Last week I served lunch at my son’s school. It was a hoot, really, serving an entire K-8 school lunch. Dishing out lasagna, broccoli, pizza, and grilled cheese provided all sorts of insight into what lunch is like in 2013. My son didn’t choose exactly as I’d predict (see below). When a 33-year prospective study published today which connects childhood ADHD with adult obesity, it got me thinking we need to be more involved in how (not just what) our children eat at school. For those children with and without attention challenges.
Previous studies have found that ADHD may increase risk for unhealthy weight because researchers theorize inattention and compulsive behavior in life changes eating patterns. We’re clearly dependent on regulation for achieving and maintaining a healthy weight. The study published today followed boys from age 6-12 years into adulthood, spanning 33 years. Results in this small sample suggest childhood inattention and hyperactivity conferred a two-fold increase in being obese as adult. The study included only Caucasian boys. The development of obesity in those men was found regardless of their ADHD continuing into adulthood or not.
It’s well established that children who are overweight have a higher risk of being overweight or obese adults. And what makes this research important is that unlike previous studies, it didn’t matter if the boys ADHD remitted in adulthood. Meaning that even if boys outgrew their ADHD, their risk of adult obesity persisted. Researchers theorize that those eating habits and attention challenges of childhood may change lifetime risk. Because the findings go against previous data that unlinked obesity and ADHD in adulthood, it will likely trigger more research.
5 Things Parents Can Do:
- Children with ADHD may be at higher risk for unhealthy weight. At every child’s well child check-up, inquire about their body-mass index and risk of overweight.
- Divide responsibilities: parents provide great food, children choose how much and what to eat from what is offered.
- Turn off the TV at any meal, it only serves as a distracter. If you think your child eats compulsively or is distracted during eating or compulsively overeats, talk with their doctor.
- Family meals are an important strategy. Don’t give up on a daily meal together even if it’s breakfast. Every meal counts.
- Goal for every meal should include having ½ the plate covered with fresh fruit and veggies.
The findings of the study certainly make sense to me. As a practicing pediatrician it also sounds a bit of an alarm. Our job as a community is to ensure we help support and protect children who may not be set up to self-regulate during meals. We have to think of ways to facilitate children sensing, feeling, and then responding to their natural cues at mealtime. We need to provide really good choices. If you’re more distractible, inattentive, and/or compulsive with any activity, you may be just the same while eating. This study encourages us to think of devising different strategies for healthy weight for those children who may have increased attention challenges.
When I served lunch at my son’s school I was able to watch as 5 year-olds to 13 year-olds came through for lunch. From the very beginning (Kindergarten), students are allowed to chose whatever they’d like from the hot lunch line, snack line, beverage fridges, and fresh refrigerated food. From the very beginning, they have minimal supervision and oversight. I saw many children who brought a lunch from home go up and get a cookie or a bag of chips. And my own son? Left to his own devices, even with me in the hot lunch line and at his table for lunch, he selected a piece of pizza, declined the broccoli, grabbed an orange juice over milk, a large cookie, and some sugar cereal in a bag. Although we typically pack his lunch daily, he has the opportunity to augment his lunch any day. A huge wake-up call. And it wasn’t just my little guy making those choices.
One child at the table I joined literally individually salted each piece of pasta he ate with the lunchroom saltshaker, one ate only the pepperoni off his pizza, a fruit juice, and a cookie, and one boy at our table ate only his lunch from home (hoorah!). And although I sound like the police detailing this, it’s not how it felt. It was refreshing to see children act like children. But the study published today made me wonder if we can do a tidge more. Our school likely isn’t so much of an outlier.
Children who have challenges with self-control may not be served by this kind of independence with eating this early. It’s important to teach children by trial and error, but with their weight on the line and obesity persisting in nearly 1 in 5 US children, we may need more oversight from savvy, invested adults in the lunch line.
I said nothing to these sweet little Kindergartners about their salt shakers, their sugary choices, and their poor selection. Even though I’d be thrilled to have another mom redirect my son while I wasn’t there, I didn’t want to overstep my boundary. I was there simply to serve lunch.
As we know it, obesity affects 17% of children. The way we eat, and listen to hunger cues, and deal with impulses may be a relevant part of the why behind some children’s higher risk to an unhealthy weight.
Statistics On ADHD And Obesity
- 17% children obese, >35% adults are obese. The study serves up a reminder that how our children learn to eat in childhood may affect their lifelong eating patterns and health.
- Obesity is one of the leading causes of preventable death.
- Somewhere between6-10% children have had or have an ADHD diagnosis in this country. The numbers are somewhat debated as research studies vary with parental surveys and report. Although a research letter published earlier this month in JAMA Pediatrics finds that parent and research statistics may overlap. Parents report that about 9% of their children have a diagnosis of ADHD in the United States. Therefore, supporting 1 in 10 families with more specific strategies may be important as we work to decease childhood and adult obesity in the US.
- Boys (13.2%) were more likely than girls (5.6%) to carry a diagnosis of ADHD, while they are also more likely to be medicated with stimulants. The CDC reports that about 66% of children with an ADHD diagnosis are on medications to support their behavior.
Overeating is a part of what puts children at risk for unhealthy weight and obesity. Sedentary lifestyles, portion sizes, and imbalances between the two do so as well.
33-Year Pediatrics Study
- The study followed boys from age 6 to age 41 years
- Men with childhood ADHD had twice the risk of obesity.
- In this study even when ADHD remitted, obesity risk remained.
- One conclusion: children with ADHD now may be at increased risk for obesity later.
I can’t help but wonder though, that since ADHD diagnoses have risen dramatically since the study began (30+ years ago) if in fact many of those boys in the study not diagnosed with ADHD would be diagnosed with ADHD today. Regardless, the take home message is we need to do a good job supporting children and families who have challenges with ADHD and ensure we work hard to help prevent development of obesity during childhood giving all our community the best shot at a long life.
What about you, would you have spoken up at the lunch table? Are you involved in your child’s school lunch program? What can you teach me?
Ann Soutter says
My son loses his appetite while on his ADHD medications. He will sometimes get a milk carton for lunch, but I’m afraid it is few and far between. We eat a late family dinner, usually between 7-9 pm, when he gets hungry. We have struggled with his low weight every year. He doesn’t take his medications on weekends or during the summer, just so he can gain some weight. I found his study to be confusing, based on my experiences.
Wendy Sue Swanson, MD, MBE says
I understand! So many patients and their families that I care for with ADHD struggle to have an appetite not the opposite. See additional comment I posted responding to Jonathan. We really do need to know more about children whose appetite is artificially suppressed secondary to medication use for attention and how they learn to eat, self-regulate and grow-up on and/or off medications and stimulants as adults.
I’m sorry you struggle with his low weight as I have experienced with many patients and their families how stressful that can be. There are many things (which I trust you have tried) that you can talk with the pediatrician about doing to potentially increase his appetite (different timing on medications, breakfast before meds, snack before bed when hunger returns if possible, drug holidays on weekends and weeks out of school, and/or a trial on a non-stimulant medication if weight gain isn’t normal or returning).
Thank you for sharing this interesting data. Ann’s point about decreased appetite on ADHD meds and your point about the increased diagnosis of ADHD raise the fascinating potential for a follow up study. In today’s world of increased diagnosis and treatment for ADHD, are ADHD and obesity still linked? Do the med’s suppression of appetite and/or suppression of compulsive behavior result in lifelong improvement in BMI? Fascinating to think about. My guess is that 33 years later, the study may be a little more diverse in its patient population.
Regardless, I agree that the education about portion control could help us all.
Wendy Sue Swanson, MD, MBE says
I agree that I’m dubious about the data holding up if a prospective study started today. As obesity has skyrocketed the last 3 decades, so has the prevalence of ADHD diagnosis. The data may not hold up.
Both you and Ann bring up really important points that I think require more study.
We certainly know that the most frequent treatment for ADHD (when a medication) is a stimulant which dramatically suppresses appetite in some patients. We therefore take away a child’s natural instinct and ability to self-regulate by listening to both hunger cues and satiety cues. I wonder if a child grows up on stimulants and doesn’t learn how to eat following natural cues if they will have a more difficult time self-regulating and eating well to maintain a healthy weight as an adult…
In general, I think this research elevates the need to prioritize and value time for nutritional counseling, support, and interventions particularly in children who have challenges with attention, hyperactivity and impulse control.
How I wish you were still practicing medicine in Mill Creek! You were my son’s first pediatrician and we sure miss you!
When my son was a little over 2 years old, we had to convince you to refer us to a speech therapist :-), but it was that early that I knew something was wrong. I first had him assessed professionally when he was in preschool and the answer comes back, “He is so smart, he will be fine!”. He struggled through kindergarten and had a breakdown in May that lasted about 8 months (severe anxiety, wouldn’t let me out of his sight even at home, lots of crying over “what ifs”, etc.). We assumed he was exhausted by our demanding schedule, discontinued carpooling, stopped all lessons and let him take it easy until January 2017. When 1st grade started last fall, I came to pick him up on day 1 and his teacher greeted me at the door with a “we need to talk”. Since then, I have done a ton of research and came up with my own plan via trial and error. We found the magic formula in food when we ditched our healthy breakfasts of whole wheat waffles with organic maple syrup and organic fruit, veggie and Greek yogurt smoothies, which we thought were great, healthy choices (we’ve never fed our kids sugary cereals or other processed crap). Breakfast became eggs and other high protein, low sugar options. We also started insisting on him drinking at least 24 ounces of water throughout his school day (what a battle that was) and started attending his school lunches 1-2 times each week (where we saw exactly what you describe in this article) and taught him to make good choices during the lunch period (such as no seconds, veggies are a required component of every lunch, no fooling around but making sure protein and fiber are consumed during the 20!! minutes they are given for lunch, etc.).
The results were phenomenal! My severely ADHD child who was unable to function in school was unrecognizable by halfway through the school year and even placed 2nd in the district spelling bee!
My huge frustration with this process has been that I’ve had to figure all of this out on my own, we haven’t found a medical professional that will listen and take on my highly functioning child. Children’s told me that our case isn’t severe enough because he is able to function and not fall behind in school, but that is only because we have gone to an unreasonable amount of effort to make sure that we don’t have an even bigger problem as my son gets older. Our school doesn’t have any resources in this area and I am unsure of where else to turn.
Do you have any insight in this area? I’d love to get your opinion/advice. We are not interested in labeling our son or pursuing medication of any kind, but I do want to understand how my son’s mind works and what approach to use with school, especially as I deal with new teachers every school year…
Wendy Sue Swanson, MD, MBE says
You’re sweet. I am still in Mill Creek once weekly seeing patients and would be delighted to see you at any time. I’m glad you “convinced me” and simultaneously sad it felt that way to you, to get the interventions and support your family needed.
So sorry that you’ve felt so alone in figuring out how to support your son and make changes for him to thrive. He is so lucky to have you as a mom and advocate. You’re not alone feeling this. Perhaps seeing a behavior expert (ADHD specialist at TEC or elsewhere or psychologist) may help you tease out what is going on, how to continue to support your son as he grows and changes and likely as what he needs does too.