Rethinking How to Help Kids Lose Weight
An Integrative Psychiatry Approach to Tackling Obesity in Children
Posted Feb 26, 2016
Although I'm a psychiatrist, I spend as much time working with children and their families on weight and other metabolic issues as I do on brain health. Children with psychiatric issues are more likely to be or become overweight, and many of the medications we use affect insulin regulation, creating a vicious cycle. I've learned a few gems along the way that, especially when implemented together, can help jump start weight loss by improving insulin resistance. Below is an interview I did for the Carlat Child Psychiatry Report a couple of years ago about my approach; the information is useful for anyone trying to help a child lose weight, and it's particularly important for children struggling with weight and mental health issues.
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.
CCPR: So once you’ve figured out where a child stands on medication, and get them on a good vitamin regimen, what do you work on next?
Dr. Dunckley: I always address the screen time issue first, and once that is under control I start addressing the nutrition piece. I really focus on the importance of insulin and blood sugar regulation. I talk about starting the day out with protein, and that however you start your day is how your whole day goes in terms of blood sugar. If a child eats a meal full of refined carbohydrates in the morning, their blood sugar is going to be erratic all day long. But if they have protein or healthy fats in the morning, the blood sugar will be better regulated for the rest of the day. Plus, some research shows that having a high protein breakfast helps with attention and cognition in children.
CCPR: Sounds great. Anything else?
Dr. Dunckley: I also talk with parents about environmental toxins. Plastics have several chemicals that have been associated with obesity, in particular BPA and phthalates. It’s important for parents to realize that plastic that claims to be “BPA free” usually has other chemicals in it instead that might be even worse, so I emphasize using glass or stainless steel instead. Also they should never microwave food in plastic, because this leeches out the toxins. Pesticides are another culprit, and have been associated with both ADD and obesity. So I recommend buying organic fruits and veggies when possible.
CCPR: How does exercise play into your approach?
Dr. Dunckley: I teach parents that not only will exercise improve sleep, attention, and mood, but that the brain requires movement for proper development. I try to get the child involved in some sort of structured sport, like tennis or basketball.
CCPR: When you have parents do their best and implement as many of these things as they can, what kind of results do you see?
Dr. Dunckley: It varies. If the parents have some health consciousness already, then things progress much more smoothly. If there are logistical barriers it can take longer, but if you keep problem-solving with parents you can usually resolve many of these. If there is psychological resistance coming from the parents, then that obviously makes treatment a lot more difficult, and in those cases I may refer the parents for individual or family therapy to address that. I often go back to motivational interviewing techniques in order to improve the therapeutic alliance. Essentially all the things that parents want—which are often improved behavior or better grades—and the interventions to achieve those things are the same interventions for weight management anyway.
CCPR: We’ve talked about some of the factors that can cause obesity. Now to switch gears, what are some of the psychological issues you see in children who are obese?
Dr. Dunckley: Commonly we see poor self-image and self-esteem, particularly in girls. Now that children are becoming obese younger and younger we are seeing a poor self-image in even school-age girls, which didn’t used to be the case. There is bullying related to being overweight that tends also to occur most in Caucasian girls. With adolescent girls, there is a bidirectional relationship between obesity and depression (Marmorstein NR et al, Int J Obesity 2014;online ahead of print). And there is also an association with suicidal ideation in severely obese children of both genders.
"A simple intervention is to tell parents that every hour of screen time should be matched with an hour of physical activity."
~ Victoria Dunckley, MD
CCPR: Are there any clear psychiatric comorbidities?
Dr. Dunckley: The best documented comorbidities are depression, anxiety, and eating disorders. Some studies show that sometimes these disorders are causative while others show they are merely comorbid. ADHD is another comorbidity, most likely because of issues with self-regulation and impulse control.
CCPR: How do you help children where you see the parents are obese as well?
Dr. Dunckley: The prognosis is much poorer for a child if the parents are overweight. So I try to talk to families about viewing the situation like you would if you had a diabetic child, which is that the whole family pretty much has to go on the diabetic diet. I explain to them that because a child’s brain is not fully developed, they do not have the impulse control to resist temptations. If unhealthy foods are in the house, they will find them, and they will eat them. And if they’re denied, they’ll feel deprived and that it’s unfair. This really takes persistence—you have to keep going over it with the parents, because they don’t want to get rid of the junk food themselves.
CCPR: From a practical standpoint, what do you think an average child psychiatrist can recommend for parents to do day-to-day, if they can’t go “all in” on some of these suggestions?
Dr. Dunckley: A couple of things. They can provide the family with an easy exercise “prescription,” like a daily walk, and also request the parents or child keep a daily food journal to get a better idea of diet content and patterns, as well as to see whether they might benefit from a seeing a nutritionist. Another simple intervention is to tell parents that every hour of screen time should be matched with an hour of physical activity. From a holistic point of view, you can motivate by reminding parents that natural play and natural food might minimize the need for psychotropic medication—a goal many parents have.
Interview originally published in Carlat Child Psychiatry Report, April 2014
For more information on the physiological impacts of screen-time, see Reset Your Child's Brain: A Four Week Plan to End Meltdowns, Raise Grades & Boost Social Skills by Reversing the Effects of Electronic Screen Time