For years, ADHD experts have recognized the link between untreated ADHD and obesity. As for many weight-control experts and gastric-bypass surgeons, well, they must have missed the memo. Is it territorial jealousy? Willful ignorance? “ADHD Denial”?
Let’s be charitable and call it one more casualty of our highly specialized medical system. That is, most GI docs aren’t connected to most brain docs aren’t connected to most hormone docs, and down the line. (As for some sleep docs’ determination to ignore ADHD’s role in sleep challenges, that’s for another post.)
In February, a new study came from two Toronto-based clinicians and researchers seeking to bridge this cross-disciplinary knowledge. Physician Lance Levy and psychologist John Fleming set out to determine whether attention deficit hyperactivity disorder (ADHD) pharmacological treatment of severely obese subjects with newly diagnosed ADHD would result in sustained weight loss. (In short, yes it did.)
Digesting the Research
Here’s a bite of the abstract (by the way, refractory means “hard or impossible to manage” and comorbid means co-existing):
RESULTS: Comorbid conditions were found to be highly prevalent (sleep apnea 56.4%, binge eating disorder 65.4%, mood disorder 88.4%). After an average of 466 days (s.d.=260) of continuous ADHD pharmacotherapy, weight change in treated subjects was -12.36% of initial weight and in controls +2.78%, P<0.001. Weight loss in treated subjects was 15.05 kg (10.35%) and weight gain 3.26 kg (7.03%) in controls, P<0.001.
CONCLUSIONS: ADHD is a highly prevalent condition in the severely obese population. Treatment of ADHD is associated with significant long-term weight loss in individuals with a lengthy history of weight loss failure. This result is likely because of the positive effects of treatment on self-directedness, persistence and novelty-seeking behaviors. ADHD should be considered as a primary cause of weight loss failure in the obese. Individuals seeking medical or surgical weight loss should be evaluated for ADHD and treated appropriately before intervention. This may improve the outcome for medically managed patients and avoid
complications in surgical subjects because of poor compliance with diet and supplement requirements.
International Journal of Obesity advance online publication, 17 February 2009; doi:10.1038/ijo.2009.5
And here’s a 2005 study from the same team:
Symptoms of attention deficit hyperactivity disorder in severely obese women
OBJECTIVE:
Past and current symptoms of Attention Deficit Hyperactivity Disorder (ADHD) were assessed in a clinical sample of severely obese females.
METHOD: Core symptoms of ADHD were examined in 75 consecutive, severely obese (BMI > or = 35) women referred to a medical specialist for the non-surgical treatment of obesity. Subjects completed both a retrospective report of childhood symptoms of ADHD (Wender Utah Scale) and two standardized adult ADHD symptom scales.
RESULTS: The frequency of clinically suggestive elevations in ADHD scores was substantially and significantly higher than the normative samples in 9 out of 11 symptom subscales. Inattentive symptoms, but not hyperactive symptoms of ADHD, were frequently reported. Overall, 26.7% of the sample reported significant symptoms of ADHD in both childhood and adulthood.
CONCLUSIONS: This preliminary study suggests that severely obese women report significant symptomatology related to both childhood and adult ADHD.
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I first read about this topic in a chapter (“Disordered Eating and ADHD,” contributed by Levy and Fleming) of Gender Issues and ADHD: Research, Diagnosis, and Treatment, edited by Patricia Quinn, M.D. and Kathleen Nadeau, Ph.D. 2002. (You can purchase the book or just the chapter here, and while you’re at it, check the other great hard-to-find resources for women with ADHD).
(By the way, psychologist Kathleen Nadeau, and physician Patricia Quinn teamed up originally to address the long-overlooked needs of women and girls with ADHD, founding The National Center for Girls and Women with ADHD. In the process — through their many books, lectures, and other efforts — this pioneering pair has expanded our knowledge in all aspects of ADHD, across genders and the lifespan. So, it’s not at all surprising to know they were on the vanguard of creating awareness on this ADHD-obesity issue. I can assure you that many men with untreated ADHD also suffer problems with keeping their weight in check.)
What Exactly is the Connection Between ADHD and Weight Challenges?
Consider this excerpt from article written by Nadeau, entitled “Diet and Weight Management Strategies for Adults with ADD (ADHD).”
“The ADHD/disordered eating connection is not difficult to understand. Healthy dietary regulation requires organization and planning – two areas of cognitive functioning that are typically difficult for those with ADHD. Good eating habits also require self-awareness – awareness of when one is hungry, awareness of when one is full. Many individuals with (ADHD) report that they skip meals because they were busy and distracted; these same individuals often report that later their hunger becomes so intense that they swing in the opposite direction, overeating well beyond the point of reasonable intake because they don’t know when to stop until they feel ‘stuffed.’ And individuals eat for many reasons besides hunger – including boredom, self-stimulation, anger, sadness, reward, simple food availability, and stress relief. It is easy to understand how consistent self-regulation, which is a well-documented difficulty for those with ADD (ADHD), can lead to patterns of chronic over-eating.”
The websites for Dr. Levy and Dr. Fleming include informative articles and video interviews.
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How about you? Do you think ADHD has affected your or your partner’s ability to maintain a healthy weight? (And remember: some people with ADHD might be chronically underweight for reasons similar to those who are overweight — lack of planning, not paying attention to internal phenomenon, etc.)
Tags: ADHD and obesity; ADHD and weight-management, ADHD research, John Fleming, Kathleen Nadeau, Lance Levy, Patricia Quinn
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Gina,
Excellent piece, as usual, – so timely and so accurate as we move further down the path of identifying how ADHD can create destructive medical issues downstream from compromised executive function. Others include hormone dysregulation, downstream from high glycemic diets [seen with polycystic ovarian syndrome, even in adolescents], high blood pressure and diabetes [nutritionally related], and many others.One interesting additioinal insight, seen quite often in my office, on this same theme of weight gain and ADHD, may prove helpful for your readers:
I have seen many who suffer with ADHD *gain weight* on medicatioins – as a consequence of the following interaction between neurotransmistters:
With comorbid depression and ADHD some simply want the depression addressed, and just don’t want to treat with a stimulant – ADHD denial is firmly in place. They will take the SSRI or SNRI, but not the necessary stimulant for the ADHD.The outcome is predictable and happens often: They gain weight on the fact that the SSRI or SNRI appears to downregulate [lower] the effectiveness of the pre frontal dopamine, with a subsequent drop in executive function – simply stated their ADHD intensifies. Good judgement about food is lost, compulsive eating can intensify.
Dopamine and serotonin appear to be sitting on both ends of a seesaw, when one goes up, the other can go significantly down – as is seen with children who have comorbid depression. Untreated, the depression almost always intensifies with stimulant meds – resulting in a big emotional crash in the PM.
Said another way on the weight issue: The downregulation of the dopamine is associated with downregulation of executive function and they become: disinhibited. Not inhibited, – disinhibited… it just doesn’t matter. And on top of eating without reservation, they are forgetting the name of their best friend, and can’t remember the first part of the sentence – all related to this downregulatory phenomenon.
The basic fix: Treat the ADHD simultaneously now or later, perferrably at the outset. Antidepressants just don’t fix ADHD, they aggravate it. Effective executive function is necessary for consistent self regulation… as you have so frequently pointed out.
Great article, thanks again for your thoughts on this important challenge,
Chuck -
The 2009 Levy/Fleming study raises a couple of questions for me….
1. Were these people given a diet to follow, or were they left to devise their own? (If the latter, then that’s a *hell* of an effective ADHD treatment they were given, and I’d like to know where to get some of that!)
2. Was anything done to address “rebound hunger,” a fairly common problem associated with long-acting stimulants?
And of course, I’d love to see a follow up. My suspicion is that the ADHD dieters will probably perform pretty much the same as non-ADHD dieters, i.e. 95% regain all the lost weight after 5 years.
As a proponent of body acceptance and Health At Every Size, I believe that an individual’s weight or body size is not necessarily a good indicator of their current health or an accurate predictor of future disease. I wish that public health authorities, and the media, would stop focusing on weight loss and instead put the focus on good food choices and enjoyable, appropriate exercise. These are health-promoting habits in their own right, and beneficial for everyone to adopt, even if weight loss does not result. That said, permanent habit change of this nature can be tremendously difficult even for those of us with no deficits in PFC function, and from what I have seen it is an absolute nightmare for people with ADHD. Even when they are diagnosed and treated, they seem to need a lot of outside structure and support in order to effect and maintain positive lifestyle changes. That’s why I’m so curious about the dietary intervention used in this particular study.
My partner has ADHD and has wished to lose weight since adolescence. She has dieted three times, each time eventually regaining the lost weight plus a bit more (just like most other people). She is nowhere near “severely obese” as described by Levy/Fleming, and AFAIK she has never been a severe junk food junkie as described by Nadeau. But despite her high intelligence, *and* ADHD medication, the executive demands of meal planning, food shopping and cooking are extremely stressful for her and take up an inordinate amount of time – or they don’t get done at all if she is the least bit busy. When I came to live with her I took on the food related duties, partly because I enjoy cooking and partly to relieve her of what was obviously a great burden in her life. She only seems able to stick to a structured eating program if someone else does all the planning, shopping and cooking for her. “Intuitive eating,” favored in the body acceptance community, does not seem possible for her – with intuitive eating, there is simply too much choice every day, and that is overwhelming.
As far as exercise, again, she seems to need a very great deal of support and motivation from outside – otherwise she simply does not find the time, despite knowing that exercise is beneficial in myriad ways. I used to provide a lot of this support and motivation, but I have recently given up. I’m tired of trying to get somebody off the couch. I need to attend to my own body, and if she doesn’t want to leave the couch that is, in the end, her problem.
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Thanks for weighing in, Dr. Parker. “Downstream” is right — we definitely need more cross-disciplinary knowledge with ADHD.
I’m so glad that you explain the serotonin-dopamine teeter-totter. (When I explain it to people in the ADHD support groups, they look a little skeptical — they’ve never heard such a thing from their physician — so it’s great to hear it from a medical expert!) I hope you’ll discuss this in your upcoming book on ADHD medication strategies.
Do you think the PM crash is primarily caused by untreated “serotonin issues?”
What do you think about B vitamin deficiency also being a culprit in the PM crash (or so-called rebound)? -
Hi Otto,
Good points about Health at Every Size. I am certainly starting to accept my own changed size from earlier years — what a relief!
Good health is what’s important, and if people can’t get organized enough to shop/cook/eat-well or motivate themselves to exercise, it’s hard to be healthy.
Given Dr. Parker’s example of the dopamine-serotonin teeter-totter, it perhaps follows that treating ADHD without treating a person’s depression, anxiety or other serotonin issue can have a similar effect, in that it could aggravate anxiety or depression. So, if the person with ADHD who is taking a stimulant still gets stressed out about food preparation and the like, then maybe anxiety is the bigger (or at least unaddressed) diet-related problem for this person.
At any rate, here’s what the study says about the role of dietary intervention:
“Subjects in both treated and control groups had an extensive
history of dietary interventions and were judged by the
clinic’s dietitian to be very familiar with diet concepts. Only
50% of subjects had one meeting with the dietitian, and only
five of these subjects, all from the treatment group, reported
substantial adherence to the written menu plans after the
first month. Records of dietary adherence were not kept after
that time, as the data were too few to be significant.”And one more point that seems relevant:
“III. Why weight loss occurred synchronously with the relief of
ADHD symptoms.“The subject’s recollections of failed past efforts at weight loss
highlighted how daily demands on their time and energy
frustrated their weight loss plans. Typically new diet plans were
launched with great intensity, and a lot of wishful thinking,
about how they would fit everything in. To find time for new
diet and activity requirements, most subjects put off some
routine tasks and often went with less sleep. However, it was
clear that within a few weeks they could not cope with
competing demands and gave up, relapsing to old habits.
Many individuals linked their failure to feelings of boredom
and frustration with the mundane and repetitive demands of
managing/deciding what to eat, shopping, cooking and paying
attention to diet and activity plans. Every diet plan they tried
ended in exactly the same way and for the same reasons.
However, our analysis was that enduring problems with
inattention, distractibility, impulsivity, restlessness, an inconsistent
level of available energy, and poor working memory
substantially interfered with time management and task
completion. Subjects habitually suspended ‘boring’ weight loss
related plans to gravitate toward tasks that were more urgent,
more intrinsically stimulating or that had a greater likelihood
of immediate success, as these were tasks that allowed them to
function most effectively.“Once pharmacotherapy treatment was begun, we anticipated
that improvements would occur in exactly those symptoms of
ADHD that were most detrimental to successful weight loss.
Careful inquiry was made as medication was titrated to
determine the mechanism by which changes in symptoms of
ADHD might have resulted in improved compliance with diet
and physical activity plans over time. A distillation of our
subject’s comments showed that improvements in daytime
energy, restlessness, distractibility, working memory, impulsivity
and mood were instrumental in their successful execution
of weight loss plans. Most often, improvements occurred in the
order in which they had been listed.“Fundamentally, drug treatment led to improvements in selfdirectedness,
a reduction in novelty seeking, and an increased
capacity for persistence. An improved ability to be selfdirected
was noted first, and this is a trait that is important
for attaining any goal. As daytime energy improved, and
restlessness and distractibility diminished, subjects could more
consistently initiate behaviors congruent with their ultimate
goal of weight loss. For example, they did not use food as
before to restore energy or to focus attention. They could stay
on task and finish their work expeditiously so that tasks related
to meal preparation or physical activity could be done reliably.
Subjects reported being more able to pay attention while
eating, so that they were aware of the signals of hunger and
fullness much sooner than before, allowing for better control
over the amount consumed.“The second change was that subjects showed improvement
in control over novelty seeking and had a much greater
ability to be persistent in a task. Control over both of these
traits is highly important to success in a long-term project,
such as weight loss.“As an example, subjects on medication reported that they
felt calmer, less restless, and less impelled to seek intense,
novel, and unplanned stimuli than ever before. Thus,
feelings that earlier had led them to leave one task to begin
a newer one, and generally one not congruent with a
previously determined long-term goal, did not intrude and
undermine their weight loss plans. Impulsive choices of food
were curtailed, and exercise plans were not forgotten in favor
of novel entertainment. With enhanced persistence, many
felt they were able to continue with or elaborate new
problem-solving strategies, as well as tolerate negative mood
states, rather than using food or engaging in other impulsive
actions to quickly relieve that distress.” -
G,
My current investigations are several in regards to the *PM drop* – and this is my current take, based on what works regularly in the office, and from the labs:1. *Office findings:* Yes comorbid diagnosis of depression is often present with the PM drop, but missed because ADHD ‘depression’ is often more cognitive and missed – just as is ADHD ‘anxiety’ – again more cognitive… and all of this is spelled out in my new book, thanks for asking.
The unhappy result of the missed depressive diagnosis, because the ‘Clint Eastwood’ guy or gal hates depression and denies it, – is a big crash in the PM. Actually the stimulant aggravates the depression, and they go from cognitive: “I do not care, whatever.” to… affect: “You have really hurt my feelings! I am in so much pain with you!” – but they still say, I’m *not* depressed – I’m just mad!! Depression is seen as weakness.
2. *Lab findings:* I have been impressed by the neurotransmitter findings we do on refractory and otherwise challenging cases with ADHD: comorbid conditions often don’t show in the office even with careful questioning, but the biomarkers from urine testing are helpful from http://ww.Neurorelief.com These findings often show 5HTP diminished as part of the ADHD picture. Evidence counts.
Lab: Neurotransmitter findings are derided by some who see the findings as *not diagnostic* – a point that the company and I completely agree upon. They are not indeed diagnostic of DSM 4 process. 5HTP [serotonin precursor] deficiencies don’t always look like depression, the can result in OCD symptoms, trichotillomania, or many other problems like ODD. But, they do work as effective biomarkers, and we have seen correction of these imbalances result in some dramatic turnarounds – even with tic disorder.
SPECT imaging gets the same heat because it is *not diagnostic* – and is, in fact, another, quite precise, biomarker. The problem with evolving evidence is simple: You can’t go from one cookie cutter diagnosis like ‘depression’ to another cookie cutter finding with a subsequent cookie cutter recommendation.
Some of my SPECT colleagues aggravate the use of evidence as they leave the recommendation piece in ‘cookie cutter land’ rather than taking the investigation to the next important level: clinical outcome functioning.
Understanding the limitations of SPECT will help with the consternation some have with neurotransmitter testing. – All of these activities are quite similar to lipid testing for coronary heart disease: not diagnostic but clearly useful.
More in my blog soon,
Thanks for your excellent work!
Chuck -
Dr. Parker,
Thank you very much for participating in this discussion. As I’ve learned more about ADHD over the years I’ve found that it wasn’t just as simple as adding a stimulant due to aggravation of anxiety issues I didn’t even initially realize I had. I’m trying to work my way through it and have made significant progress, but I hope to read your book and see if there is more in it that might apply to me. Thanks again…
– Carl
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Gina,
I came on this post just now. I am reminded of the retrospective study conducted by my colleague and office mate Jules Altfas, MD (who I consider to be our local best-doc for AD/HD in adults).He looked at the records of a number of his weight management patients who he also diagnosed (very conservatively) with Ad/HD. The study was published in 1992 and so far as I know, did not receive wide attention.
Here’s the URL (my skills stop short of inserting links).
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=130024
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One more thing: Paul Elliott, MD from Texas, a one-time luminary/maverick in the field of AD/HD treatment (since retired I believe), asserted at many national conferences that anytime there is substance abuse of any kind (inc. cigarettes, coffee) except for hallucinogenics, AD/HD should be presumed present until ruled out.
Ten years ago this created a lot of discomfort and skepticism. I imagine it would do less of that, now.
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The information is very informative and has helped at least narrow down why, in layman’s terms, in the evening I have to stop reading my book, put it down and make a special effort to get a snack (and all the time not wanting one because I am not hungry and wish the urge wasn’t there). I do have ADHD and Tourettes Syndrome so it is unbelievably difficult. I only take Concerta on the weekends because my tics would be out of control at work during the week. I am 61 and nothing has slowed down with age. I do appreciate the fact that the medical profession is taking this seriously and involved with so much research.
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HI Jacqueline,
I’m glad you found the post helpful. I know that some people are able to find solutions that don’t trigger the tics. I would encourage you to keep searching. Perhaps at Dr. Parker’s blog. http://www.corepsychblog.com
In the meantime, I feel for you. It’s hard enough to find ADHD treatment that works well, without having to deal with tics.
Good luck!
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