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Curr Obes RepDOI 10.1007/s13679-012-0012-0 OBESITY TREATMENT (AM SHARMA, SECTION EDITOR) Attention Deficit/Hyperactivity Disorder and the ClinicalManagement of Obesity Sherry Pagoto & Carol Curtin & Bradley M. Appelhans &Miguel Alonso-Alonso # Springer Science+Business Media, LLC 2012 Abstract Attention deficit/hyperactivity disorder (ADHD) pharmacological treatment, exercise, and cognitive behavior has been associated with increased risk for obesity and therapy. ADHD is a barrier to the clinical management of obesity treatment failure. The present paper discusses how obesity and more research is needed to further understand features of ADHD, including inattention, reward sensitivity, the link between ADHD and obesity. Effective treatment and impulsivity, may impact obesity risk and have implica- approaches are needed given the significant difficulty tions for the management of obesity. In addition, we review patients with ADHD encounter in their attempts to regulate emerging research on how obesity may contribute to brain their weight in the context of an obesogenic environment.
changes that are associated with ADHD-like symptoms.
Finally, suggestions for improving the clinical management Keywords ADHD . Attention deficit/hyperactivity of obesity in patients with ADHD are discussed, including disorder . Obesity . Impulsivity . Treatment Division of Preventive and Behavioral Medicine,Department of Medicine,University of Massachusetts Medical School, 55 Lake Avenue Attention deficit/hyperactivity disorder (ADHD) is a neuro- behavioral disorder, essential features of which include a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than typically C. CurtinEunice Kennedy Shriver Center, Department Family Medicine observed in individuals at a comparable level of develop- & Community Health, University of Massachusetts ment. The Diagnostic and Statistical Manual 4th edition Medical School, 200 Trapelo Road, Waltham, MA 02452, USA (DSM-IV) [] specifies that these symptoms must have persisted for at least 6 months, originated before the age of 7 years, and impairment is present in two or more settings.
Preventive Medicine, Rush Medical College, 1700 W. Van Buren, The DSM-IV describes three subtypes of ADHD: 1) inat- tentive type; 2) hyperactive-impulsive type; and 3) com- bined type. ADHD has been shown to persist into adulthood in half of children with ADHD and affects Neurology, Harvard Medical School, Boston, USA over 9 million US adults [An association between ADHD and obesity is well documented both in population Berenson-Allen Center for Noninvasive Brain Stimulation, In addition to ADHD being linked to greater risk for obesity, evidence is also emerging that ADHD may pose asignificant barrier to the management of obesity [In the present paper we discuss the neurocognitive features of Division of Cognitive Neurology, Beth Israel Deaconess MedicalCenter, 330 Brookline Avenue, Ks-158, Boston, MA 02215, USA ADHD that may lead to obesogenic behavior and affect the patient’s ability to engage in the self-management skills that eating might serve a “self-medicating” function for are instrumental to weight control. Treatment strategies for some individuals with ADHD [Given that ADHD patients with comorbid ADHD and obesity are discussed as is generally characterized by reward sensitivity, obese well as future directions for research on the clinical man- adults with ADHD may be more sensitive to rewards relative agement of obesity in the patient with ADHD.
to their obese counterparts without ADHD, which mightmanifest in eating pathology. For example, Davis et al.
] found that individuals with ADHD were more Inattention, Reward Sensitivity, and Impulsivity May likely to meet criteria for “food addiction” than those without ADHD. Similarly, binge eating disorder has beenshown to play a mediating role in the relationship between Some research has explored neurocognitive features of ADHD, including inattention, reward sensitivity, and impul- Impulsivity is another common feature of ADHD that has sivity, to determine the extent to which these problems are implications for obesogenic behavior and possibly risk for associated with obesity and/or interfere with the ability to obesity. Although it is a multifaceted construct, impulsivity lose weight. Inattention, a hallmark of ADHD, refers to can simply be characterized as action without foresight [ distractibility, reduced ability to sustain attention, and sus- Some evidence suggests that people high in impulsivity are ceptibility to interference ]. Inattention may adversely prone to overeating, weight gain –and obesity [ impact the individual’s capacity to execute goal-directed Among 228 adolescent girls with ADHD, impulsivity was a dietary and physical activity behaviors and the ability to much stronger predictor of eating pathology than inatten- regulate one’s weight resulting in irregular eating habits tion, although both inattentive and impulsive ADHD sub- and poor adherence. Inattention might also affect awareness types were equally likely to be obese ]. This suggests that of internal hunger and satiety cues, especially when the impulsivity might be instrumental in the observed associa- individual is engaged in other activities , This could tion between ADHD and binge eating disorder , result in externally cued eating, which tends to be associated Greater impulsivity could also lead to greater difficulty with overeating. Inattention may also interfere with other inhibiting the consumption of high energy–dense palatable behaviors critical to successful weight loss, such as meal foods, especially in response to stress and other cues, as planning, implementation of specific behavioral skills (eg, described by Lowe et al. [Cognitive models of ADHD consistently keeping a diet diary), following through with emphasize the role of inhibitory control as a critical require- planned exercise, and the ability to detect changes in food ment for other executive functions that subserve self- portion sizes ]. In some studies, the inattentive type of regulation and goal-directed behavior [. Consuming a ADHD has been found to be more prevalent than the hy- healthy diet in an obesogenic environment or restricting intake peractive/impulsive type in obese samples to lose weight can be thought of as goal-oriented behavior, Additional research is needed to further describe specifically thus any impairment in inhibitory control could hijack their how inattention affects one’s ability to regulate their weight, optimal execution. The increasingly obesogenic environment as well as interventions that could be helpful in this contest may be particularly challenging for people high in impulsivity (eg, cues/reminders, frequent feedback, etc.).
(ie, low inhibitory control), given the omnipresence of food Reward sensitivity is a biologically based personality cues. Supporting this contention is a study showing that trait originally described by Gray ] that may stem from impulsivity was associated with greater food consumption in hypo- or hyper-reactivity to reward at the neurobiological an environment characterized by high food variety, but not level. High “reward sensitivity” describes individuals who in one characterized by monotonous foods []. This are especially sensitive to rewards in their environment, impulsivity-by-environment interaction suggests that persons while diminished reward sensitivity describes individuals with ADHD might be disproportionately vulnerable to obeso- who are especially insensitive to rewards in their environ- ment. Recent evidence has emerged that individuals with Impulsive individuals also appear to have less inhibitory ADHD, particularly those with the inattentive type, are control during hunger, as evidenced in a study that found highly reward sensitive ]. Reward sensitivity is implicat- that impulsive individuals consumed more food when ex- ed in appetitive motivation, such that it may mediate posed to highly palatable food than their less impulsive responses to appetitive stimuli, including drugs, food, and counterparts under conditions of hunger, but not under con- sex []. Mesolimbic dopaminergic (DA) processes are ditions of satiety [These findings suggest that restrictive central to reward sensitivity , ], with greater sensitivity diets in the context of an obesogenic environment might be to reward at the behavioral level being associated with either especially challenging for people with ADHD. Accordingly, a hyper- or hyporesponsive mesolimbic DA system [].
Nederkoorn et al. reported that impulsivity predicted less Because palatable foods enhance dopamine activation, weight loss following treatment in children.
One particular manifestation of impulsivity, delay Chicken or the Egg? Obesity May Produce ADHD-Like discounting, seems particularly relevant to understanding the association between ADHD and obesity. Delay dis-counting reflects the degree to which an individual Aside from common underlying mechanisms between undervalues rewards with increasing delays [For ADHD and obesity and the impact that ADHD may have both humans and animals, immediate rewards have a on weight gain and obesity, there is some, albeit limited, disproportionately strong influence on our decisions evidence for the possibility that obesity contributes to the and actions. Less valuable immediate rewards (eg, $200 development of ADHD-like symptoms. For example, short- today) can often be preferred to more valuable future term experimental overfeeding in lean humans has been rewards (ie, $240 in 3 months). A number of studies shown to lead to brain changes including an increase in have found steeper delay discounting among children the activation of the default mode network (DMN), a set and adults with ADHD relative to controls of areas that are active typically at rest and seem to be These effects appear to be more robust among those with involved in self-referential cognition and introspection the hyperactive/impulsive or combined subtypes [], ]. This effect goes in the direction of ADHD-like brain which is consistent with the conceptualization of delay changes, characterized by DMN overactivation and difficul- discounting as a facet of impulsivity. The tendency to dis- ty in suppressing this network during effortful tasks [ count delayed rewards steeply is associated with several con- Additional evidence comes from a study showing ditions in which impulsivity and hyper-responsivity to improvements in attention/executive functioning in obese appetitive cues are thought to play an etiological role, such subjects following weight loss ]. Animal studies provide as compulsive gambling, tobacco use, and drug addiction more direct evidence in support of this association. Diet- induced obesity in a swine model leads to changes in brain Recently, delay discounting has also been linked to perfusion that are selectively located in areas implicated in eating behavior and obesity [•, For example, obese ADHD, such as the dorsolateral prefrontal cortex, and the women show steeper discounting of delayed rewards than amount of weight gain negatively correlates with perfusion normal weight women [], and greater delay discounting in these locations [Lastly, a brain effect of obesity is has been associated with higher intake of palatable food supported by biological plausibility, as obesity-related among lean, overweight, and obese subjects who are changes can affect neuroplasticity and cognitive function most sensitive to the rewarding properties of food [ through different mechanisms (eg, the release of proinflam- It has been hypothesized that a greater predisposi- matory substances to the systemic circulation) Alto- tion for delay discounting would likely manifest as gether, the evidence suggests that obesity may worsen heightened sensitivity to the immediate reward from ADHD symptomatology or facilitate the development of palatable food and decreased valuation of the long- ADHD-like symptoms via brain changes; however, direct term rewards associated with a healthy diet and weight evidence for this association in humans is not available yet maintenance, which in combination would contribute to and future studies are warranted. To the extent that obesity- obesity [, The neurobiological mechanisms un- induced brain changes impair weight control, patients with derlying individual differences in delay discounting have long-standing obesity and more severe obesity may be the also been linked to the neurocognitive deficits in ADHD most treatment resistant. Research is needed to determine and the brain regulation of eating behavior. Specifically, whether these brain changes are reversible via weight loss alterations in mesolimbic dopamine function have been and/or lifestyle changes (eg, caloric restriction, exercise).
associated with a stronger preference for immediaterewards in the context of delay discounting tasks, palat-able food intake, and ADHD ]. In contrast, “exec- Obesity Management in the Patient with ADHD utive” brain regions found to be altered in ADHD, particularlythe lateral prefrontal cortex, appear to play a critical role in Because the association between ADHD and obesity has inhibiting impulsive behaviors and pursuing long-term goals, only recently been observed, specialized interventions have including sustained weight loss [•, –]. Thus, height- not been developed; however, some evidence suggests that ened delay discounting appears to stem from a neurocognitive individuals with ADHD are less responsive to standard profile implicated in both ADHD and obesity. Developing a behavioral interventions for obesity. Only two studies have regular pattern of eating and the removal of food cues in the examined weight loss treatment outcomes in individuals home environment may be helpful for the impulsive individ- with ADHD and both found that these patients lost less ual, in addition to assistance in setting shorter-term goals.
weight in a behavioral weight loss program than their coun- Additional research is needed to identify effective weight loss terparts without ADHD , Altfas [conducted a strategies for individuals who are high in impulsivity.
retrospective chart review for 215 weight loss clinic patients and observed that patients who met diagnostic criteria for underwent pharmacological treatment (primarily stimulants) ADHD achieved only 65% of the weight loss of patients for ADHD for a mean of 466 days. Patients who stayed on without ADHD (2.6 vs 4.0 kg, respectively). In spite of the medication (83%) lost a mean of 15.05 kg (12.36%), poorer weight loss outcomes, patients with ADHD had a while patients who went off the medication gained 3.26 kg greater number of visits than their non-ADHD counterparts (2.78%). Although not a randomized controlled trial, this (mean, 56.6 vs 39.4 visits), and although not statistically amount of weight loss among individuals with ADHD is far significant, longer treatment duration (38.7 vs 28.6 months).
higher than observed in other studies that did not utilize Pagoto et al. [also documented weight loss in 63 patients medication (eg, [, ]). Although concerns had been of an outpatient behavioral weight loss program. Similar to raised about the cardiovascular side effects of stimulant Altfas [patients screening positive for ADHD lost only medications, a large population-based study recently 60% of the weight of their counterparts who screened neg- showed no impact of stimulants on cardiovascular events ative (mean weight loss, 3.72 vs 6.17 kg, respectively).
Participants with ADHD symptoms reported significantly Others studies have shown a weight loss effect of medi- more short-lived (< 3 days) weight loss attempts than those cations that are often used to treat ADHD in obese patients who denied such symptoms. They had significantly more who do not have ADHD. Anderson et al. ] conducted a frequent fast food consumption, higher emotional eating double-blind, placebo-controlled, randomized trial of obese scores, rated weight loss skills as more difficult, and adults who were assigned to placebo, bupropion sustained- reported lower self-efficacy to control their eating. Although release 300 or 400 mg/d. All participants received behav- more research is needed comparing weight loss outcomes ioral weight loss counseling and meal replacements. Results among patients with and without ADHD, these studies indicated that bupropion yielded statistically and clinically suggest that patients with ADHD lose significantly less significant net weight losses relative to placebo. A second weight than their counterparts and may have more difficulty study by Gadde et al. [randomized 30 obese women to atomoxetine, a norepinephrine reuptake inhibitor, or placebowith both conditions receiving a behavioral weight lossprogram. Patients in the atomoxetine group lost significantly Improving Clinical Management of Obesity in Patients more weight than did controls (-3.6 [1.0] vs 0.1 [0.4] kg, respectively). Three other studies have shown that methyl-phenidate acutely suppressed appetite and energy intake Given that symptoms of ADHD appear to be associated with –]. Although only 25% of adults with ADHD are obesogenic behavior and greater difficulty losing weight, estimated take medication to control their symptoms obesity treatment approaches that offset these symptoms stimulants and other ADHD medications may be a particu- are needed. Research supports the potential for psychophar- larly important treatment option to consider for adults with macology, physical activity, and cognitive behaviorial ther- apy (CBT) to assist in the clinical management of obesity inthis population.
Exercise may be especially beneficial for patients withcomorbid ADHD and obesity. Both human and animal Psychopharmacology, including psychostimulants, some studies strongly support the impact of exercise on improved antidepressants, and norepinephrine reuptake inhibitors, is cognitive function ]. Exercise has been found to improve considered the first-line treatment in ADHD for both chil- executive function and increase prefrontal activation during dren and adults []. These agents have been shown to executive function tasks in children •], and some initial improve clinical and core symptoms of ADHD, including work has documented that exercise in children with ADHD vigilance, divided attention, focused attention, and cognitive has yielded improvements in overall behavior, sustained flexibility in adults []. Medications appear to have an attention, vigilance, and impulsivity []. Exercise impact on risk for obesity among children with ADHD.
increases brain-derived neurotrophic factor, a molecule in- Two observational studies of children showed that ADHD volved in synaptic plasticity, learning, and memory, which was associated with obesity only in children who were not may be particularly important for individuals with ADHD using medication for their ADHD, but not in children who ]. Additionally, Gapin et al. ] reported some prelim- were medicated ]. Other research suggests that medi- inary, albeit indirect, evidence that exercise increases dopa- cations for ADHD may cause weight loss. For example, an mine levels in children with ADHD ]. Exercise might be observational study by Levy et al. ] followed a sample a first step in treatment for patients with comorbid obesity of 78 obese adult patients diagnosed with ADHD who and ADHD given that its cognitive benefits might also result in improved self-regulation, which could facilitate adher- pathology, poor adherence to structured attempts to lose ence to other weight loss strategies [].
weight, and increased vulnerability to obesogenic environ-ments. When ADHD is suspected in an obese patient, refer- ral for assessment and treatment is highly recommended.
The clinician should note that people with ADHD may A version of CBT ] has been developed specifically for experience greater than average difficulty with organization, adults with ADHD to reduce ADHD symptoms and im- self-monitoring, planning, follow through on goals, resisting prove overall functioning. Because ADHD symptoms inter- food temptations, and consistency. These symptoms should fere with the execution of weight loss skills, CBT for not be confused with poor motivation or irresponsibility in ADHD might be a useful adjunct to obesity treatment the patient who is unsuccessful at controlling his/her weight.
among adults with ADHD. CBT provides patients with the It should also be considered that even in the absence of an opportunity to learn the functional skills that do not come ADHD diagnosis, obesity may be associated with brain naturally to them (eg, time/task management, organizational changes that produce symptoms that mimic ADHD. Patients skills, and task analysis), resulting in new skills that can with comorbid obesity and ADHD likely require extra sup- enhance functioning and effectiveness in occupational, port and more intensive weight loss intervention to over- scholastic, and interpersonal domains. CBT also incorpo- come these challenges. In addition to pharmacological rates cognitive modification strategies that assist the patient treatment, exercise and CBT are two potentially helpful in identifying automatic thoughts, recognizing the ensuing adjuncts to weight loss treatment for those with ADHD.
feelings and behaviors that lead to maladaptive responses, Further research is needed to understand the association and in reframing and problem solving to devise and imple- between obesity and ADHD and/or ADHD-like symptoms.
ment more adaptive behaviors. Several studies have shownthe efficacy of CBT in improving ADHD symptoms [–],organizational skills ], depression and anxiety [inpatients with ADHD. Research is needed to determine wheth- No potential conflicts of interest relevant to this article er the incorporation of CBT strategies for ADHD into abehavioral weight loss program would improve both ADHDsymptoms and weight loss.
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Patient name: __________________________________________________ 1. D/C home when awake, oriented and vital signs stable. 4. Provide Rx when patient goes home. These are located on the last page of Dr. Watson's Discharge Instruction form or on the chart. 5. Have patient and family READ and SIGN Dr. Watson's Discharge Instruction form and provide a copy for the permanent chart and provide the or

Post-operative instructions

Benjamin Domb, M.D. Discharge Protocol for Hip Replacement and Resurfacing • Take 10 deep breaths each hour • Get up and walk every hour. Walk as much as possible. • Use walker only as needed. Progress to full weight-bearing as quickly as • Keep incision dry until 5 days after surgery. Then may begin showering. • Do not bathe or swim until incision completely healed.

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