Dr. Dunckley: To name a few, stress, anxiety, and depression can contribute to children becoming overweight. However, I think the more significant causative factors are environmental. The biggest contributor in my view is screen time, and that is the first thing I address with families because changing it can give them the most benefit in the shortest amount of time.
CCPR: What do we know about this?
Dr. Dunckley: If we look at the research on screen time, we know it is associated with stress reactions and can affect cortisol levels and sympathetic and parasympathetic balance. It’s also associated with weight gain and metabolic syndrome, irrespective of physical activity levels. It can reduce melatonin levels, and some research has shown that low melatonin levels are associated with obesity and that replacing melatonin can actually help with weight loss. Not only does the light from the screen reduce the melatonin, but there is also some preliminary evidence suggesting that wireless radiation may also suppresses melatonin (Suchinda Jarupat et al, JPhysiolAnthropolApplHum Sci 2003;(22):61-63). Research shows that children who are in front of a screen eat more calories and more energy-dense foods, and they also make more poor food choices, partly due to advertising, but partly due to just lack of awareness. Plus, children’s sensory system are still integrating, so if they are eating mindlessly, they are not learning to be aware of hunger and satiety cues.
CCPR: So what kind of strategies do you use to talk to families about reducing screen time?
Dr. Dunckley: As a psychiatrist, I tend to focus more on interactive screen time because it is more dysregulating than passive screen time, like television viewing. In regard to obesity, television may be worse; but studies show both kinds of screen activities make people gain weight. So I address screen time as a whole, otherwise, parents think they can get rid of one activity—television for example—but replace it with another, like video games. What I like to do with nearly every kid I see is place them on a three- to four-week electronic fast. Parents worry about what the kids will do without their video games or smartphones. But once you get rid of them, within a few days the kids will start doing what they do naturally, which is creative and physical play. Following the fast, it’s easier for the parents to moderate screen time more strictly.
CCPR: What are some other ways to help families treat obese children?
Dr. Dunckley: Optimizing vitamin D helps improve insulin regulation and metabolic rate, as well as a host of other things. It is an easy thing to check:“normal” levels are between 30 and 100, but integrative practitioners try to optimize the level between 50 and 70. A lot of kids will need 5,000 units a day and kids with psychiatric problems burn through their vitamin D more quickly due to more stress and more inefficiencies in the brain. So supplement, recheck the level in three to four months, and then adjust again if need be. In addition, we know that certain minerals are low in people with insulin dysregulation, and that replacing magnesium and zinc can help with glucose reuptake and weight loss. I put children on a pharmaceutical-grade multivitamin with chelated minerals (chelated minerals are better absorbed), and sometimes add supplemental magnesium, because it can also help with mood, attention, and sleep. Alpha lipoic acid is an interesting supplement; it’s a very potent antioxidant that helps regulate blood sugar, and it is also one of the only supplements that crosses the blood/brain barrier and promotes detoxification by reducing oxidative stress, improving glutathione levels, and chelating heavy metals (Petersen Shay K et al, Biochimica et Biophysica Acta (BBA) – Gen Sub 2009;1790(10):1149-1160).
CCPR: So do you run lab tests on every obese child who comes into your practice?
Dr. Dunckley: I draw labs on most kids. I always check thyroid, a lipid panel, a basic metabolic panel and vitamin D levels. Sometimes I check B12 and folate also, along with the genetic test for MTHFR (methylenetetrahydrofolate reductase) mutations, which influence how well you utilize folate. If a child has the serious form of the mutation from either or both parents, I start them on prescription-grade B vitamins, which can help brain function as well as possibly help with weight. This test is available through both labcorp and Quest and it is usually covered by insurance.
CCPR: Are there any other tests you perform?
Dr. Dunckley: I check for food allergies or sensitivities sometimes. It is really common for the gluten sensitivity test to come back positive in the psychiatric population; probably about one in three patients test positive. so if that happens, it presents a good opportunity to talk to the parents about reducing or eliminating gluten, and if they do that they will automatically reduce the child’s intake of refined carbohydrates. Most integrative practitioners believe that addressing food sensitivities promotes weight loss by reducing inflammation, but that is controversial.
CCPR: How do you approach psychiatric medication in relation to obesity, for example, in children who are on antipsychotics, which are known to have metabolic effects?
Dr. Dunckley: When we talk about psychiatric medications and weight gain we think of the antipsychotics, but also there is some evidence that even the SSRIS can cause weight gain over time by the same mechanisms involving insulin resistance. And although we all typically associate stimulants with weight loss, there was a recent study demonstrating stimulant usage was associated with weight gain in later years (Schwartz BS et al, Pediatr 20l4;online ahead of print). If all else fails, I will use metformin in adolescents to help with psychiatric medication-induced weight gain.