Does the Attention Deficit Hyperactivity Disorder interfere with bariatric surgery results?

Doglas Gobbi Marchesi TCBC-ES Jovana Gobbi Marchesi Ciriaco Gustavo Peixoto Soares Miguel TCBC-ES Gustavo Adolfo Pavan Batista ACBC-ES Camila Pereira Cabral ACBC-ES Larissa Carvalho Fraga About the authors

ABSTRACT

Objective:

to analyze possible negative effects of Attention Deficit Hyperactivity Disorder (ADHD) on the success of bariatric surgery.

Methods:

we evaluated forty patients undergoing bariatric surgery and with regular post-operative follow-up of at least one year. To all, we applied the questionnaire advocated in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association for ADHD, as well as analyzed their postoperative data.

Results:

fifteen (38%) patients presented a positive questionnaire for ADHD. Patients with ADHD presented higher BMI than patients without the disorder (45.8 vs. 40.9 kg/m2, p=0.017), and the difference remained in all postoperative stages. There was no statistically significant difference in surgery success (33.3% x 66.7%, p=0.505) or in BMI reduction (30.71% x 31.88%, p=0.671) one year after the procedure.

Conclusion:

ADHD patients have a higher BMI. However, the presence of ADHD does not influence the success of bariatric surgery and the reduction of BMI.

Keywords:
Bariatric surgery; Obesity; Attention Deficit Disorder with Hyperactivity.

RESUMO

Objetivos:

analisar possíveis efeitos negativos do Transtorno do Déficit de Atenção e Hiperatividade (TDAH) no sucesso da cirurgia bariátrica.

Métodos:

foram avaliados 40 pacientes submetidos à cirurgia bariátrica e com acompanhamento pós-operatório regular mínimo de um ano. Todos foram submetidos ao questionário preconizado na quarta edição do Diagnostic and Statistical Manual (DSM-IV) da Associação Americana de Psiquiatria para TDAH e analisados os dados pós operatórios.

Resultados

: quinze (38%) pacientes apresentaram questionário positivo para TDAH. Os pacientes com TDAH apresentaram IMC maior do que os pacientes sem o transtorno (45,8x40,9 Kg/m2; p=0,017), mantendo-se a diferença em todas as etapas do pós-operatório. Não foi encontrada diferença estatisticamente significativa no sucesso da cirurgia (33,3% x 66,7%; p=0,505), e na redução do IMC (30,71% x 31,88%; p=0,671) após um ano do procedimento.

Conclusão

: pacientes com TDAH apresentam maior IMC, entretanto, a presença do TDAH não apresenta influência no sucesso da cirurgia bariátrica e na redução do IMC.

Descritores:
Cirurgia Bariátrica; Obesidade; Transtorno do Déficit de Atenção com Hiperatividade.

INTRODUCTION

besity is a chronic disease that affects an increasing number of individuals worldwide11 Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obes Surg. 2003;13(3):329-30.,22 WHO. World health statistics 2011. Geneva: World Health Organization; 2011.. There are estimates of overweight prevalence of 50.6%33 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção de Saúde. Vigitel Brasil 2012: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2013.. It is associated with a significant increase in morbidity and mortality and raises the incidence of several diseases, among them hypertension, diabetes mellitus, metabolic syndrome44 Buchwald H. The future of bariatric surgery. Obes Surg. 2005;15(5):598-605.

5 Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5-24 million UK adults. Lancet. 2014;384(9945):755-65.

6 Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S. Erratum: Obes Res. 1998;6(6):464.
-77 Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683-93..

Bariatric surgery is a definitive treatment for morbid obesity and presents good long-term results, with loss of up to 70% excess weight88 Fobi MA. Surgical treatment of obesity: a review. J Natl Med Assoc. 2004;96(1):61-75.. The most commonly performed technique in Brazil and the world is the Roux-en-Y Gastric Bypass (RYGB).

Despite the great efficiency of bariatric surgery, about 10 to 20% of patients submitted to it regain weight after the procedure99 Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922-33.,1010 Sjöström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-84.. Both the weight regain and the procedure failure are due to multiple factors. Psychiatric disorders such as anxiety, depression and attention-deficit / hyperactivity disorder (ADHD) are listed among them99 Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922-33.,1010 Sjöström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-84..

ADHD is a neurological disorder of genetic causes1111 Matthews M, Nigg JT, Fair DA. Attention deficit hyperactivity disorder. Curr Top Behav Neurosci. 2014;16:235-66.,1212 Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57(11):1313-23., present in about 5% of the adult population1313 Polanczyk GV, Casella EB, Miguel EC, Reed UC. Attention deficit disorder/hyperactivity: a scientific overview. Clinics (Sao Paulo). 2012;67(10):1125-6.,1414 Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9(3):490-9.. Symptoms revolve around the triad of inattention, restlessness, and impulsivity of varying degrees1515 Mattos P, Palmini A, Salgado CA, Segenreich D, Grevet E, de Oliveira IR, et al. Brazilian consensus of specialists on the diagnosis of attention-deficit/hyperactivity disorder in adults. Rev Psiquiatr Rio GdSul. 2006;28(1):50-60.. The etiology of ADHD is still unknown, but recent studies suggest alterations in the reward mechanism, also related to eating disorders and obesity1616 Johnson RJ, Gold MS, Johnson DR, Ishimoto T, Lanaspa MA, Zahniser NR, et al. Attention-deficit/hyperactivity disorder: is it time to reappraise the role of sugar consumption? Postgrad Med. 2011;123(5):39-49.. There is evidence of increased ADHD incidence among obese and of greater difficulty in adherence to treatments and weight control1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.. However, few studies have evaluated the prevalence of ADHD in candidates for bariatric surgery and no study has evaluated its possible effects on the success of this procedure.

The purpose of this study was to evaluate the effect of the presence of ADHD on the results of bariatric surgery.

METHODS

We conducted a retrospective, observational study under the approval of the Ethics in Research Committee (CEP) of the Federal University of Espírito Santo (UFES) (CAAE: 05524512.3.0000.5060). We analyzed the specific charts of the bariatric surgery program of patients undergoing bariatric surgery from November 2011 to May 2013, according to the inclusion and exclusion criteria mentioned below.

After the selection of the volunteers, we obtained a list of 122 patients, who were invited to attend the Bariatric Surgery Outpatient Clinic of the Cassiano Antônio de Moraes University Hospital (HUCAM), where they signed the Informed Consent Form.

The inclusion criteria were patients submitted to the RYGB, respecting the indications of bariatric surgery according to the guideline of the National Institute of Health (NIH)66 Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S. Erratum: Obes Res. 1998;6(6):464., postoperative time greater than one year,and regular follow-up with the multidisciplinary team.

Exclusion criteria were diagnosis of neurological and/or psychiatric diseases and use of psychoactive medications, to avoid confusion bias due to symptoms' masking.

After this initial screening, we included 40 patients for data evaluation, according to the algorithm shown in figure 1.

Figure 1
Algorithm of patient selection.

After data collection, we performed a descriptive analysis with mean, standard deviation, median, absolute frequency and percentage, as well as maximum and minimum values, and drew up a profile of the cohort, recording data such as schooling, marital status, profession, age, ethnicity and comorbidities, seenin table 1.

Table 1
Characterization of the sample.

We followed the patients at the institution's bariatric surgery outpatient clinic with programmed returns for three months, six months and one year. We evaluated variables such as weight, body mass index (BMI), percentage of BMI loss, and success of bariatric surgery (defined as loss of 50% or more of excess weight, considering a BMI of 2588 Fobi MA. Surgical treatment of obesity: a review. J Natl Med Assoc. 2004;96(1):61-75.,1818 Geloneze B, Pareja JC. Cirurgia bariátrica cura a síndrome metabólica? Arq Bras Endocrinol Metab. 2006;50(2):400-7.). In addition, researchers previously trained by a neurologist applied the Adult-Self Report Scale (ASRS) structured questionnaire1111 Matthews M, Nigg JT, Fair DA. Attention deficit hyperactivity disorder. Curr Top Behav Neurosci. 2014;16:235-66., for the diagnosis of ADHD. The questionnaire has 18 questions, the answers of which are divided into five groups (never, rarely, sometimes, often, very often), and grouped in part A (nineattention deficit questions) and part B (nine hyperactivity questions). For ADHD diagnosis, we used the criteria of the fourth American Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)1919 American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994. of the American Psychiatry Society, and deemed present when six or more responses were positive in part A or part B, or both, not considering the sum of the positive answers in the two parts. We divided the patients into two groups: with ADHD and without ADHD.

In the comparative analysis, for categorical variables, the statistical technique used was the chi-square test. For metric variables between two groups, we used the t-test for mean (parametric) and the Mann-Whitney test (non-parametric) for the comparisons. Statistical significance was set at p <0.05.

RESULTS

Of the 40 patients evaluated in the one-year period, 24 (60%) were successful. The ADHD group showed a higher average of comorbidities, but there was no statistically significant difference (Table 2).

Table 2
Relationship between number of Comorbidities and ADHD.

We observed a statistically significant difference in BMI at all times of follow-up. (Table 3).

Table 3
BMIaccording to ADHD.

When comparing the percentage of BMI loss, ADHD individuals had a statistically significant difference in six months; however, this difference did not persist after 12 months (Figure 2).

Figure 2
Percentage reduction of BMI.

Both in the absolute weight loss assessment and in the comparative analysis of surgery success, there was no statistically significant difference between the groups with and without ADHD (Table 4).

Table 4
Weight loss according to presence of ADHD.

DISCUSSION

The relationship between ADHD and obesity became clear in recent years, both because of similar etiopathogeneses1616 Johnson RJ, Gold MS, Johnson DR, Ishimoto T, Lanaspa MA, Zahniser NR, et al. Attention-deficit/hyperactivity disorder: is it time to reappraise the role of sugar consumption? Postgrad Med. 2011;123(5):39-49. and because of the difficulty in adhering to treatments and weight control1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.. Concomitantly, despite the efficiency of bariatric surgery, a not insignificant portion of the patients, up to 20%, presented weight regain and the associated relapse of some comorbidities99 Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922-33.,1010 Sjöström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-84.. Faced with this situation, review studies performed to evaluate psychosocial predictors of failure in bariatric surgery have shown that the vast majority of studies are conflicting and inconclusive20, 21. This result is due in part to the fact that manybariatric surgery teamsautomaticallyconsider patients diagnosed with psychiatric disorders as ineligible for the procedure2020 van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg.2005;15(4):552-60..

The prevalence of 38% of ADHD found in our sample was in line with the studies that evaluated obese patients in general1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.,2222 Altfas JR. Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC Psychiatry. 2002;2:9.,2323 Pagoto SL, Curtin C, Bandini LG, Anderson SE, Schneider KL, Bodenlos JS, et al. Weight loss following a clinic-based weight loss program among adults with attention deficit/hyperactivity disorder symptoms. Eat Weight Disord. 2010;15(3):e166-72. and with a value far above that found in patients in bariatric surgery programming2424 Gruss B, Mueller A, Horbach T, Martin A, de Zwaan M. Attention-deficit/hyperactivity disorder in a prebariatric surgery sample. Eur Eat Disord Rev. 2012;20(1):103-7.,2525 Alfonsson S, Parling T, Ghaderi A. Screening of adult ADHD among patients presenting for bariatric surgery. Obes Surg. 2012;22(6):918-26.. Studies evaluating the obese population in general found a prevalence of ADHD between 27.4 and 32.2%,1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.,2222 Altfas JR. Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC Psychiatry. 2002;2:9.,2323 Pagoto SL, Curtin C, Bandini LG, Anderson SE, Schneider KL, Bodenlos JS, et al. Weight loss following a clinic-based weight loss program among adults with attention deficit/hyperactivity disorder symptoms. Eat Weight Disord. 2010;15(3):e166-72. but one of the studies identified a higher incidence in individuals with BMI=40kg/m2 22. Two of these studies used as a diagnostic method a semi-structured interview and psychological follow-up1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.,2222 Altfas JR. Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC Psychiatry. 2002;2:9.. Pagoto et al.2323 Pagoto SL, Curtin C, Bandini LG, Anderson SE, Schneider KL, Bodenlos JS, et al. Weight loss following a clinic-based weight loss program among adults with attention deficit/hyperactivity disorder symptoms. Eat Weight Disord. 2010;15(3):e166-72. used the same ASRS scale that we used in our study, but considered as positive the patients that met four criteria only. Thus, these studies opted for greater sensitivity in diagnosis.

On the other hand, studies in groups of patients in preoperative bariatric surgery showed prevalence between 10.2 and 12.1%2424 Gruss B, Mueller A, Horbach T, Martin A, de Zwaan M. Attention-deficit/hyperactivity disorder in a prebariatric surgery sample. Eur Eat Disord Rev. 2012;20(1):103-7.,2525 Alfonsson S, Parling T, Ghaderi A. Screening of adult ADHD among patients presenting for bariatric surgery. Obes Surg. 2012;22(6):918-26.. However, Gruss et al.2424 Gruss B, Mueller A, Horbach T, Martin A, de Zwaan M. Attention-deficit/hyperactivity disorder in a prebariatric surgery sample. Eur Eat Disord Rev. 2012;20(1):103-7. considered positive only those patients who fulfilled criteria in two scales. When evaluating only the ASRS use, they found a prevalence of 29.3%, which is the closest to our result. We also note that these two studies used the ASRS scale with the patient reading and completing it alone, while in our study the researchers/interviewers conducted the questionnaire, as previously trained. We consider this adaptation necessary since we work with a portion of the population of low socioeconomic level, which would compromise the understanding of the questionnaire and its due fulfillment. In addition, we increased the accuracy of the diagnosis and avoided false-negative results.

Regarding comorbidities, we observing no difference between the patients with ADHD and the group without the disorder. We found no articles in the literature comparing these variables. We believe that the obesity degree directly influences the number of comorbidities66 Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S. Erratum: Obes Res. 1998;6(6):464., without direct influence of ADHD.

We observed that the BMI of patients with ADHD were higher than of those without the diagnosis. An American epidemiological study of 2013 with 34,653 people directly interviewed by psychiatrists confirmed that there was a significant difference in both weight and BMI in ADHD individuals2626 Cortese S, Faraone SV, Bernardi S, Wang S, Blanco C. Adult attention-deficit hyperactivity disorder and obesity: epidemiological study. Br J Psychiatry. 2013;203(1):24-34., which corroborates our results.

Our success rate with surgery was 60% after one year. However, some factors may have negatively influenced this result. The maximum weight loss can occur up to the second postoperative year2727 Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortalityin Swedish obese subjects. N Engl J Med. 2007;357(8):741-52.. Our serieshad a large proportion of blacks, who display less weight loss in bariatric surgery2828 Costello EJ, Keeler GP, Angold A. Poverty, race/ethnicity, and psychiatricdisorder: a study of rural children. Am J Public Health. 2001;91(9):1494-8.. Finally, weight loss after bariatric surgery is usually lower in superobese patients and in diabetics2929 Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006;73(11):993-1007.,3030 Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000; 10(3):233-9.. Thus, one expects that in a sample with a high percentage of diabetics and superobese like ours, with 37.5% diabetics and 15% superobese, the percentage of excess weight loss is lower than the general average. Several studies analyzed this fact, such as the one from Schauer et al.3131 Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-29., who had a sample of 275 patients, 6.5% of them diabetic, who presented a mean weight loss of 68.8%3131 Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-29.. Wittgrove et al.3030 Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000; 10(3):233-9. found 17% of diabetics and observed 80% weight loss in 18 months, but considering only the diabetic population the value was approximately 70%.

When assessing ADHD with the evolution of patients after Gastric Bypass, we found no significant differences between the groups, leading to the belief that ADHD did not influence the procedure success. Although we found a single difference in the percentage of BMI loss at six months, this trend did not persist in the 12-month period.

Even with limited sample size, lacking sufficient external validity to prove that ADHD would affect surgery success, the data are relevant because there is a huge shortage of such studies. It is known that individuals with ADHD have a higher mean BMI and even less weight loss with clinical obesity treatment1717 Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.. Concurrently, the higher the BMI, the greater the surgical morbidity and mortality3232 Bruschi Kelles SM, Diniz MF, Machado CJ, Barreto SM. Mortality rate after open Roux-in-Y gastric bypass: a 10-year follow-up. Braz J Med Biol Res. 2014;47(7):617-25.. Thus, it is expected that the treatment of such patients since the preoperative period allows better weight loss before the procedure and provides reduction of surgical complications.

We conclude from our study that patients with ADHD have a higher BMI on average. However, bariatric surgery success of was not affected by the disease. This study has limitations on the sample size of and may not have statistical strength for definitive conclusions. However, these are preliminary results and further prospective studies are needed, with larger samples, longer follow-up times and multivariate analysis of the different confounding factors.

REFERENCES

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    Deitel M. Overweight and obesity worldwide now estimated to involve 1.7 billion people. Obes Surg. 2003;13(3):329-30.
  • 2
    WHO. World health statistics 2011. Geneva: World Health Organization; 2011.
  • 3
    Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção de Saúde. Vigitel Brasil 2012: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Brasília: Ministério da Saúde; 2013.
  • 4
    Buchwald H. The future of bariatric surgery. Obes Surg. 2005;15(5):598-605.
  • 5
    Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5-24 million UK adults. Lancet. 2014;384(9945):755-65.
  • 6
    Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults--the evidence report. National Institutes of Health. Obes Res. 1998;6 Suppl 2:51S-209S. Erratum: Obes Res. 1998;6(6):464.
  • 7
    Sjöström L, Lindroos AK, Peltonen M, Torgerson J, Bouchard C, Carlsson B, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683-93.
  • 8
    Fobi MA. Surgical treatment of obesity: a review. J Natl Med Assoc. 2004;96(1):61-75.
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    Karmali S, Brar B, Shi X, Sharma AM, de Gara C, Birch DW. Weight recidivism post-bariatric surgery: a systematic review. Obes Surg. 2013;23(11):1922-33.
  • 10
    Sjöström CD, Lissner L, Wedel H, Sjöström L. Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Obes Res. 1999;7(5):477-84.
  • 11
    Matthews M, Nigg JT, Fair DA. Attention deficit hyperactivity disorder. Curr Top Behav Neurosci. 2014;16:235-66.
  • 12
    Faraone SV, Perlis RH, Doyle AE, Smoller JW, Goralnick JJ, Holmgren MA, et al. Molecular genetics of attention-deficit/hyperactivity disorder. Biol Psychiatry. 2005;57(11):1313-23.
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    Polanczyk GV, Casella EB, Miguel EC, Reed UC. Attention deficit disorder/hyperactivity: a scientific overview. Clinics (Sao Paulo). 2012;67(10):1125-6.
  • 14
    Willcutt EG. The prevalence of DSM-IV attention-deficit/hyperactivity disorder: a meta-analytic review. Neurotherapeutics. 2012;9(3):490-9.
  • 15
    Mattos P, Palmini A, Salgado CA, Segenreich D, Grevet E, de Oliveira IR, et al. Brazilian consensus of specialists on the diagnosis of attention-deficit/hyperactivity disorder in adults. Rev Psiquiatr Rio GdSul. 2006;28(1):50-60.
  • 16
    Johnson RJ, Gold MS, Johnson DR, Ishimoto T, Lanaspa MA, Zahniser NR, et al. Attention-deficit/hyperactivity disorder: is it time to reappraise the role of sugar consumption? Postgrad Med. 2011;123(5):39-49.
  • 17
    Levy LD, Fleming JP, Klar D. Treatment of refractory obesity in severely obese adults following management of newly diagnosed attention deficit hyperactivity disorder. Int J Obes (Lond). 2009;33(3):326-34.
  • 18
    Geloneze B, Pareja JC. Cirurgia bariátrica cura a síndrome metabólica? Arq Bras Endocrinol Metab. 2006;50(2):400-7.
  • 19
    American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-IV. 4th ed. Washington, DC: American Psychiatric Association; 1994.
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    van Hout GC, Verschure SK, van Heck GL. Psychosocial predictors of success following bariatric surgery. Obes Surg.2005;15(4):552-60.
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    Herpertz S, Kielmann R, Wolf AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554-69.
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    Altfas JR. Prevalence of attention deficit/hyperactivity disorder among adults in obesity treatment. BMC Psychiatry. 2002;2:9.
  • 23
    Pagoto SL, Curtin C, Bandini LG, Anderson SE, Schneider KL, Bodenlos JS, et al. Weight loss following a clinic-based weight loss program among adults with attention deficit/hyperactivity disorder symptoms. Eat Weight Disord. 2010;15(3):e166-72.
  • 24
    Gruss B, Mueller A, Horbach T, Martin A, de Zwaan M. Attention-deficit/hyperactivity disorder in a prebariatric surgery sample. Eur Eat Disord Rev. 2012;20(1):103-7.
  • 25
    Alfonsson S, Parling T, Ghaderi A. Screening of adult ADHD among patients presenting for bariatric surgery. Obes Surg. 2012;22(6):918-26.
  • 26
    Cortese S, Faraone SV, Bernardi S, Wang S, Blanco C. Adult attention-deficit hyperactivity disorder and obesity: epidemiological study. Br J Psychiatry. 2013;203(1):24-34.
  • 27
    Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, et al. Effects of bariatric surgery on mortalityin Swedish obese subjects. N Engl J Med. 2007;357(8):741-52.
  • 28
    Costello EJ, Keeler GP, Angold A. Poverty, race/ethnicity, and psychiatricdisorder: a study of rural children. Am J Public Health. 2001;91(9):1494-8.
  • 29
    Brethauer SA, Chand B, Schauer PR. Risks and benefits of bariatric surgery: current evidence. Cleve Clin J Med. 2006;73(11):993-1007.
  • 30
    Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up. Obes Surg. 2000; 10(3):233-9.
  • 31
    Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232(4):515-29.
  • 32
    Bruschi Kelles SM, Diniz MF, Machado CJ, Barreto SM. Mortality rate after open Roux-in-Y gastric bypass: a 10-year follow-up. Braz J Med Biol Res. 2014;47(7):617-25.

  • Source of funding:

    none.

Publication Dates

  • Publication in this collection
    Mar-Apr 2017

History

  • Received
    17 Oct 2016
  • Accepted
    01 Dec 2016
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