ADHD, Eating Disorders, and Weight Issues

Imageby Roberto Olivardia, PhD

Mike (not his real name) is a twenty-seven-year-old single male with a thirteen-year history of binge eating disorder. He would eat two gallons of ice cream, a large pizza, a dozen donuts, and two hamburgers two to three times per week until he was sick. He could not stop. He has been to various therapists over the years, some who were eating disorder specialists, and no therapy or antidepressant seemed to help. All the while, his weight was dangerously increasing by the year and his self-esteem was plummeting to nothing. His last therapist said he was "treatment resistant" and probably did not want to get better.

When I first met Mike, I saw a man who desperately wanted to be free of this eating disorder. Upon further inquiry, I discovered some important details about Mike and his treatment history. He reported that he could not get himself to the appointments on time. He would often sleep through them. He had every intention of filling out a food log, but would lose it or simply forget to do it. "I always say I will follow through, but I just can’t." He often skipped meals because he would be working through lunch, unable to get out of his hyperfocus. Then he was hit with hunger at dinner and ended up "pigging out." After much assessment, history taking, and a comprehensive clinical interview, it was absolutely clear that Mike had undiagnosed ADHD. It was when we applied this lens to his eating disorder that Mike made progress for the first time in his thirteen-year battle with food. He is now of normal weight and working day by day at managing his food intake.

THERE IS A GROWING SCIENTIFIC LITERATURE REGARDING ADHD and eating disorders, weight, and obesity. Eating disorders come in many forms. Anorexia nervosa is a disorder characterized by starvation and a fear of fatness. Bulimia nervosa is characterized by binge eating episodes (eating a larger than average amount of food in a short period of time to a point of being uncomfortably full). This binge is then compensated for by a method of purging, including self-induced vomiting, excessively exercising, fasting, laxative use, or use of diuretics and diet pills. Binge eating disorder is the binge eating without the purging. However, there are many people who might not fit the above criteria for a clinical eating disorder yet struggle with food. In addition, there is an epidemic of obesity in the United States.

Recent research studies have begun to see an association between ADHD and eating problems. A study in 2005 assessed morbidly obese teenage boys and girls at an obesity clinic and found that fifty-eight percent had ADHD, which is significantly higher than what you would see in the general population. What was striking was that sixty percent of the adolescents were undiagnosed prior to the study. A study of obese patients who were getting gastric bypass surgery found that almost one-third had inattentive ADD. For those patients who had a body mass index over 40 (morbidly obese), the rate of ADD was almost half. A recent study found that girls with ADHD are at high risk for bulimia nervosa compared to their non-ADHD peers. A 2004 study of ADHD patients found that ten percent of subjects had an eating disorder sometime in their life, which is higher than what we would expect in the general population.

ADHD as a predisposing factor

How can ADHD predispose someone to develop an eating disorder or become obese?

People with ADHD have difficulty with the executive function of organization. Eating healthy requires a high degree of organization. If you plan on cooking a meal for dinner, you need to start thinking about it hours before. Perhaps you need to defrost the meat. You may need to run to the market to get ingredients you don’t have at home. Or, you might have to pick up your child from soccer practice and make sure that the meal is made before you go. People with ADHD often think about meals at the time they are due to eat. This leads to relying on fast foods, microwaveable meals, or takeout food, most of which are high in sodium, sugar, and fat.

Self-regulation is also a challenge for those with ADHD. In order to eat healthy, you need to be attentive to physical cues of hunger and fullness. Many with ADHD skip meals if they are hyperfocused on a task. Once a meal is skipped, metabolism decreases and cravings for fat, carbohydrates, and sugar increase. Many with ADHD report not getting enough sleep because it is too hard to shut their minds off at night. When we are sleep deprived, a hormone in our body called leptin decreases, which then results in storage of body fat, as well as cravings for fat. It is harder to lose weight if you are not sleeping properly.

It is common for people with ADHD to eat while doing another activity, like watching television. This can lead to overeating, since one’s ability to be mindful is compromised. Many report feeling grounded and focused by the sensory aspects (smell, taste, texture, touch, visual) of eating.

Eating can be a means of quelling the stress, anger, and/or sadness that can arise from the challenges of having ADHD. The most common emotion I hear my patients with ADHD reporting that trigger their binge eating is boredom. When they feel little stimulation, they gravitate to food as the surefire, accessible form of stimulation. After all, food is always available, is legal, and is sensory stimulating. Eating can also be a relief from racing thoughts and distractibility. College students with ADHD might binge before writing a paper as a way to help them focus. Patients who self-induce vomiting report a euphoric stimulation that comes along with purging. They report an intense ability to focus immediately after vomiting. The problem, of course, is that bulimia is associated with several serious health problems, notably cardiac problems that can lead to death.

ADHD brains tend to have low levels of dopamine, a neurotransmitter that is involved in reward systems and thrill-seeking behavior. When there are low levels of dopamine in the brain, people tend to seek out activities that will elevate these levels and produce a reward. Eating is one such activity.

Treating both disorders

Although there are many factors that make people with ADHD at risk for eating disorders or obesity, the encouraging news is that these issues can be treated, provided that the relationship between the ADHD and the eating disorder is fully understood.

Clinicians too quickly dismiss ADHD as an important factor in this problem and it comes at a cost. A therapist with knowledge in both areas is essential. If you cannot find a therapist who specializes in both, find a therapist who specializes in eating disorders and add an ADHD therapist or coach to your treatment so that the two professionals can work in conjunction in wholly treating the eating problem. Eating disorders are serious and need to be carefully treated and monitored as they can lead to serious medical consequences. Traditional modes of treatment might need to be creatively adjusted in order to work with the ADHD symptoms.

Develop an ADHD-friendly list of alternative forms of stimulation. Meditation might work for some people to reduce stress, but some with ADHD would find it impossible to quiet their minds that much. Don’t waste your time on strategies that you intuitively know won’t work for your ADHD. It can feel defeating for people with ADHD to hear that something "should" work since it works for the majority of people. It comes down to whether it works for you. Time management strategies and scheduling your meals out is essential. Sleep more. Not only will your body like it, but sleeping will mean that you are not up late at night eating.

Breakfast really is the most important meal of the day. Start your day with protein. Impulse control tips are important. Something simple like putting your fork down while you are chewing can go a long way. Using small plates so that you put less food on the plate is also helpful. Those with ADHD respond well to external cues.

For individuals with ADHD and bulimia nervosa or binge eating disorder, stimulant medication can be incredibly helpful in managing their eating disorder, mainly because it is managing the ADHD symptoms that can give rise to the eating disorder.

Most important, if you struggle with an eating disorder, know that you are not alone. This is especially true for males. Contrary to popular belief, eating disorders affect millions of males as well.

Both eating disorders and ADHD can negatively affect one’s self-esteem. People who have either an eating disorder or ADHD struggle with feelings of shame, ineffectiveness, and being perceived by others as being lazy or lacking "willpower." These negative feelings are exponentially increased when people struggle with both ADHD and an eating disorder.

Treatment does work and can free people of the painful experience of an eating disorder. It is important, however, to have the right lens through which you are seeing the problem and therefore using the most appropriate interventions.



ImageSigns of an eating disorder include:

  Image  Significant changes in eating habits (increased eating or restrictive eating, not eating in front of others, not eating in public, eating faster than normal)
  Image  Inflexible adherence to a specific food or exercise schedule
  Image  Negative body image (negative talk about one's body, increased self-criticism, increased mirror checking)
  Image  Social avoidance (often due to shame, poor body image, choosing food over social events)
  Image  Use of food as a way of treating ADHD symptoms
  Image  Excessive or compulsive exercise behavior
  Image  Rigid, inflexible thinking about food and dieting (If I have a piece of cheesecake, I might as well eat the whole cheesecake, since I broke a dietary rule)
  Image  Hoarding or hiding food

If you suspect that you or a loved one with ADHD may have an eating disorder, do not wait for treatment. Take your child to his or her pediatrician to assess him or her medically. Seek help from a specialist in eating disorders. Eating disorder specialists (psychologists, psychiatrists, nutritionists, family therapists) can be found through the website of the Academy for Eating Disorders.

Roberto Olivardia, PhD, is a clinical psychologist and clinical instructor in the department of psychiatry at Harvard Medical School in Boston, Massachusetts. He is coauthor of The Adonis Complex: The Secret Crisis of Male Body Obsession (Free Press, 2000), a book about body image and eating disorders in boys and men. He has a private therapy practice where he specializes in the treatment of ADHD, eating disorders, obsessive-compulsive disorder, and body dysmorphic disorder.

This article originally appeared in the June 2012 issue of Attention magazine. Copyright © 2012 by Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). All rights reserved. No portion of this article may be reprinted without written permission from CHADD.


Posted in: 2012, June