Eating Disorders: Pediatric Obesity 2017

But I wanted to start off first by introducing our first speaker, who is Doctor Christine Wood, and she was very kind to get up super early since she's out on the West Coast. Um, so we really appreciate this early wake up on her part. Um, she's a private practice pediatrician out there and. Um, she also is a medical consultant for a residential eating disorder center out in Valhalla. Um, what I'm really excited to hear about, and I think this topic is so timely, is talking about the connection or how to really work with obesity and eating disorders, because I know it's something that pediatricians often have questions about how to sort of do these conversations in a way that promotes healthy eating. So she is the co-author of the new AAP clinical report on preventing obesity and eating disorders in adolescents. And thank you again, Doctor Wood. We're very excited to hear your presentation. Great. Thank you very much. This, uh, is an exciting format. So here we go. All right, so I am going to talk about the addressing obesity safely, which, um, There was a new AAP article that I co-authored, which discussed the role of prevention of obesity and eating disorders in adolescents. And, you know, I've been doing pediatrics over 25 years and definitely, I just feel with time, I've just seen such a continuum. Of issues and so many of the issues shared by children and adolescents who are overweight and have eating disorders have many of the same roots. And so this article um really came to try and pull some of those things together as far as what is going on. All right. Um, I have nothing to disclose, and next slide. So this, this billboard, which was actually not Photoshopped, I understand it, it came from somewhere in New York City, I think sort of discusses, um, I call it sort of the yin yang of what our culture is dealing with. Um, here we are, we have ads for fast food, and then on the other side. We have things about childhood obesity, and unfortunately, the messaging out there that uh many of our families will be seeing create a lot of difficulty as far as what we need to, you know, be doing with our families. OK, next slide. Again, I'm not able to advance there, so if somebody can do that for me. Thank you. So what I, what I see here is that, you know, I feel like our society sort of rewards being thin by many of the body image things that we see out there, but unfortunately, our society sort of creates lots of opportunity for foods and activities that are less active, that create more of a risk for obesity. So, just to start first with The things about uh uh as far as uh eating disorders. Um, there have been some changes in the DSM-5 for anorexia and bulimia. So these changes actually look like this, um, for anorexia, criterion that looked at ideal body weight. That was one of the criteria that we had to have in order to make that diagnosis. But now we're seeing that um there's um less focus on Body, all these types of things. Bulimia also has had uh a bit of a Change, it's less stringent on the frequency of the binging and inappropriate behaviors, the, the vomiting. Um, some, some of our, uh, teens use compulsive exercise, lacked, you know, diet pills, etc. And so we've, uh, relaxed some of the, uh, frequency uh guidelines on that. Next slide. I, I love that, I love that slide with the uh juxtaposition. And it's unfortunate. I know that we did a lot with media in the past and some ad campaigns, but it's Yeah, it's interesting to me how. There's no intention, you know, whoever's selling the, you know, you have that right there like that. It's very, uh, yeah, they're just looking to see who's paying for that billboard and get it up there, not worried about, not worried about the message that you're sending, not worried about the message that you're sending. It's very interesting. I think that, I think that's what she's really going to get into is sort of the, the difference, right? You have these, these mixed messages everywhere. Certainly, you know, I know Christine's going to talk about this, but for women. You know, the thinness and all that, that, I mean, there's just so much involved. There's so much more than just those two things and being funny is realizing sort of the difference in how society promotes. You should be able to eat and have fun and then also the need to be thin, particularly for women. I mean, you have daughters, daughters, so you probably see this a lot more than I. Well, I have two daughters that have both have and are very much involved in ballet, so it's, uh, you know, I see it firsthand with some of these girls because there's And you can see, I'm sure Chris Christine's gonna get into this, but just some of the behaviors that you see where it, it really. You know, they'll go out. I mean, you'll hear, it's like there's everything's all about food. There's like so much. The conversation, like everything is all about it, and then you have these girls that are trying to be thin. It's, yeah, it's a very tough situation, you know, this is something I'm really, um, this is something as a, as a practicing pediatrician, you know, this is first and foremost in parents' minds, because I think you immediately get into, I don't want to trigger an eating disorder, you know, I don't know if you guys have, um, seen many you hear me. Oh, there, there she is. OK, is that better? Is that better? Yes, much better. OK, all right. So let's go to the slide called uh DSM 5 new additions. Which is back, uh, 2 I think back actually you're going forward 1 more back maybe. All right, we'll try and get through this. OK, so here we go. All right, so, um, a couple of new additions are binge eating disorder to the DSM-5. This was officially recognized, um, and this has been obviously under the radar screen, and I think a lot of people have understood that this is a real disorder, but now it's been officially recognized as recurrent binging at least once a week for 3 months without any compensatory behaviors. And a really interesting one that I've actually been seeing a fair number of younger children with, it's usually in my mind it's occurring in like even school age kids, not maybe as much in the teens, something called avoidant restrictive food intake disorder or we call it RFID. Which is just a failure to lose, you know, to gain the weight. They, these, I have one kid who was at age 7, had a really bad stomach virus, was vomiting, and she doesn't want to eat because of that. She went, she's, you know, had to really work with a therapist. She just has this fear of vomiting, so it's unfortunately really affected her growth. Um, so this is another new addition. Next slide. OK, um, let me just pull it up. OK, so, and you can open all these up just so we can just save time. So 20% of our youth actually have mental disorders and there's one more part to open up, but many are not getting care. Um, 33% of US teens have an eating disorder, but most don't even get treatment, and, um, many of these, uh, teens that I see with eating disorders have at least one other psychiatric disorder diagnosis. And what's really starting to become more of a trend is our transgender population. They've reported that up to 16% of our transgender college students have an eating disorder, and I have several that I've been dealing with over the years that have had that. And then you can open up one more. I think there's one more bullet here. And what we need to realize is eating disorders actually affect all ages and ethnic groups. Next slide. Um, the other thing is the lifetime risk. So the lifetime risk in American females, you can see are listed here. I'm not going to read those, but um, you know, they, they seem fairly small and insignificant, but you know they're unfortunately what we understand with the new DSM-5 is that we're likely to see increases in these numbers now due to our less stringent criterion. And in addition, what we have to really understand is the mortality rate for females between 15 and 24 years with anorexia. The mortality rate is 12 times higher than the death rate of all other causes of death, and 20% of the deaths are by suicide. So, although the numbers may appear uh somewhat on the smaller side, the, um, the actual mortality rate is very astounding when you look at what goes on with this disease disorder. Next slide. So if we look at a few other just things we're seeing an increased prevalence among males, and you can open, open up all these bullets, increasing prevalence among minority groups with interestingly Hispanics seem to have a higher rate of bulimia. And again, another thing that really impacts us as pediatricians is we're seeing a, a sharp increase in the number of eating disorders that need hospitalization. Um, here at our children's hospital in San Diego, we now have a Uh, uh, a medical behavioral unit that just deals with eating disorders, and I will tell you that most of the time their beds are full and sometimes we have a hard time getting patients in. Next slide. Um, what we see is there's a lot of issues, um, psychodevelopmentally that happen again. I'm not gonna read all these, a lot of family functioning issues that, um, uh, can override some of these things, and we sort of have an idea that many of these, um, children, teens particularly have very high risk personalities. They're perfectionists, they're obsessive, you know, etc. etc. Next slide. And we also understand that there's a lot of socio cultural factors out there. If you look at media, for example, uh, they really promote that body image and so this unfortunately becomes a real factor in creating, you know, kids who in adolescents who really want to model that. And there's websites that many of these um uh teens look at. They're called Prona websites. And the lifestyle. Sometimes families become very preoccupied with healthy eating. The parents are dieting or they really value thinness. And then there's a lot of peer pressure. There's some teens I've seen, they don't want to hit over 100 pounds. They think there's something wrong with that, or they have other peers that are that are dieting. Next slide. And just personal issues. Fortunately I'm, I'm hoping we're seeing less on the front of sports pressure that used to be a lot, particularly in our aesthetic sports like ice skating, gymnastics, but I think it is still there under the radar screen. And then other issues like trauma or if there's a special event, bullying, statement by statements by others, etc. Next slide. And what we see is eating disorders actually become a coping mechanism and unfortunately, as I mentioned, there's many other comorbid conditions like anxiety, depression, OCD, substance abuse. Most of these patients have these comorbid conditions, and we really need to treat all those other underlying comorbidities in order to really treat the eating disorder per se next. So if we do the flip side and we look at the statistics on childhood obesity, and many of us are aware of this, and I know we have an international population, and I think we recognize that it's increasing, you know, globally, but if we just look at some of the US statistics, the latest statistics show that the prevalence of obesity in children has actually remained fairly stable, but the numbers are still quite high, and you can see here about 9% among our younger kids. Um, the school age kids around 17.5% and among our teens around 20%. Next slide. And I love this, this graphic because I think it really captures all the things that are out there that affect our child's weight status along with genetics and all the internal things that may be going on, but there's a lot to do with parenting styles which we'll get into kind of as I talk about some of the factors that related to both obesity and eating disorders. And then I think the biggest thing that I was very involved in here in San Diego is the community issues. We just recognize if, if children are growing up in an area where there is violence, perhaps a lot of stress, they don't have access to fresh fruits and vegetables, it is very hard to create a healthy diet based on that. Next slide. And one of the things we we've really captured is the ACE study, which I think has really put a new spin on what we understand about childhood stress and how it affects health. And one of the parts of this is that when they looked at 9-year-olds who were exposed to stress, whether it be their poverty or residential crowding, child separation, exposure to violence, all of these things actually made it more difficult for children and teens to self-regulate their diet and actually led to an increase in fat and sugar consumption. Next slide. And when we looked at the adult health outcomes and the bottom line being when you're exposed to all these adverse childhood events in childhood, they actually have a 4 to 12-fold increased risk of things like alcoholism, drug abuse, depression, suicide. Um, and what I think what we're looking at here is a 1.4 to 1.6 fold increase in physical inactivity and severe obesity. So clearly affects, um, many, many things with the, the health outcomes out there. Next slide. And what's interesting, I think, is we're starting to see a shift in how people view obesity as as looking at this slide which sort of asks the question, do we feel like it's a personal problem or do we feel like it's it's a community problem basically. And there's been a shift in over the last couple of years as far as more people starting to feel as far as healthcare professionals and the general population that there is more to do with um with a um health care, with, I'm sorry, with a community type of problem. Next slide. So when we look, and these are just some strategies that I summarized from an MMWR report and you can see here there are many things and I and I think for all of us who are doing frontline primary care, I think really understanding and perhaps finding ways that we personally can each. Uh, affect some of the community strategies can be very powerful, um, looking at ways that communities can provide affordable, healthy food and beverages and foods, encouraging breastfeeding, um, looking at ways that we can limit sedentary activity, and creating safe communities and, and encouraging communities to organize for change. It is something that we did here at our San Diego, um, San Diego Childhood Obesity initiative. And we have an amazing website with lots of information about some of the tasks that have been done. So for those of you who are interested in more, you can look at that next slide. All right, so I'm gonna get into, uh, finish off here with sort of the nitty gritty of sort of what we came up in this, uh, article that we, we did next slide. And this is the article that was published in Pediatrics, um, this last year, next slide. Um, so if we look at the factors that align themselves with both obesity and eating disorders, these are the five factors, and I'll cover a few, few of the studies on each of these. The first is dieting. Next slide. And when we look at a study of elementary school children, we found that those who read, and these are magazines that have to do with teens and celebrities and all these things, 69% say that pictures influence their concept of their own ideal body shape, and 47% say the pictures make them want to lose weight. Next slide. So it's really unfortunately led us to creating kids who continue to have poor body image as they grow up. It starts in 1st to 3rd graders where 42% say they want to be thinner, 10-year-olds, 81% afraid of being fat, and American women looking at that, 80% are dissatisfied with their appearance. Next slide. So dieting actually becomes a means to obtain that ideal. And when we looked at studies as an example, this one that was published in Pediatrics that looked at a range of kids from 9 to 14 and followed them for 2 years, they found that dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls. And we know in both pediatric and adult literature, particularly that studies show that dieting is generally a counterproductive effort in creating weight management. Next slide. Um, the other, um, the next one here. Can we pull up the next, there we go. So, um, and this is one other study that looked at a little bit of older children, 14 to 15, and it was actually became very predictive in developing an eating disorder. Many of these teens would severely restrict energy intake. They would skip meals, which I find is a real problem with our teens, um, and that they were 18 times more likely to develop an eating disorder than those who did not diet. Um, so we really have to recognize that dieting itself, trying to really restrict energy intake, try to creating that dieting mentality can actually do more harm than good. Next slide. And even among girls who were not overweight, over 13 of them reported that they had dieted. Next slide. The next thing, which I think is something that those again of us in primary care can really make an impact, I feel, as far as how we teach parents from a very young age to deal with their kids and their meals is the idea of family meals. Next slide. So what we understand with frequent family meals is that they can lower the risk in our teens of many sort of behavior issues such as smoking, drinking, disordered eating, depression, and being overweight. Next bullet here. And it also can show that they had better grades and they ate healthier. Next slide. And the frequency of family meals actually improves the diet quality. They have more fruits, vegetables, and a prospective study of 13,000 preteens and teens found that those who ate family meals on most or every day were actually protected against things like purging, binge eating, and frequent dieting. And for girls, the family meals, they perceived them to be enjoyable, who perceived them to be enjoyable were protected from extreme weight behaviors. So I really try to encourage families that family meals not only mean sitting down for a family but making it a positive experience, you know, leave things like problems and nagging the kids at other opportunities. I call them family meetings where you do those kind of things, but leave the family meals to be more of a pleasant type of thing. Next slide. And why does it work? It's because the families are consuming healthier foods, so teens tend to choose that even when they're on the outside. They provide the interaction. The parents are actually monitoring the eating issues, and that home environment reduces again the risks of some of these unhealthy weight control behaviors. And some of the kids that I've admitted into my residential eating disorder facility have been teens that eat in their room, and they never have a family meal, which is so sad. Um, they've just chosen to do that because I think they've just recognized that the family meal has sort of not been available for them. Next slide. And one of the things that I really talk to about parents with the family meal, and you can open up the next bullet, is that it does need to include meaningful conversation, find ways to do really pleasant type table topics I call them, um, and you know, turn off the TV while eating dinner. And what we see by some statistics are that the average parent really only spends about 38.5 minutes per week in meaningful conversation with their child, so family meals can offer that incredible opportunity to be able to do that. Next slide. And I love this because this is a graphic of what we talk about when we talk about perhaps family meals, how it should be done mindfully, where we're really being in the moment, we're not judging, we're savoring, we're being aware, we're tasting versus the mindless munching. Next slide. You can open up all these bullets. So, you know, set a goal. This is what I talk to families about. If you're only having family meals once a week, try to have them 3 times a week or twice a week even start somewhere. No TV, phones, or texting. And obviously I think with all the texting that goes on, I find that this can be a real interference. Involve the kids in planning. Uh, planning the meals for kids can be a real positive thing in creating healthier, healthier, um, types of choices and eat slowly, you know, it shouldn't be rush and let's get on to the next thing. I try to have teach parents to for our picky eaters involve all the senses, have kids just smell of food or lick a food. And avoid that portion distortion. Sometimes we get to that point as parents where they want to offer these portions because they think this is the right amount to eat, and then they're sort of helping their children lose some of that. We call it self-regulation, keeping the males pleasant as I, as I mentioned and setting the mood. Next slide. And um the next two factors in this article, and I'll kind of lump them together are weight talk and weight teasing next slide. What is weight talk? It's usually comments by family members, and it doesn't necessarily need to be teasing, but it can just be comments, comments about maybe what their kid looks like or that they comments about their own weight perhaps. And so these are things that we have found are not beneficial for, for children and teens. And so talking about this has actually been linked to both overweight and eating disorders. And interviewing patients who are in recovery from eating disorders found that this kind of weight talk impacted them negatively. And again, when I've done interviews with many of my teens and I asked them what triggered them with their eating disorder, sometimes it is a comment by a parent or a family member about something about their weight or their own, their the child or teen's weight or the parents who are really obsessed with their own weight. Next slide. The other thing is weight teasing. You can open up the second bullet. In overweight adolescents, they found that weight teasing is quite common, um, and you can see the statistics here. Next bullet. And family weight teasing predicts overweight binge eating, and I've seen kids who are teased by their own siblings, and that becomes a real issue and hurtful comments and by family members and significant others were again associated with unhealthy weight control behaviors. Next slide. And what's interesting is, you know, the teasing and bullying. I think we're all recognizing in pediatrics is becoming a real issue. I think the schools are really trying to cut, you know, really try to focus on this as far as trying to discourage this. But what we see is that teens, children are, you know, they're actually teased and bullied based on all kinds of weights that they have, even if they're average weight or underweight. So there's a lot of teasing about weight that goes on out there. Next slide. And the last bullet that I'll discuss is body image. Next slide. And 50% of the teen girls and 25% of teen boys are dissatisfied with their bodies, and these numbers are higher in our overweight teens. And this unfortunately again becomes a risk factor for both eating disorders and disordered eating. They have more dieting, unhealthy weight control behaviors, and binge eating. Next slide. So I'll just wrap up with what is our role in this whole prevention issue as far as it comes together with the obesity and eating disorders. Next slide. Um, I think one of my main things is avoid the nutritional trauma. There's a lot of statements that we as health professionals can sometimes make, and I have interviewed teens who have had that happen to them. And you know this, this can be very traumatic and very sort of scarring for some of these kids. Next slide. And when we're we're working with nutrition as a health professional, I think it's very important to learn about motivational interviewing, and it's way beyond the scope of what, you know, we're going to do. But the AAP actually has an excellent app. It's called Change Talk that you can download, and I tell parents, don't label your foods as good and bad. That sometimes cues them for, oh, I'm good, I'm bad because I eat these good or bad foods. Um, trying to work with families to understand what it means to have their children self-regulate, um, using their own cues for being hungry and full. Have parents critically view media with their, with their children and teach parents not to talk about diets, dieting, putting inappropriate pressure about food, weight, or body image on themselves or on others. And identify stress as we've seen stress can be a real factor in offering stress reduction techniques. Next slide. This is the app called Change Talk, which again you can get on Google Play or Apple iTunes next slide. And then also understanding something we call weight bias, um, you know, avoiding language as health professionals that places blame. We want to emphasize lifestyle change and health improvement. But we want to help establish with them, not, you know, for them, what is realistic, achievable goals, um, and I love this statement weight is not a behavior and so it's not a target for behavior change. Um, and if you want to learn more about this, the, the Yale Rudd Center for Food Policy has a lot of information about weight bias and stigma. Next slide. And what we've seen is that reactions from adult patients and parents, they can get upset by comments about their weight depending on how it's put. If, if they feel berated, disrespected, if they feel that they're being blamed or dismissed about their, their problems, then this becomes a real negative impact on these families. Next slide. So we need to focus on what I consider more of an integrated approach. Randomized control studies showed that obesity prevention programs can reduce things like purging and decrease concerns about weight. So we, we understand that obesity prevention programs do have an impact, but it needs to take that focus of less, um, and if you could back up again, sorry. Uh, needs to take a focus less on weight and, and more of a healthy family-based lifestyle modification, encouraging those family meals, home, home-prepped meals, and fewer discussions about the weight and dieting per se. Next slide. And so it does create for us a role that we have to have as far as having a balanced approach, you know, applying the principles of proper nutrition and physical activity, but avoiding that unhealthy emphasis on weight and dieting. And again, I just appeal to everybody out there in whatever community you're in to look at your communities and see what is going on and look at ways that perhaps you yourself can collaborate within the community because people really take that to heart when we when they see. Physicians out there really trying to be champions in the community to try and create opportunities to, you know, prevent healthy foods, because that often is the, is a problem in many of our lower socioeconomic societies or areas. Next slide. And so, you know, this is my last slide. I think we just need to be the change we wish to see in the world and um I'm sorry for all those glitches in the beginning, but I think we got through, so thank you for your patience, everybody. That was an absolutely fantastic uh overview and talk on the subject, uh, during the course of your talk, Christine, we had a couple polling questions that were out there and I just wanted to get your comments on them. Uh, so we asked the audience, have you ever had a patient who is overweight who developed an eating disorder? And about 55% said no, but 45% said they have had a patient. Uh, that had that was overweight and then developed an eating disorder. Yeah, and I, I have seen a lot because I do admit a lot of adolescents into residential. So these are kids who have obviously been through many types of treatments already, outpatient treatments. So what I, I would say, what I see is sometimes a common trigger is some of these issues that I talked about, those 5 bullets. You know, perhaps as being an overweight child or teen, they've been bullied or teased about their weight. I see that very commonly. It's often by their peers, but again, I've seen it happen from other family members. Or I had one mother who felt her daughter at age 12 was overweight, so she wanted to put her 12-year-old on a liquid diet. And you know, obviously the teen said, no, I'm not going to do that, but she did it her own way. She just stopped eating. So, um, and ended up in the hospital. So these are the types of things we as pediatricians, um, have to realize that we have to share with families. You know, healthy ways to deal with being overweight without putting that excess emphasis on the weight itself, you know, and looking for just again those behavior changes and and watching for risks of of messages that are out there. And the other thing too, I think that would be very good is if we're dealing with kids who are overweight is to also screen them for things like anxiety. Because many of these kids, when they have anxiety or, um, you know, other types of depression, you know, even some early depression in our children and certainly in our teens, this also becomes a risk for them because they start to focus on that weight issue and that's how they develop the eating disorders. You know, one thing I read, excuse me, in the paper that you put out was that if you're overweight and you start to lose weight, that you're often praised for that behavior, right? You weight loss and some people are saying, Oh, isn't that great? You're losing weight, but you're doing it in such an unhealthy manner that it's actually, you know, you're headed in the wrong direction. So, yeah, absolutely. And that, that definitely can be a problem that I've seen also. Good point, Christine. Yes. Yeah, so, we, we, I once did a, a focus group on parental attitudes about preschoolers with, who are, who are getting over, becoming overweight. And two of the parents that were in our, in our focus group really wanted to participate because they were parents who had eating disorders themselves as children and adolescents. And they said, you know, I want to really learn the right way because if we don't talk about it, We're more prone, I, I, the parents, these parents felt like they were more prone to setting their kids up for eating disorders if they didn't talk about weight. Um, in a healthy way with their kids, you know, the way you're talking about it, you know, like, that they felt both of these parents felt like they were victimized by not being assisted as adolescents. When you guys wrote the policy on this, was there any more, like, to, to verify that or to say that, you know, like, we, you know, by ignoring the issue, that is a risk, you know, by, by letting kids find their own way or just stopping eating, that that's an issue. You're talking about overweight kids, younger overweight children. You know, you know, if we ignore the issue altogether and just don't, yeah, I love that your slide that said like, you know, it looks like healthy weight management prevents eating disorders. I guess that kind of answers my question a bit, but. Yeah, I don't, I don't think we uncovered any studies that really pointed to that or looked at that more in depth. Um, you're right, other than that one that I mentioned where there are ways to create healthy weight management and I think, you know, and it's, it's always that balance. I mean, I don't want pediatricians to feel like, oh, I should never. Talk about this because I could do more damage and that was really what we were trying to say is that that that's not what we're saying basically but we need to look at factors that are gonna promote healthy weight management on all spectrums and how does that look? What are factors that we need to be as pediatricians focusing on and I think that's what we came up with, you know, with, with the bullets, so OK. Thank you. Because on this, the second polling question, actually 75% of folks said that parents have asked them not to discuss this because they are afraid of eating disorders. So I think that's such an important point, and it does, it makes you nervous as a pediatrician how to have the conversation and make sure you're doing it in, in a positive way. And I know we've, and we're a weight management clinic, and we have folks who say, can you call ahead of time and make sure that we're not going to be talking about weight. Um, so it's really interesting that there seems to be some sort of awareness from parents, but again, how to proceed as a pediatrician, you feel like you're walking a fine line. Yeah, that's, that's always a tough question, you know, particularly when I'm dealing with adolescents. I always ask them, and obviously with our teens we're doing a part of the interview with the teen itself, right, without the parent, and it is interesting because sometimes you find that they want to talk about it. It's the parents who are more on eggshells about it. And so my question usually is how do you feel about how you're growing? Do you have concerns about your height or your weight? So when you, when you can kind of get them sort of in a very open-ended question to see what their concerns are and then you start to get their permission for that, that's how you can move forward and that's really what the motivational interviewing is, is about is finding ways to really get them to sort of uncover what they're looking for. And um hopefully that is something that we as pediatricians can start to become better at, and the motivational interviewing is a big piece of what we need to be focusing on. Um, and I get it that sometimes parents are worried because perhaps they've already uncovered some sensitivity, um, but I think it can be done in the right way in a pediatric office. Regardless of, of how the parents are looking at it, OK. You know, you know, Christine, the one other thing too with motivational interviewing, just as a reminder for our listeners out there, it's great for helping determine what's going on. I do, um, whenever I do trainings with adaptive motivational interviewing, I'm always encouraging my learners, don't try to manage an eating disorder with it though, because that is really the bailiwick of the mental health professional too. Um, it's really, it really is a very specialized thing when you do. Uncover it, boy, move them on for referral too. It's, it's such a difficult thing to treat. Um, you really, it's, I, the general, us general pediatricians out there like you, I, we all know that, boy, when you have a heavy duty, um, eating disorder, you really need help. Yeah, that's a really good point, and we really talk about a triad. It needs to be a health professional, a psychologist, slash sometimes we need a psychiatrist and a dietitian, and you really need those groupings to really be effective as an outpatient. But you know, many of these eating disorders need much more support with a real outpatient program that they're there every single day, 5 days a week, so. And we're really fortunate in our program and actually online we have our psychologist Doctor Sheathel already on the screen as well, and I know you do a lot of screening Sheeel in a short period of time. You want to talk about that a little bit? I, yeah, first I wanted to say, Christine, I thought this was an excellent talk. I, I feel like I walk a very fine balance with parents who are more concerned about the weight issues than they are concerned about the messaging that they're sending their kids. So I think a lot of the bullet points you had in your talk um have. Started me thinking about how I'm gonna be speaking with my families about this, um, particularly a slide about some of these commonalities between risk factors for obesity and for eating disorders, um, and, um, also I think your slides on the weight talk, um, are gonna be particularly helpful, um, so I think a lot of parents. Because they're so overly concerned about their child being overweight, they don't realize um that some of the messaging that they are starting to give their children, particularly the younger ones, um, preteens, um, and particularly the young girls, um, how that's impacting their body image. So, so I just wanted to say I thought that was a great talk and I think it's um definitely helpful um for those of us that are actually speaking with these families and trying to get them on the right path without pushing them. Um, you know, in one direction or the other. Um, we have a comment from the, uh, chat room. I just wanted to bring up, Christine. It says, I find that some parents are offended and take any conversation about weight as a parenting fail, especially if they are obese themselves. I guess he's asking about any scripting on how to address this, uh, would be helpful and having resources to help the family, not only the child, would be helpful. Yeah, uh, you know, it's that that's always a tough, tough arena. I get a lot of questions about that. Um, generally I sort of try to look at perhaps health risks like if there's a family history of diabetes, um, you know, high cholesterol, all these types of things, um, often what I do is I will do some screening on them and if I find some lab work that I can sort of circle back around and say, you know what, these are. kind of medical health risks, you know, and I'd really like to delve into maybe some things and again not talking about necessarily that it's a weight issue, but perhaps, you know, when you're screening them if you find they're drinking a lot of sodas, you know, hey, if we just cut down on that, that may start to make an impact, would you be willing to to look at some ideas on these things? So again, it, it can be sometimes small steps, sometimes you're literally looking for one thing. Um, uh, you know, sodas or screen time or something without labeling it that, um, I need your child to lose, you know, weight or whatever. So, um, I think that just how we sort of approach those families I, I recognize is really touchy. So, and I'm sure Chris has some ideas too out there perhaps. Yeah, it's just, it, it really is just such a delicate issue to, to know when, what to say to families. But yeah, I, I, and I, I would really echo, I, I just think like, you know, the, the discussions about around how to talk about weight and when not to are just critical. I think we're at 9. I think it's time to wrap up this. Thanks so much, Christine. That was a great presentation, great discussion. Thank you so much for getting up in the wee hours of the morning so we can do this.