Influence of attention-deficit/hyperactivity disorder on binge eating behaviors and psychiatric comorbidity profile of obese women
Introduction
Although obesity is one of the most easily recognizable medical conditions, our understanding of this disorder is still limited, and success of available treatments even more [1]. Obesity is not only associated with the development of somatic medical conditions and psychiatric disorders. Obese patients have a 55% chance and an odds ratio (OR) of 1.5 of developing depression [2]. Recent studies ponder whether attention-deficit/hyperactivity disorder (ADHD) patients are more likely to become obese since, obese adults have a higher prevalence of ADHD than expected to normal weight subjects [3], [4], [5].
ADHD has a prevalence rate in the adult population of 4.4% [6]. Approximately 65% to 89% of adults with ADHD have one or more comorbid psychiatric disorders [7]. ADHD alone can impair social, marital, work and educational areas of functioning [8]. The presence of a comorbidity in ADHD patients leads to greater psychological distress and medical risk [9].
Independent of weight status, disrupted eating behaviors are thought to have a relation with ADHD. Two longitudinal studies addressed whether ADHD girls were at risk for Eating Disorders (ED). Mikami et al. (2008) conducted a 5-year longitudinal study of girls, who were 9-years old at baseline, and found that ADHD subjects developed more frequently eating disorder symptoms at puberty [10]. Biederman et al. evaluated the course of ADHD girls over 5-years up to late adolescence and reported that they exhibited 3.6 higher chance of meeting full criteria for ED at final assessment [11]. Three other longitudinal studies of ADHD patients found a higher risk for the occurrence of Bulimia Nervosa (BN) in girls [12], [13] and in women [14]. The prevalence of ED is higher in ADHD individuals than in the general population, independent of Body Mass Index (BMI) [15]. Four studies evaluated ED prevalence in specialized ADHD centers and found an ED prevalence from 9% to 12% [9], [16], [17], [18]. Three studies found Bulimia Nervosa (BN) as the most common ED [9], [17], [18]. Our group was the first to demonstrate Binge Eating Disorder (BED) to be the most frequent ED comorbidity with ADHD [16]. Two studies investigated the impact of ED in ADHD patients and suggested that patients with ADHD + ED have often other psychiatric comorbidities [16], particularly mood and anxiety disorders [11] than ADHD patients without ED.
Three studies evaluated ADHD in ED specialized centers, of which, two were conducted with inpatients [19], [20], and one with a mixed sample of in- and outpatients [21]. These studies reported that ADHD was associated with binge/purge behaviors, but the analysis was performed as a single group, mixing together Anorexia Nervosa and BN subjects. Wentz [21] found a significantly higher prevalence of ADHD in ED samples (17%), whereas two other two studies found rates of 5.3% [20] and 6% [19]. It is noteworthy that, when studying only BN patients, the ADHD prevalence in the study by Blinder increased to 9% [19]. None of these previously cited studies evaluated obesity or BED in their samples.
BN and BED have in common the occurrence of binge eating episodes [22] but BN patients frequently engage in inadequate compensatory methods to lose weight (such as, purging, use of diet pills, laxatives or diuretics and fasting) [22]. The prevalence of BN in women in the general population is 1.5%, and for BED 3.5% [23]. In weight loss clinics, the incidence of BED in obese individuals is higher than would be expected from the general population, at about 29% [24]. Obesity is considered a general medical condition but not an ED, however it is strongly associated with disordered eating patterns and BED [24].
The objective of the present study was to evaluate the impact of ADHD in obese patients’ psychopathology. Our first hypothesis was that ADHD impaired obese psychopathology and thus, would be associated with a greater number of comorbid psychiatric disorders and scores in rating scales, especially, of impulsivity measures [15], [11], [25]. A secondary hypothesis was that ADHD could influence the severity of binge eating and predict its severity.
Section snippets
Subjects
The sample was comprised of obese women seeking non-surgical treatment for obesity or eating disorders in the State Institute of Diabetes and Endocrinology, a public endocrinology hospital with an eating disorders and obesity clinic in Rio de Janeiro. Since our group is well known in Brazil to treat severe eating disorders we have a patient profile of eating disordered obese higher than other obesity clinics. Over a period of two years, a total of 171 patients aged 18 to 59 years old, with a BMI
Results
The demographic characteristics and results from self-report scales of the total sample and groups studied are given in Table 1. There were no statistically significant differences between the “Obese ADHD”, “Obese ED” and “Obese Only” groups with respect to demographic characteristics. The Obese ADHD group reported significantly more depressive, trait anxiety, binge eating and impulsivity symptoms (Table 1). The number and frequency of psychiatric comorbidities in the sample and for each group
Discussion
It should be noted that all subjects with ADHD were comorbid for ED. “Obese ADHD” patients had a significantly more severe Binge Eating pathology as measured by the BES than “Obese ED”. The ED profile, both BN and BED were significantly associated with ADHD diagnosis. Cortese et al. (2007) reported in a previous study increased bulimic behaviour in ADHD girls [38] but no association between more severe BN full syndrome and ADHD in women. Biederman [11] has found that childhood ADHD increases
Conclusion
This study suggests that obese women should be routinely evaluated for ADHD. When ADHD is present in obese women, a thorough evaluation for ED should be performed as our findings suggest a high association between ADHD and ED. ADHD in obese women is associated with the occurrence of other psychiatric comorbidities, especially AD and SUD [7], [11]. The presence of depressive symptoms and inattention can predict the presence of binge eating in obese women.
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