Phil Anderson and Lisa Mangel from ADHD three sixty. If I can welcome them now. Wonderful to see you guys. Thank you so much for joining us.

Hi. Hi. And.

Thank you for supporting this with your with being part of it. It's probably if I let you introduce yourselves. Do want to quickly tell us about yourself about yourselves?

Go on, Lisa. Fire away.

So my name is Lisa Mangle. And my background in ADHD is that I've I've worked as a clinician for twenty years, setting up my own nurse led clinic back in 2002. And within that time, I was involved in clinical trials for most of the modern medicines in ADHD. And then I went to work in the pharmaceutical industry for for nearly ten years and then worked with Phil along that way. Actually, I've known Phil for twenty years as well. And then I I now currently work as the clinical director at ADHD three sixty. So I'm responsible for the clinicians, and I also assess patients as well. Phil is my amazing business partner. So I do clinical stuff, and Phil does everything else.

Follow that. I I felt felt having Heston Blumenthal and Adrian Charles as my warmer pact was difficult. Following that, Lisa, is is quite incredible. So very difficult to know how many people are listening. So if there is anybody out there, good evening. My name is Phil Anderson as as mentioned. I'm the managing director of ADHD three sixty. There's three of us that run the company, Lisa, myself, and Samantha Underton Marshall. And we've been invited to talk to you tonight about ADHD and ADHD medication. And I guess this is a bit of a myth busting session. There's been a lot of chat as opposed to PowerPoint from what I've seen today, which is really, really good. I think there's a world of death by PowerPoint. And.

With Lisa and I, when we run our webinars, which we run regularly as a service, we tend to go for a fireside chat kind of principle as opposed to a slide led monologue. So what we're going to look at is ADHD treatment, ADHD medication, I think we've about forty minutes to go through that. If somebody from ADHD UK wants to alter any of those timings, just give us a shout and and we will meet your needs. Lisa, I was I was with some sorry. Go on. You're golden. Look. We want your time and.

We have we are running, I think, fifteen minutes late, which we think is perfectly reasonable in ADHD then. And but we don't want to like, what you're talking about is so incredibly important that we you know, there's no risk of you being cut. Like, that's like, we're thrilled to have you here. We want all the time we possibly can have. So back back to you. I must not take any of that time.

Okay. So thanks for that, Henry. And first of all, congratulations on putting this on. And they're they're not shallow hollow words. That that's that's well meant from the heart. Bringing all these people together from across the globe is a unique perspective on this, and it's a privilege to be taking part. I was with somebody yesterday who's not connected to my ADHD world, and and he was asking me about the ADHD work we do and and medication. And he said, well, hang on. Hang on. Does does somebody take ADHD medication just then become a zombie and completely dulled down to the point where they can't function? And and I knew that Lisa would react to that as soon as I said it, which is why I've opened with that statement really.

Because what Lisa and I are gonna do is look at some of the myths, look at some of the stories, and actually then look at the science in relation to medicine. And Lisa and I run an academy once a month over a long weekend for clinicians to become ADHD specialists. And one of the things that ring really brings that to life is the session on ADHD medication. So, you know, pin your ears back. Here we go. But what about that, Lisa? Does medication not just make anybody feel completely dull down to the point where they can't function?

It does. You've got your medicine wrong. I think it's a really interesting statement that I've heard banded around for many years, and I have my own theory on why this might happen. And one of my theories is that there are many introverts with ADHD. And they may behave in a very extroverted way because of their ADHD symptomatology before they're diagnosed. But then when you treat their ADHD, they might lose that hyperactivity, impulsivity, and attention and become their natural stance that where they feel comfortable, which is that sort of introverted personality, which may upset a few people who are around them, but actually as a person, they're really comfortable with who they are. So I think that's one potential.

But then if you tend to overmedicate someone or you medicate them with the wrong product, then they can be a little bit reserved, but then you have to amend your medicine. So, no, it doesn't turn turn kids or adults into zombies, but you do need to think about your medicine and what you're prescribing and how you're prescribing it.

There's a there's a there's a kind of if we go back twenty years from when we started working together, you know, ADHD medicine was only being taken by children to sell in the playground, and nobody was benefiting from it. And and how the story has moved on to things like this today and how medicine's moved on in in its technology. We'll look at the technology of medicine in a minute or two. And I think as we start to talk, you you and I are both picture talkers, aren't we? And and and and we're here without pictures deliberately. Yeah. Well, let's discuss the place of medicine and the place of nonmedical treatments because, you know, we hear from a lot of people that I have. In fact, I I was running a.

I was running a leadership course today for a management consultancy in London, and two of the group of four people in my group declared that they had ADHD. And that was without knowing my background. Neither of neither of them are are are taking medication because they didn't have the confidence that medication would would be able to help them. And I sort of said, right. We need to have a chat and and we'll have a chat. But there's this constant argument and attention between nonmedical treatments and medical treatments. And we we we have a working hypothesis, and we've many, many thousands of patients now, which kind of prove that hypothesis. That if there's a 100 units of developments available to the individual.

You'll get a fair percentage, let's call it 75, 80 of those units of improvement from accurate use and appropriate use of medicine. And then your additional 20, as Adrian was saying earlier, you still have to coach yourself. You have to be helped by others and come from that CBT, that coaching, that scaffolding, and that support. And if we transpose those and do the 20 units of nonmedical interventions first, what we find is we're trying to intervene in someone's life before they're medically fit to receive that treatment and receive that help. So we have to go for the eighty first and then the 20 or at least start to run them in parallel when we're getting up in the higher numbers of of that that that that medical intervention.

And and, Lisa, I I watch your work on a daily basis and and across our team of clinicians. And what what what is the biggest change you see when someone is appropriately medicated for ADHD? And and and, genuinely, how quickly do you expect to see those results?

That's a really good question. So I guess I guess in terms of speed of response, it would depend on what I was prescribing and how I was prescribing it. And and obviously, when I do the assessments and the questions I ask and the answers I receive, that will let me know whether I can titrate this patient in a quicker way, safe but quick, or whether I think I might need to take it a little bit slower. If the medicine that I choose to begin with is the right medicine, and some people respond better to one stimulant than the other. So it's a little bit of a it's a bit of luck sometimes if I pick the right medicine straight away, then I could have my patient optimized in in a couple of months, if not quicker than that. I think for me.

What does optimal look like is is a bit deeper than than it might seem because when we assess patients and when we get information from patients right at the beginning, we ask for goals, we ask for three goals, You know, what is your what do you want to achieve? And and that that's a really good question for a variety of reasons. One, to see if the realistic expectations and is this about the ADHD or are they wanting to just get a PhD in three months or something daft? But but what do they want to achieve out of this? And then when I think that patient's optimal, I will ask them about the goals. And I ask them every three weeks, but definitely when I think they're optimal, I will ask about about the goals.

But then the next question I ask them is, what's been the biggest improvement? What's been the most impactful change? And you know what? It's often not been one of those goals because the most impactful change is something that they didn't even realise was an issue or didn't realise was part of ADHD. And so if someone was to ask me why would you medicate someone for ADHD, I think that would be my answer because there's things that are an issue that they don't even realize was an issue. A lady the other week when I asked that exact question.

I said, what's been the biggest change? And she said, Lisa, I'm happy. And she said, but you know what? I didn't realize I wasn't happy before. And so she'd had this epiphany of what life could look like on optimized treatment. And I think that's invaluable, you know, to to really dig down to what the patient wants, what the clinic what the client wants, but then look at what that most impactful change is. And it's and it's likely to be something that they didn't even realize was an issue.

You mentioned a number of things there, and and and there's a couple I wanna pick up and and sort of explore for the benefits of people listening. The the the first one is we've used that expression in in in this evening's webinar of optimizing your patients and how we we we as an organization translate the NICE guidelines and the DSM five, the big the big international manual that nobody can afford to buy, but everybody has to read. The the the manual, we interpret it as we've got to find the right medication and the right dose for the patient, but then we've got to go more than that. We've got to optimize their treatment and optimization for us is achieving those goals like you've just eloquently described. But it also involves.

Being subjected to a screening test at the start of treatment, pre treatment, and then through the treatment process so we that we know when screening results are becoming negative screens that we're starting to get somewhat objectively and subjectively. And I think it's really important for people to realize, especially going back to that very first question of people being too dulled down. If you don't optimize your patient, then you might be over medicating, over treating, and and and closing them down. And that's that's inappropriate medicine. And Yeah. I I I don't think we see that as much as we used to because.

I think the the the medicines have got better and the understanding has got better medicines. But we we have to recognize that optimal treatment is neither too high nor too low. It's it's the word is optimal, and and that's exactly where we seek to land it, isn't it? Yeah. And I think for me, the thing around optimal treatment, I'll never forget listening to a speaker talk about quality of life and ADHD.

And they there's some studies that have been done into the quality of life of a variety of different conditions. And the quality of life of someone with poorly treated ADHD is as poor as someone with poorly controlled type two diabetes. And that really shocked me because I thought type two diabetes that's poorly controlled can be life threatening for one, but also it can cause a lot of significant health problems. And so but then it went on to say that if you partially treat someone with ADHD, yes, the quality of life will improve, but it will still be suboptimal and that patient will not be experiencing, you know, a good quality of life and their life trajectory will be impacted. So for me.

Optimal treatment is the only only way to go. And and I don't want someone's quality of life to be impacted because I've not got the medicine right or I've not taken the time to get the medicine right. And what Phil said about ensuring that a medicine's optimal and screening and rescreening, you know, that's something that I train my clinicians to do a lot. And so for example, if I'm trying to optimize a patient and I I don't think the medicine is is quite right, I will do a screen then. I will do a questionnaire again to see exactly where they are because when I've switched them to a different meds, and I can guarantee they won't remember where they were at that point. So quite a few of my patients will have multiple.

Screening questionnaires completed, and I think that's good medicine. And it's a good reminder for my conversation in three weeks time exactly where they were three weeks ago because they'll forget. So I think it's important that we strive for that optimal treatment with minimal side effects. So obviously, there's no point in the treatment being optimal if they've got side effects that we can't tolerate. So it's important to have that balance between the two.

Anyone who think this is a scripted session and it's massively not because you've just segued into two opportunities of areas to go down there. One is is side effects. The other is risk. And then earlier on, you talked about choosing the right medicine for the patients and not not being able to always get that right. And I think if we talk if we start with that first in terms of exploring medicine for ADHD and and for the benefits of of people who who are trying to get an understanding of medication without trying to turn everyone into a mini clinician, There are three groups of medicine available to ADHD. There are many medicines, but they're grouped into three groups. One group is a stimulant group based on methylphenidate.

The classic for that is Ritalin, but there are others, and I'll just ask Lisa to whiz through them in a second. The second group is based on the stimulant, which has its its its origins in amphetamine, which sounds really terrible because that's that's a street drug. But medical amphetamine is is incredibly safe and and and and well produced. And and then you have a third group of non stimulants. So two stimulant groups, methylphenidate, and you've got the the the stimulant based on amphetamine, and then you've got non stimulants. And one of the things you alluded to there, Lisa, is that the different medicines in the different groups work in different ways.

And they take different times to kick in and start to what we would call efficacy to work properly, especially some of the nonstimulants such as atomoxetine and inchnip, which which take a while to build up. Now without getting overly medical, one of the things that we've worked within the last couple of weeks together is the issue of the different methylphenidate medicines, delivering their medicine in a different way and how that impacts on the patients. And I was when when I was prepping for tonight, I just thought, actually, the difference between Concerta and Ritalin and.

Equisim and and and what have you would would be really interesting in terms of not necessarily expecting people to take an exam on the numbers that come from that, but why we have the different medicines and their delivery. I just wonder if you can counter through why we have the different medicines and and and and and how, importantly, how you apply those differences to the different needs of the patient group that you're treating to make your first decision, if you will, if you're in the methylphenidate group?

So so when I'm doing my assessment, I'm asking hundreds of different questions, and I've got more questions in my brain depending on where those answers are going. But all those questions are leading me to a specific medication at the at the end of that that assessment period. And in in relation to methylphenidate, so take a step back actually. So I'm looking at the patient's difficult times of day. So, you know, are the mornings really difficult? You know, I wake up on task and the morning's complex and I've got children and I've got to get them to school, and I've got to get to work, blah blah blah. Or actually, is is.

The morning period till lunchtime the most important because this is the primary school child. And in The UK, primary school children do their numeracy and literacy in the morning time when they're fresher, and the the less important subjects are done in the afternoon. Is this actually a high school child who who's got a longer school day? So do I need a medicine that lasts a little bit longer? So specifically in the methylphenidate group, in The UK, we have immediate release medications that last about four hours. So, obviously, that's gonna be taken multiple times a day. So is this going to be a child or an adult that can remember to do that? So that's one consideration. If it's a long acting medication.

That I think is required, which one? So the the long acting medications that we have available in The UK are Equisim, Medicina XL, Concerta XL, or something similar. And they've all got varying percentages of immediate release and extended release products. So EchoSim, for example, is 30% immediate release and 70% extended release. So you're not gonna have as much immediate release component in the morning when it's probably important. However, in a primary school day, it's probably gonna last the duration of that school day and maybe the journey home. With medic net excel, it's 50% immediate release, 50% extended release. So a nice product to use if actually the focus is in the morning for the for the important lessons.

But may not last the whole of the primary school day or may just about get to the end of the school day because the extended release component is is is less. And then with Concertrexel, that's a 22% immediate release and 78% extended release. So again, a smaller immediate release component. So what you'll probably find is sometimes not a high enough immediate release component. But what you can do, if you know your patient and you know your medicine, you could actually have an immediate release dose on top of your ConceptRx cell. So that sort of kick starts that medicine working and gives you a slightly higher immediate release percentage. Or indeed with either of those, and it those are the methylphenidate.

Products, you could have a top up of immediate release at the end of the day to give you that longer duration. So it's about understanding your patient, their difficult times of day, and understanding the various methylphenidate products that we've got available and and and tallying those two up to to start with what you think is the right medicine for that patient.

Now now if I was to just summarize that, Lisa, before we move on, what we're saying is within the methylphenidate group, there are different medicines, and they have a different balance between immediate release and extended release medication. And it's the clinician working with the family or the patient that helps make that decision. If we're going with the methylphenidate group, which one is gonna suit those tricky times of day so we get the best medical coverage that is possible. Yeah. Now methylphenidate, we know works in the in the prefrontal cortex of the brain. It works in a certain part of the processes that we're working with. We don't need to get too technical, but we know what it does.

But it could be a fact that when we actually get methylphenidate in there, that's not the part of the synaptic process that needs the help, And we get what's called a nonresponder to methylphenidate. And if that were to happen, we would switch to probably the amphetamine group of medicines next because they work on a different part of the brain in a diff in in a different way to the methylphenidate, and we would look for a response there. Now in in that amphetamine based, we've got an we've got an immediate release medicine, and we've got an extended release medicine again. And without getting over overly technical, the clinical choice is whether to go for one medicine for a long period.

Or or to go for a medicine that will last for about three or four hours and take it three or four times a day. Yeah. So we we would we would we would plumb for a patient led discussion that would make the decision of going really long lasting in the amphetamine or moderately long lasting and which one to fit the day in methylphenidate, and we'd see which one which one we got a best response from and there we'd be. Yeah. Now there might be medical reasons or there might be lifestyle reasons that cause us not to use either of those stimulants, or we may fact that may find that neither of those are tolerable by the patients in terms of side effects, and we have to try the third group, the third group being the nonstimulants. So.

In there, we've got Ingeniv and we've got got atomoxetine. And I think it's really important that we talk about both of those for a minute because they're very, very different, whereas the other two are relatively similar for the patient outcome, the the nonstimulus significant. So if I ask a couple of poignant questions, atomoxetine, brand name of Strattera, takes a lot longer to work its way up to being appropriate in terms of symptom control. The efficacy takes a long time to work up. In your experience, how long does atomoxetine take?

Well, it depends on how long it takes you to get to the right dose because it is a weight related medicine. So you work the dose out on milligrams per kilogram. And and also it's around tolerating the medicine. So I start with a smaller dose and I titrate up for the first month to quite a subtherapeutic dose, but a decent dose because I want to get to that optimal dose for the patient's weight as as quickly as I can, but I also need them to tolerate the medicine. So it's probably gonna take me a couple of months to get to the right dose, and then I need it to work. So I would I always say to my patients it's gonna take a good three months to get going, provided I can get to the right dose quick enough.

If I if I have to do it a lot slower because they're not tolerating it as well, then it's gonna take longer. But I I better prepare them for that.

And what what we've what we've got there, of course, is a classic scenario of a medicine taking a long time to become noticeable in terms of its effect, positive effect for the patients in a patient group that aren't particularly wanting to wait for something to happen. And one of the difficulties with using a non stimulant is absolutely keeping the patients on on side as we go through those possible twelve, fourteen weeks of getting to the place where we need to be, whereas the stimulants are much, much quicker in working. So we all have to recognize that when working with the non stimulant group, we have to give them longer, and that is counterintuitive for an ADHD patients. We can if there is a minimal response to an a stimulant.

We can have a stimulant as well whilst we're building things up. But we've normally swapped out of a stimulant for a reason, so therefore, we have to be very careful not to bring those reasons into play, whether that's health or or or lack lack of coping mechanisms for the side effects as we go. Now Intinib's completely different again, isn't it? An an Intinib, without getting into the mode of action of Intrudiev works in a completely different way. It's a different medicine. And talk to us about how long that takes to get up to speed. And and also, Alicia, if you can, mention the side effects about sleep and things for Intrudiev, if you will. So.

So from a side effect perspective, it can cause fatigue, somnolence, which can be a bit of an issue. However, it can also be a positive because because some of our patients don't sleep very well. So I would always start a medicine in the morning. And if they do because I want to know if they're getting side effects. And if they do, then I'll switch them to the switch it to the evening and and then the bulk of the side effects effects are in the evening when the patient's asleep or it might assist getting to sleep. And it also lowers blood pressure, which depending on whether you're giving it to an adult or or a child can also be an issue. So if it's if it's an adult whose blood pressure is up a little anyway.

Then it's a positive side effect. If it's a child whose blood pressure is on the low side, then dropping the blood pressure further can be an issue. However, I plan for that. So what I would say to the parents is up the fluid so that you are, like, more likely to keep maintain the blood pressure, but also to raise the salt in the diet because salt's something that we try not to give our children much of. However, just upping the salt in the diet as well as the fluids, again, can help them to to maintain the blood pressure. That those are two side effects that we need to be mindful of, but they can be seen as positive depending on who we're prescribing it to. In terms of prescribing, again, it's a weight related medicine. So.

Depending on how much you weigh will depend on on how long it takes you to get to the optimal dose. So if it's a smaller child, then it might only take a couple of weeks to get to the optimal dose, and then we need to maintain that dose and tolerate it. If it's an older child or an adult, then it may take a couple of months to get to the optimal dose, and then they need to maintain it. The thing to say about both of those stimulant non stimulants though, is that they have to be taken every day. You know, you can't have days off with the non stimulants, otherwise the medicines don't work. So it's important that the patient understands that, that they can't just dip in and out of medicine, they have to take it regularly.

So I but but I think also there are a lot of positives to non stimulants, know, once they are effective, it covers twenty four hours a day. I think that's a huge bonus when a medicine for ADHD works. You know, they're waking up on task, they're going to bed on task. They have a sameness across the day, whereas the stimulants can be up and down, which doesn't always suit patients, and they don't wake up on task or often go to bed on task. So there are positives to to all of the medicines for ADHD. So it's about understanding the patient and what's going on in their life and any and any issues that they may have might lend itself to to one medicine over another to begin with.

So I guess I guess what we're saying is that it's really tricky world, but actually, when your clinician gets it right, it becomes quite simple because the the the working effort is on the clinician, and the patient's responsibility is to take the medicine as prescribed. And don't dip in, don't dip out. It won't work properly. Trust your clinician and and go for that 80 units of improvements and then see what's left at the top. And in fact, we find an awful lot of our patients when we get them up to that 80 are more than happy because they they got hell of a lot better lifestyle than they they had before. And I was listening to Adrian earlier, and he talked about his anxiety.

That that he had prior to treatment. And he talked about elevated blood pressure and being hypertensive. And, you know, when we're talking with the the the stimulant medication, I I think what I'd like to do is introduce some of the things we we we work with on the academy, Lisa, is that management of risk, that balance of clinical risk. And and and the the obvious place to go with this straight away is somebody who's hypertensive, whose hypertension may well be caused by anxiety, and that anxiety may well be caused by the fact that they've got their ADHD symptoms, and they've had them for a long time. They've had to struggle and battle with their impairments. And and the words I heard today were waging war on their impairments.

On a on a daily basis, hourly basis Yeah. Causing anxiety, causing hypertension. The general rule of thumb is don't treat someone who's hypertensive as Adrian was outlining, and and that caused him some struggles at the start of his treatments. Don't treat the hypertensive patient with stimulant medication. However, we've done some pretty sexy stuff with that, and and we're quite excited by the findings of what we've done. And we've got this expression that we use, situationally cheesed off. It's not cheesed off. It's another word that begins with p and ends in d, situationally off. Where you've gone through life being cheesed off with your situation in life, it just produces tension and anxiety and can result in hypertension.

And what have you. But we we started treating some of these patients, haven't we, Lee? So it's about managing risk. Is is hypertension and anxiety a higher risk than appropriately treating someone?

Just explain how we would treat that person rather than run the risk of non treatment, if you will. I mean, obviously, when we're assessing our patients, we're looking holistically at the whole patient. So we're looking at whether there's a reason why they might be hypertensive. So is there something else going on? So we would request, you know, bloods and and the usual things that you would do if someone presented with a significant hypertension. And when you've ruled all those things out, you know, you have to then think, okay, they are anxious, they've got low moods, they've had untreated ADHD for thirty years or whatever.

This could be down to that. And so what I tend to begin with is we we provide a blood pressure machine for all our patients. So I get them to take the blood pressure a couple of times a day, every day, get them used to taking it so that it's not a bit of white coat syndrome. We get true blood pressure readings. We get them to log that on our chrysalis portal. So we get a pattern of of what the blood pressure is looking like. And once we've done that, we then consider medication. But again, whilst doing the blood pressure on a daily basis to monitor that. Because like Phil says, you know, if you've if you if you've got a low mood and anxiety because of your untreated ADHD, and you've been continually struggling.

And and hearing negative things, maybe a bit of a binge eater, so your BMI might be on the higher side, you know, the likelihood is that you are going to have an issue with your blood pressure. And we've we've tracked some of our patients over time. And I'll never forget the first guy we saw who was 27, never had his blood pressure taken before. And when I did his blood pressure, it was one eighty over one twenty, and I thought, wow. And I I followed the process that I've just explained, and we did start some medication. And that guy gave me his blood pressure every day for weeks. And we tracked it and we tracked it, and you could see by optimizing his treatment, his blood pressure just gradually came down. And I think his.

Final blood pressure was something like one twenty seven over 70, and which was a perfect blood pressure for his age. But then so did his weight as well. So he was obese, and he he's he's stopped binge eating, and he stopped snacking, and he started having the ability to to buy food and buy healthy food and and eat appropriately. And I look at him, and I think, well, we've probably saved a stroke or a heart attack in his forties, and and now he's a dad with a little boy and his ADHD is under control, and he's not overweight and his blood pressure is normal. And most people probably wouldn't have treated him, but I think it's about taking calculated.

Risks and looking at someone's lifestyle and thinking, yeah, I can see that that could be an issue. Like Phil says, you know, anxiety and depression are common in my untreated ADHD patients. Seventy five percent of them come to my clinic with a diagnosis of depression, anxiety or both. And if I diagnose ADHD and treat them, ninety percent of them are not anxious or depressed anymore. And some of those on day one of treatment, they are not anxious anymore. And it's a game changer, an absolute game changer for physical and mental health. But but physical health in particular, I think we need to think about the patient as a whole, not just about their ADHD.

Again, it's as if we have a script here, and we honestly don't. But we're working with this day in, day out, and and and we're assessing an awful lot of patient. I I I a great amount of patients each month, And therefore, the the focus and the the the the data, the real world evidence that we're gaining on a daily basis from the clinical team is just quite incredible. You talked about physical health there. Let's stick with physical health and ADHD for a second or two because, again, listening to other people that have spoken and and and and looking at our patient group. And you mentioned obesity and earlier you mentioned you mentioned the connection between symptoms.

In terms of scale of impairment with diabetes. And the piece of work we're just starting off and looking at is the is ADHD and and diabetes, isn't it? And the type two diabetic who can't plan a meal, can't plan to shop for the food for a meal, perhaps can't even budget their food properly their money properly to buy the food to plan for a meal. And those life skills that perhaps are taken for granted when neurotypical that are real challenges when neurodiverse can and do lead to binge eating, inappropriate.

Food, and an inappropriate relationship with food. Yeah. And instead of having a planned meal with meat and two veg as it were, diving in the fridge or going to McDonald's and having a burger and chips because it's instant and it's gratuitous and it's available as opposed to planning and cooking meat, meat, veg and what have you. So we got we got this kind of life story that pans out and becomes an inappropriate relationship with food caused by impulsivity, lack of planning capabilities, lack of foresight and forethought, budgetary planning, all those things. And yet when we can when we treat medically for ADHD, we can see improvements in all of those life skills that become really important.

And and as you've said, we we start to get into a regime where the relationship with food can improve and and loss can become a matter of of record in that regard. And then we flip the to to throw it back to you in a second, what we we flip that into another domain of the relationship with physical health, weight, and BMI, and those other measurements. Because, of course, some of the medicines are suppressant to appetite, that has a profound effect on the on the overweight stroke obese patients as well. Now just give us a two minute synopsis of why that's the case and what's happening there, if you will, from the medical perspective, not from the social perspective.

So my my untreated patients with ADHD, I describe their brain as being like a laptop with twenty, thirty, forty, fifty tabs open. And so if you can imagine that I mean, I've got one tab open now, and it's this this session, but I don't have ADHD. If you've got ADHD untreated and you've got 50 tabs open in your brain and one of them is food, you can dip into that tab whenever you like, and that will be multiple times a day whenever you go into the kitchen to make a cup of tea and you see a pack open packet of biscuits. By the time you've made your drink, that that packet's gone. So so that tab's there, and it's there all the time. So you might have a binge eating history or a disordered eat eating history. Because.

That tab's there and you're impulsive because you've got untreated ADHD. Now if I optimize your treatment for ADHD, I am gonna shut all those tabs down so that you've just got that one tab open that you you're working on right now. So you can find that tab if you want to, but it's a little bit like if I find a weird and wonderful web page and I don't save it to favorites, I can find it again, but it'll take me a little while. And that is the same with those tabs that you shut down. You can find them again, but it'll take you a little while. And by the time you've got to that tab, you've talked yourself out of it or you've said no. I don't need that packet of biscuits. I've eaten enough today, and I'm not hungry. So that's one.

One reason why treating your ADHD will will help with your binge eating. But like Phil says, it also helps you to plan, to organize, to do your food shop, to have that time to cook. You know, if you if you do an eight hour a day, but it actually takes you twelve hours because you've procrastinated four hours, you don't have time to cook. So there's a lot of reasons why optimizing your ADHD symptoms will also help with your with your your eating and your physical health. And your BMI, I mean, some of the medicines for ADHD are licensed for binge eating, so there's a definite link between eating and and ADHD. I suspect most of the stimulants are good for binge eating. But monitoring the BMI of over time from from baseline to to optimization.

You can see the BMI, you know, coming down smoothly, which is which is always something I I look for treasure when I see that because I know that what I'm actually doing is changing that patient's quality of life and probably the length of the life moving forward.

And and and sticking with food, and we've had a nod from from Henry that we we've got about five more minutes. So stick just stick with the food thing for a second in terms of turning that all into from the science into pragmatic life. One of the things you will find is with the suppressant appetite suppressant elements of some of the ADHD medication is that the patient won't get hungry in typical times. They'll be hungry when they're coming off their medication. And and for for for a lot of patients, that's around about now, 08:00, 09:00 in the evening. And.

We're typically locked in Western society to well, you have your lunch at lunchtime, your tea at tea time, and you have your breakfast in the morning. And and what we want you to do is rip that rule book open and and just literally throw it in the bin. So get some food in inside.

Child or yourself before you start taking the medication in the morning. That's really good for taking medication anyway, but it's really good to give you the fuel to get through the day. So some high energy fuel to get you through the day. And that may sound counterintuitive for a hyperactive person. It's not. It's good fuel. It's what you need. You may then not be hungry through the day, and that's that's okay. That's that's fine. Don't get locked into that social cycle of must eat three times a day, and it must be a square meal or what have you.

But when you're getting towards the end of the day, now 07:00 in the evening onwards, have something healthy prepared even if someone else, your partner, a mom, dad, whatever prepares whoever prepares it for you. Have something in the fridge that's relatively healthy. It's not gonna drive you to Kentucky or to McDonald's or to the chocolate bar in the fridge, whether it's a sandwich or a salad or whatever it is, and it got salad sandal, don't they? I've just heard myself. But have have something in the fridge prepared so that as your appetite comes off as as as and and and you start to want food again.

You go to the fridge and you've got something ready there. You haven't got to start thinking, right. My meds are wearing off. I'm no longer gonna be as organized as it was. So we've this balance between being organized and actually not being hungry. Now the organization skills are dropping off and the hunger's coming back. We're back to that fast food, immediate food, want gratification through food. So have something prepared. Have something healthy and and ready for you.

And don't be prepared that the fam don't don't don't mind if the family's eating habits are disconnected for a good while whilst we get used to this because it really doesn't matter. We can still sit around the table even if the and and have that that tea time chat even if the person with ADHD or medication isn't eating with us, still be with us. We can still have the sociability, but just recognize that eating patterns do not have to be locked in. There is no health benefit from that. It's all about it's all about making sure we're fed, making sure we've got that energy, making sure we've got that fuel. Now I'm I'm Lisa, I'm watching the chat here, which is bay mainly instructions from Henry.

To to us. And and Henry said, can we quickly talk about the difference for women medication? My favorite part. I just texting things through. I think what we'll do, Henry, is we'll segue that into 07:00 tomorrow morning, and we'll really major on that tomorrow morning. We will just give it we'll give a little teaser for that now in the in the couple of minutes that we've got, if that's okay. Sticking with physical health and the links between ADHD and physical health. One of the things that we I think almost uniquely in the way that we treat a woman, a young girl really through womanhood on the menstrual cycle is that one week in four, the whole hormone level in a woman's body will fluctuate violently really.

And ADHD medication becomes less effective for that one week. And what Lisa Lisa and I have done is work that through into how can we actually have a steady line of impairment control and symptom control rather than it going back to being severe ADHD for one week because the woman's body's chemicals have changed. And we and we treat our our female patients who have that dip in impairment. We treat them differently for that one week, and we work with the GP. So we give different medication levels for that one week. And when when Lisa proudly says, I like to optimize all my patients, we like to optimize optimize a woman for four weeks of the month, not three weeks of the month. And Lisa's famous words are.

Losing one week in four, which is a quarter of the year because you're having a period and you've got ADHD is not that's not fair. So we we work with that. And and Henry will pick that up in in greater detail tomorrow morning if that's okay. So what I wanna do in my last two minutes, our last two minutes here is sort of say, look. We've talked about why medication over nonmedication and how that runs together. We've looked at the three groups of of medications and why the clinician would choose one group over another. And when you're in a group, which medicines would you choose within that group, and why would you make that clinical decision? We've hopefully covered.

Some of why we'd stabilize on a medication and and balance side effects against impairment reduction. And we've looked at optimizing and what that means to us to optimize the patient to get the very best so they can lead their best life. We've then looked at what treatment can do for physical health, not least of which is hypertension, obesity, and there's a direct connection between the two. And then just touched on the female body and the menstrual cycle, which we'll pick up tomorrow morning when we're back at seven. So, Henry, come back in if you will.

Figurative handshake because I think we hand over now back to you and to our colleagues in New Zealand to go into another time zone and keep things moving. Is that correct? We've got one more here and oh, no.

Two more here. Sorry. Two more here. And Then handing over to New Zealand. That was incredibly important and I I sent in the text brilliant, really brilliant and the discussion on medication and the nuances on a fit in different aspects is so important. Like we know there's a massive stigma around it that you know we want people to be making medical choices not stigma choices and this discussion is reducing that stigma and also just informing people as a basis ongoing. I thought obviously your deep, deep knowledge and insight is something else. Just honestly, just wonderful. Thank you so very, much.

So we'll be back at seven tomorrow. We'll stay in touch to get ready for that. If there's anything in the chat, Henry, that because we can't see the chat on Zoom, the chat that be happening through the YouTube channel. If there's anything you want us to pick up tomorrow that's come out of today, if you just drop us an email with that or somebody copies and paste it into an email, we'll pick that up tomorrow morning at seven. Sounds good.

And do you there is also there's the Q and A on globaladhd.com. Go and for people, do you click on the Q and A, put your questions in there and we'll pick those up for tomorrow. That's the place to do it. And obviously, we are this is a charity event. Like the aim is to change what positively change what it means for ADHD, but also to raise funds for the contributing charities and for them to continue their fight. Do go to adhdglobaladhd.com and click donate. I mean, it's a big deal. These guys are donating their time, giving their expertise for free, it's a big deal supporting this change and thank you so much from the bottom of my heart. Thank you so much for that. I can't thank you enough. Know it's pretty late.

And you're getting up early again to do it all again. So like it's like you're pretty he's very very kind. And I'll be here, so I'll see you then. Yeah. Wish us luck through the night. Yeah. Good luck. Thank you very much. I have to do this. It's a sort of always things I said goodbye on Zoom. It's like it's such a big thing you've just done, and then you come to say goodbye. But we must say goodbye. So goodbye. Thank you very Take care.

Cheers. Bye now. Bye. Bye.