For years, ADHD experts have recognized the link between untreated ADHD and obesity. As for weight-control experts and gastric-bypass surgeons? Most 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. One that too often overlooked undiagnosed ADHD’s contributions to many physical issues.
But make no mistake: It is extremely important that anyone considering drastic weight-loss surgeries first be screened for ADHD.
With their research, two Toronto-based clinicians and researchers sought to bridge this cross-disciplinary knowledge. Physician Lance Levy and psychologist John Fleming set out to determine if medically treating severely obese subjects with newly diagnosed ADHD would result in sustained weight loss.
In short, yes. Yes, it did.
Let’s examine two of their studies, hear from a veteran ADHD expert who early on spotted the connection between ADHD and eating patterns, and take a peek at the mounting literature.
The connection is undeniable: ADHD is associated with obesity. Moreover, stimulant medication reduces the risk of obesity for these people.
But First: the Highlights
Update to the original version of this post, in response to this e-mail:
I’m at work and CAN’T GET DISTRACTED and don’t have the PATIENCE today to give it deep thought (sounds ADHD like).
- Yes, stimulant medication has been shown to reduce vulnerability to obesity.
- Yes, eating can be “stimulating” (see #1 for a better stimulant).
- 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 you last ate!
- Poor read of the signals (e.g. Body says, “we’re full now” but you don’t hear it…you can’t “put on the brakes”).
- Poor sleep contributes, too.
- Disorganization and lack of follow-through in getting regular exercise.
Digesting the Research: ADHD and Obesity
Here are the summaries for two early and important studies:
- The first study: Among people who had failed 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.
- The second study evaluated for ADHD 76 women who had been referred to a medical specialist for the non-surgical treatment of obesity. Of the 76 women, 26.7% reported significant symptoms of ADHD in both childhood and adulthood
Now let’s examine the details for each study.
Study #1: Will ADHD Treatment Help?
The first study identified subjects who had a history of difficulty with weight-loss and who likely had ADHD. The hypothesis was that untreated ADHD was proving an impediment to weight loss.
(For reference, refractory means “hard or impossible to manage” and comorbid means co-existing.)
To determine whether attention deficit hyperactivity disorder (ADHD) pharmacological treatment of severely obese subjects with newly diagnosed ADHD would result in sustained weight loss.
Longitudinal clinical intervention study of the effects of ADHD medication on weight change over 466 days.
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 (binge eating disorder, mood disorder, sleep apnea, chronic pain, 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 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
Study #2: How Many Obese Study Subjects had ADHD?
Past and current symptoms of Attention Deficit Hyperactivity Disorder (ADHD) were assessed in a clinical sample of severely obese females.
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.
This preliminary study suggests that severely obese women report significant symptomatology related to both childhood and adult ADHD.
The website for Dr. Fleming 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
Early Connections: ADHD and Eating Patterns
I first read about this topic in a book chapter called “Disordered Eating and ADHD.” It was contributed by the researchers above, Levy and Fleming, to the groundbreaking Gender Issues and ADHD: Research, Diagnosis, and Treatment, edited by Patricia Quinn, M.D. and Kathleen Nadeau, Ph.D. 2002.
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 [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.
Consider this excerpt from an early 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.”
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.
More Food For Thought: ADHD and Obesity
More recently, the literature is mounting on the relationship between ADHD and eating behaviors.
Consider two recent papers.
Paper #1. Attention-Deficit Disorder and Obesity: Update 2016
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.
Paper #2. 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
- 1) reporting odds ratios adjusted for possible confounding factors;
- 2) diagnosing ADHD by direct interview;
- and 3) 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.
This post originally appeared 4/27/09. Updated 8/9/18
How about YOU? Do you suspect that 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, and so forth.
I welcome your comments.