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.
Papers of particular interest, published recently, have been
Although bariatric surgery is often indicated for individuals
who have repeatedly failed to lose weight in structured
programs and/or on their own, individuals with ADHDmay experience the same difficulties with weight control
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