adhd and eating disorders - chadd and eating disorders ... 8 were 90% more likely to have obesity as...

James Greenblatt, MD Chief Medical Officer, Walden Behavioral Care

ADHD and Eating Disorders

CHADD CONFERENCE November 10th

Atlanta

Disordered Eating

DISORDERED EATING

SHAME

GUILT

Cathy

The Evolution of ADHD

Defective Moral Control (1902)

Restlessness Syndrome (1920s)

Post-Encephalitic Behavior Disorder (1920s-1930s)

Brain Injured Child (1940s)

Minimal Brain Damage (1950s)

Minimal Brain Dysfunction (1960s–1970s)

Hyperactive Child Syndrome or Hyperkinetic Reaction of Childhood

(1960s)

Attention Deficit Disorder with or without Hyperactivity (1980)

Attention Deficit Hyperactivity Disorder & Undifferentiated Attention

Deficit Disorder (1987)

Attention Deficit Hyperactivity Disorder & Attention Deficit Disorder

(1993)

ADHD (2013) – DSM V

Brain Injured Child (1940s)

Minimal Brain Damage (1950s)

Minimal Brain Dysfunction

(1960s–1970s)

2017

14th Century

Evolution of Anorexia Nervosa

Catherine of Siena practiced an extreme form of

fasting and eventually died of starvation

Sir William W. Gull names the illness anorexia

nervosa – which means “nervous loss of appetite.”

Charles Lasègue, without the knowledge of Gull’s

work, described the condition as “L’anorexic

hysterique.”

John Berkman: “Among adolescents the cause for

the psychic upset can often be traced to a parent.”

Hilde Bruch’s psychological or cultural factors

1868

1870

1973

1947

Diary of a Young Psychiatrist

DRUGS! NO

DRUGS!

New Career

You don’t

see

what I

see!

ADHD: The Facts

Inattention – poor persistence of effort

Impulsivity

Hyperactivity – Cognitive Vs. Behavioral

Variability in performance

Difficulty with rule-governed behavior

Greater than 30% of patients with AN become

chronically ill over 10 years

Mortality rates: 10% at 10 years, 20% at 20

years!

Highest risk for suicide among all psychiatric

illnesses

Highest number of hospital days

Stress

Eating Disorders: The Facts

Treatment Fatigue

BED: Most Common ED in U.S. Adults

Bulimia Nervosa &

Anorexia Nervosa

Combined

Binge Eating

Disorder

DSM-5 Diagnostic Criteria for BED

Recurrent episodes of binge eating characterized by both of the following: Consuming an abnormally large amount of food in a short period of time compared with what others

might eat in the same amount of time under same or similar circumstances

Experiencing a loss of control over eating during the episode

Episodes feature at least 3 of the following Consuming food faster than normal

Consuming food until uncomfortable full

Consuming large amounts of food when not hungry

Consuming food alone due to embarrassment

Feeling disgusted, depressed, or guilt after the binge

Overall, there is significant distress about the binge eating

The binge eating occurs, on average, at least once per week for 3 months

The binge eating is not associated with regular compensatory behavior associated

with bulimia nervosa and does not occur solely during an episode of bulimia

nervosa or anorexia nervosa

Comorbidity

• Depression

• Anxiety

• OCD

• ADHD

• Bipolar disorder

• Personality

disorders

• Substance use

disorders

Up to 95% of ED patients suffer

from psychiatric comorbidity

Hudson. Biol Psychiatry. 2007 Feb 1;61(3):348-58.

Comorbidity is related to

treatment dropout


2016 meta-analysis of 12 studies assessing

ED in ADHD populations and 5 studies

assessing ADHD in ED populations

Individuals with ADHD were 3.8x more

likely to have an ED diagnosis

Individuals with an ED were 2.8x more

likely to have an ADHD diagnosis

Nazar. Int J Eat Disord. 2016 Dec;49(12):1045-1057.

ADHD and Disordered Eating

1Surman CB et al. J Clin Psychiatry 2006;67(3):351-4. 2Castellanos FX et al. Biol Psychiatry 2013;e1731-e1738. 3Altfas JR. BMC Psychiatry 2002;2:9.

12% prevalence of ADHD in women

with bulimia compared to a 0-2%

percent prevalence in a control group1

Men who were diagnosed as children

with ADHD were twice as likely to be

obese in a 33-year follow up study2

Study of 215 patients in treatment for

obesity found that 27.4% of

participants had ADHD. Among those

with extreme obesity: 42.6%3


Review of 37 studies looking at ADHD and eating

disorders across the lifespan

“The systematic review findings suggest

that children with ADHD are at risk for

disordered eating, while adolescents,

emerging adults, and adults are at risk

for both eating disorders and disordered

eating”

Levin & Rawana. Clin Psychol Rev. 2016 Dec;50:22-36.

Impulsivity

Five-year longitudinal study on girls with ADHD aged 6-12 years

Children with ADHD-combined type demonstrated more bulimia symptoms at follow-up than those without ADHD

Impulsivity was the strongest predictor of eating disorder

behavior

Mikami. J Abnorm Psychol. 2008 Feb;117(1):225-35.

Impulsivity

Patients with both an eating disorder

and ADHD have more impulsive traits

than patients with either condition alone

2017 review of 75 studies on the

association between ADHD

symptomatology and disordered eating

behavior concluded:

Kaisari. Clin Psychol Rev. 2017 Apr;53:109-121.

There is consistent evidence

that impulsivity symptoms of

ADHD are positively

associated with overeating

and bulimia nervosa

ADHD is a Risk Factor for Obesity

6,934 children from the Northern Finland Birth Cohort

ADHD symptoms at age 7 to 8 years significantly predicted

obesity at age 16

Children with inattention and hyperactivity symptoms at age

8 were 90% more likely to have obesity as a teen

Childhood ADHD symptoms predicted physical inactivity in

adolescence

Khalife. J Am Acad Child Adolesc Psychiatry. 2014 Apr;53(4):425-36.

ADHD and Obesity Statistics

25% of treatment-seeking obese adults meet criteria for

ADHD, with a higher prevalence in the most obese

Reinblatt. Curr Treat Options Psychiatry. 2015 Dec;2(4):402-412.

Up to 50% of youths treated for overweight have ADHD

A 33 year old study found males with ADHD were 2x more likely to be obese at follow-up than controls

Neural Correlates of Food Behaviors

Examination of the neural correlates of

addictive-like eating behavior

Forty-eight healthy young women

ranging from lean to obese recruited

for a healthy weight maintenance trial

Elevated activation in reward

circuitry in response to food cues

and reduced activation of inhibitory

regions in response to food intake

Arch Gen Psychiatry. 2011;68(8):808-816.

Disordered Eating

Bulimia – Binge Eating Disorder – Obesity

Driving force is not that we

are choosing to binge,

rather our bodies are

unable to regulate appetite

and asking us to eat more

A diverse range of physiologically

generated eating behaviors

Consuming sufficient food for energy metabolism is

essential for the survival of all species in the animal

kingdom.

Mammalian brains have evolved several interrelated

neural and biochemical systems that drive feeding

behaviors.

The most potent drive for

feeding behavior is its

rewarding nature

The Facts

Binge eaters and those with disordered eating

experience physical cravings that are physiologically

based, rather than socially or environmentally based.

The Theory

Neurobiological Mechanisms of Addiction

Phase 1: Binge/Intoxication

Phase 2: Withdrawal/negative effect

Phase 3: Preoccupation/cravings

“ Dopamine made me do it ”

Obesity and the Brain

A 2010 study found that the BMI of adolescent

females was positively correlated with abnormal

patterns and levels of activation in brain areas

known to be involved in reward processing

The higher the BMI, the higher the level of brain

activation observed in these girls, who were tested

by being shown pictures of appetizing food after a

4-6 hour fast

Stice. Neuroimage. 2010 May 1;50(4):1618-25.

Obesity and the Brain

Obese individuals are hyper-responsive

to food stimuli and show less reduction

of activation of reward regions after

eating

The dopaminergic reward

system is key in explaining

the comorbidity of obesity

and ADHD

Finally Focused

Is there a need to get

something?

Is there a need to avoid

something?

Nutrients

Vitamins

Minerals

Fatty acids

Amino acids

Hormones

Light

Love

Nature

Positive Feedback

Allergens

Food

Pollen

Dust

Dander

Chemicals

Mold

Germs

Toxins

Elementary

(lead, mercury, etc.)

Biologic

(plants, germs, etc.)

Synthetic

(mostly

petrochemical)

Pesticides

Autoimmune

Celiac Disease

Medications


Integrative treatments include:

PLUS

Omega-3 Supplementation

Neurofeedback

Medications

MINUS

Sugar

MSG

Sugar Addiction

Pleasure Centers in the Brain

Sweet sensations conveyed to the center

of the brain

Taste bud receptors

GI receptors

Stimulates release of dopamine

Sex and narcotics activate same

pleasure centers

Animal Studies

Rats love sugar water and will drink as much as offered

Release of dopamine initially

DA receptors become exhausted and over time starts to

decrease in number

Rats must ingest more sugar to get the same DA response

Features of Addiction:

Withdrawal of sugar: shaky, teeth chattering, tremors, agitation, and

hyperactivity

Binge Eating Disorder

40 day sugar diet: Decreased DA receptors and increased

food intake and obesity

Chronic sugar intake causes addiction like symptoms in

animals affecting regulation of food intake

Sugar-Sweetened Beverages

The amount of sugar-sweetened beverages consumed by

U.S. youth has nearly doubled since the 1970’s

Two-thirds of children aged 2-19 consume at least one

sugar-sweetened beverage on a given day

30% have two or more sugary drinks a day

Linked to SSBs:

weight gain

type 2 diabetes

kidney disease

cardiovascular

problems

Rosinger. NCHS Data Brief. 2017 Jan;(271):1-8.

Children in the top quintile of

“sweet” dietary pattern

(ice cream, refined grains,

sweet desserts, sugar, soft

drinks) score had almost 4x

the odds of having ADHD

compared with those in the

lowest quintile

Azadbakht & Esmaillzadeh. Nutrition. 2012 Mar;28(3):242-9.

High Sugar Diet and ADHD Risk

375 children, mean age 8 years


Suglia. J Pediatr. 2013 Nov;163(5):1323-8.

In a national sample of nearly 3,000 5-year-

olds, 43% consumed at least 1 serving of

soda per day, and 4% consumed 4+ a day

Soda consumption was associated with

higher aggression on the Child Behavior

Checklist in a dose-response pattern

Children who consumed the most soda

had the most attention problems

1,649 middle schoolers

reported quantity and types of

sweetened beverages

consumed in the past 24 hours

Risk of hyperactivity /

inattention increased by 14%

for each additional

sweetened beverage

consumed


Schwartz. Acad Pediatr.

2015 May-Jun;15(3):297-

304.

Refined sugars such as sucrose and high fructose corn

syrup can cause addiction like symptoms and can affect the

ability to control food intake

Sugar addiction may play a role in Binge Eating Disorder

and Obesity

Physiologically Generated Food Behaviors

ADHD

Vulnerability?

Food Addictions in the Church

“Sugared spices are

nonetheless not eaten with the

end in mind of

nourishment, but rather for

ease in digestion; accordingly,

they do not break the fast any

more than the taking of any

other medicine.”

— St. Thomas Aquinas (1225-1274)

Catholic priest and theologian

Taste Buds Hijacked

What is Monosodium Glutamate?

Monosodium Glutamate (MSG)

is a toxic food additive that

causes the brain to think that the

food has more protein and tastes

better.

MSG is approximately 78% free

glutamic acid, 21% sodium, and

1% contaminants.

MSG is Everywhere

MSG Causes Disordered Appetite

MSG consumption causes resistance to

the hormone leptin

Leptin resistance means that the brain

cannot properly “hear” the messages

the leptin sends it and will therefore

continue to be hungry and store fat

Physiologically Generated Eating

Behaviors

MSG can cause addiction like symptoms and can affect the

ability to control one’s food intake

MSG may play a role in Binge Eating Disorder and Obesity

Sugar

MSG can cause

addiction like symptoms

and can affect the ability

to control food intake

Physiologically Generated Food Addiction

ADHD

Vulnerability

Fats of Life

Essential Fatty Acids And Cholesterol in

Neurotransmission

Synthesis

Degradation

Release

Re-uptake

Binding

NO FATS?

Cultural Chaos

Omega-3 Fatty Acids

Every aspect of

neurotransmission involves adequate

functioning of omega 3s.

Essential Fatty

Acid Deficiency Anxiety

Depression

Suicide Risk Psychosis

Distorted

Perceptions

Aggression

GI problems

Just the Facts

ADHD Eating

Disorders

Omega-3’s and ADHD

A 2014 meta-analysis evaluated whether children

with ADHD have abnormal levels of blood lipids

compared to non-ADHD children

9 different studies, including over 500 participants,

revealed that children with ADHD consistently

and reliably displayed lower omega-3 blood

levels than their non-ADHD counterparts (on

average 38% lower)

Hawkey & Nigg. Clin Psychol Rev. 2014 Aug;34(6):496-505.

Six-month follow up of 200 children aged 8-16 randomized

to 300 mg DHA, 200 mg EPA, 400 mg alpha-linolenic acid,

+ 100 mg DPA or placebo


Raine. J Child Psychol Psychiatry. 2015 May;56(5):509-20.

42% reduction in externalizing

behavior and 68% reduction in

internalizing behavior

Parents showed significant reductions in their own antisocial and aggressive behavior


2016 review of 25 studies on omega-3

supplements for ADHD

The results overall showed evidence for successful

treatment of ADHD symptoms

“The dosage of stimulant medication could be

reduced when used in combination with

omega-3 PUFA supplements”

Königs & Kiliaan. Neuropsychiatr Dis Treat. 2016 Jul 26;12:1869-82.

Omega-3’s and Eating Disorders

Patients with EDs tend to present with low

levels of omega-3’s and highly imbalanced

omega-3:omega-6 ratios2

As many as half of all BED patients have a

history of depression

Women with AN are 57x more likely to commit

suicide than non-sufferers1

1. Keel. Arch Gen Psychiatry. 2003 Feb;60(2):179-83.

2. Swenne. Acta Paediatr. 2011 Dec;100(12):1610-5.

The Tragedy

Suicide is the SECOND leading cause of death for ages 10-

24.

Average of over 5,400 daily attempts by young people

grades 7-12.

One death from suicide every 40 seconds.

By 2020, the rate of death from

suicide will increase to one every

20 seconds.

EFA’s and Serotonin

EPA regulates serotonin function by controlling serotonin

release in presynaptic neurons

Patick & Ames. FASEB J. 2015 Jun;29(6):2207-22.

EPA promotes

serotonin release

Omega-3’s have been positively correlated with a serotonin metabolite in cerebral spinal fluid

DHA regulates the

serotonin receptor

Genetic Vulnerability

Children with ADHD were 60% more likely to have a single nucleotide polymorphism in the fatty acid desaturase 2 gene

Fewer omega-3’s are incorporated into the cell membrane

Low omega-3 concentrations in ADHD subjects with out lack in dietary intake

Brookes. Biol Psychiatry. 2006 Nov 15;60(10):1053-61.

It takes at least 10

weeks for cerebral

membranes’ highly

unsaturated fatty

acid levels to

recover following

chronic deficiency.

Not a Quick Fix

Bourre. Prostaglandins Leukot Essent Fatty Acids. 1993 Jan;48(1):5-15.

The Human Brain: The Franklin Institute

“By modifying natural fats, we have altered the

basic building blocks of the human brain -

weakening cerebral architecture. And, like

unstable buildings that come apart in an

earthquake or storm, poorly structured human

brains are failing to cope with the mounting stress

of modern life.”

Vyvanse (lisdexamfetamine) Review

2 controlled trials with 1,033 adults

↓ in weight ranged between 5.2% and

6.25%

Discontinuation rates due to adverse

events were low

Vyvanse 50 or 70 mg/d significantly ↓ #

of binge eating days per week

Citrome. Int J Clin Pract. 2015 Apr;69(4):410-21

Dasotraline

Dasotraline is under development for the

treatment of ADHD and BED

A novel dopamine and norepinephrine reuptake

inhibitor with slow absorption (10-12 hours) and

a long half-life (47-77 hours)

When rats were given dasotraline, they had significantly reduced impulsivity

Dasotraline for BED

Navia. 2017. APA Annual Meeting. Poster abstract P7-084.

Those taking

Dasotraline for BED

had decreased binge

eating days

Dasotraline for ADHD

Those taking dasotraline

8 mg/d had significantly

improved ADHD symptoms

compared to baseline and

compared to placebo

Koblan. Neuropsychopharmacology. 2015 Nov;40(12):2745-52.

Comorbidity of ADHD and Eating Disorders

Summary

Those with ADHD are more likely

to have an ED

Those with an ED are more likely

to have ADHD

These associations are

consistently found in samples of:

Males

Females

Children

Adults

Those seeking

treatment

and

the general

population

Prevention is Possible

Chart review of 252 patients, mean age 10

years, in two pediatric mental health clinics

Significant association between ADHD and

binge eating

26% of children with ADHD had binge-eating

behaviors vs. 2% of children without ADHD

Reinblatt. Int J Eat Disord. 2015 Jul;48(5):505-11.


7,120 males and females from the Avon

Longitudinal Study of Parents and Children, a

cohort study of children in the UK

Childhood ADHD symptoms increased the risk of

binge eating later in adolescence

Sonneville. Psychol

Med.

2015;45(12):2511-

20.


Regardless of BMI,

anxiety, or depression Yilmaz. J Adolesc Health. 2017 Aug;61(2):140-146.

Higher ADHD symptoms

throughout childhood and

adolescence were

associated with increased

disordered eating risk in

late adolescence

2,315 Swedish twins from a longitudinal cohort

ADHD checklist completed at ages 8, 13, and 16


ADHD brain studies have revealed abnormalities in regions

that control motivation, satisfaction, and impulse control

Seymour. CNS Spectr. 2015 Aug;20(4):401-11.

These regions, particularly the hypothalamus, also regulate eating behaviors, and it is no coincidence that similar brain abnormalities tend to show up in cases of EDs

ADHD and Obesity

Genetic mutations that determine how many dopamine receptors are present and active may be one of the explanations for understanding the ADHD-ED connection

Genes provide the kindling

and environment provides

the fuel

Nutrition and Health

Understanding the

role of Nutrition

and Health is not

Alternative

Medicine

Psychiatry Redefined and Reimagined

Prevention is Possible.

Mental Illness may be seen as

a reflection of multiple errors in

physiology.

If we find the Causes,

we may find the Cures.

Thank You Psychiatry Redefined and Reimagined

Dr. Hallowell Dr. Shaw Dr. Lombard

James Greenblatt, MD Chief Medical Officer Walden Behavioral Care [email protected]

Thank you!

JamesGreenblattMD.com

Finallyfocusedbook.com

adhd and eating disorders - chadd and eating disorders ... 8 were 90% more likely to have obesity as...

Documents