ADHD and Obesity: Reviewing the Research

1. 

   J P

   06/13/2022 at 4:36 pm

   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.

   Reply
   1. 

      Gina Pera

      06/14/2022 at 8:48 pm

      Hi JP,

      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.)

      https://adhdrollercoaster.org/adhd-news-and-research/the-tragic-truth-of-prescription-adderal-or-madderall/

      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.

      take care,
      g
2. 

   M. Virginia Leslie

   08/18/2021 at 1:05 am

   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.

   Reply
   1. 

      Gina Pera

      08/18/2021 at 7:07 am

      Hi Virginia,

      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.

      g
3. 

   Kathy Harris-Keeler

   08/17/2021 at 9:00 pm

   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!

   Reply
   1. 

      Gina Pera

      08/18/2021 at 7:11 am

      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!

      g
   2. 

      Gina Pera

      08/18/2021 at 7:12 am

      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.

      g
   3. 

      Maria A Pugliese

      08/18/2021 at 1:18 pm

      Right on, Kathy! Vyvanse is approved for BED Binge Eating Disorder! Finally science has caught up with real life.
   4. 

      Gina Pera

      08/19/2021 at 9:13 am

      Hi Maria,

      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.

      g
4. 

   Alan

   08/16/2018 at 1:30 am

   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.

   Reply
   1. 

      Gina Pera

      08/16/2018 at 12:05 pm

      Thank you for your evangelizing! Truly changing people’s lives for the better, Alan!

      g
5. 

   Jacqueline Blue

   07/21/2012 at 8:48 pm

   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.

   Reply
   1. 

      Gina Pera

      07/22/2012 at 11:29 am

      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!
6. 

   betsy davenport, phd

   05/11/2009 at 3:27 pm

   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.

   Reply
7. 

   betsy davenport, phd

   05/11/2009 at 3:25 pm

   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).

   https://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=130024

   Reply
8. 

   Carl Morris

   05/08/2009 at 3:47 pm

   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

   Reply
9. 

   Dr Charles Parker

   04/30/2009 at 6:16 am

   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

   Reply
10. 

    Gina Pera

    04/28/2009 at 10:06 pm

    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.”

    Reply
11. 

    Gina Pera

    04/28/2009 at 9:48 pm

    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)?

    Reply
12. 

    otto

    04/28/2009 at 11:44 am

    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.

    Reply
13. 

    Dr Charles Parker

    04/28/2009 at 3:15 am

    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

    Reply
    1. 

       Emily

       06/06/2013 at 9:02 pm

       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.
    2. 

       Gina Pera

       06/06/2013 at 9:45 pm

       Hi Emily,

       Dr. Parker is full of these kinds of “missing pieces” of the puzzle. Be sure to check out his blog: http://www.corepsychblog.com

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