substitution reinforcement, which replaces the rewards of food with the rewards of cigarettes could occur. Nicotine absence increases the rewarding value of food. Reward circuitries in the brain, similar to those activated by smoking, are activated by increased intake of food high in sugar and fat. Furthermore, nicotine withdrawal leads to an elevated reward threshold, which might cause individuals to eat more snacks that are high in carbohydrates and sugars.” There are also known effects of smoking on impulsive overeating and individuals with binge eating disorder are at risk of even greater weight gain with cessation. Smoking cessation also has metabolic effects including a drop in metabolic rate that may promote weight gain and new evidence shows that smoking cessation can even change your gut microbiota. The authors provide evidence that behavioural interventions can prevent much of the cessation weight gain and argue that such programs should be offered with cessation programs. Finally, it is important to always remember that the health benefits of smoking cessation by far outweigh any health risks from weight gain, which is why fear of weight gain should never stop anyone from quitting. @Drsharma Edmonton, AB

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Leading The Charge In Addressing Weight-Bias in Canada

In 2008, the Canadian Obesity Network’s  Board of Directors identified weight bias and stigma as one of the Network’s top strategic priority. The board firmly believes that everyone deserves to be treated with respect and dignity independent of size. To this end, the Network is working hard towards reducing weight bias and stigma through research, education and action. The following are just some of the examples resulting from the Network’s many collaborates with researchers, patients, knowledge users and partners to develop education initiatives and practitioner resources to address weight bias in health care settings, the media and public policies: Incorporated weight bias and stigma in all CON-RCO education and knowledge exchange programs such as the Canadian Obesity Summits (2009, 2011, 2013, 2015 and biennially thereafter); Dietitian Learning Retreats (2010-present); Canadian Obesity Student Meetings (2010, 2012, 2014); Obesity Research Summer School (formerly known as Obesity Research Boot Camp); Obesity Management Certificate for Post-Graduates (2013-2015). In collaboration with health services and primary care experts, CON-RCO has developed the 5As of Obesity Management framework to support primary care practitioners in their interactions with patients with obesity. This was a two-year initiative supported by the Canadian Institutes of Health Research (Knowledge Translation Supplement Grant) and the Public Health Agency of Canada (Innovation Strategy Grant). The resources incorporate weight bias sensitivity training and have now been adapted for pediatric and pregnancy populations. CON-RCO under the leadership of Dr. Mary Forhan, associate professor, University of Alberta, Faculty of Rehabilitation Medicine, Department of Occupational Therapy, coordinated the first Canadian Weight Bias and Discrimination Summit in Toronto, Ontario (January 2011). The purpose of the summit was to raise awareness about weight bias and discrimination as it relates to obesity and its association to the health and well being of Canadians.  The event drew a capacity crowd of 150 health professionals, students, policy makers, industry representatives, and educators who heard from an expert panel of eight speakers from Canada and the United States. CON-RCO partnered with the Canadian Institutes of Health Research to inform a Canadian Bariatric Research Agenda, which included a priority on weight bias and discrimination. CON-RCO and the Public Health Agency of Canada collaborated to poll CON-RCO members to identify and counteract some of the most common obesity myths.  Results of this study were published and disseminated to CON members and partners. CON-RCO partnered with the Rudd Centre for Food Policy and Obesity to develop an image bank to combat stigmatizing images of people with obesity in the media. In 2012, CON-RCO partnered with the World Obesity Federation (formerly known as International Association for the… Read More »

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Mental Health Issues In Patients Seeking Bariatric Surgery

There is no doubt that bariatric surgery is currently the most effective long-term treatment for severe obesity, however, there is also some evidence to suggest that patients seeking bariatric surgery (or for that matter any kind of weight loss) are more likely to have accompanying mental issues that individuals with obesity who don’t and that such issues may affect the outcomes of surgery. Now, a paper by Aaron Dawes and colleagues from Los Angeles, CA, published in JAMA presents a meta-analysis of mental health conditions among patients seeking and undergoing bariatric surgery. They identified 68 publications meeting inclusion criteria: 59 reporting the prevalence of preoperative mental health conditions (65,363 patients) and 27 reporting associations between preoperative mental health conditions and postoperative outcomes (50,182 patients). Among patients seeking and undergoing bariatric surgery, the most common mental health conditions, each affecting about one-in-five patients were depression and binge eating disorder. However, neither condition was consistently associated with differences in post-surgical weight outcomes. Nor was there a consistent relationship between other mental health conditions including PTSD or bipolar disease and post-surgical outcomes. Interestingly, bariatric surgery was consistently associated with a significant decrease in the prevalence and/or severity of depressive symptoms. So what do these findings mean for clinical practice? As the authors note, “Guidelines from the American Society for Metabolic and Bariatric Surgery and the Department of Veterans Affairs/Department of Defense recommend routine preoperative health assessments, including a review of patients’ mental health conditions. Other groups advocate for a more comprehensive, preoperative mental health examination in addition to the general evaluation currently performed by medical and surgical teams. The results of our study do not defend or rebut such a recommendation.” So why are these data not clearer than they should be? Here is what the authors have to offer: “Much of the difficulty in determining the effectiveness of preoperative mental health screening is due to the limitations of current screening strategies, which use a variety of scales and focus on mental health diagnoses rather than psychosocial factors. Previous reviews have suggested that self-esteem, mental image, cognitive function, temperament, support networks, and socioeconomic stability play major roles in determining outcomes after bariatric surgery. Future studies would benefit from including these characteristics as well as having clear eligibility criteria, standardized instruments, regular measurement intervals, and transparency with respect to time-specific follow-up rates. By addressing these methodological issues, future work can help to identify the… Read More »

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Why Does The Food Addiction Model of Obesity Management Lack Good Science?

Yesterday’s guest post on the issue of food addiction (as expected) garnered a lively response from readers who come down on either side of the discussion – those, who vehemently oppose the idea and those, who report success. Fact is, that we can discuss the pros and cons of this till the cows come home, because the simple truth is that the whole notion lacks what my evidence-based colleagues would consider “strong evidence”. Indeed, I did try to find at least one high-quality randomized controlled study on using an addictions approach to obesity vs. “usual” care (or for that matter anything else) and must admit that I came up short. The best evidence I could find comes from a few case series – no controls, one observer, nothing that would compel anyone to believe that this approach has more than anecdotal merit. Yet, the biology (and perhaps even the psychology) of the idea is appealing. Self-proclaimed “food addicts” that I have spoken to readily identify with the addiction model and describe their relationship to “trigger foods” as an uncontrollable factor in their lives that calls for complete abstinence. Animal studies confirm that foods do indeed stimulate the same parts of the brain that are sensitive to other hedonic pleasures and substances. So why the lack of good data? After all, the idea is hardly new – intervention programs for “food addicts” using the 12 steps or other approaches have been around for decades. Can it be simply the lack of academic interest in this issue? I find that hard to imagine – but nothing would surprise me. Is it perhaps because addiction researchers do not take obesity seriously and obesity researchers don’t like the addiction model? I certainly don’t buy the argument that there is no commercial interest in such an approach – if there were strong and irrefutable evidence, I’m sure someone would figure out how to monetize it. So again, I wonder, why the lack of good data? Honestly, I don’t know. I’m open to any views on this (especially if substantiated by actual evidence). @DrSharma Berlin, Germany

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