ADHD and Eating Disorders: Research, Diagnosis & Treatment Guidelines

Individuals with ADHD face a heightened risk for eating disorders, most notably bulimia nervosa and binge eating disorder, according to a growing body of research. What’s more, eating disorders appear to grow in severity alongside ADHD symptoms.

Several factors – biological, cognitive, behavioral, and emotional – may explain why ADHD predisposes individuals to eating disorders and challenges. Understanding these factors, including the relationship between a patient’s ADHD and eating disorder, is essential when devising an appropriate and effective treatment plan.

Types of Eating Disorders

Roughy 30 million people in the U.S. (20 million women and 10 million men) suffer from eating disorders¹. Eating disorders are thought to be caused by a complex interaction of genetic, biological, behavioral, social, and psychological factors.

Binge Eating Disorder

Binge eating disorder (BED) and bulimia nervosa (below) are both impulsive eating disorders prevalent in individuals with ADHD.

BED is defined by recurrent episodes of binge eating, characterized by both of the following:

• Eating, in a discrete period of time (e.g., within any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
• A sense of lack of control over eating during the episode (e.g., a feeling that you cannot stop eating or control what or how much you are eating).

[Click to Read: ADHD and Impulsive Eating]

In addition, the episodes are associated with at least three of the following to merit a diagnosis:

• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of feeling embarrassed by how much you are eating
• Feeling disgusted with yourself, depressed, or guilty afterward

Marked distress regarding binge eating must also be present for a diagnosis. Episodes must also occur, on average, at least once a week for three months.

Bulimia Nervosa

Bulimia is characterized by recurrent episodes of binge eating (as described above) as well as recurrent, inappropriate, compensatory behaviors exercised to prevent weight gain from binging. These behaviors can include self-induced vomiting, laxative misuse, fasting, or excessive exercise.

Binging and inappropriate compensatory behaviors must occur, on average, at least once a week for three months to satisfy a diagnosis. Self-evaluation is also unduly influenced by body shape and weight; often, people with bulimia suffer from negative body image.

[Read: “My Appearance Is the Only Thing I Can Control.”]

Anorexia Nervosa

Anorexia is an obsessive-compulsive eating disorder defined by restriction of energy intake leading to a significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health). The disorder is not as prevalent in people with ADHD as are the impulsive eating disorders.

With anorexia, there is either an intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain. Anorexia is accompanied by body image distortion – including disturbances in the way one’s body weight or shape is experienced; body weight or shape influence self-evaluation, or there’s a persistent lack of recognition of the seriousness of the low body weight.

Clinicians also specify whether a patient is of the restricting type (no binging; weight loss accomplished through dieting, fasting, and/or excessive exercise) or binge-eating/purging type (i.e. self-induced vomiting, laxative misuse, diuretics, enemas).

Other Eating Disorders

• Avoidant/Restrictive Food Intake Disorder (ARFID): An eating or feeding disturbance manifested by persistent failure to meet appropriate nutritional and/or energy needs. It’s often associated with significant weight loss, nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference in psychosocial functioning. Absent in this diagnosis is negative body image.
• Other Specific Feeding or Eating Disorder (OSFED): Includes atypical anorexia nervosa (all criteria for anorexia met, but patient’s weight is within or above the normal range); bulimia nervosa of low frequency; BED of low frequency; purging disorder; Night Eating Syndrome; and Chewing and Spitting disorder (chewing but not swallowing food).
• Orthorexia: While not in the DSM-5, orthorexia is characterized by an obsession over healthy, clean eating. It can look like anorexia, but individuals with orthorexia are not motivated by thinness or aesthetic.

Eating Disorders: Medical Consequences

Eating disorders are associated with adverse health consequences including the following:

• Dental problems
• Hair loss
• Dysregulated metabolism
• Sleep problems
• Acute ADHD symptoms (for individuals with existing ADHD)
• Temperature dysregulation
• Problems with concentration
• Cardiovascular problems
• Gastrointestinal problems
• Neurological problems
• Endocrine problems
• Kidney failure

Given these adverse health consequences, eating disorders have high mortality rates². It is estimated that only 10% to 15% of women with eating disorders seek treatment, and an even smaller percentage of men seek treatment.

Eating Habits and ADHD

What Do We Know About ADHD and Eating?

1. Studies show that individuals with ADHD can be quite impulsive with their eating habits. In one study involving a simulated kitchen, children with ADHD consumed more food than children without ADHD. Consumption, furthermore, was not influenced by their mood state, level of hunger, or even their liking of the food³. This means that even for foods the ADHD group didn’t like, they tended to eat more of it simply because it was there.
2. Studies also show that people with ADHD tend to have disruptive eating habits.⁴ In one study, children with ADHD skipped meals more often than did children in the control group, ate fewer fruits and vegetables, and drank more sweetened beverages.³

ADHD and Obesity

These factors may explain why studies have found a high prevalence of ADHD in obese populations.⁵ In a study of 215 bariatric patients, 27% of them had ADD, and the prevalence was highest in patients with extreme obesity (43%).⁶ The same study also found that at all levels, patients with ADHD were less successful at losing weight than their non-ADHD peers. The researchers concluded that, in treatment for obesity and ADHD, outcomes were more closely tied to ADHD symptoms than to level of obesity.

While it is often assumed that individuals with predominantly hyperactive type ADHD are always “on the go” and thus not likely to develop weight issues or eating problems, this is not the case. One study that examined about 100 male patients with ADHD-hyperactive type found that they were significantly more overweight compared to a reference population.⁷

ADHD and Eating Disorders

Numerous studies show that individuals with ADHD are at greater risk (three⁸ to six times⁹ the average) for developing eating disorders compared to non-ADHD individuals.

Research on eating disorders and ADHD has primarily focused on bulimia nervosa and BED. Studies have found that bulimia is more common in adolescent girls with ADHD than it is in their non-ADHD peers¹⁰, and that girls with ADHD are 3.6 times more likely to have bulimia nervosa or BED compared to their peers.¹¹ In a study of patients being treated for bulimia, a quarter of subjects had ADHD.¹²

Few studies have focused on males with eating disorders, but in my clinical practice, where I specialize in the treatment of boys and men with eating disorders, I’ve treated many men with bulimia and binge eating disorder with comorbid ADHD.

ADHD Risk Factors for Eating Disorders

How can having ADHD predispose someone to develop an eating disorder?

Biological and Genetic Factors

• Reward deficiency syndrome. The ADHD brain produces insufficient dopamine, a neurochemical implicated in reward, which may cause individuals to seek satisfaction through food.
• GABA deficit. ADHD brains have lower levels of GABA, a neurochemical implicated in inhibition.
• Purging can be a euphoric, almost addictive form of stimulation that increases dopamine levels.
• Restrictive behaviors can build up reward sensitivity – individuals may purposely restrict food so that when they do eat, it is much more rewarding to them.
• Dopamine receptors could overlap with obesity, binge eating, and ADHD.
• ADHD brains take longer to absorb glucose than non-ADHD brains, which could lead to higher sugar and simple carb consumption.

Cognitive Factors

• Executive function deficits can impact all aspects of eating and preparing foods. Individuals with ADHD, like those with eating disorders, have poor interoceptive awareness, which affects the ability to understand hunger and satiety cues. Planning and decision-making around food can be difficult, which can contribute to impulsive eating or even restriction to avoid the executive task of preparing food.

Behavioral Factors

• Poor impulse control can lead to overeating
• Poor sleep habits can dysregulate metabolism
• Irregular eating schedule can lead to overeating
• Poor self-regulators make it difficult to understand the quantity of food eaten

Emotional Factors and Self-Esteem

• Boredom could be a major predisposing factor to binge eating
• Food can be a relief from anger, sadness, anxiety, and other difficult emotions
• Many individuals with ADHD often struggle with low self-esteem. Food can become a way to cope and feel in control, which could lead to eating disorders

ADHD and Eating Disorders: Treatment

Guiding Principles for Clinicians

• Treat both ADHD and the eating disorder together and don’t discount the relevance of ADHD symptoms in driving the eating disorder. ADHD has to be treated in order to unlock effective ED treatment.
• Understand the patient’s ADHD-ED link, or how the patient’s ADHD symptoms impact and are impacted by the eating disorder.
• Destigmatize ADHD, especially for girls and women, as many remain undiagnosed.
• Destigmatize eating disorders, especially for boys and men.

Treatments

Treatment for an eating disorder is multimodal, often involving a team of psychiatrists, psychologists, nutritionists, and family therapists. While comparatively few individuals with eating disorders seek treatment, patients who do seek treatment should know that recovery is possible. For patients with ADHD, approaches should be adapted to symptoms and should suit their strengths:

• Executive function skills training can address the cognitive factors that contribute to ED
• Cognitive behavioral therapy (CBT) can help undo negative thought patterns and build self-esteem as well as positive body image
• Dialectical behavior therapy (DBT), which focuses on mindfulness, emotional regulation skills, interpersonal effectiveness skills, and distress tolerance is very helpful for patients with ADHD and eating disorder
• Acceptance and Commitment Therapy (ACT) looks at a patient’s value system and helps line up appropriate behaviors to it
• Nutritional therapy is essential for patients with eating disorders
• Group therapy
• Parent coaching

Psychopharmacological Treatments

Stimulant treatment helps regulate eating in patients with ADHD and an eating disorder.

• Vyvanse is the first FDA-approved medication for BED, and is only the second medication approved for ED
• SSRIs are FDA-approved medications for bulimia nervosa
• Stimulant medication can help patients with ADHD and bulimia, according to research¹³
• There are no approved medications for anorexia (partly because of the difficulty for the starved body to metabolize anything)

Eating Disorders: Next Steps

• Free Download: Guide to Delicious (and ADHD-Friendly!) Eating
• Read: Healthy Eating Habits for Impulsive, Dopamine-Starved ADHD Brains
• Read: Disordered Eating and ADHD: Weight Gain and Loss Understood

The Clinicians’ Guide to Treating Complex ADHD from Medscape, MDedge, and ADDitude

• What should I consider when developing a comprehensive treatment plan for ADHD?
• What medications and other approaches should I turn to as first-line treatments for ADHD?
• How can I decide which ADHD medication to prescribe first?
• What challenges and side effects should I anticipate from ADHD medications, and how should I address them?
• How can I improve treatment outcomes for patients with ADHD and comorbid diagnoses?
  • How should clinicians approach treatment for patients with ADHD and comorbid conditions?
  • How should clinicians adjust pharmacological treatment for children with ADHD and comorbidities?
  • What is the recommended approach for treating ADHD with depression?
  • How should clinicians adjust treatment approaches for patients with ADHD and comorbid eating disorders?
  • How is executive dysfunction related to ADHD, and how should it be treated?
  • Free Webinar: Substance Use Disorder and ADHD: Safe, Effective Treatment Options
  • Free Webinar: Current Guidelines for Treatment and Behavioral Interventions for Tourette Syndrome and Tic Disorders
• What dietary, behavioral, or other complementary interventions should I recommend to patients with ADHD?
• How should I follow up with patients with ADHD, and what should we discuss during these checkups?

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The content for this article was derived from the ADDitude Expert Webinar Diagnosing and Treating Eating Disorders in Children and Adults with ADHD [podcast episode #358] with Roberto Olivardia, Ph.D., which was broadcast live on June 8, 2021.

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