The Right Tool for the Job: Child & Adolescent Obesity 2015

Trying to uh get um uh the right tools out there for you guys to use in practice so we're really working on ways to to think about all the various tools that are out there so we can get uh a better um uh uh approach for you so you can use uh a variety of things that are out in the community. So, um, as, as I said, I, my name is Chris Foley. I'm a pediatrician in Northern Kentucky, which are the greater, uh, suburbs of Greater Cincinnati. And we wanna, by the end of this session, we wanna go over and, and give you a, a sort of a plan on how to, um, use all the various and sundry, um, uh, uh, tools that are out there and give you a strategy for how to, how to go about that. We're gonna go over um the, the ways that you should be thinking about using these tools as they fit into your practice cause we know everybody's practice is very different. Everybody has a very different way of wanting to approach this and has different capacity for, for addressing obesity in the office. So what I'm planning on doing is just giving you a variety of things that are out there and let you figure out how to use them. That's kind of how we've all done this, how Tory has done it, how Stephanie's done it, how uh Natalie and Steven and I have all done this as well. I do wanna go through a few disclosures with you if I can. First, I have no financial relationships to disclose with any of the things that I'm going to talk with you about today. Um, I will not discuss off-label uses, but, um, I will discuss commercially available products and a heck of a lot of other things from nonprofit sites. So I will name names. When Stephanie, uh, Walsh and I were talking about this, I said this is, this kind of talk is useless if I talk in generalities. So I will name particular products. I just want you guys to know I have no relationship with these whatsoever. Um, and I'll say it one more time. Um, so what are the basis for the, the tools that we think are good to use? Well, it really goes back to the papers that we all know, the 2007 guidelines that formed the basis for the algorithm that Tory talked with you all about this morning, um, and really these are the, the tools that are based on this, uh, uh, that are based on the, uh, 2007 guidelines. So this really forms the framework for those products that we think are helpful. Um, and if you remember, this very busy slide is not meant to be studied in detail, but it's meant just to represent how we think about this. We think about our tools along the lines of an age-based thing first. We then think about it based on, you know, the various levels where our kids are, uh, on the obesity. Spectrum, you know, our kids, there's, there's certain things that we have for everybody who's at no risk. We have ones for kids that are, um, eighty-fifth and ninety-fourth, ninety-fourth, uh, uh, ninety-fifth to ninety-eighth, and those ninety-ninth and those kids who are greater than the ninety-ninth percentile. They're all very different things. Um, I want you to think a little bit too just so we can kind of, uh, a couple of constructs when we're thinking about all these tools. I want, wanna give you an insight to the way that I kind of think about these tools, you know, what do we really. Doing with them and why, how do we think of one tool is good for this and one tool is good for that. Well, we really think about obesity treatment as a spectrum. Everything from prevention and healthy lifestyle promotion on the left side of your screen all the way over to surgical intervention and possibly treatment failure on the right side of the screen with everything a little bit in between where you as a practice shake out depends on several factors, depends on. The time you have to allot to this kind of endeavor, um, the kinds of resources you have, the needs of your community, etc. and also too, it's important to know where other people are gonna fit in on this spectrum, you know, schools and built environment have a lot to do with prevention and healthy lifestyle promotion. Community interventions tend to be on the same level as some of those practice interventions that many of you are looking to implement. Um, there are various medical providers that will provide mid-level, high level, um, and even surgical, uh, interventions. And then there are also hospital-based programs, um, that we need to learn to interact with. Another way of thinking of this as a spectrum is also to think about it as a pyramid, um, that, you know, the, with each level of the pyramid representing, um, progressively fewer numbers of patients, but in requiring increasingly more detailed types of interventions as you go up the pyramid. So, you know, certainly the base of the pyramid, lots of people, people at risk only. Again, this is sort of that, if we go back a slide, that's that left side of the spectrum again. Um, but we're talking about those people that are just sort of at risk only and then as we move up, we're talking about people who happen to be at higher risk, people who tend to be overweight, people who tend to be obese, and people who tend to be severely obese, um, and we know certainly that, you know, it's fewer and fewer numbers of people as we work our way up the pyramid, but they require more and more detailed types of interventions. Um, so let's talk about some of the tools and how we approach some tools that are for the base of this pyramid, prevention for everyone. Um, we start off with talking about harmonizing with your community. And, and that's sort of however you define that is your community, and I think of my community in a number of different ways. You know, I think of my community as my, my city, my group of practices. I think about it in a lot of different ways. Um, it, it really kind of goes back to our, our interpretation of what our community is, uh, as it fits into the socio-ecological model. You know, we, we, to refresh for everybody, you know, certainly there's, when we're talking about behavior change and we're talking about affecting obesity, it's gonna be affected certainly by individual behavior and individual responsibility, but it's also affected by your network of interpersonal friends, your organization. Educational structure, um, your, your, your job, your school, etc. it's also, um, affected by your community and it's affected by public policy, um, so the, the, the, the spectrum and the pyramid that I mentioned really kind of fit into the socio-ecological model as well. So when we're talking about community-based interventions, they can come um from a lot of different areas. They can come from states um and if you're looking for good prevention programs, one of the ones that I would like to mention is Let's go.org. This is a fantastic website. It's put together by Tory Rogers, who spoke earlier, and John Fanberg, who's the, um, uh, former chairperson of the Maine AAP, um, with a lot, lot, lot of community partners. This is the place where the 5210 messaging really got its start. Um, but, uh, 5210, um, there are toolkits on this website. There are ways to interact with suggestions on how to interact with your community, etc. but there's a lot of great stuff on here if you're looking for prevention sorts of, uh, uh, kinds of prevention sorts of, of, um, of approaches. I think it's also good to mention another state initiative that that I really think a lot of is Eat Smart Move More North Carolina and if you notice these are, you know, the statewide initiatives do a lot of, of work with prevention. What you're gonna find on these websites on both Let's go.org and um Eat Smart Move More North Carolina, is you'll find a lot of things uh of, of handouts for your office. You'll find a lot of things that you can use in terms of 5210 messaging. You'll find a lot of different items that are out there that are very, very helpful when you're trying to come up with, um, good prevention strategies. Um, at let's go.org, you'll find, um, posters that you can put up in your office, um, you. Find logos that you can use in other places. What we've done is we've used the 5210 messaging a bit and, and made it kind of our own, um, but we use a lot of our own, uh, materials that are sort of based out of 5210 materials. Again, same thing goes for eat more Eat Smart move more North Carolina. One of the other things that, uh, uh, places you'll find things is you'll find a lot of, uh, of good prevention materials on, um, city-type websites. One of them being the Consortium to Lower Obesity in Chicago Children or CLC. Clock.net is where you find, um, this material. Um, and at clock.net, you find things if, if 54321, go is a message that you think resonates better for your community. A great place to adapt their materials um for health promotion and uh prevention messaging. So it's, it's really kinda up to you um where you find these resources, but they are out there and I, and I encourage you to look at state websites like Maine and North Carolina's or city websites like Chicago. One of the other places that I'd encourage you to go is the pediatric e-practice or the PEPP, which is available at um the AAP website. You just go to Pep.AAP.org and what pediatric e-practice is, this takes a little bit of navigation to figure, figure it out, but it's pretty intuitive. The first screen that you'll get on PEP.AAP.org, uh, and this is a, a product, uh, jointly from the AAP and from the Institute for Healthy Childhood Weight. On the PEP website, what you see is a virtual office, virtual pediatric office, um, shown in this slide with the waiting room, exam room, break room, um, measurement area, etc. And what you're in a doctor's office. And so what you do is you go into these particular rooms like in this case, I've gone into the, into the exam room and you can click on the. One of the cabinets in this room and pull up things that I would potentially want in my exam room, things like patient education on screen time, physical activity, nutrition, overweight and obesity, comorbidities, etc. So really everything is in here. And the PEP is a tool that kind of collates everything for you um by subject area and the other ones like in the in the office or in the billing office, um, parts of the PEP office what you'll find is information on coding. And information on billing and suggestions on making things financially viable. On the break room area, you'll see stuff in there on um work site wellness um in the waiting room you'll find materials and ideas for books for your waiting room and posters. So it's another great resource for prevention. Um, you'll see in this one too, like we scroll down further in the physical activity, um, part of the folder and we get into things like, um, the particular handouts on, on how to play with toddlers, um, getting fit and staying healthy, a lot of other topics that are not, not displayed here, but it's a great resource all kind of piled into one location for you. The other thing on the um on the American Academy of Pediatrics website that's a big help, in my opinion, is HAAF or Healthy Active Living for Families, which is nutrition guidance for all families, not families of kids who are overweight or obese necessarily, but it has a very, very strong obesity prevention message. So what we do in our office is we actually have a, a, a small card that we hand out to families on the well visits. That direct them through our website to Healthy Active Living for Families. We could also do, well, our web, our card also shows them how they can get to them around our website, but we like to direct people through our website so they become more familiar with it as well. But we direct them to the Healthy Active Active Living for Families website, which is housed at AAP.org. The way you click this, if it is not on your website, it's pretty simple. You go to healthychildren.org. Under that, you click the Healthy Living tab, and under that tab, you click the health, the Growing Healthy tab. So, I, that's a little typo there. It should go Healthy Children.org, healthy living tab, growing healthy, and it takes you back to the Healthy Active Living for Families page. Further down on the page, you see this, and what this is for families is an interactive way to establish good eating habits with their kids at a very early age. We also put in because we know that obesity prevention and obesity prevention strategies are a lot about family patterns. And they're also a lot about um they're a lot about families and they're also a lot about um parenting strategies we also include a lot of information on those topics as well um and they're organized as you noticed we're organized by age as well just like we do. So, um, after you go through the Healthy Children.org website, um, you, you, what you wind up getting is the, is the, um, uh, widget here that shows with guides on how to approach, uh, food and feeding, physical activity, and also parenting tips for patients. Um, if you scroll down, like if you went into, um, food and feeding further into the, um, HA website, you would then get things like quizzes for parents, uh, parent advice, uh, from other parents, um, you'd also get some quick tips on. On how to address certain behaviors, our families tend to really like the sections on picky eaters quite a bit, but these are things that I say, these are obesity prevention and obesity prevention tool, um, that is really available and out there and free for everybody to use. Um, so then we kind of move on to the next set of, of tools that are out there, and these are tools that are really guided toward that prevention plus area, um, of, of, you know, for, for your, for your practices that are trying to do a little bit more than just prevention. So there's a whole group of, uh, tools in this area as well that I kind of like to go over with everyone. Um, one of the things, the strategies that I think is very helpful is to find a collaborative. If, uh, and these exist in a lot of different places. There are national collaboratives, there are, uh, state and regional collaboratives, citywide collaboratives, but obesity prevention collaboratives that manage to get you some good, uh, maintenance of certification credit, but also really managed to hone your obesity prevention strategies. Um, one of the other strategies and one of the other things we're gonna talk about is getting up to speed on counseling because if you can get counseling into your, into the equation, you're gonna feel much more comfortable about using a lot of these other tools. Um, it's also important to find content that works for you and we're gonna talk a little bit about that as well. I'd also say if you're going into the area where in your practice, you want to deliver prevention plus kind of treatment, I'd suggest that you make sure that you stay connected um with other people in the field. It's a rapidly changing field. I'm constantly learning about new tools and new tricks that are out there, um, and I only learned that because I'm engaged and connected with other people who know more than I do about this area. Um, it's also really important that you continue to update your patient aides and things that you're using if you're going into Prevention Plus. OK. So with those kind of principles in mind, let's talk about some of the tools that are out there for practices that are going into a Prevention plus sort of mode in terms of treating obesity. So here's some suggestions on collaboratives that you might look at. Um, one that's kind of shutting down at this point is Nicke's collaborate for a Healthy Weight. Um, the AAP's Childhood Obesity Performance Improvement Collaborative is currently finishing one of their cycles. Um, there are state initiatives like Pound of Cure from Ohio or Maine's Let's Go, um, and Next Steps, which operate as collaboratives and coalitions and improvement and, and, and operate on the improvement model in order to increase, um, obese, improve obesity treatment. Um, you'll also find some institutional or insured sponsored programs. Um, some of the examples of those are, uh, the ones in Rochester, New York, San Diego, or my home city in Cincinnati, Ohio. Um, we have, we can really get a lot of, we got a lot of practices that have exited our collaboratives, um, by really, uh, with a lot of materials on hand and with a good strategy for measuring and improving their obesity care. So if you're looking for finding those two just stay on the uh section for obesity website we keep some of those posted there um and and and. Keep looking around. They are out there and they're really tremendously helpful when you're trying to fire this up in your practice. Sort of an automatic, um, it's just an automatic way of developing your network and getting a lot of resources and materials. Um, like I say, it gets you to dive in collective effectively. The other thing that's really nice, you can get a locally active one, you really tap in in a very real and very deep way with your, um, local experts, which will come into play later in the, in my talk. Also connects you obviously to national partners and really helps we find with practical aspects like coding, billing, scheduling, practice management kinds of issues really get discussed in these improvement collaboratives. Um, getting up to speed on counseling, what do I mean by that? Well, the, the bulwark of your counseling that we think is that I, I personally think is a great tool to be used for pediatricians who wanna do weight management or need to do weight management in their practice is to get up to speed on motivational interviewing. I mean, one thing you can do um is to engage with your local schools of public health, schools of uh nursing, schools of health education, take a course in motivational interviewing. It does not matter at all if it is weight-based motivational interviewing. It can really be any sort of motivational interviewing course can be a great assist when you're trying to learn these techniques. Um, you can also find classes if you go to motivationalinterviewing.org. It's a wonderful site that has up to-date things. They have weekend programs. They have, um, a week-long programs. I happen to take a program through the, um, University of Minnesota School of Public Health. It was a summer Public Health Institute. You'll find lots of stuff out there if you go to motivational Interviewing.org to look for it. Um, as, as I said to you, you'll also find things in health educator seminars. You'll find things in a lot of different places, colleges of nursing, um, you'll also find if you have, um, if you have, um, uh, people who are, um, you know, uh. Uh, available to you who know a lot of cognitive behavioral therapy, that's also a help. It's not an either or kind of proposition. Elements of CBT are very helpful, um, when you're doing weight management, um, issues and when you're doing motivational interviewing. Um, you know, we've often talked that, you know, motivational interviewing is the why. CBT sorts of strategies are the how. One of the things that you can also do, um, I think Stephanie mentioned it earlier in the talk. Um, uh, a free, a free thing to download, which I really like a lot. I got to work on this with Bob Schwartz from our, um, from the section on obesity's executive Committee. There's an app and a desktop, um, site where you can go to Cognito's Change Talk. Um, it's available in multiple forms. It's a great little way to get yourself exposed to motivational interviewing and really pediatric obesity-specific motivational interviewing. Um, some of the other Cognito products can you can help it can be used to kinda help your skills along. Great little program. Really enjoy it and it's on my iPhone. Um, When we talk about content that works you have a lot of options on this one. I think it's very important to make your content something personal. It's really helpful if we see those things, um, uh, if you're. You see those things coming out of your own office. I think, you know, with your own logo, with your own, um, uh, vernacular, that's really helpful. It's really important that your content, it makes sense locally for your patients. There's a lot of national stuff, but the more you can make it local and personal, the better. Um, it really, you know, it doesn't do any good to say that like, oh well, Boys and Girls Clubs have this program if there are no Boys and Girls Clubs in your neighborhood. Um, it pays to look at a lot of different places. Um, there are certainly, um, sometimes there are community partners who you least expect that can be very, very helpful. Um, medical societies, um, Mississippi Medical Society, for one, was one that's done a lot, um, with supporting content for providers who want to do obesity prevention, state chapters, um, our state AAP chapter here in Kentucky is working on a, on a toolkit that is Kentucky-specific obesity content. Um, local health departments can be a big help. Um, the CDC can also be a big help. Some of my other favorite groups, um, well, certainly the section, uh, for getting connected, um, certainly for resources also, but when in staying connected with your colleagues who are doing this work, um, the soup is obviously a place that I want you to look. Um, the section on obesity has a pretty big and broad geographic network. Um, we can be pretty helpful, I think, in getting you connected with other people when you. Questions. We have a listserve that happens to be very active. Um, so if you, um, are looking for colleagues around the country to figure out how to handle things like care in rural areas, etc. join one of our virtual groups. Um, Nicke's Childhood Obesity Action Network, um, has been more active in the past but also has some good resources as well. Um, Academy Health is a great place to, um, subscribe to. Um, that's, um, led by Lisa Simpson, who has been involved in pediatric obesity work for many, many years. And Academy Health has a lot of strong, um, uh, messaging and strong ways to stay connected with other people who are interested in our discipline. I also would not underestimate the impact of being on Twitter. Um, uh, certainly, a lot of today's presenters are, uh, Twitter people. Uh, mine is Fit KY Kids. Um, if you also search for Christopher Bowling, you'll find us. Steven Pot and I were tweeting about Globalcast just before, just over the break. Um, so don't underestimate the value of social media. You'll find some other really interesting people out there, people that you don't necessarily always agree with. But people that have a lot of good insight on this, um, Natalie also tweets, um, we just, there are a lot of who, who's coming up next. Um, there's a lot of us out there who, who find it's a great way to connect. Um, Dan Flanders from Toronto, I follow him. I follow also a bit of a firebrand, a guy named Janni Friedhof, um, who just, you know, when you're looking for something to get yourself fired up, um, but there's a lot of ways to get connected, and it's really important, uh, and that's why I put it in the toolbox. Um, patient aids, there's a lot of great ones out there, um, where you'll find things. Um, I personally love the resources at choosemyPlate.gov if you're looking for content when you start doing obesity prevention in your office. Great place for things, um, like tear-off sheets of the, of the Choose My Plate, um, graphics. That you see here, um, there's lots of different things on there. The one of the other things that I love on, on the, um, website is the Super Tracker, um, from Choose MyPlate.gov. It's a great way for families to, um, track physical activity, food, uh, find recipes, etc. but Super Tracker is a great resource for your families. Um, I also like a lot of material that's on Let's Move. Um, if you go to the Let's Move, uh, uh, website, let'smove.gov, um, there's a lot of great things on there, um, from the First Ladies' Initiative. Um, there's, um, information about, um, eating healthy, being active, and taking action in your community. Um, but there's a lot of great things in there that can help you with your patients when you're trying to move into this prevention plus phase, trying to give them materials to help them with particular behaviors. Um, I also think there's a lot of good aids for your families. Like if you are talking with families about and you identify that the issue is, you know, lack of fruits and vegetables or, you know, inability of kids to be accepting of food, um, there's great, uh, patient aids like Chop Chop magazine, um, which is a creation of the institute, again, the Institute for Healthy Childhood Weight and the New Balance Foundation. Um, if you go to ChopChopmag.org, you can find great resources for your families in promoting fruit and vegetable intake and getting kids to cook with you. The whole, um, the whole, uh, message here is that kids are more likely to eat, um, if they are partic active participants in the pre in the preparation process. There's some fun apps that we find that are really useful for my patients, um, you know, it sometimes when we're talking about just activity, um, I'm not above encouraging a Fitbit. I'm not above encouraging my watching my having my patients see that I'm watching, that I'm wearing. Um, either a pedometer or an accelerometer. Um, a lot of times when they see it hanging on my wrist and I wear it proudly, it then opens up the door for me to talk about, you know, 10,000 steps and being able to maintain good physical activity on a daily basis. I also think that MyFitnessPal and Lose It are very helpful for certain families. Um, so I do not discourage those at all. Those I think are very helpful as well. Um, online communities oftentimes work great as a patient aid for your families as well. Um, Wait Waiters online, um, Spark people online are both great places for your families to interact with other families and looking for ideas for patients that are so inclined. I think it's unlikely for certain families to, you know, to go to a, a specific meeting, but they may, some families are much more likely to interact with the other families online. There's some great cookbooks out there. Um, I'm just gonna name a few. Um, I'm sure everybody's got some of their own favorites out there. Chop Chop not only has a magazine, but it's also got a cookbook. Um, Spark People Cookbook, again, not only is it an online community, they've got a good cookbook. South Beach Stage Two. To, um, is sometimes helpful. It's gonna take some effort from you as a provider to help patients understand what certain cookbooks provide and do not provide. But if you're looking for simple recipes, um, uh, the South Beach Stage Two diet book is not a bad one. there's also a lot of other good ones out there that I would encourage people to look for for your families. Um, The next thing we're gonna talk about, so those are, so when we talk about um prevention plus, we talk about, you know, getting your content together, getting your counseling strategy together, getting your materials together and getting connected, um, but sometimes that's not it, you know, if you remember the obesity care spectrum, a lot of times for your severely obese patients, that is not going to be enough. They're also gonna need to do higher level care because they have significant comorbidities. Um, you need to be able to expand your care, um, to include things that are things like comorbidity management, um, finding people in your community to help you with this, and training of dedicated staff, so you might be able to do some of the higher level care in your own office, I guess is what I'm saying here is that there are gonna be times when you are gonna be the person who needs to interpret that, that elevated, um, hemoglobin A1C or that elevated blood sugar. Uh, or you're gonna be the person who's gonna need to interpret, um, those abnormal lipid profiles. So getting yourself trained up is very appropriate to be able to deal with those things. We're gonna have our message from the section on obesity is, you know, we're gonna have to act a lot more like internists as we go through this process because our kids are developing comorbidities. We need to be equipping ourselves with, with expertise and how to handle this. Um, when we do higher level care in our office, um, I mentioned to you, you know, that we, we do prevention plus, our both our prevention plus and our higher level obesity care. Um, we use a program that we've developed ourselves called basic training, and this is this is essentially a handout sheet that when we find a family that is interested. And more um um obesity care, we will hand them a basic training handout and let them think about it. And then we have a way for getting them plugged into our offices um obesity treatment program, which is delivered by me and is delivered by one of our nurse practitioners and one of our physician assistants. Um, when we're doing this kind of care, um, we use materials like the 5210 obesity clinical decision support chart is also available from AAP. It's a great flip chart, um, very, very helpful. Um, some of the other books that I really think are great when you're trying to do higher-level care. I like Jeannie Huang's Curbside Consultation on Pediatric Obesity, Sandy Hassan's pediatric obesity book, and a new book called The Clinical Care of the Child with Obesity, A Teacher and Learner's Guide, which is really focused on how we teach residents, but I think there's a lot of great lessons in there for how we teach ourselves to do obesity care in practice. What does tertiary care look like? Um, you know, tertiary care can look like a lot of different things. I think it's important for you to formalize your relationship with the tertiary center no matter how far away they may be. I live, like I said, I live in the Kentucky suburbs of Cincinnati, so our tertiary care center is Cincinnati Children's, which is, uh, you know, 2025 minutes away from all my, um, uh, patients who live in the Kentucky burbs. Um, but, you know, sometimes the, the catchment area is pretty far afield. I mean, you, we have families that will drive 4 or 5 hours. No matter where your tertiary care center is, you need to get attached with them. Um, know that your obesity contact may reside in many different divisions. It could be in Gedes, endocrine, GI, cardiology, psychology. It could be in a lot of different places. So you have to, you have to keep looking around at your tertiary care facilities when you need help. Stay connected via the Children's Hospital Association website, um, where there is where a, a list of, of programs, uh, that conform to, um, Children's Hospital Association recommendations and CHA CHA recommendations are located. Um, I put, um, our, um, uh, tertiary care center up here because what it provides for me, it provides me a connection, provides a network of other providers who are interested in taking care of obesity, but also connects me to some specialty care, opens up therapies for my patients. Patients that I need from time to time like bariatric surgery and there are a lot of other things that are out there when you're connected with the tertiary care center that you'll find. So I really encourage you to be connected with the center, uh, as an important resource for dealing with kids with severe obesity. Because they're the ones that are gonna come to you, you know, you're gonna come to like, OK, here's a patient coming through foster care or at school who is morbidly, morbidly obese, and you don't know what to do with them in your office. So it's really important to have a tertiary care connection. So with that kind of saying, you know, like your toolbox is out there. It can help you with prevention. It can help you with prevention plus. It can help you with starting your own, um, uh, in-office obesity program, and it's also, um, there, there are tools out there to help you take care of your most ill patients with, uh, pediatric obesity. So get used to your toolbox, uh, fill it up with things that you like to use. Um, feel free to contact me if I can help you. There are particular things you're looking for. I'm a big fan of, uh, of, of, of helping, uh, I, I like Next Steps a lot out of Maine, and we're, we're trying to figure out ways to help our providers implement that program in their office, um, who people who wanna do obesity treatment in their office. There's lots of great, great tools that are out there. So with that, does anybody have any questions? Well, thanks, Chris. That was great. It's just nice to get some sort of feel for all the things that are out there. And you mentioned next steps and somebody was actually asking, do you actively use that in your Office with your family. Did you wanna add anything about that? Yeah, I sure do. I really like Next Steps quite a bit. I think it's a great program. What I do is I sort of do a boiled down version of Next Steps. I have, uh, the way Next Steps is structured is there are 17 goals, um, and what I do is I actually have sort of my 8 hot button goals when I'm working with a patient who's working on obesity treatment. So those 8 hot button goals are things like the 5210 behaviors plus restricting eating out to 3 times a week, um, doing good portion size control, doing healthy snacks and eating a healthy breakfast, um, so what I'll do is I'll kind of talk with them about those, those, uh, uh, I have a goal sheet that I present to the families and let them sort of pick with where they wanna go and then I also have a goal sheet based on the other, the other 9 things that next step. Kind of goes through and I'll use the next steps flip chart, um, a lot of times I think what you'll find is, as the more you do this, like you'll, like for example, if you have a patient who you're working on obesity with and you want to address, um, uh, sweet drinks, you're gonna have your sweet drink handout that you go over with them and your sweet drink. It, um, uh, talking points that you go over with them, you'll very quickly get away from your cheat sheet. I mean, it's like, you know, it's like all of us, uh, you know, after you do a few ear infections, you know how to prescribe amoxicillin. After you do have a few kids who say, I really wanna talk about how I can change my fruit and vegetable intake, you're gonna have your talking points. And you'll use motivational interviewing to elicit that. Can we put, let's put all the faculty up. I'm just curious, uh, if we can just pull and talk to some of them about, uh, what tools they use. Uh, can we get, can we get the all faculty you up? See, we'll try that. We haven't tried that yet today. We'll see how it goes. Uh, there we go. So anyone, anyone there wanna just, uh, I feel like I'm on CNBC, Mark. Yeah, there you go. Like firing line or something. Any takers? Well, I, I'll start. Oh, go ahead, Natalie. Go ahead. Uh, Chris mentioned a lot of the ones that I use as well. One that he pointed out that I think a lot of pediatricians may not know as much about is the Super Tracker resources that are available through ChooseMyPlate.gov or supertracker. USDA.gov. So a lot of times families will be asking like how much should their kids be eating or kind of what's recommended for their. Child's age and you can go to Super Tracker and they can give you a nice plan um based on what's typical for that child's age, but it's also got resources for families to do self-monitoring. They can enter uh food intake. They can kind of see how their eating plans, uh, stacks up kind of to what the recommendations are. So not everyone will use all those tools, but it's pretty useful to know that they be able to provide them when it's appropriate for families. Yeah, I think that's, that's great, Natalie. Those are great resources. The other thing I think, Chris, that you said was really important was that there's tons of resources out there and as a primary care doc, you just start using some of them, and then you start to figure out the ones that sort of work for you. Uh, a lot, a lot of it is just based on your own comfort level and using some of your own experiences. Steven talked about this, uh, before lunch about how he does tell people that he has struggled with weight issues, and I think sometimes that can be very, very helpful. Um, so I think going to what's comfortable. For you, talking about topics initially that are comfortable for you. As clinicians, sometimes it's not easy for us to talk about uh label reading and, and things like that or maybe they have more of a nutrition background that some of us didn't get in medical school where we might feel pretty comfortable talking about sugar-sweet beverages or screen time or sleep. So going to an area that's comfortable for you, then picking the tools that you like. And then like with most of us, we just then start developing tools on our own, um, and then sharing them as Chris said, I think being part of the section or the coaching network or anything else that you can be part of to share the tools that, that really helps. Um, and I, um, all I use many of the tools that you mentioned as well, um, but I want to plug, um, some of the tools that we have available for both parents and providers at StrongForLife.com, um, with Children's Health Care Atlanta. It's a great resource for parents, for healthy eating ideas, um, for, uh, getting active, and also, um, this morning as we talked about the P's and C's in the Provider tab of um StrongForLife.com, there's, it's a wealth of resources that you can use um with your patients with handouts and just um information for you, but we have a series of handouts that go through just the developmental stages related to using the P's and C's and encouraging your parents to use those for both eating and activity. So please check those out in the provider tab in the clinical resources. Those are great, you know, Strong for Life is just, is one of those ones that is a, a model along with, um, uh, Next Steps and Pound of Cure from Ohio and Healed from Tennessee. There's some really wonderful programs out there. You're absolutely right. Strong for Life is one of those that we, that we really like a lot too. Good, I'm glad you like great suggestions from, from everyone. Thank you, Chris. Uh, great talk. Thank you. While we have everybody still up on the screen, it's a great opportunity for Chris. You know, Chris, again, as I'd mentioned earlier this morning, is one of our co-directors. He's education chair of the, of the SUB and is the incoming chair of the, uh. on obesity, but uh we're gonna have Chris. Uh, we got you and Natalie up there. We'll let you go ahead and introduce Natalie. Uh, it's my pleasure. So I, I was very excited. I get to introduce Natalie Muth, who's on the section for obesity with me at AAP. Uh, Natalie and I share a lot in common because Natalie is also A general pediatrician, first and foremost, but she is also a, an obesity treatment and prevention guru. Um, and I really look to Natalie a lot for her expertise on activity as it relates to obesity. So, I think you'll really enjoy Natalie's, uh, discussion today. And with no further ado, I'll turn it over to Natalie.