The Impact of ADHD on Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis

Bariatric Surgery Is Highly Effective and Underutilized in Patients with ADHD: A 5-Year Retrospective Cohort Study

INTRODUCTION

Obesity and ADHD have become increasingly common diagnoses. In the last decade, research has found that there is a high prevalence of obesity in patients with ADHD. The mainstays of management in the general population include lifestyle modifications, pharmacotherapies, and/or bariatric surgery. However, there is a lack of understanding of appropriate management of patients with both ADHD and obesity.

METHODS

We identified those with obesity for at least five consecutive years (BMI > 30) in the TriNetX database before separating into two groups based on the presence or absence of ADHD. We assessed both the distribution of treatment modalities and the change in average BMI over time in each of our four groups across 5 years.

RESULTS

Average BMI decreased over time in all groups, with the smallest change seen in the ADHD Pharmacology cohort (- 0.366 kg/m2) and the largest in the ADHD Surgery group (- 8.532 kg/m2). Average BMIs at the 5-year mark were significantly different.

CONCLUSION

Our research found that pharmacological management of individuals with ADHD was only half as effective for individuals with ADHD than our control. Though surgical management of patients with ADHD is roughly 20 times more effective in managing obesity, it was not used as frequently in comparison to medication for management of weight.

A systematic meta-review of systematic reviews on attention deficit hyperactivity disorder

BACKGROUND

There are now hundreds of systematic reviews on attention deficit hyperactivity disorder (ADHD) of variable quality. To help navigate this literature, we have reviewed systematic reviews on any topic on ADHD.

METHODS

We searched MEDLINE, PubMed, PsycINFO, Cochrane Library, and Web of Science and performed quality assessment according to the Joanna Briggs Institute Manual for Evidence Synthesis. A total of 231 systematic reviews and meta-analyses met the eligibility criteria.

RESULTS

The prevalence of ADHD was 7.2% for children and adolescents and 2.5% for adults, though with major uncertainty due to methodological variation in the existing literature. There is evidence for both biological and social risk factors for ADHD, but this evidence is mostly correlational rather than causal due to confounding and reverse causality. There is strong evidence for the efficacy of pharmacological treatment on symptom reduction in the short-term, particularly for stimulants. However, there is limited evidence for the efficacy of pharmacotherapy in mitigating adverse life trajectories such as educational attainment, employment, substance abuse, injuries, suicides, crime, and comorbid mental and somatic conditions. Pharmacotherapy is linked with side effects like disturbed sleep, reduced appetite, and increased blood pressure, but less is known about potential adverse effects after long-term use. Evidence of the efficacy of nonpharmacological treatments is mixed.

CONCLUSIONS

Despite hundreds of systematic reviews on ADHD, key questions are still unanswered. Evidence gaps remain as to a more accurate prevalence of ADHD, whether documented risk factors are causal, the efficacy of nonpharmacological treatments on any outcomes, and pharmacotherapy in mitigating the adverse outcomes associated with ADHD.

Eating disorders and emotional dysregulation are associated with insufficient weight loss after bariatric surgery: a 1-year observational follow-up study

PURPOSE

Subjects with obesity, especially those seeking bariatric surgery, exhibit high rates of mental disorders and marked psychopathological traits. The primary objective of this prospective, non-interventional study was to investigate whether the presence of different psychiatric disorders, attention deficit/hyperactivity disorder (ADHD) symptomatology and emotional dysregulation influenced weight loss at 1-year follow-up after surgery.

METHODS

Subjects consecutively referred for pre-surgical evaluation at the Obesity Center of Pisa University Hospital were recruited. Psychiatric diagnoses were made through the Mini-International Neuropsychiatric Interview (MINI) and ADHD symptomatology was assessed with the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). Emotional dysregulation was investigated through the WRAADDS and self-report questionnaires. After surgery, weight and obesity-related comorbidities were monitored during follow-up.

RESULTS

Of the 99 participants recruited, 76 underwent surgery and 65 could be reevaluated 1 year after surgery. Subjects with insufficient weight loss (excess body mass index loss ≤ 53%, n = 15) had more frequent lifetime binge eating disorder (BED) and BED-mood disorders comorbidity than subjects with favorable post-surgical outcome. Additionally, they scored higher on both physician-administered and self-report scales assessing emotional dysregulation, which represents a nuclear symptom of ADHD in adults. At the logistic regression analysis, older age, higher preoperative excess body mass index and greater affective instability were predictors of reduced weight loss at 1-year follow-up.

CONCLUSION

Emotional dysregulation seems to be associated with a worse outcome after bariatric surgery. Further studies with larger samples and longer follow-up are needed to confirm the influence of different psychiatric disorders and psychopathological traits on post-surgical outcome.

LEVEL OF EVIDENCE

V, prospective descriptive study.

The Association Between Lipedema and Attention-Deficit/Hyperactivity Disorder

Introduction The current study aimed to investigate the overlap between symptoms of lipedema and attention-deficit/hyperactivity disorder (ADHD). Lipedema is a condition that causes abnormal fat accumulation and inflammation in the legs and buttocks, often accompanied by edema and pain. ADHD is a common condition characterized by difficulty paying attention and controlling behavior, affecting the social, academic, and occupational quality of life. The study's primary objective was to assess the prevalence of ADHD symptoms in a population of women with lipedema symptoms and compare the clinical characteristics. Method The study used a lipedema screening questionnaire and the Adult Self-Report Scale (ASRS-18) to assess the prevalence of ADHD in a sample of 354 female volunteers with or without a prior lipedema diagnosis. Results Of the lipedema group, 100 (77%) were ASRS positive, and 30 (23%) were ASRS negative. In the group without lipedema, 121 (54%) were ASRS positive, and 103 (46%) were ASRS negative, with a relative risk of 1.424 (p<0.0001). Conclusion Our results demonstrate a positive correlation between lipedema and ADHD and suggest that targeted strategies to improve clinic attendance for individuals with ADHD may improve lipedema treatment outcomes. Patients with lipedema symptoms are more likely to have ADHD symptoms.

Association between attention deficit hyperactivity disorder and outcomes after metabolic and bariatric surgery: a nationwide propensity-matched cohort study

BACKGROUND

The risks and benefits of metabolic and bariatric surgery for patients with attention deficit hyperactivity disorder (ADHD) remain to be investigated.

OBJECTIVE

The aim of this study was to assess short- and long-term outcomes after metabolic and bariatric surgery in patients with previous ADHD compared with matched control individuals.

SETTING

Registry based.

METHODS

This 2-staged matched-cohort study included all adults with a body mass index of ≥30 kg/m² who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy from 2007 until 2017 registered in the Scandinavian Obesity Surgery Registry. Patients with prescribed medication for ADHD were matched with control individuals without ADHD with a follow-up of up to 11 years after surgery.

RESULTS

Among 1431 patients with ADHD and 2862 control individuals (mean body mass index, 42 kg/m²; mean age, 35 years), no difference in weight loss or follow-up attendance over 2 years was seen. ADHD was associated with a higher risk for early postoperative complications (odds ratio [OR] = 1.31; 95% confidence interval [CI], 1.05-1.63), self-harm (hazards ratio [HR] = 1.39; 95% CI, 1.11-1.75), and substance abuse (HR = 1.34; 95% CI, 1.16-1.55), while associations with overall mortality (HR = 1.42; 95% CI, .99-2.03), major adverse cardiovascular and cerebrovascular events (HR = 1.93; 95% CI, .98-3.83), and effects on obesity-related diseases were uncertain. ADHD was associated with a lower health-related quality of life in all aspects before surgery. These differences increased for mental and obesity-related aspects but remained unchanged over time for physical aspects.

CONCLUSIONS

Compared with patients without ADHD, patients treated pharmacologically for ADHD experience similar weight loss and remission of obesity-related diseases without an increased risk for serious complications but report a lower health-related quality of life and have an increased risk of substance abuse and self-harm. This further emphasizes the need for close follow-up care for this group of individuals.

Psychiatric, psychological and addiction management in obesity surgery: Early identification for better support

Although bariatric surgery results in a significant weight reduction and an improvement in the quality of life in most people who undergo surgery, there are inter-individual differences in terms of postoperative results. Psychological, psychiatric and addictive disorders contribute substantially to these difficulties. Between 20% and 50% of bariatric surgery candidates have a current psychiatric/addictive disorder and approximately 30-75% have a history of a psychiatric/addictive disorder within their lifetime. Surgery is accompanied in the short-term by an improvement in depressive symptoms and binge eating, but these symptoms tend to increase again beyond the 3rd postoperative year. Over the long-term, only the improvement in depression remains durable, whilepostoperative anxiety and disordered eating symptoms do not differ significantly from the preoperative levels. There is a two to four fold increased risk of post-surgical suicide and suicide attempts (from the 1st postoperative year onward), as well as an increased risk of alcohol-abuse (beyond two years after surgery). Psychological support must therefore continue long-term. Several psychotherapeutic and pharmacological treatments have demonstrated their effectiveness in improving the postoperative prognosis of patients with psychological/psychiatric disorders. The early integration of psychological/psychiatric/addiction evaluation and support into multidisciplinary management makes it easier to identify these difficulties and to optimize the postoperative prognosis, both in terms of weight and quality of life. Prior to surgery, patients should be systematically evaluated by a psychologist or psychiatrist in order to identify and to manage disorders that could negatively impact the postoperative prognosis. After surgery, this assessment and support can be carried out in a programmed and systematic way for those patients who were identified preoperatively as the most vulnerable, but support can also be offered during follow-up in the event of specific symptoms (i.e., loss of control over food intake, failure in terms of weight or quality of life, suicidal ideation, loss of control over alcohol use, significant depression or anxiety symptoms).

Lisdexamfetamine Pharmacokinetic Comparison Between Patients Who Underwent Roux-en-Y Gastric Bypass and Nonsurgical Controls

INTRODUCTION/PURPOSE

The objective of this research was to characterize the impact of Roux-en-Y gastric bypass (RYGB) on the pharmacokinetic properties of the pro-drug lisdexamfetamine and its active metabolite, d-amphetamine.

MATERIALS AND METHODS

A case-control design was used where patients who had undergone RYGB 9-24 months prior were matched on sex, age, and body mass index (BMI) to nonsurgical controls who had no history of weight loss surgery. Each participant received a single 50 mg dose of lisdexamfetamine, and plasma samples were collected over a 24-h period following dosing. Noncompartmental analyses were used to compare pharmacokinetic measures between groups.

RESULTS

There were no significant differences between the RYGB (n = 10) and NSC groups (n = 10) on sex (70% female), age (40.9 ± 9.6 vs. 41.3 ± 8.9 years), BMI (30.3 ± 5.2 vs. 31 ± 5.9 kg/m²), or ethnicity (100% vs. 80% White). The pharmacokinetic parameters between the RYGB and NCS groups were found to be equivalent for lisdexamfetamine and d-amphetamine, including maximum plasma concentration (Cmax), time to maximum plasma concentration (Tmax), and area under the plasma concentration-time curve (AUC_(0-∞)).

CONCLUSION

These data suggest that there is no need to routinely adjust lisdexamfetamine dosing following RYGB. However, given the potential for inter-individual differences, patients who undergo RYGB should be clinically monitored and individualized dosing strategies should be considered for concerns surrounding efficacy or toxicity.

High prevalence of attention-deficit/hyperactivity disorder in adolescents with severe obesity seeking bariatric surgery

AIM

To examine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and related post-surgical weight loss in adolescents with severe obesity seeking bariatric surgery.

METHODS

The study population included 84 adolescents (age 13-19 years; 44 males, 40 females) with severe obesity who sought bariatric surgery at the Sheba Medical Centre in Israel during the years 2011-2017. Anthropometric and clinical data were collected from medical records. A subgroup of 20 participants filled questionnaires that evaluated ADHD-like symptoms, eating behaviours and quality of life. Data on adolescents that ultimately underwent surgery (n = 45) were also obtained.

RESULTS

The prevalence of ADHD was 28.6% in adolescents seeking bariatric surgery, much higher than that of the general adolescent population of Israel (17.1%, P < .001). There were no significant differences in reductions of weight, body mass index, body mass index standard deviation scores and body fat percent between participants with or without ADHD. In the subgroup that filled questionnaires, higher scores on ADHD-Rating Scale at baseline were associated with greater excess weight loss.

CONCLUSION

The prevalence of ADHD in adolescents seeking bariatric surgery was very high. Diagnosed ADHD was not related to post-surgical weight loss, whereas baseline ADHD-related behaviour was associated with higher post-surgical weight loss.

The Association between ADHD and Obesity: Intriguing, Progressively More Investigated, but Still Puzzling

This narrative review is aimed at presenting the most recent evidence on the association between attention-deficit/hyperactivity disorder (ADHD) and obesity. The review is informed by previous relevant systematic reviews and a search in Pubmed and PsycINFO up to 1 August 2019. Although the association between ADHD and obesity would seem, at first, paradoxical, in the past two decades there has been an increasing number of studies on this topic. The present review shows that there is meta-analytic evidence supporting a significant association between these two conditions, at least in adults. Growing evidence is also being published on the genetic and environmental factors underlying the association. However, the cause–effects paths, as well as the exact mechanisms explaining the association, remain unclear. Additionally, empirical evidence guiding the management/treatment of patients with the two conditions is still limited. Therefore, after almost 20 years from the first report of a link between ADHD and obesity, this association continues to be puzzling.