Social Determinants of Health: Pediatric Obesity 2017

Hey, everybody. Welcome back. Hope everyone had an enjoyable lunch and we're getting ready to start with the second half of our program. I have the distinct honor to introduce someone who probably doesn't need much of an introduction as he is one of our co-hosts here, Chris Bowling. So most of you know he's the chair of the AEP section on obesity. He's also a volunteer associate professor at Cincinnati Children's, and what he is primarily is a private practice pediatrician, and many of you know that Chris has this extreme passion and dedication to children and their health, and what I think he offers most of us is some very. Real practical information with a lot of humor. So Chris, we're really excited to hear your talk because this is an issue that's been up and coming about how to really tackle the undercurrent of obesity. Thanks, Stephanie. Um, it really is, um, an area, you know, we're talking about an area that we really need to kinda get better at. It was nice to kind of have to do a little bit of research on it because this is not an area that um I think a lot of us know a whole lot about how it connects exactly to obesity, and I think that's OK because I don't think there really is a a huge amount known yet, but it was an area that was really of interest to me, um, and also dovetails a little bit with what I do, actually dovetails a lot with what I do as a general pediatrician. Um, so before we get started, I just want to remind everybody, it is Groundhog Day. So happy Groundhog Day, and I regret to inform all of you that 7:20 a.m. this morning in Punxsutawney, Pennsylvania, Phil did see his shadow. So we have 6 more weeks of winter. Not too depressing for those of us who are eastern skiers, but still kind of sad in a way, so, get used to it. Um, who I am, as I mentioned, I am, I have nothing to disclose first and foremost. Um, I'm a general pediatrician and I practice in suburban Cincinnati, which is actually in the northern Kentucky suburbs, which is an interesting kind of area to practice. It is very suburban, but we also pick up a lot of, uh, Kids in a lot of different settings. We have a rural population. We have one office that has a fairly diverse population. We have, um, um, Appalachian families, we have African-American families. We have some Latino families in from more rural areas. So it's a real mix, although it is primarily suburban. And I say that for a reason because it connects with what we're gonna be talking about in, in this talk. Um, I am the current chair of the AP section on obesity, and I throw that out there. Just if, uh, folks have, um, if you're not a member of the SU, please join. Um, and if you have suggestions for us to address, for Stephanie and me to address on the section, um, please. Pass them our way. Um, we have several of our, uh, executive committee members who've been instrumental in making this today's program a success, Matt Hamer and Tory Rogers and John Rauch and Sarah Armstrong and Mark Mowski. So we're really blessed with a really good group of folks. I do have specialty areas in motivational interviewing and practice management with obesity, and also some special interest in um adolescent weight loss surgery and also in young children with obesity. That's mostly where I do uh most of my research with folks at Children's here in Cincinnati around young children. But then also I'm involved with uh Mark uh Malsky and Sarah Armstrong and Kirk Reichert with, um, developing a policy statement on adolescent weight loss surgery. So there's a reason, so these are the reasons I have a lot of interest in this topic, but it's also important to say who I am not. I am not a developmental specialist, even though I do a lot of developmental pediatrics, um, uh, and I'm not really a, a specialist in toxic stress. Um, so I have a lot of limitations with this, so please be merciful as I go through this. If you have things where I'm getting it not quite right, I'd love correction. Um, you guys are the first time that I've done this talk on this topic. So, as I mentioned, I am a, you know, a pediatrician in a major metropolitan area that we're over, you know, when we count us with Dayton, we have about 3 million people in greater Cincinnati a little over 3 million people in Greater Cincinnati and Dayton. Um, you know, big, big, pretty well off from a, from a, um, uh, economic standpoint, although there's a lot of poverty in, in Greater Cincinnati. Um, but we're adjacent to an area in my home state, Kentucky, is really, um, uh, rife with a lot of illness. You know, I, I, these are the latest, um, age standardized mortality rates put out by the NIH published just last couple of weeks ago in JAMA. And what we noticed is a lot, you know, a lot of clustering with mortality. In certain parts of the country, across a variety of illnesses. So some of the things we know, you know, as I said, I'm a native of Kentucky. Um, black lung is in the history and it really in the DNA of, of my home state. Um, there's a lot of chronic respiratory illness in the, in Appalachia, and you can see that by this deep, deep red uh. Counties, uh, this is county level mortality rates, high, high rates of respiratory disease, deaths per 100,000 in eastern Kentucky, southern West Virginia, really those those coal mining areas, um, and also areas where there's a lot of smoking still. We also know that cardiovascular disease is very high in those areas. It's also really high if you look um in the Mississippi Delta region, you know, the along the border between Arkansas, Tennessee, Mississippi, Louisiana. So you really see like heavy, heavy, um, and high mortality rates in those zones of cardiovascular disease. Um, diabetes and endocrine disease also follows a very similar pattern, um, you know, those areas in, in northern Mississippi, um, eastern Arkansas, north, northeastern Louisiana, um, and also clusters around the country. Again, the, the area I was mentioning before, Appalachia, really high rates. Um, this, this one creates a lot of sadness for those of us in the state of Kentucky because we really are the epicenter along with West Virginia for the current uh uh heroin outbreak. Um, it's everywhere, um, but our raids in eastern Kentucky and southern West Virginia are just. Absolutely staggering. Um, for those of you who do not live in the Ohio River Valley or in the, in our general vicinity, um, I think you know it's a problem, but it's just absolutely overwhelming in certain parts of our state. Um, we have counties where it's just, I, I, I can't even exactly explain it. Um, for those of you who are, you know, wondering why is this the case, I think we had the perfect storm of a, of a distribution network of, of, um, um, heroin, um, encountering a population that was really primed by the prescription drug epidemic, um, of several years ago, um, to, to have dependency on opiates, and it's just absolutely been a powder keg in eastern Kentucky and West Virginia. Um, we also know too, you know, you look at these areas, again, the, the Mississippi Delta region and um Appalachia have very, very high rates of cancer. Again, maybe somehow tied into, um, tied into, um. Uh, the chronic respiratory illness, but there's also something more going on here as well. Um, and if you think about it, you know, thinking about these counties where we're seeing all these very, very high rates of mortality and shortened life expectancy. They really look very much like our areas that are really affected by obesity and pediatric obesity. It's almost the same kind of distribution, so we see these epidemiologic factors where it goes across a lot of different disease processes. Um, it even transmits into areas that you really wouldn't expect. Common infections. So we're talking about pneumonia, diarrhea, um, things that are, you know, like, not really, they wouldn't really seem to be tied into lifestyle, um, but what they are tied in with, like obesity, like oral health, um, they're really tied in with socioeconomic status. And I don't think that comes as a surprise to anybody who's on this, um. Uh, in this conference right now, these are areas that really suffer from a very, very high burden of disease. So, you know, there's, it's easy to say, OK, these are areas that um this is connected by socioeconomic status. This is really something that is, you know, it's sort of ingrained into the culture, there's poverty, there is um a, there's food insecurity, there are all these other socio-economic challenges going on, and that's what's going on. They lead into behaviors that cause problems. I don't know that that's right. Um, what we really seem to understand is that there's probably something much more going on here. That not only are these areas, not only do these areas have a common problem with low socioeconomic status, um, you know, I think for a long time, a lot of us were saying like, is there a, is there a racial ethnic sort of feature to these things? Is there's a cultural, you know, a lack of a cultural Prohibition on, on, on, on gaining more weight. I, I think, you know, we, we came up with all these sort of crazy ideas when really there's something more underlying going on and something more biologic happening. So what could this connection be? Well, there's a lot of theories, um, and for those of you, I'm gonna kinda start back at the beginning, for those of you who may not remember or may have never heard of some of the theories around toxic stress. Well, toxic stress actually um is a term that's kinda come to the forefront more recently here. Um it was really developed in '97 by two research, two researchers, uh Felitti and Anda in California, in San Diego actually, where Doctor Wood was from. Um and it actually, what most people don't realize is that it started as a dropout study from an obesity treatment program in San Diego. So Felitti and Anda were noticing that they had patients who were succeeding in an obesity treatment program. They were doing quite well. But the problem came up, they, we, like we all experienced, they had a high dropout rates, and they were questioning, like, why are some of the people who have the most Success, they seem to be dropping out at an equal rate to people who are really struggling. And I think we all experience that, you know, like, there are these patients who stick with you, who aren't doing very well, but they're sticking with you, and there are other people who are doing really well who for some reason drop out. So anyway, in their studies, they actually found that there were some other things going on. That these patients were experiencing other factors in their life. Um, for those of you like me who do a lot of community, um, outreach sorts of programs, I remember, I live in a part of Cincinnati called North Avondale, which is right next to Avondale, which is a very, um, Very challenging neighborhood. Avondale has some of the highest crime rates in our city, some of the highest rates of child poverty in the city. And I remember talking with mom, a mother, saying, you know, like, well, kids really need to get outside and play. And a mom said to me, you know, Doctor Bowling, that's great. Um, I'm more worried about my child getting shot when they walk out the door rather than them getting exercise to be at a healthy weight. Um, so what we find is, you know, that a lot of these patients that were dropping out and patients where obesity is not at the peak of their hierarchy of concerns, um, they're really dealing with a lot of other things going on, and that's what Felitti and Anda found out as well. Uh, you know, these were families that were really experiencing other significant stress. And you could leave it there, you know, you could say, well, I guess it's just, you know, they're too busy with other things, they have other things on their mind, it's just taking up their time. Well, Fellini and Anda didn't stop there, and thank goodness they didn't. Um, what they found was that there were some very specific things that these people were in, were, um, being exposed to, the people who dropped out of the study. Um, and then as a result, what they did was they did a much larger study called the ACEs study. And the ACES study was done across the entire Kaiser Permanente healthcare system, um, uh, or a large portion of it, I shouldn't say the entire one, but a large portion in California. And they really screened people for very specific things. And what were these specific things? They were called ACEs or adverse childhood experiences. And really, childhood is the important period of time here. So these ACEs or adverse childhood experiences were things like, Physical abuse Sexual abuse Emotional abuse. Physical neglect Emotional neglect, some obvious things, but also some less obvious things. If the mother had been treated violently, or there had been aggressive parenting. If there was household substance abuse, alcoholism, drug abuse, etc. If there was a case of household mental illness, so, you know, things that we wouldn't necessarily say are linked to socioeconomic status. I mean, certainly, mental illness can drive you into poverty, but it's not something we necessarily immediately think of being more prevalent in a, in a lower socioeconomic status family. Parental separation or divorce. An incarcerated household member. So these were all things that were considered to be adverse childhood experiences. So what do these things really do when you're living with one of these situations, what is happening? Well, what we find is that there's a really, that there are increases in these families, um, that there's increases in smoking, there's increases in substance abuse, there are increases in obesity, but also in these families, there are increases in diabetes, there's increases in heart disease, there's increases in stroke, there's increases in cancer, sort of mirroring some of those things that we saw on the earlier maps. And it's not just about behavior, when they controlled for behaviors, so they looked at kids. Who experienced these things, who didn't have obesity, didn't have um uh substance abuse, didn't turn out to be smokers, they still had higher rates of diabetes, heart stroke, heart disease, stroke, cancer, even when you controlled for these other factors. So there's something more than behavior going on that was uncovered by this study. And, and what uh shockingly too, I or maybe not surprisingly, is there was a shortened life expectancy because of these kids who were exposed, even when you control for all these other things, these kids who were experiencing ACEs on a regular basis were really having significant, significant health outcome problems. So they found in this study that ACEs are very common, that in this group of patients, 67% of families reported at least one ACE. 40% had 2 or more ACEs. 12.5% or 1 in 8 had 4 or more. And that the effects were almost more than cumulative. They were not additive, they were almost more multiplicative. Once you started getting more and more ACEs, the effect on all of these health outcomes was very profound. So we really started, they really started seeing that patients who had multiple specific types of events, they had problems. So what's really going on here? OK, so we know that these kids are that a lot of kids are living under these types of stressful situations. They have these things going on in their household, um, but what's really going on physiologically? Well, when you think about it, you know, if you think back about the fight or flight response, what's going on with the fight or flight response? You know, you're presented with a bear in the woods, and you get a fight or flight response. You have a surge of neuroendocrine hormones. You have to decide very quickly what to do in order to survive. That's fantastic if you encounter a bear in the woods. But as a speaker, I'm gonna link to this talk too, but as Nadine Burke Harris, who's a speaker on this, says, what's the issue if that bear comes home every night? Um, your fight or flight response is persistent, and it may not even, it's not rare, as we know from the ACES study, and sometimes it's not even really episodic, it's continuous. You're constantly bathed in this toxic milieu of epinephrine, of cortisol, of norepinephrine, um, and you're really, your, your system is under continuous assault, um. Like I say, it's great if you have, if you have your survival instincts going, but over a lifetime, having it too heightened for too long has real physiologic consequences. So what are those consequences? They're pretty widespread. Um, certainly our neurons become somewhat desensitized and they become. They respond differently, um, for lack of a better term, very, you know, they're, they're just, they're under assault for so long, um, their, their response is different. Um, it certainly affects the hypothalamic pituitary adrenal axis, and it does other things to the endocrine system as well. Um, you know, certain. Certainly for those of us in obesity, brings up a lot of questions. What is happening to our kids who, you know, who, what's happening with leptin resistance and insulin resistance? Definitely things are affected by an over overstimulation of, uh, of, um, norepinephrine, epinephrine, and cortisol. It also affects the immune system, you know, it really um will um decrease your ability to fight off infection. It changes your immune modulation. There's lots of things that we think occur when you're in this constant state of alertness and terror. And probably most interesting and hardest to wrap our minds around is that it changes your genes. You know, like when I first heard this, I'm like, really, what are you talking about? How possibly can living in a stressful situation affect your genetics? The entire area of epigenetics is really about activation and deactivation of certain parts of our genes. Um, and if we think about it, there actually are two particular processes that are especially important to turning on and turning off genes. Um, methylation, which is, uh, both of these are, are, are totally normal. Either activations of histones by epigenetic factors or methylation of genetic targets, um, happens all the time with us. Um, and what happens when you are in a constant state of alertness, a constant state of stress, um, methylation occurs in a different way. Um, other epigenetic factors, um, I say they're the unraveling of a hisstone tail, um, and I'm sure the geneticists in our audience are, are cringing right now as I try to explain this, um, but what we find is that these, uh, genetic triggers have profound impacts on development. They have impacts on aging, they have impact on mental mental health, they have impacts on diabetes and cancer. So when these genes are turned off or inappropriately turned on, um, what happens is not good from a health perspective. So, the stress actually has a biologic effect on our genes that can result in adverse health outcomes. OK, so this is all well and good. We know that there are certain factors that are particularly a problem. We know that these factors can change our biology, they can change our genetics. Um, so what does this really mean about, you know, what, how do we put this into practice and what does this mean for, um, us and those of us who are general pediatricians? Well, it means that social determinants are a way to screen for adverse childhood experiences. We can use some proxy questions. We can figure out what's going on with families and try to categorize by risk factor who's gonna be at most risk for later illness. Um, there are challenges to doing this. It's really difficult, you know, I, last, I'm, I'm participating in a project and I'll tell you a little bit more about it, where we are actually, um, helping pediatricians identify these using some tools, um, and I'll, I'm gonna show you one of those tools in just a moment. But one of the pediatricians just, you know, I, I thought she was about ready to, to. Cry as we're going through a motivational interviewing training and trying to figure out what's going on with families. She's like, you know, I just, I can't even imagine trying to screen for some of these things in the midst of all the other things I'm asked to do as a pediatrician. You know, we're asked to, to talk about everything, including difficult discussions around weight, etc. So there are some real barriers. Um, there are barriers we're worried that parents are gonna fight back with us. We worry a lot about time just because we have so many things we have to do. Um, you know, one of the things that happens and what this pediatrician was saying was like, OK, I've uncovered that the mother is in an abusive relationship. Now, what do I do? I have no resources to deal with this. So these are real challenges when you're in practice. We just don't know how to deal with this. And you know, at the bottom of the list is reimbursement. I think, you know, in general, we're all like, oh, we need to be doing this. This is not getting reimbursed for it is a real problem, but I think that's what is the least barrier for pediatricians. I mean, we're used to fighting that all the time and really we should be getting reimbursed for trying to help patients out on this, but reimbursement's terrible for things like. This, um, hopefully we'll get it better, but there are a lot of barriers, um, you know, and, and I'm gonna backtrack a little bit, the attitudinal barrier, you know, I'm thinking not so much about the attitudes of the providers. I think what we're worried about is do parents and caregivers really feel like this is an appropriate role for a medical professional to be, you know, broaching this topic, um, and I think actually we have a unique way of being able to do that. Um, but it's, it's a little scary because it's out of the, out of the mainstream for what we typically do. Um, so when we're translating ACEs into practice and translating this, it really is kind of an urgent need, you know, I mean, I think we say like, I don't know how we're gonna do this, I don't think we have the resources. I think all you have to do is look at the mortality rates, and you know, in some of the statistics that indicate Americans are living shorter, unhealthier lives, um, this is a, this is a health crisis. Um, I will tell you that screening tools do exist. Um, and that certain places are putting this type of practice into, into practice, um. You'll hear certain terms and I bring these up, not to say that, you know, you have to know what's going on across all venues, but you may also hear other agencies. There's an agency here in town. That I'm very involved with, it's called Lighthouse Youth Services. They do a lot of work with youth homelessness and kids who are under a lot of stress, kids who are in foster care, um, former teenage sex offenders, um, kids who are out on the street, um, kids who are timing out of the, um, foster care system. So they have a lot of kids who've gone through a lot, a lot, a lot of these adverse childhood experiences. Um, and they use a model that's called trauma informed care where you sort of assume that people have these things going on. For them, you know, for an organization like Lighthouse, that's a pretty safe assumption. I think you, you, everybody in the room, you know, who's in practice will has contact with social service agencies. So when you hear them talking about trauma informed care, um, it's in the same ballpark. These are people that have also kind of had some of this training. Um, I mentioned that we're, my practice is doing something right now. We're part of a group, um, that's called Parent Connects. Um, it's a grant from one of our local hospital foundations, um, and a parenting center named Beech Acres Parenting Center. And what we're doing is we're trying to screen for these social determinants of health. We're trying to find out which kind, who, which kids are really being affected by these adverse childhood experiences and what can we do to intervene early. So what we have actually this grant provides to us, um. Resources to do screening with kids at different ages, but also any time we find a patient of any age, um, we refer them to a parent parenting specialist who's in our office who can counsel, get them connected with resources, who can counsel them on behavioral techniques. Who can really give them some um ways around getting out of abusive situations, give them ways to deal with behavior in such a way that's not quite so harsh that we're reducing the impact and reducing the frequency of adverse childhood experiences. Um, what we have, um, like I say this is a, um, an experiment for us really. It's, it's a study, and we're, and we're tracking our outcomes very closely. We do a this screening tool, um, called the SEC, which is shown here, um, comes out of the University of Maryland. We give the SEEK tool to our patients who are parents who have either a one month old where we're trying to really pick up those moms with. Maternal depression, 9 months, 2 years, and 3 years. Um, if we uncover somebody who we suspect has a has adverse childhood experiences going on outside of those time periods, we refer them on to our parenting specialists anyway, but, um, they don't have to fall out. But with the see what we find this does is it kind of tips us off, and this is something that the nurses. Give our patients and then we quickly look at it, score it, and do a little bit of counseling if we have time for it, but then very quickly involve our parenting specialist. Um, we're very fortunate to be part of this program. We're really learning a lot about, um, you know, just exactly how much time it takes, but how helpful these sort of situations and these sort of interventions can be. Um, we're really encouraged by it. Um, you know, there's also a connection. I was really glad, um, to be following. I initially, I was gonna be ahead of Christine Wood and Kelly Brownell on, um, on today's agenda, and I was really glad to be following them because they both talked about how this toxic Um, uh, uh, toxic stress that kids experience at home is really also connected to their community. Um, you know, we, you know, we really see, you know, that there are certain communities where, um, you can either do things to reduce toxic environments, um, by providing high quality childcare, um, you can do things by making a, a, a, a. A community safer, that you can reduce some exposures to violence and exposures to other, to other um uh offending agents, but the environment is really important, you know, even when Christine was talking about eating disorders and weight management, you know, it's really kind of a community issue. It's something that if we can create healthier communities, we really are going to create a healthier population. Um, environmental control is really important. I think that speaks to a lot of us and behavioral economics, to those of us who do weight management. Um, you know, it really fits into that socio-ecological model that Christine tossed up on one of her slides, um, you know, and really, as, as Kelly was talking about, where you're changing the defaults, changing optimal defaults. Making healthy choices and making less stressful choices part of the environment, giving people a way out of, um, of stressful settings. You know, I mentioned that, you know, this, this lighthouse organization that we're involved with, it's really important because it takes those kids out of those settings sometimes, and we have to get them sometimes out of these toxic environments that are really having gonna have profound impacts on them later. So I think, you know, this is a, a, there are some really unique challenges for obesity care. When I was putting this talk together, I just, you know, it's a brainstorming session of one, I know I'm missing. Many, many unique challenges to obesity care, but I came up with a few that I wanted to share with you and just some food for thought. I mean, I really think that food security has a direct connection with um adverse childhood experiences, you know, whether families are, are really, you know, struggling to make ends meet. Financial insecurity is really a big one, and these are families, we all know it. Our families who have the biggest problems with obesity are ones that are often ones that have the hardest times making ends meet. Um, it's one of our questions that drops out on our seat questionnaire. We, in my practice, we have about 10% of our population, 10 to 15% of our population drop out on it. Um, and, and one of the more commonly answered questions is, yes, I've had a hard time putting food on the table in the past month. Um, you know, we're gonna see some interesting and scary things happening with uninsured and underinsured again. Um, I think certainly that has a big impact. Um, we really, you know, it's, it's, it's an important part of the discussion with our families, like when, when they're dropping out, it really means that we need to be addressing some of these other things that if we're gonna get, have any success with weight management, then we need to be addressing some of these other things that might be higher priorities for the family. Um, I think I, I alluded to it earlier. Certainly these hormonal effects that toxic stress provides to these kids really has gonna have a profound impact. I think we're gonna find out a profound impact on leptin, on insulin, on a lot of factors that really affect obesity. Um, unstable, variable housing really impacts our ability to get healthy food environments there and really even just to maintain contact with our families. Um, I, and I know I'm missing hundreds of other challenges that are unique to obesity care. We have a very complicated subspecialty, and you know, when people ask me why do you like obesity care, I kinda like trying to bring chaos out of order, honestly. Um, and this is certainly something that's going to that contributes to that chaos that we all see. So, I mean, I think there are some things that we do all know, um, but I think there's a lot of things that we don't know. Um, you know, it isn't really about someone else. Um, very few of us actually live in those counties in eastern Kentucky and in southern West Virginia. Um, I think it's important to remember that the original ACEs study, the one that showed that 40% of patients had at least one ACE, was 70% white, was in the 70% college educated, and 100% insured. So, this isn't someone else's problem. This is affecting all of our patients, um, and I think it's important to know that. Like I said, our group, we have a very, we have sort of a diverse couple of offices, and our more diverse office has a little bit higher um uh completion rate of finding something on our, on our screening, but really across our three offices in a pretty suburban practice in a large metropolitan city, um, we have about 10 to 15% of our population, uh, testing positive for adverse childhood experiences. Um, and that is just on a single point in time. This isn't saying like at any point over their childhood. Um, if you're looking for a great video on this, I mentioned Nadine Burke-Harris. This is 16 minutes. If you're trying to get to understand it a little bit better yourself or trying to share something with, um, a colleague who just doesn't quite get, um, why social determinants are important for pediatric care and. For obesity care. This is a dynamite little 16-minute video that I would point you to. Again, Nadine Burke-Harris, it's a TEDMed talk. It's on YouTube. If you just Google, um, Nadine Burke-Harris, um, you'll find it. Um, she's great. She's a developmentalist, um, in, um, um, uh, California at UCLA. Um, so any questions at this point? Hey, great, Chris, that was awesome. Thank you. Um. I think this topic is really so important and as we start looking into it, all you do is uncover another area, another area that you need to get into, which sometimes makes it feel very overwhelming um as you guys have started implementing this in your practice, is there a way that you suggest folks should just start? So for us, I mean, we had a very good fortune being part of this um parent Connects program. I think, you know, it really, you have to think about what you're gonna do with what you find first. You know, and I think it it like, um, we have to determine how much obesity care we can deliver in our offices. I think you have to think about what you can really accomplish in a practice setting. You know, I, I, it, for those of us, I mean, I think sometimes you talking about it with your Institution is helpful if you're running an obesity center on how they go about doing it, um, certainly you have allies in other parts of medical systems, um, but they're also too if you're in practice, I think sometimes partnering with um a social service agency like we're we're partnering with this parenting center currently that I don't know how we would do it without Beach Acres. Um, I really, I just think we would be overwhelmed trying to do it on our own. And that talk by Nadine Burke Harris is fantastic. Um, what I like it, yeah, I like what she says is she's like, you can't do it all. There's not necessarily a validated perfect tool. So kind of either maybe just pick an issue. I know in our clinic, what we decide to do is to start with food insecurity, and we actually found that we have 25% of our folks are food insecure. So it's really hard to start talking about weight management when you have a 25% of the folks who can't even put food on the table. Absolutely, absolutely. And I just, you know, I think about those times in practice where I have just gotten a smackdown from a parent, just saying like, you know, this is all well and good, but you have no idea what I'm dealing with at home. Right? Tory, any comments from you? Yeah, it's, it's great talk, Chris, fantastic, and, and Nadine is incredible. Uh, we've started to do a lot of the work. Steve Steve Di Giovanni here in Maine is leading our ACEs campaign, and it, it's amazing how, uh, the uptake from the primary care providers, they feel supported in asking these questions. Uh, we also have connected with our behavior health colleagues who are incredible on this, um, so. So I, I, I think it's, it's so connected to the work that we do. I think the questions that you can ask are, are, they're not intimidating to ask, um, and the, and when you get the answers back there, it feels like we've set up at least a safety net so that we can refer out when needed, but sometimes you don't always need to refer out. Sometimes you're gonna keep having those conversations here within that primary care setting. I, I love the connection with obesity work like you're alluding to, Tory. You know, I, my role with the Beach Acres project that we're doing is training our pediatricians in motivational interviewing because it's, they need those skills in order to um know how to ask those questions in a non-threatening way and really get to the root of the issue with the family. So it's using those skills that I think that we as obesity providers are kind of unique. In having, but using them in other, in other venues. Sheel, do you want to talk a little bit about what we've been doing in clinic or any of the, any of the screeners and what we've gotten back? Yeah, it's been, um, you know, I think we all have the same hesitations initially, um, the first question being what do we do if we have a child or a parent who's reporting food insecurity or we also screen for depression and anxiety, but what happens when we have someone who's elevated on this? So I think we, um, like Chris was saying, we first had to kind of have a conversation about what are we going to do, what's our obligation to the family, um. And we're actually pretty lucky in that we also have um social workers that are not necessarily part of our program but part of the hospital that we can reach out to and get resources from them as well um but it's, I think it's largely been accepted by most of the families we really haven't had any kind of resistance or pushback or questioning about it. Um we'll have a few families that will ask well why are you asking these food insecurity questions and once. Um, that's explained by the nurse. Um, most families are, um, You know, totally understanding of why we're asking these questions, so it really hasn't been as I guess as stressful in asking the questions as maybe we anticipated it would be. That's been our experience too, much less. I'm glad you said that Sheel because it just, it hasn't, I, I, when you explain it to families, they're like, well, thanks for asking, you know. And John, what about it at your program? What are you asking? I think you're on mute there. You need to unmute. There you go. Sorry. Hi. So we, we ask about a lot of the social determinants. I think our big issue has been, uh, how to put the, how to put it all together. Um, and, and, and how to do it in a way that is, uh, That's comprehensive but also easy for our practitioners, and I think uh we are gonna hopefully get some money to, to start working on this. I think that helps. I think it, we have a ton of student volunteers that really help us with some of this, um, and I don't think we could do it on our own. No, I think it's always, it's always a group effort. And I think the first step too is also making sure you have somewhere to refer folks to. It doesn't have to be perfect, but as long as you're taking that first step, I think that's what we need to understand. Sometimes, if we allow it to be overwhelming, then we don't do anything and we're not necessarily moving the needle forward like we really want to, when it comes to this issue. Anyone else with any comments? No, I think this is a really complicated. Subject and. You know, I know in our institution, Stephanie, when we first started talking about this, it made, it actually made the administrators really nervous because they said, what do you do if, like what, what do you do if you get this information? And it's like, you know, we ask people about smoking or firearms or whatever it is, and it's like, it's, it's, it's information that you use clinically. You don't always have, you know, it'd be great if we had somebody to refer all these kids to, but even when you don't, I think just recognizing it and helping the families recognizing that this could be a factor influencing where they are now will be very helpful. I mean, it's an issue whether we ask about it or not, right? So the more we ask, maybe we can't help them this time, but maybe we can help them next time. So I think it's so important and I agree with Chris. There's lots of good experts out there, and thank you so much for that talk. I think it was very timely and appropriate, and again, it's sort of the bigger picture of how we're taking care of all these chronic illnesses that our families are facing either as the child or the parent. And I think we've been a little bit better at it, like even in our bariatric centers, cause we, you know, they, those kids go through a lot of, of other testing and we really learned a lot about their families, but I mean they're not the only ones that are really getting affected by a lot of these issues. Yeah, absolutely, and we've certainly done that ourselves in our program because it's a smaller group and so you feel like you can actually help them and now we look at sort of how do we expand that so we can be there for all families. All right, well, thank you, Chris.