Weight Bias: Child & Adolescent Obesity 2015

To make, I will say though that I'm passionate about what I do, which I think that we all are. If you're listening in here, you probably have some interest in childhood obesity, and passion is great, but sometimes we do need to check that passion because it can lead to impatience, especially when we're working with our patients and our families. And if we move too far, too fast, too much ahead of. Then, then that passion can lead to an imbalance in that relationship and sometimes not help us to be as successful working with those patients as we would like to be. And then I do share with my patients oftentimes that like my patients, I also have to make daily choices every day. I can put on weight very quickly and have been challenged by my weight in the past. So I put out some thanks and acknowledgments to my great colleague, uh, Doctor Jane Gray, our director of Be behavioral Health for Child and Obesity Center and our team back here in Austin, and then the great folks at the now Yukonn Red Center and Rebecca Poole, who's a huge, uh, leader in weight bias research and, and advocacy, and then the Obesity Action Coalition, that is also a wonderful advocacy group that has lots of great resources on many things, specifically with weight bias as well. So before I talk about obesity, I always like to put a disclaimer out there as well, recognizing that due to weight bias and the other influencers that the term obesity is, is one that can cause damage and can cause heart hurt and harm to our patients. So I use it sensitively. I use it as a medical diagnosis and specifically mention to my patients, well, if I do, you gently that it's not intended to result in guilt or blame. So what is stigma and what is bias? So stigma generally is attitudes that can influence our interactions and in a detrimental way. It can be verbal, physical, relational. It can be something that we do actively, or it can be something that we do sometimes unconsciously, and that part perhaps is the more concerning one that we really need to raise, raise our self-awareness so we can be aware of our own tendencies and have them not impair our relationship with our patients and, you know, more importantly, our patients' success. And then it can be subtle or it can avert, and it can lead to other things in the future as far as prejudice, bias, discrimination. Bias is more when that stigma is then put into action and then actually impacts someone in a negative manner. So generally, stigma is more of an attitude and bias is then the effect of that attitude being put into motion in a negative manner. Where does weight stigma and weight bias come from? So I'm sure you just turn on your TV or look in the newsstand and quickly you can find images that are are putting out. Images that we would say are are resulting in weight bias, basically that really put everything on the individual and discount all the other reasons why it's difficult to be healthy in, in America and in every country in the world for that matter. So, I'm not sure if Chris is tuned in, but sorry, Chris, this one's from Kentucky. Uh, again, so call to action, fight childhood obesity in Kentucky and look at the image. It, it really is pointing on an individual perhaps suggesting gluttony and, and weak-mindedness, and this is from a, you know, a public health campaign. This is from my home country of England. I'm English born and Texas bred, but obesity linked to poor academic performance. I'm not sure what this picture has to do with anything. But if you just think about the B-roll that we tend to see whenever a story on obesity or healthy living for that matter, if we're talking about wages in the news or the media, it always involves sort of cutting off the head of the individual and, and putting out images that would not be images that we would choose to have of ourselves in any format shown publicly. Another one here, obesity associated with hearing loss in teenagers. Again, I have no idea what this picture has to do with that, unless maybe it's a teenager's midriff. And even in our scientific papers, perhaps a misguided or unintentional, or probably intentional drive to try and catch some headlines with a catchy title, maybe unintentional Impact on Patients when they read the title and feel badly about it, but chewing the fat Discourses of Childhood obesity in the US, unfattening our Children, forks over feet. Again, it really always focuses on the individual and that that's the problem why we're facing this. So many folks who are struggling with their weight. But if we think about the socio-ecological model and think about what are all those factors, then it gets pretty complicated. So it is about our nutrition that we take in and our physical activity, how we burn it off. But if we think about all those influences, then it's no longer simple. So, we all work with individual patients. So I absolutely believe that my individual patients and their families can be successful, even if it's difficult and making individual choices to be healthier. However, We're not really doing our job if we don't recognize all the other forces at play, and that's a separate topic that I really think advocacy and looking outside the walls of our clinic is also a critical aspect of our jobs and responsibilities if we really want our patients to be helpful. But if we think about these different structures, individual factors like genes that patients can't change their genes, but then just their family influences are more individual, but their social networks influence their behaviors, their environmental settings certainly influence their behaviors, and all these are magnified if. Socioeconomics is also a challenge. If we have folks who live in communities that might have parts, but they're not safe due to crime or gang activity to play in. That's something that's difficult for an individual alone in that community to solve, or perhaps in that community there isn't an ability to access fresh fruits and vegetables or even afford to purchase them. That again it is difficult for an individual to change. So thinking about these things instead and focusing on trying to find solutions to that rather than just saying it's it's about. Weak-minded individuals, and that's why folks are struggling with your weight. Again, looking to us more as health professionals, this is an image that came out from pediatrics from a while, a few years back, and instead of having an age progressed child left on the milk cartons, this is a weight progressed child. So this is trying to visually demonstrate which child is not a bad child or maybe not really experiencing any of the health complications or comorbidities right now, but who might be at higher risk for complications now or in the future due to, due to their weight, so. The one little guy here on the left is 55th percentile BMI. The guy in the middle is 75th percentile, and the guy right here has already crossed into the obese, obese category, or certainly I would consider it a risk category and that they are now at a higher risk for other comorbidities and complications now and in the future. But due to the huge prevalence and the rising incidence of child obesity in the US, even us as health practitioners. Now have a great difficulty in identifying which kids fall into this range without actually attaining the BMI percentile and plotting them out. So if it's difficult for us, you know, it's probably difficult for parents as well. And so just really thinking when we first have that clinical encounter with them, this might come as a surprise to the parents and certainly to the kiddo. Like I've certainly had patients you guys probably have as well, where the parent might, I might say, you know, tell me about what your hopes are, what you'd like to get done today in the clinic or what were your thoughts about the clinic, or do you know where you are? And they usually know. Hospital, but sometimes not much beyond that. And sometimes the parents might say, well, you know, we didn't really talk about what this was because he might not have come if he had known why. You know, that's, that's a big red flag that clearly there's a lot of emotions involved here, maybe some guilt and blame and stigma that are either being put on by the parents intentionally or unintentionally, or certainly by peers or in other environments where those kids are spending their time. And so again, you know, we as healthcare practitioners, as experts, can't visually identify which kids fall into a higher risk category, we certainly shouldn't expect our parents to be able to do that as well. So just being very mindful when we even bring up the topic that this might come as a surprise to them. So weight bias, uh, the great folks at the Red Center again with Dr. Rebecca Poole and her colleagues there at the Yukon Red Center, actually the image Ir says Yale, but they have recently moved to Yukonn, so look for them there at Yale. Uh, they've done some great studies there and continue to put out great work. So looking at weight bias, we see that it has increased substantially over the last decade or since 2006, and those rates are still continuing and are not going down with more recent data. And we see that it's more prevalent and that women experience, tend to experience it more than men, and then the more severe that the kids or the adults are, the more that they experience that way bias, which would make a lot of sense since this is something that that folks are latching onto visually. And we also see that this is something that kids are experiencing as well, and they're certainly vulnerable, and they feel this from their peers and then in the environments where they spend time. So school is obviously a large amount of time, but then they also experience it from family members, you know, if you ask your patients, have your friends or family ever said things that make you feel bad regarding the way you look, a lot of kids are going to say yes, and others might say no, and they might not feel comfortable sharing that with you, even if they had experienced that. But unfortunately, uh, it's something that we also bring and, and unfortunately, there is something that they experienced from us as health professionals as well. So we're in different environments where our weight bias can impact. So it can affect adults and parents and teenagers when they start to enter the workforce as well. We see studies that document differences in hiring preferences and promotions and differences. And wage and again it's that thought that folks who are struggling with their weight might be lazier, they might not work as hard, and this then feeds itself into these situations and even early termination for folks challenged by their weight as well. We see bias in education, again, specifically with kids. It's something that our patients are wearing very visibly, and so it puts them as a target for bullying and for teasing, for the, and the more overt active, uh, active things tend to come more from boys, not always, and then more, more but not always always from, from girls who see more social exclusion versus, versus overt active teasing or bullying, but both can, can occur with, with either group. We also see it from educators and teachers also. Uh, intentionally, usually not intentionally but often unintentionally, uh, exhibiting signs of weight bias in the events experienced by our patients and their students. But then also similar things within the work environment, we see that, uh, being demonstrated in educational institutions. So, us health professionals, we're advocates for our kids and for our patients. When we start to verbalize this, we might look, uh, in an introspective manner and think that this isn't something truly, I don't do that, but unfortunately, when we, when studies are conducted, we do see that this is something that is unfortunately experienced by our patients, by health professionals. And unfortunately, when we, when studies are reporting out what these rates are, it, it shows that health professionals are some of the worst offenders actually of weight bias as experienced by our patients. And so thinking that we have this sacred and special relationship with our patients, yet our, yet our Making them feel biased and hurt and stigmatized due to their weight, uh, we really need to become more aware of that and find out ways to, to mitigate that. And I think that we can probably, I mean, I can, I can experience this as well, and I can empathize with the situation that it can result in frustration. Again, I think some of that comes from our passion that we want our kids to be healthier, and it results in us moving faster than they do. And sometimes we think, oh, why can't they just get it. And that's where I think if we start to feel that it's just really important to talk to our team members. I have the great blessing of working with a multidisciplinary team. And so if I start to feel that frustration, I can talk with my colleagues and say, no, I'm just, I'm really frustrated that we can't make more progress. And usually when I talk to my colleagues, they can share with me, well, hey, actually there are some positive steps that these folks are making. And so sometimes when we take a step back we can see. the patients and their families are making a lot of positive steps. It might not have worked in a reduction in the BMI percentile yet, but, you know, especially for a bigger teenager, it's taken a long time to get them where they are. It's going to take them a long time to get them back from that. And so we really need to be patient and provide a supportive environment, knowing that if we're implementing best practices, that we will be successful in time. So again, some of the studies reporting out, these are a little bit embarrassing to share, you know, physicians that we review. Folks who are challenged by the way, that is noncompliant, dishonest, lazy, lacking self-control, weak-willed, unintelligent, unsuccessful, I mean, it, it makes me feel sad to think that our patients are, are feeling this way by the way that we're interacting with them. Nurses unfortunately are in a similar boat, endorsing similar feelings about their patients in this particular study here suggesting that 31% of nurses said they'd prefer not to care for individuals affected by obesity and that 24% said that folks with obesity repulse them. I mean, I don't know that I would want anyone caring for me who was saying these types of things about me if I was someone who was challenged by their weight. So again, these are pretty striking comments that again, really speak to something that I think that we can all relate to to some degree, and then really hopefully are motivated to, to find new skills and new ways to identify that in ourselves and then address it so we're not, uh, not allowing our patients to feel this way. And then, you know, uh, unfortunately, uh, Doctor Reddy and colleagues, our psychologists, also, unfortunately, these studies are also subject to feeling weight loss towards their patients as well. So the studies have shown that they're endorsing these folks as having more pathology, perhaps even worse symptoms that are more severe, and there's negative qualities for these families as well. And then on the initial assessment, thinking that the prognosis would be worse, and these, these studies are. are quite well done and under control for a number of different factors as well. So the summary point really is not that we're necessarily bad professionals, and certainly I think if we're all talking about this today, that's a great sign that we are all therefore engaged in finding ways to, to come at this from a different angle, um, but it's out there, and I've certainly heard stories from my patients tell me about how they, how other And healthcare professionals have made them feel it, and some of those are quite shocking. I, I've had one patients where, um, the physician, I think it was well attended. But sort of shared his frustration in what I would suggest is a less than constructive way, said, you know, if, if we don't start to show any progress here, you know, it might result in a CPS or Child Protective Services case. Uh, report, and that, as you can expect, completely severed that relationship. The family loved the physician and some of her siblings continued to see that same physician, which is a testimony to the clinical care that's provided in those relationships. But, um, but my patient would not step foot back into that physician's office for fear that she might be removed from her family. So again, these are, these are hugely impactful things that, that we can as health professionals can either use positively or negatively. You know, I think all of us, if we think that we got into a physical confrontation with someone and they punched us in the face, we probably could get over that long term, faster than if they said a really hurtful comment. Those are the things that really, really carry with us for, for a great deal of time, if not forever. So why, why is weight bias important? When we look at the actual objective implications and consequences of that, we see that it has real consequences. We see that folks who are endorsing more weight bias tend to have higher levels that are more likely to also experience depression, anxiety, low self-esteem, poor body image. Those, these are all things that are not helpful in motivating our patients to make positive change and actually more, make them more likely stuck where they are. We see the social effects of weight bias. We see more social rejection by peers. Again, this is all this negative feedback cycle that is leading to or make our patients less likely to make these healthy changes. We see the impact on interpersonal relationships, also can impact academic performance. Physical health outcomes are similar. Uh, again, when, when you're feeling bad, and if you're a physician or psychologist or health professional has made you feel worse, when you leave that encounter, you tend not to be motivated to run out and exercise. You tend to not be motivated to run out and eat more healthily. You instead tend to be probably more likely to grab an easy open bag of junk and, and consume that or something that you might consider your comfort foods. You're going to be more likely to sit on the couch and not move, which again feeds into that negative feedback cycle. Then if we actually look at healthcare utilization, folks who are experiencing weight bias, again, if, if your doctor is mean to you, it's not going to make you more likely to go back and see the doctor for most people at least. Uh, so you're gonna see that less preventative health services, less exams. If we're not. You know, I say in other parts, the solution to the obesity epidemic is not in the doctor's office, but the doctor's office has to be part of the solution. And so if they're not coming, we can't be part of the solution for our patients. And so again, we see more cancellations, more delays, less, less healthcare access. And then also if we are, they also feel that patients feel that their healthcare team is addressing making healthy changes less often if weight bias is playing, playing a role here as well. So again, with, with weight bias, all this milieu that's there, it, it tends in our minds to shift the blame to the patient without recognizing all the other reasons why it's difficult to make healthy changes. And unfortunately, sometimes I think again perhaps due to inpatients or whatnot, we feel that using that guilt and shame and blame can motivate individuals to make healthy changes, but when we look at the outcomes of that approach, we see that that is not the case. And again, it makes folks less likely to make healthy changes and more likely to stay where they are and or get worse. So the evidence is not supportive of that, which again is why we need to get the word out about we have bias and be 1, aware, and then 2, take actions so that we're not continuing to make it worse. So again, instead of all of those negative images that we see in the media, instead of thinking about presenting a positive, so we are about health. We are about folks being healthy, but we're not going to focus just on shape or size or weight. It's a multitude of things. And someone who is at a healthy weight certainly could have a number of other health complications and other negative health behaviors that might be far more serious than some of our other patients who might be challenged by their weight. And again, just these are some great images from the Yelp or the Conrad Center, uh, again showing folks who might be challenged by their weight who are living healthy and are much more positive images rather than some of the, the junk that we see so often in the media. So what is our responsibility, as healthcare professionals? And again, it's one that we need to be self-aware of our own tendencies, but then also to discourage weight bias in our practice in the physical environment and also with the folks with whom we work. Again, like Dr. Reddy had mentioned for our parents, I think us also as health professionals need to model this behavior, one for the parents and for our kids and for our staff, and then also to be advocates for this and share this message with our colleagues and with our trainees. And then also about advocacy. So one, changing the environment in our clinic, but then wherever possible, sharing these messages out into the community to try and address all of those negative influences that are outside the Walter clinic. So there's some great resources from the Yukon Red Center that give you nice lists of things you can think about in the different environments where you work to try and address weight bias. So, there are some, some common things to think about in the waiting room if your, if your families are coming in, and, OK, say we're pediatricians or if you're going to practice to see adults too, then even more so. But if you're a pediatrician. You need to make sure that your, your larger teenagers and also their parents can comfortably sit in your waiting room. Some of the smaller chairs that have the handrails might be of a size that your patient's parent might not be able to physically sit down in the waiting room. So that's certainly not presenting an environment that is welcoming. And again, if you're starting to poke on these sensitive areas. All, all in the way before you actually get into your clinic room, you set them back and they're going to be far less likely to be interested in talking about a sensitive area where when you've already inflamed them. Unintentionally before they've even gotten to your part where you're running into the room. So again, thinking about how we can create a more welcoming and inviting manner. So thinking about that the chairs allow folks to sit. I mean, God forbid if someone sat in a chair and it broke, I mean that would be horrific for a number of reasons. So just being mindful of those things in our children's hospital, when we first started our clinical programs, we had to change out our examination tables because the previous ones just went up to about 350 pounds and, and. So we just need to be mindful of that. So just double check the fine print and make sure that, that you provide an accommodating, you know. Other things are thinking about your, your posters on your walls, your reading materials, you know, the majority of magazines have not even real people on the cover. They're digitally enhanced. They're, that person doesn't actually look that way. So just being mindful of the unintended, uh, subtle messaging we can have by the types of reading materials that we have there too, and, and other, uh. Other things we have on the walls and whatnot. Again, thinking about in the clinic, and these lists are again all available at the obesity reaction.org website. They have a nice brochure on this, and you know, if you had a gown that doesn't fit your patient, again, how horrible is that? Blood pressure cuffs, we always think about that. All these things, if you can't handle the, the, the patient and provide good care, these are gonna make you far less likely to be able to be impactful when you actually get in there to do your work. Even sometimes if you are in the planning stage of building a new environment or if you can remodel your clinic space, just thinking about making sure that the doors and the hallways and the walkways can accommodate folks, especially if you have some folks who might have walkers or wheelchairs or scooters. And again, as Dr. Reddy had mentioned before, the bathrooms, again, check the fine print because some of the toilets might not be able to handle the weight of a much larger patient. And again, how horrific would that be? So one, just the physical ability of the toilet to handle the weight, but then also the ability of your patients to get themselves up and down onto the toilet. Obviously weight scale is something that comes to mind. If your scale cannot measure your patient's weight, again, these are, these are sort of life changing stories that will stick with our patient forever. So we really need to go out of our way to make sure that we don't provide that for our patients. So making sure we have a scale that one can can handle their weight, but then also thinking about where that scale is in the middle of the big open office area that might, that is not the best place for a scale, especially when we're dealing with a sensitive topic of weight with our patients. So generally, in summary, uh, with regards to the way bias, think about what we can do clinically, I think to kind of summarize it, but think about being nice and being patient and being mindful of it we're moving faster than maybe where our patients are, and Even if you're not feeling that way, if you need to review the literature and see, please do that, to see that being nice and being patient is going to result in a more impactful and more positive clinical encounter, even if you're not feeling nice or even patient. So, so some things I sort of say to remember that, you know, be nice, be patient, and if you're not feeling that way, if you just, you're a busy clinical morning, you hopped out of one room and then, you know, had a difficult. Situation with the patient or the family and you feel a bit frazzled, then one just shake it and the other is just shake it. So Dr. Reddy probably do more to this, but physically shaking yourself before you go into the next room, you can get rid of that. You can feel a little bit goofy, but, but there you can y'all can't see but I got a smile out of Dr. Reddy, so I have at least a little bit of engagement in it. We were laughing over here, smiles. But, uh, but really, I mean, literally fake it and shake it because, because that just allows you to be goofy. You can release that and then you can go into your next encounter not carrying the baggage from the previous encounter with you and then realizing I was, I was going to say you could even do that in the room with a new patient. They'll probably think you're goofy and funny and tear down some walls too. I, I have not tried that, but I, I might try that. Um, but again, just, just try these things and I think you'll see again that that having this approach, and again there's other, other ways to weave these things in, uh, patient-centered, empowering approach, utilizing motivational interviewing techniques. It really can save you time, it can improve your impact, and you will have a much more pleasant encounter as a provider as well. Um, so I really encourage you all to think about these techniques as we're interacting in a very sensitive area with our, with our patients. So again, we all bring our, our bias and our baggage to the clinic and, and having those thoughts is, is one thing. Another thing though is when they turn into actions. So, um, you know. I work in childhood obesity every day, and I still have thoughts sometimes. I mean, I've gone into a patient room and there might be a Coke bottle there being drunk by a parent or something, and in my head I'm like, oh my goodness, did you really bring that into my clinic? But sharing that thought is not going to be productive, so that's where I fake it, and I haven't shaked it in front of them, but I might want to leave the room, but Just again, realize that we have our values, so it's one thing to be aware of it not don't, don't have it impact your relationship with the patient. And again, recognizing when we're talking about weight and due to weight bias and the patients and their parents too, because the parents are likely bigger folks too as a kid I was challenged by the weight, they're coming out banged up and bruised, and their defense walls are high. We really need to create a safe environment where they can become comfortable knowing that they're not going to be attacked due to, you know, personal responsibility and all the bad choices that they're making, and the, the parent is feeling that and then, oh my goodness, now you're a bad parent because your child is experiencing, uh, being challenged by their weight as well, and so, We, we need to recognize this, and again, that patience really feeds in here because every family is going to be a little different. Some are going to have higher walls and some are going to require more visits before they even feel comfortable starting to engage in a positive and productive conversation. So even recognizing that your report, your patients in a more difficult situation is getting better visit to visit, that's success, and we need to lay that foundation before we're going to start to see an impact in their BMI percentile. So brief, brief plug for any of you guys out there. We have our new American County Pediatrics section on obesity. It would be great to engage and collaborate with you all there as well. You get lots of information on that at AAP.org/obesity, and we are the American County of Pediatrics, but we, we have tons of, we have a lot of different affiliate member. Categories as well. So you don't have to be just a physician or a pediatrician to be a member. Um, and actually, if you're not, then it's, it's the best 30 bucks you could spend because you don't have to be an AAP member to be in some of the affiliate member categories. So we have a number of great, great ways to stay in touch with each other. We have a two-way active listener where you can post out questions and get feedback from, from experts around the country. We have other newsletter updates and whatnot. The coaches network that Dr. Rogers has played a great role in spearheading and that really is helping to foster local experts in childhoodC around the country and then we'll be pushing out other opportunities through that network and then there's great opportunities and great, great collaborative webinars like what we're participating in right here. So I encourage you guys to check that out and I'd love to collaborate with you all there as well. And then final shout out to my great team we have here at Adult Children's, and uh I can't do any of this without my wife and kiddos as well. Oh, thanks, Steve. That's a great talk. You know, one of, one of the most sobering points in there was when you started talking about weight bias among healthcare providers, and if I were just seeing that in a vacuum, I'd be like, that can't be true, it's just not possible. But yet we all see patients in our clinic and you know, they'll start telling you stories that are, you know, Fairly unbelievable. So how do we from an advocacy standpoint or even within our pediatric-related professions, how do we, how do we address this and how do we change some of this in society? So I think in a similar way as just with the obesity epidemic generally that there's so many causes and so many factors and weight bias, it sort of weaves itself into so many different scenarios and situations that really did this, the leaders to advocates and whenever we see it, to try to address it. So I think having more talks like this will be, will be very helpful to help to continue the conversation from the American Academy of Pediatrics standpoint, we We'll be coming out with a policy statement regarding weight bias in the next couple of years. That could be another opportunity to continue to get the message out there. But, but really, I think um in a non-judgmental way, even with our colleagues, if we see them exhibiting signs of weight bias with their patients or families in a, in a non-judgmental way, I think trying to bring that up with them to help to have a discussion so they can be more mindful and aware. I think that even if we don't agree on The individual and personal responsibility and the other forces that are at play, I think we can all agree that we want to be as productive and successful with our patients as possible and therefore taking this guilt, blame, shame approach is not productive. Yeah, absolutely, and I really liked your initial talk when you said, you know, we can't always even know when kids are heavy, yet we're expecting parents to know it because I know a lot of the phone calls that we get to our clinic from new patients, the parents are very upset and there's a lot. A lot of tears and crying and emotion because they've been given a diagnosis of obesity and it is, it is something that happens gradually and parents don't always realize it, so the blaming is, is hard when parents don't see it themselves. I thought that was a great point. Yeah, so 11, they don't, they oftentimes don't see it, and then if they don't see it, they don't think that there's a problem there as well. So if our first interaction with them is to say that make them feel that they're terrible or bad and they don't even think it's a problem, then they're definitely not going to be coming back. Uh, so again, just trying to create that environment where we can share information at a pace that they can receive it in a non-judgmental way, I think is so important. Because we have, some of our patients, you know, I'll go in after the first visit and I'll say, so, so what do you think, you know, how's the visit been for you? And they'll say, well, I'm just so happy you didn't yell at me. And it's, it's just, it always shocked me, so I'm like you would never come back if I yelled at you, but it really is their experience when they go to talk about weight or discuss any of these issues. It's, it's such a negative environment. So I, I think it's so important. I don't know that we, everybody realizes the negative. Impact they could be having on these families like you were saying and and someone made a note in the chat box that they wanted us to mention that the Red Center website has a free appropriate media images for use by clinicians in PowerPoints, um, and also media guidelines that could be used for advocacy. Yes, and some of those, those images I showed, the nicer images, those are from the Red Center, so you can utilize them. And download them from their site. They also, which I didn't mention, so I just check out this site. They have a ton of awesome stuff. They have some videos that sort of highlight weight bias that can be another great way to engage in that conversation with colleagues, and they have one specifically on healthcare, and they have another one specifically from the perspective of a pediatric patient. And they also have a toolkit that can actually, you can utilize with trainees and for yourself with self-assessment. There's other questionnaires that can help to raise self-awareness and then actually take steps to address it, but they have a free online toolkit about what weight bias for health professionals that again, I would encourage folks to check out. Yeah, you know, you talk about our own biases and a lot of times people are not aware of what they're bringing to the table. Um, I'll, I'll share an embarrassing anecdote is, uh, we, uh, this is completely unrelated to anything related to, to, to weight and it was, uh, we were forming a, uh, a team to look at some patient access issues and one of Our counties and the county's name was Fayette County and so you can imagine what an acronym somebody came up with and just didn't even think twice about it. It had nothing to do with this before it even got any further than just an email, you know, I just pointed it out to him and he was very embarrassed and it just never occurred to him. He's a good guy, good person, but just someone who's You know, in the culture and just, it's so embedded that people don't even think about it and it's, it's really hard to break through those barriers, but I think that we as health providers need to be advocates for that and try to do what we can. Yeah, absolutely. Um, and so again, I mean, I think it's working individually and then it's also out, out in the community. Um, I, I took a, I was on a flight once and happened to sit next to a bigger parent and I was actually working on a talk. I think I might have climbed up to see you, Tory, and I think I was talking a little bit about weight bias, and he saw my slides and he said, yeah, you know, as we're descending, he's like, Yeah, I have, we have, my wife and I are both bigger folks, and we have our kiddo, and he's kind of a bigger kiddo too, and we feel that he's going to evolve to be just like us. And, and so we've just started calling him like little chubby one and other names like that because they're like he said, I, I always experienced that as a, as a child growing up from friends and family and so we thought if we just started calling him that now from the beginning he would be used to it and it wouldn't make him feel bad and I was like, oh my goodness, I wish we had started that conversation before we were like descending down the land. Oh gosh, gosh. Well, thanks, Steve, uh, great talk. Thank you, Steel.