For years, ADHD experts recognized the link between untreated ADHD and obesity. As for weight-control experts and gastric-bypass surgeons? Maybe they missed the memo. Or, is it territorial protection?
Let’s be charitable. Consider it one more casualty of our highly specialized medical system. One that too often overlooks undiagnosed ADHD’s contributions to many physical issues.
At the end of this post, I’ll link to another post sharing the results of a large study finding ADHD as a risk factor in most chronic conditions, including these:
- Alcohol-related liver disease
- Sleep disorders
- Chronic obstructive pulmonary disease (COPD)
- Fatty liver disease
ADHD & Obesity: Closely Correlated
In short, research increasingly points to a strong correlation between ADHD and obesity.
How strong a correlation? Someone with ADHD is four times more likely to become obese than is someone without ADHD. Brain chemistry, poor impulse control, difficulty organizing shopping and preparing meals, and erratic sleeping habits all conspire to encourage unhealthy eating — and to make weight loss feel or be impossible.
The implications are clear: Treating ADHD early means many people could avoid these disabling illnesses and conditions. Even treating ADHD later, after these conditions have set in, could still help reverse or at least slow disease progression while also treating ADHD symptoms, perhaps for the first time.
Takeaway Points On ADHD & Obesity
- Stimulant medication can reduce vulnerability to obesity for people with ADHD
- Eating can be “stimulating” — and medication can provide a more reliable, regulated form of stimulation
- Chronic disorganization means no food at home, poor inclination to cook, plan meals, etc….so eat fast food or whatever’s handy (chips, donuts, etc.)
- Forgetting when last ate!
- Weak internal signals (e.g. Body says, “we’re full now” but you don’t hear it or can’t act upon it…you can’t “put on the brakes”)
- Poor sleep contributes, too
- Disorganization and lack of follow-through in getting regular exercise
Considering Surgeries? Screen for ADHD First
Anyone considering drastic weight-loss or sleep-apnea surgeries should first consider screening for ADHD. Don’t expect that your weight-loss specialist or surgeon or sleep specialist will know how to recognize ADHD.
Commonly, we see disordered eating attributed largely to psychological issues — such as trauma, anxiety, unresolved childhood issues, willfulness, attention-getting. No matter how many of those torturous A&E shows I’ve watched, ADHD hasn’t even been on the radar.
This Post Covers:
Below you’ll find four categories of information on this topic:
- Early research on ADHD and obesity
- Words from veteran ADHD expert who early on spotted the ADHD-obesity connection
- More recent research
- Links for further reading
1. Early Research Findings: ADHD and Obesity
Toronto-based psychologist John Fleming, Ph.D is among the first researchers to link ADHD and weight gain.
In 2009, physician Lance Levy, MD joined Fleming in attempting to answer this question: Will medically treating severely obese subjects with newly diagnosed ADHD result in sustained weight loss?
Here are the summaries for their two early studies:
- The 2005 study evaluated for ADHD 76 women referred to a medical specialist for the non-surgical treatment of obesity. Of the 76 women, 26.7 percent reported significant symptoms of ADHD in both childhood and adulthood
- The 2009 study found that among study students who had been unable to lose weight by other means, 33 percent were found to have ADHD. After 466 days of stimulant-medication treatment, subjects lost 13 percent of their original weight.
Now let’s examine the details for each study.
2005: 27% of Obese Female Study Subjects had ADHD
The paper: 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.
- 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.
2009: ADHD Highly Prevalent in the Obese Population; Treatment Helps
The first study (2009) identified subjects who had a history of difficulty with weight-loss and who likely had ADHD. The hypothesis? Untreated ADHD was proving an impediment to weight loss.
The paper: Treatment of refractory obesity in severely obese adults following management of newly diagnosed ADHD
(For reference, refractory means “hard or impossible to manage” and comorbid means co-existing.)
Objective: To determine whether attention deficit hyperactivity disorder (ADHD) pharmacological treatment of severely obese subjects with newly diagnosed ADHD would result in sustained weight loss.
Design: Longitudinal clinical intervention study of the effects of ADHD medication on weight change over 466 days.
Subjects: 78 subjects (6 male, 72 female, mean age 41.3 years, BMI 42.7 kg m(-2)) out of 242 consecutively referred severely obese, weight loss refractory individuals were diagnosed as having ADHD. Sixty-five subjects received treatment and 13 remained as controls.
- Standard screening tests identified subjects likely to have ADHD. A diagnosis was made in 78 subjects by semi-structured clinical interview.
- ADHD subjects were screened for comorbid conditions. That would include binge eating disorder, mood disorder, sleep apnea, chronic pain, and gastroesophageal reflux disease.
- Satisfactory resolution of symptoms of comorbid conditions was achieved prior to the introduction of pharmacotherapy for ADHD.
- Subjects not accepting, tolerating or remaining on ADHD medication served as controls.
- Weight was measured at sequential clinic visits after initiation of pharmacotherapy.
Comorbid [or, co-existing] 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.
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 due to 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 undergo evaluation 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.
2. Early Writings: ADHD and Eating Patterns
I first read about this topic in 2002, in a book chapter called “Disordered Eating and ADHD.” Fleming and Levy contributed the chapters to the groundbreaking Gender Issues and ADHD: Research, Diagnosis, and Treatment, edited by Patricia Quinn, M.D. and Kathleen Nadeau, Ph.D. 2002.
Psychologist Kathleen Nadeau and developmental pediatrician Patricia Quinn teamed up originally to address the long-overlooked needs of women and girls with ADHD. They founded The National Center for Girls and Women with ADHD [update: closed in 2013].
In the process —through their many books, lectures, and other efforts — this pioneering pair expanded our knowledge in all aspects of ADHD. Across genders and the lifespan. [See a recent post about their new book, Understanding Girls with ADHD: A Must-Read about Girls with ADHD.]
Therefore, it’s unsurprising that Quinn and Nadeau stood on the vanguard of creating awareness on this ADHD-obesity issue.
Excerpt of Early Article
Consider this excerpt from an early article written by Nadeau, entitled Diet and Weight Management Strategies for Adults with ADD (ADHD) [no longer available online]
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.”
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.
3. More Recent Research: ADHD and Obesity
More recently, the literature is mounting on the relationship between ADHD and eating behaviors.
Consider three more recent papers, starting with the most recent.
2021: Half of the children with ADHD and obesity studied reach normal weight with stimulants
Lead researcher Jovanna Dahlgren, MD, is a pediatrics professor at Sweden’s University of Gothenberg. Her research covers a range of topics; she is not an ADHD specialist. Perhaps her cross-disciplinary knowledge aided her ability to make the connections here.
Half of the children with overweight or obesity and attention-deficit/hyperactivity disorder reach normal weight with stimulants
Aim: Treatment of childhood obesity is often insufficient and may be aggravated by high co-occurrence of attention-deficit/hyperactivity disorder (ADHD). We aimed to investigate whether children with overweight or obesity normalised in weight when receiving stimulant treatment for ADHD.
Methods: Growth data of 118 children were obtained from medical records at outpatient paediatric and children’s psychiatric services in the Gothenburg area, Sweden. The children were diagnosed with ADHD and were between 6 and 17 years at the start of stimulant treatment. The pre-treatment data act as an internal control where every child is their own control.
Results: At the start of treatment, 74 children had normal weight and 44 had either overweight or obesity. During the year with stimulants, the mean (SD) body mass index (BMI) in standard deviation score (SDS) decreased significantly: -0.72 (0.66) compared with 0.17 (0.43) during the year before treatment (p < 0.01). After one year with treatment, 43% of those with overweight or obesity had reached normal weight.
Conclusions: Stimulant treatment for ADHD yields significant weight loss. In children with overweight or obesity and ADHD, this is an important finding showing additional benefit in terms of weight management.
2016: Attention-Deficit Disorder and Obesity
Here are some highlights from Attention-Deficit Disorder and Obesity: Update 2016, by Samuele Cortese and Luca Tessari.
- We retained a total of 41 studies, providing information on the prevalence of obesity in individuals with ADHD, focusing on the rates of ADHD in individuals with obesity, or reporting data useful to gain insight into possible mechanisms underlying the putative association between ADHD and obesity.
- Overall, over the past 4 years, an increasing number of studies have assessed the prevalence of obesity in individuals with ADHD or the rates of ADHD in patients with obesity.
- Although findings are mixed across individual studies, meta-analytic evidence shows a significant association between ADHD and obesity, regardless of possible confounding factors such as psychiatric comorbidities.
- An increasing number of studies have also addressed possible mechanisms underlying the link between ADHD and obesity, highlighting the role, among others, of abnormal eating patterns, sedentary lifestyle, and possible common genetic alterations. Importantly, recent longitudinal studies support a causal role of ADHD in contributing to weight gain.
- The next generation of studies in the field should explore if and to which extent the treatment of comorbid ADHD in individuals with obesity may lead to long-term weight loss, ultimately improving their overall well-being and quality of life.
2015: Association between ADHD and Obesity: A Systematic Review and Meta-Analysis
Also from a team headed by Samuele Cortese: Association between ADHD and Obesity: A Systematic Review and Meta-Analysis.
- Forty-two studies that included a total of 728,136 individuals (48,161 ADHD subjects; 679,975 comparison subjects) were retained.
- Researchers found a significant association between obesity and ADHD for both children (odds ratio=1.20, 95% CI=1.05-1.37) and adults (odds ratio=1.55, 95% CI=1.32-1.81).
- The pooled prevalence of obesity was 70% higher in adults with ADHD (28.2%, 95% CI=22.8-34.4) compared with those without ADHD (16.4%, 95% CI=13.4-19.9), and by about 40% in children with ADHD (10.3%, 95% CI=7.9-13.3) compared with those without ADHD (7.4%, 95% CI=5.4-10.1).
- The significant association between ADHD and obesity remained when limited to studies
- reporting odds ratios adjusted for possible confounding factors;
- diagnosing ADHD by direct interview; and
- using directly measured height and weight.
- Gender, study setting, study country, and study quality did not moderate the association between obesity and ADHD.
- ADHD was also significantly associated with overweight.
- Individuals medicated for ADHD were not at higher risk of obesity.
Links to More about ADHD & Disordered Eating:
Dr. Fleming’s website includes informative articles and video interviews, including articles on these topics:
- Weight Management with ADD: Understanding the Problem and Finding ADD-Friendly Solutions
- ADHD and Disordered Eating
- Symptoms of attention deficit hyperactivity disorder in severely obese women
Dr. Levy wrote this book: Understanding Obesity: The Five Medical Causes
Related Topic: Nicotine
Remember a few decades ago when millions more Americans smoked cigarettes? Remember when smokers complained of gaining weight every time they tried to quit? Nicotine is a fairly effective (if highly problematic) stimulant. I wrote about this topic here: ADHD & Nicotine: Historical Ads.
How About You?
Do you suspect that ADHD has affected your or your loved one’s ability to regulate eating?
And remember: Some people with ADHD might be chronically underweight for reasons similar to those who are overweight. Consider similar challenges with lack of planning, not paying attention to internal phenomenon, and simply finding eating boring. A chore to get through.
I’ve known several late-diagnosis adults with ADHD—rail-thin all their lives—who gained weight once they started stimulant medication. What? We only hear about stimulants resulting in weight loss, not gain. They gained weight because, among, they could finally pay attention to internal phenomenon and they could taste more flavors. Food became more interesting, instead of just a chewing exercise.
This post originally appeared 4/27/09. Updated 8/1/21 and again 9/24/22
I welcome your comments.
23 thoughts on “ADHD and Obesity: Reviewing the Research”
I wish I had seen this article 2 years ago when I was contemplating bariatric surgery. I don’t regret the decision to have the gastric sleeve but I always assumed AD/HD and weight gain were opposed to one another, likely because hyperactivity would be the driving force for burning excess calories. As a young child I was normal weight but around 3rd grade I started putting on the pounds and by fifth grade was told by an impetuous female classmate that I needed a training bra because of my ‘boy-boobs’. The self-identity those years and my adolescence suffered greatly.
I was never diagnosed pre-adulthood as having AD/HD, but now, as a PMHNP student and an RN for almost 10 years I have learned that I should have been. After my surgery 18 months ago my weight eventually got to 89 lbs lost and my behavior more impulsive. I was less reserved. My interactions with people more open, particularly at work, which led to some poor decision making. This landed me in a new depression from which I had been clearly awakening. I have long associated my depression with my obesity. But I never considered my obesity might be a result of untreated AD/HD. There were two other periods in my life where my weight came back down to more normal levels and in each case I experienced less self-regulation and increased impulsivity. I just assumed it was always based on my obesity-induced depression being lifted by activity and weightloss which also led to increased selfworth.
I have leveled out at 70 lbs lost since my surgery. Thanks to a patient wife, an openmindedness toward psychotherapy, and addiction recovery programs, I feel more in tune with who I am and value myself more than I have at any other time in my adulthood. And thanks to a terricific PCP, my ADD is not as impactful as it once was, particularly in keeping me from avoiding tasks that require a great deal of tedious work and study. The one thing I will say is that amphetamine use is not a desired intervention on my part, though I do use it at times as needed. The change in my tolerance level and an increase in irritability makes it an intervention of last resort. “Madderall” is right. Yet, having this awareness helps mitigate the impact this side effect has on my family.
Thank you for your work. I especially appreciate your focus on research to support ideas being expressed here. I’m sure many, many people have found life changing insights about who they are, how to appreciate themselves, and live life without the need for external validation society so frequently attempts to convince us of needing.
Thanks for your insightful comment. It pains me to read yet another story where ignorance caused so much pain and suffering….and questioning.
Yes, I could see that, a personality change after stopping the “self-medicating” with food. My good friend lost 100+# and she just wasn’t the same — had a sharp edge to her, seldom smiled, a bit scary the change. Especially that she didn’t see it.
I love that as a medical professional, you’ll have opportunity to shine more light on ADHD when necessary.
You know that amphetamines aren’t the only stimulants, though, right? In fact, Adderall is the most problematic stimulant. Did you see this post by chance? (I guess you did through your use of “Madderall”; but many are using the term that I coined 20 years ago.)
BTW, two years ago? I was writing about ADHD and bariatric surgery TEN years ago. 🙂
I also called into a popular PBS radio station here in SF, KQED, when they were interviewing gastric bypass surgeons.
“Do you screen for ADHD?” I asked. I knew for a fact that the surgeons speaking did NOT screen for ADHD, despite their protests to the contrary. A woman in my local Adult ADHD group had the bariatric surgery two years before ADHD diagnosis.
Another timely article. I had come to the conclusion, on my own, that a big part of my weight problem was due to my ADHD, mainly Inattentive type, and was wondering if there were any ADHD Weight specialists, since a dietician that doesn’t understand ADHD wouldn’t be very helpful. I really would like to lose some weight, but it’s hard for me to exercise consistently, and I eat junk and comfort foods when I’m stressed, including when I’m bored. It doesn’t help that my metabolism was high enough as a child that I was skinny until I hit college (and maybe when I started taking higher level estrogen birth control pills in the 70’s?), so I had really bad eating habits by the time I reached adulthood. I’m just hoping that the very real need to exercise regularly following knee replacement surgery will help me develop healthy habits I can stick with. Some how I managed to finally become consistent about flossing every day, so I figure there’s hope.
I’d say there’s definitely hope. Once you learn the reason for those challenges, you can better target solutions.
I don’t know of an ADHD weight specialist, sorry. As these studies show, stimulants helped many study subjects.
Hi Gina, for me your article was Always laughed when I was young, (remember back then girls, esp. girls who skip a grade can’t get ADHD ). So I used to say I can eat and eat which of course, having no impulse control, I did and remained a toothpick until WHAM 22 first time I started to gain excess.
Impossible I thought while eating as many chips that would fit in my mouth instead of one chip at a time. I put myself in check, started my first diet and walking 7 miles a day. Early 20’s weight fell off and stayed off until pregnancy. Took me over 2 years of the exact same 20’s program for the weight to come off. Ate for every reason and didn’t know when to stop. I also gained too much weight in pregnancy. Ever since then, I have had a love hate relationship with food. Kept up the 7 to 10 miles a day but I loved eating to keep hands busy, instant gratification and poor impulse control and found it hard.
Now having gone through menopause and basically the past 2 years in Toronto, Canada have been in some form of shutdown and long periods of complete shutdown, any structure or diet regimen I had went right out the window and I am 35lbs heavier than my ideal weight and my whole body feels off. I know I got my ADHD from my dad and now I understand why my grandmother was so obese she needed a wheelchair. My dad fought it too. I have a friend in her late 20’s who yo yo’s up and down from obesity. She stopped taking medication when she finished University 4 years ago. I know if I don’t do something I will become my grandmother.
Unfortunately an autoimmune disease and that damn arthritis getting in the way. I have inherited the osteoarthritis but steroids have added to the damage. I have eaten poorly through the pandemic and live with 2- 6’3” males and I can out eat them. Hunger has nothing to do with it. It was all about instant gratification till I started Vyvance. I don’t care if I am older, being obese in a wheelchair can’t be healthy either.
And a study just came out saying seniors who walked had less chance of almost every physical ailment and have now discovered walking staves off dementia more than playing brain games etc. It is a major plus. So as soon as life gets back to whatever normal is, no more ordering in. And September weather, walk those miles. The doctor said women can basically just look at a french fry after menopause and gain weight. Lol She said I may have been sorely disappointed that even with 8 miles a day, while it was fantastic for me, not all the weight would come off but between diet, exercise and VYVANCE it should for me. Did I mention VYVANCE!
I hope to not be one of the ADHD people who die 13 years early due to self- medicating, food binges, or just not being able to get it together. I hope to return post pandemic with my medication, exercise, eating foods good for my autoimmune and be one of the examples. On a side note, they are now giving senior men with mild dementia Ritalin in the mornings as it greatly improves their day. So in closing I would say the article is bang on as I have lived it, my father lived it and I saw my grandmother live. Hope I have it in me to break the chain.
Thank you Gina!
Good for you, Kathy. Break that chain!
Walking 7 miles a day. I’m envious.
Two ….no make that three…injuries (most attributed to sitting too much at this desk working) limit my walking to 2-3 miles max now. I’m working on it. You, too!
P.S. Kathy, I was just talking to a friend yesterday who has an autoimmune disease. She said she found great benefit from eliminating the “whites” — sugar, flour, pasta, white rice, etc.
Right on, Kathy! Vyvanse is approved for BED Binge Eating Disorder! Finally science has caught up with real life.
Actually, Shire money caught up to market share. 🙂
It paid for the approval.
It’s great that now there is more of an “official” connection. But, most prescribers being what they are, they will try only Vyvanse. If that doesn’t work, they won’t think to try another stimulant.
58% of morbidly obese people are ADD according to research. Every time I talk in front of people who are severely overweight about ADD and weight, about 1/5 of the people come up to me afterwards asking for information on ADD and tests for ADD.
Thank you for your evangelizing! Truly changing people’s lives for the better, Alan!
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.
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!
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.
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).
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…
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!
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
“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.”
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)?
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.
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,
Dear Dr. Parker,
Your comment sheds light on a huge piece of my ADD history. Having just been diagnosed with ADD at 24, huge pieces of the puzzle of my life are falling into place. Your explanation of an SSRI’s effect on the ADD brain makes sense of an incredibly important period of my life that I have struggled to reconcile with for years.
At 19, I was diagnosed with major clinical depression and prescribed an SSRI. However, it not only exacerbated my depression symptoms, it completely changed me. I went from an adventurous, (too) hard-working, and athletic college sophomore to a girl who rarely left her bed, binge ate uncontrollably, struggled with thoughts of suicide, and gave up on studying for an entire semester in college. It left me utterly shaken and stripped of any sense of self. Finally, I switched to an SNRI which, though it did not push me further into depression, did not address what I now know to be ADD concerns.
Thank you so much for commenting on this article. Your expertise and insight have helped to fill a black hole in my life that has been dogging me for years.
Dr. Parker is full of these kinds of “missing pieces” of the puzzle. Be sure to check out his blog: http://www.corepsychblog.com