Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and to sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today’s episode. This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode of the Conquer Your Weight podcast. I'm really excited today to bring in a guest, Dr. Stephen Cook. This is really exciting because I have been partnering with the OAC, the Obesity Action Coalition and they do a lot of advocacy work in obesity medicine. And so we are going to do a three week series where we are working with Dr. Cook. And then we'll have a couple others over the next couple of weeks talking through some really interesting topics that we haven't addressed yet on the podcast, as well as then talking about what is the OAC and how are these members involved. So Dr. Cook is a medical and he's dual trained in medicine and pediatrics and serves as the director for the Center of Healthy Weight and Nutrition at Nationwide Children Hospital in Ohio. We are so excited to have you here today, Dr. Cook. We are going to be talking about pediatric obesity and family and how all those things interact. Thank you so much for joining us. Dr. Stephen Cook: Thank you so much for having me, Sarah. Dr. Sarah Stombaugh: Yes, absolutely. So tell a little bit more about yourself and how you got into obesity, medicine, weight, nutrition, because I know your story presents like a lot of ours where you're learning and then it really becomes part of how you apply this to your career. Dr. Stephen Cook: Yeah, it's probably like a number of people in medicine. You have a clinical case or something like that that really impacts you. And I remember being a Med-Peds resident on a pediatric floor and we had a preteen patient admitted to the hospital with severe weight, but he had an asthma attack and was admitted. And I remember thinking this kid could have pre-diabetes or type two diabetes, and this is in the late nineties before we had really started to talk about it, but for some reason I had an interest in it a little bit. And lo and behold, the steroids we gave the child and the underlying weight, family history, all the things pushed this patient over into developing diabetes. But he was a type two diabetic and in a pediatric hospital at Children's Hospital, children's floor, no one knew what to do for 'em. But at the same time I was like, all right, we're going to start some insulin and stuff. And they're like, no, they got to go to the ICU. And I just remember feeling like this isn't that hard. But again, I had this adult medicine background and so seeing how we were doing better in medicine and we had young adults and teenagers with cystic fibrosis going into adulthood with CF and that's why I actually chose Med-Peds because of these kind of emerging, these childhood diseases merging into adulthood. But this was an adult disease and adult antecedent presenting in pediatrics. So that's kind of how I got myself to this area. I briefly flirted with the idea of doing an endocrine fellowship, adult and pediatric medicine, but that would've taken way too long and they weren't really formed. So I did a general academic fellowship, I got a master's in public health and that really ended up being a very good fit because it gave me a good research background, a better understanding of epidemiology and clinical research, unlike a basic science fellowship or at least where the research would've been at the time with endocrinology, more of a basic science research, which is not what I wanted. So this was a great way to understand practice change and behaviors and things that in the early two thousands were just emerging as clinically relevant type of skills. That has really served my career very well. Dr. Sarah Stombaugh: Yeah, absolutely. And I think that's one of the things that stands out the most to me is that the acknowledgement of things like obesity as a disease process, even type two diabetes, seeing it as a disease of metabolic disorders that can occur at any age. We've always, not always in the past thought of it as an adult disease, but recognizing that this is an underlying metabolic disease that can present at quite young ages sometimes. And while we see that more and more now and understand that a decade, two decades or more ago that was not as commonplace, and so I can absolutely imagine people being confused or surprised by this presentation. So tell me a little bit, when we think about the contributors to pediatric obesity, what do those look like? And if you're thinking how you're talking about this to parents, to families, what are the things that we think about contribut contributing to pediatric obesity? Dr. Stephen Cook: Well, it's really important that we learn a better way to talk about this with all our patients. And just as we have started to realize with adults thinking of weight bias and stigma, we have to think of it in pediatrics. So even asking a parent like, is it okay if we talk about your child's growth today and not just jump into your child's overweight and we have to do something about it, we really have to engage. Many children, not all, but many children with high weight have a parent with high weight and they've probably experienced shame and stigma from dealing with their weight. And then when it's brought up in a well-child visit with the pediatrician, pediatricians don't realize this as much, that have parents probably already been through a lot on their own personal level and now they're seeing it play out in their child. So before we even start talking about it, being aware of this and understanding weight bias and stigma for primary care is really important. I practiced most of my career in primary care. And so it is important to kind of get that permission to have a discussion about this. And I say this to pediatricians because as an internist I see the more immediate health impacts in adults with high weight, developing high blood pressure for years and then heart failure. But we don't see immediate emergencies in pediatrics related to weight. They're very rare and they're usually a surgical type of condition. So the urgency of which pediatricians sometimes address this also has to be taken into account to be okay with the idea of asking a parent permission to talk about their child's growth, talk about their height, and then talk about their weight and where that is relative and asking if it's okay and asking the family what language to use when discussing it, because it's really important that if there are terms that they're not comfortable with, you don't want to use that. We try to do this with every other disease, we should do it with obesity. And then you can get into the fact that our genetics plays a big role in terms of setting the table in terms of what may or may not trigger weight, but our environment is a big contributor to that. And pediatrics, it's really complex. And I mean, as a person who's really followed and studied it for 20 years to try to describe fetal programming, maternal weight gain, early childhood exposure to food, screen time, all these things over time, it's so much. I mean, these are like two or three medical lectures. And so to try to explain it to a family is really complex. So try to keep things simple as lots of things play into this, our family history, our exposures, things that we don't even realize have a contribution. And it's important to understand that even small changes in terms of calories in more screen time for less activity every day for years, we'll take a child from a normal weight range into an obese range. And it may be subtle, it's not often that you identify a triggering event where a child's weight rapidly goes up. Now, unfortunately, the world experienced that with the pandemic where we saw this massive shutdown and a huge changes in our lifestyles that triggered a lot of increase in weight in adults and kids. But we've seen that reverse to some extent. But with kids, it is really rare, and it's rare that there is a genetic cause or a single genetic cause. It's multifactorial. Dr. Sarah Stombaugh: Well, I think that's, as you're saying, that's so important to point out to help people understand too and shift with our bias. There's so much blame and shame that can come up. And so how do we take away some of that blame and shame and then start moving forward to empowering our patients, the families, the parents, so that they can move forward in a way that can be really helpful for everyone? Dr. Stephen Cook: Right. It is really important because every other condition where we push and nudge and bully our patients to change behaviors, like you got to quit smoking and you got to stop drinking, we've already learned that that type of negative approach doesn't really work. Same thing with trying to change behaviors around weight, whether it's screen time, fast food, sugary drinks, any of these types of things, and realizing that while we're talking about a disease or a state, the precursors, the behaviors are what we're doing on the clinical side to counsel families. And then as these signs has evolved, we have drug therapy options and we even have surgery options for adolescents. Dr. Sarah Stombaugh: Absolutely. And tell me when you're starting, so you've had this conversation, you've asked permission, they're interested in engaging, and you've had a conversation and come to the conclusion of, we'd love to help implement some lifestyle changes in the family. How do you start thinking about realistic changes and how do you layer those on? Dr. Stephen Cook: So my background in pediatrics and primary care is where I've spent most of my time and how that has changed and the time demand on primary care doctors of what time they have to counsel is really, it's really shrank. And so to be able to, if a family's engaged around changing a behavior, that's why I try to emphasize with teaching providers and students' read, so what are the behaviors we're going to change if it's focusing on one thing and trying to track it or monitor it is going to be helpful, what is our bedtime routine and can we get a reasonable amount of sleep in getting to bed at a period of maybe 9 30, 10 o'clock, getting up by six? How are we going to implement that? What type of things get in the way of changing that behavior? Making a small change? Now I work in a tertiary care center where families are coming to us and they're usually more motivated than in the primary care setting. So it's a different conversation in that sense. The family usually has already bought in and understand there's changes to be made. Now they may not realize the same ones we want to discuss. And so that takes a balance of what to do. But everything we do around weight management in our tertiary care setting has that foundation of lifestyle and is really important. On a pediatric side, we emphasize this is family lifestyle. So if I talk about something like, well, let's cut back on the sugary drinks. It's not for just the patient in front of me, it's for everyone in the home. And then it becomes a harder lift when the family thinks about it. If I'm talking to mom or dad, like, okay, they spend part of the time with mom and maybe they spend weekends with dad because that's a family. Alright, let's try to get everyone on board for that one change. It's more than just the simple words of let's cut out the sugary drinks. Dr. Sarah Stombaugh: Absolutely. Well, and I think to so many great things to unpack there, I mean, so for one, as we're thinking about a tertiary care center, just to think about that with our patients, we're talking about patients who are coming to you at your weight care center. Is that correct? And so patients who've been screened by their primary care pediatrician, maybe elsewhere in the hospital system, they have expressed interest and now they're coming to you and your team who's helping them support them in their weight journey. Is that correct? Dr. Stephen Cook: Yes. Dr. Sarah Stombaugh: Okay. And so a lot of these things in theory could happen or at least start to happen in a primary care setting. And then patients who are interested need additional support are being referred to you and your team. And to start really taking this at a more aggressive level to support those lifestyle changes, but maybe even layering on whether that's medication support or surgical support, if those things make sense. And I love, so as we're thinking about the behavioral change, I think this happens across so many areas of medicine. Sometimes my background is also in primary care and it's easy if you're looking at, oh, you need to do this thing and this thing and this thing and this thing, and the patient walks out and they're like, wait, I'm supposed to make these five different changes. And then they do none of them because we haven't really gotten to explore any of those things in depth. And so taking it sort of one thing at a time can be really impactful. I also, let's talk a little bit about this family piece because I think exactly as you're saying, especially in the pediatric situation, but this honestly can even apply a lot of times in adulthood, but we don't want to single out a child. We don't want to say, Hey, you are the one with a problem. It's so common that I've experienced in my practice even that a family will have multiple children. Let's say they have three children. All three children are eating the same, obviously involved in the same environment and similar genetic factors. And one kid sometimes struggles with obesity where the other ones do not. And so when you look at a behavioral change of, Hey, let's cut out sugary drinks, if that's applied just to the kid who's been struggling with their weight, I mean, it doesn't necessarily, it may make sense on the surface to do that. And I think that's how things have been done a lot of times in the past. But when we think about something like sugary drinks, for example, that's not healthy for anybody. So how do we start to implement this to improve the health of the whole family and maybe change the trajectory too for the other two siblings who don't have weight issues, let's say this may impact them in a significant way into their adolescence or adulthood without the risk of developing it. So tell me a little bit about some of those, applying it to the family. Dr. Stephen Cook: Yeah, a lot of things, it's very complex. So it kind of depends on what the index patient is. Is that a teen or a preteen, other family members, are they teens or preteens? So how much independence they have. The basic things that we can fall back on is these lifestyle strategies are healthy for everyone, and that's what we want to make sure. So even if one of the other kids in the home is normal weight, even a little underweight, more fruits and vegetables is going to be a good mix. And I will point out to families that my experience has been that the way our food environment has changed with processed foods, you can have a child with a normal weight pattern and they can still be undernourished because they're not getting enough fruits and vegetables, they're not getting enough vitamins and minerals. And a child who appears to be underweight or on the low end of growth curve, but actually has a pretty good mixed diet that isn't calorie dense and maybe has lots of fruits and vegetables is probably very well nourished and doesn't have any type of nutritional deficiency. So it's really tough and we want to try to find out where the family is with the index and who else is around and where parents' concerns and anxieties are, because that's going to be a big driver in primary care. One thing I learned years ago with pediatrics was parents want to know two things at the end of a visit, is my kid going to be okay? And am I a good parent? Am I doing a good job? And I always learn that and try to carry that in primary care. And I say the same thing in our clinic right now in terms of working with our team and how to communicate to families because it is so much of, what do you mean my child's unhealthy high weight? So much of what I'm trying to do is care for this child and now they've come out wrong. That is an oversimplified way, but it's a way parents interpret some of the stuff we say. So trying to have simple behavior changes and explaining everyone's a little different, and if this difference in calories is five or 10%, you don't even perceive what difference that is if it's every day in the life of a growing child. So trying to make these changes needs to involve positive attitudes and behaviors, good role modeling. I find that very important. If parents are like, they're really picky, I ask the parents how picky they may be. They don't eat carrots, kids don't eat carrots. Well, it's not too surprising. So understanding all these factors that play into it, and that's why it's really important that we have behavioral health specialists in our clinic to have that discussion. And on the primary care side, I reemphasize a lot what is a one thing that you can focus on because you don't have the training and time to really delve into this with family, and it's important to look at that balance, try to reassure them that these are going to be healthy even for the other kids in the home, for the parents, maybe there's grandparents at home too, where engaging in less screen time, more active play, regular sleep, these are all going to be good for everyone regardless of their body size. Dr. Sarah Stombaugh: Absolutely. And so I want to reiterate, because some of these, they are very, I say simple, right? They're not easy, but they are straightforward things that one at a time we can work on how are we implementing this in the family? And so things like encouraging more fruits and vegetables, decreasing sugary and sweetened beverages in the home, having a good bedtime routine and having adequate sleep, making sure that we're having active play, having limits on screen time. Are there other things that really stand out as these are some pillars that we like to recommend to our families as they're sort of layering on these different changes? Dr. Stephen Cook: Yeah, I mean there are a number of them. I've been practicing over 25 years and technology and screen time and stuff has really thrown us for a curve. It's so much so that we're just starting to get a sense of how much damage it's doing. So in the late nineties, early two thousands, people still smoked a lot and teens smoked a lot. And a lot of work I had done early on was around cardiovascular health and getting kids to not smoke, and a number of major public health laws and victories on the environment side help with smoking. But smoking is a single behavior. And cigarettes, unfortunately, there are a product which when used as intended kill people. And so that's a simple message. We can't say that in the same way around food or physical activity or things like that, but it's very analogous. And so as a primary care doctor, the use of screens, whether it's a child on a tablet or a phone, even a toddler, we are seeing significant developmental delays, language delays, social skill delays, because the screen is taking a part of their life that should be spent in active play with other children where you learn social skills and nuances. So kids coming in primary care as well as in specialty settings are coming in with more mental health issues, more issues of anxiety. There's a far more complex presentation in our tertiary care center of these kids, and not just medically, behaviorally, very, very picky eating to the point of being really extreme almost to an eating disorder. There are eating disorders mixed in there. There's body image issues, there's anxiety and depression, there's a lot of isolation. Number of kids who, because of weight and whether it was pre-pandemic or since the pandemic went to homeschooling and because it remained an option, have continued to online school. And that's something asking my colleagues at the institution I'm at now who had been there longer than I had, do you recall seeing this? They're like, no, it definitely went up with the pandemic, but it's still there. So a lot of kids with really severe weight who we're seeing in referral in a tertiary care. So the more extreme cases, a fair number of these kids are still homeschooled, online schooled, and maybe not in the best way because it's, oh, they go online, they do some tasks for class through their homeschool district, and then they're done, and then where's the rest of their day? And there's no social interaction with peers, there's no time outside. And it is really concerning. Now, it's also done at times because the child has experienced so much difficulty in school and teasing and bullying that they don't want to go back to that setting also. So the mental health complexity that is part of this is very significant. And as an internist, I readily ask parents about their mental health. It's the old joke, if mama ain't happy, ain't no one happy. And I make that joke to moms, but I say, listen, mom, you got to take care of yourself, you and dad. Having the right space for yourselves is extremely important because these small changes aren't easy, though. They sound that way. And then when it's more of a stressor, it's just another thing that really can push a family over. Dr. Sarah Stombaugh: Absolutely. When I love thinking about the mental health piece is so important because it's really, if we're having a challenging time with our mental health, it makes it so much more, it's such a bigger lift to be able to implement any of these other things in our life. If you're feeling down, if you're feeling depressed, you're feeling overwhelmed, the idea of, okay, let me just change up our total family lifestyle, that is only going to add to that overwhelm or maybe just simply too much. And so I love that piece of are we understanding the child's mental health, the family mental health situation, and then how do we help support that? Because a lot of times too, if you're dealing with depression for example, and having that lack of motivation or not desiring to move, it all sort of plays together. And so I love that you guys are addressing that piece. Dr. Stephen Cook: Yeah, I mean, we try to, and it's definitely a rapidly and changing environment. I've been at Nationwide Children's Hospital now for almost a year in a true tertiary care setting. Prior to that, I was in primary care in an academic center at a medical school in upstate New York. And seeing that shift and coming out of the pandemic, my colleagues on the obesity side working in tertiary care, we have medications approved for adolescents now, but there has been this change anyway. And to what extent medication awareness has led to more willingness for families to engage around care families that may not have been willing to talk about or seek it, I think is helpful. But with that is coming a really complex set of patients. Dr. Sarah Stombaugh: Absolutely. Well, and I think this piece of, as we've seen the popularization, especially of the GLP medications, it's changed the conversation in this space for our whole community where all of a sudden I even still encounter patients who are like, I had no idea that obesity medicine physicians existed. And this is true whether we're talking about the adult space or whether we're talking about the pediatric space. And so there's been this interest, there's been these conversations. And so I love that because it's driven, patients starting to advocate for themselves a little bit more, asking around even doing Google internet searches for these type of things. Tell me if someone has been struggling with their child's weight and they're interested in who is someone who should be seeking care at a weight care center, tertiary care center sense is yours, what are the things that might drive someone your direction? Dr. Stephen Cook: I think it's an important balance to understand what their relationship with their primary care provider is and what's in their community for resources. We're trying to help primary care doctors to be able to handle certain components of this younger children, children with less severe levels of weight. And when I present that simple concept of pediatricians, they're like, oh, okay. I said, well, let's think of it as a severe disease like asthma. If a kid has their first episode of wheezing and you believe it's asthma, do you go to the big guns and refer 'em to a pulmonologist and do all these really aggressive approaches or do you try to address it with first line medication? Are there triggers in the home? A couple things you can deal with. And when they think of it that way, they're understanding The hard part is at early levels of weight, if a child is just crossing into the range for obesity, that is a subtle amount of weight in a 6-year-old, that might be a five pound difference, and you can't visually perceive that. So it's real hard for a parent to hear a pediatrician say, your child's obese or has obesity or is in obese range. And I say, forget the overweight category because that's just such a mix in early childhood and even in adolescence. And if a child is tracking through the overweight range throughout their childhood, I don't worry about that. I'm more worry about obesity and the more severe levels. And I explained, we think of Class 1 as 95th percentile to 120%, and then Class 2 is 120 to 140% of that. And Class 3 is about 140% and above. So lots of number there are, sorry, but obesity is adult would be BMI of like 30. Class 2 for adult would be about 35 and 40 would be a Class 3. So these percentiles kind of line up with those numbers. When people think of it, we still have a significant percentage of kids who are in that class two and higher, depending on your area, maybe five or six, seven, 8%, maybe even higher. So it's not an insignificant amount. And so when thinking of addressing weight, it's severity and complexity. So some kids will have a really high weight, but if they're young, they may not have any medical problems related to it. The blood tests are normal. Maybe if they snore, they have some sleep apnea, their blood pressure is usually well maintained. They don't have that age related chronicity where they develop the complications. Yet a child who's BMI is at the 160 percentile age seven may have significant things down the road. So trying to address that in an early age is really important. So as a teenage years start to arrive, whether it's 10, 11, 12, because some kids start showing signs of puberty at that age, then you do start to see more of the complications related to the cholesterols, their glucose metabolism, maybe some sleep apnea, they may actually be having musculoskeletal pain, some back pain or knee pain or other things. And then the actual symptoms and other additional signs and complexity disease start to manifest. And that can be another reason to target more aggressively what I mean more aggressively, meaning we're going to start with lifestyle change. We're going to try to incorporate a number of these things and then do we need to cross over to consider medication? And medication can't be a solo treatment, and this is a really important conversation with families. It's not just a matter of here, you got to start taking this medicine. This medicine allows the lifestyle changes to work better. It's not going to cause you to burn calories. It's more helping how you try to adjust your appetite, but you still have to try to exercise and sleep better and get less screen time. So it's very important that we have that conversation. And medicines aren't without complications with side effects, and some families ask right away, so do they have to be on it for life? I say, we don't know that, but we know that when we stop it, people experience weight gain. So we have to talk about how to look at those in obesity, medicine and pediatrics. We do have to start thinking about what are the first generation of medications that have been around for a while? What are the more recent ones? Especially some of the more recent GLP ones, because I think of those as second tier. They're very effective, but they're not the first thing I would go to. And this is where teaching medicine and nursing about obesity as a disease and that there's a pathophysiology, there's appetite regulation, there's body composition and pharmacotherapy. It's not just, oh, you can treat obesity with this drug. Move on next chapter. We really have to start identifying and train people of how to think of this as a chronic disease. Dr. Sarah Stombaugh: I love that. And this is true honestly, whether we're talking about pediatrics, whether we're talking about adults looking at obesity as a chronic disease, looking at medications as one of the pillars of treatment amongst the other lifestyle changes, and it's really the magic sauce for a lot of people when you've made all these lifestyle changes and it's not taking hold in the way that you wanted to, there is an underlying metabolic disease that needs support. Sometimes doing things like layering on medication or surgery or what makes most appropriate sense in that scenario allows all of those changes you've been trying to implement to start taking effect in a more significant way. So I love the way that you described that, especially in the pediatric setting because we do take this seriously as a disease process and how we help support people recognizing that this is a lifelong thing that we want to understand and support people through. And so for someone who's listening who's like, okay, my child's struggling, or I maybe have a family member or a close friend whose child is struggling, recognizing that this can start in the primary care space and often does, I think as our physician and provider community has become more familiar with obesity as a disease, even going back to what you said at the very, very beginning where you're asking permission, you are using more neutral language like growth, for example, weight. Is it okay if we talk about your child's growth curve today? Every parent wants to see their child's growth curve. And so that's such the electronic medical records. I guess even pre EMRs, we had the beautiful paper charts, the CDC, your WHO where you have it charted out, but now being able to have that plugged in, look at that trajectory over time, it's a really nice visual to then have that pretty neutral conversation of these are the growth curves that I'm seeing. This is what I'm concerned about. Is it okay if we spend a moment talking about your child's growth today? And so I see and hear a lot more of those conversations are happening and there are still providers who may not be comfortable bringing it up. Maybe they've gotten negative reviews from having talked about people with their weight and so, or they're too busy. And so what that looks like that they don't spend the time in the visit talking about the concern for obesity, for example. And so what I would encourage parents to do is even ask if you are concerned about your child's weight when you're in a well-child visit, to say directly to the pediatrician, if it hasn't been brought up, Hey, are there any concerns about my kids' weight? If you are concerned it's worth voicing it. What do you think about that Dr. Stephen Cook: Definitely is parents overall in general know their child best. Another old joke I have is, I have an md, but you have an MOM and you know your child best, and especially kids with complex diseases and complex histories, the families are there every day, but having a parent bring it up and say, I'm just concerned about this. Where are they? We have a lot of confusion around there and implementing these guidelines and how to discuss it. It's one of the guidelines that we've talked about a lot, and I think of cholesterol guidelines and blood pressure and asthma guidelines and things that the teaching and experience has been that a guideline comes on. It's not fully implemented for 10, 11 years. Not that we've implemented these guidelines that quickly, but they definitely have come on and they've hit a lot of attention. And part of the reason of the attention has been medications that emerged very quickly at the time, these guidelines coming out in 2023. So if families are aware of it as a primary care doctor, you want to try to make a couple small changes, things that they realize, getting understanding of what they expect or don't expect. Maybe they say, doc, we're all big bone, this is how we're built. So I hear you, but I'm not worried about it. The reality is you're not going to cajole or bully or tease or oversell it like, well, this is really important. You got to do something now because yes, it would be easiest to intervene earlier in a lesser degree and less of an impact needed to have that effect as opposed to when they're 17 or 18. But you also have to work with their setting. If a parent is expressing a concern, try to address it. Try to identify one or two behaviors that may go on and really try to engage in things that they think they can change, even though you realize it may not be a big change in their calories. So going from whole milk to 1% milk that's not chocolate or flavored may not be much of a calorie shift, and we're like, that's not going to do anything. But if they succeed in doing that for the whole family, they've had success in making change. That's a big win from a behavior and motivation standpoint. If there's higher levels of weight, definitely if a child is in a Class 2 or Class 3 and you believe there's a medical complication related to it, whether it's, I like to think of complications and weight in kids in the three Ms. First M is mechanical. Do they have a lot of weight on their chest and snore and have trouble breathing or get short of breath easy? Do they have a lot of weight on their knees and their back and have joint pains? I think of the second M as metabolic. So all these old people diseases, we worry about the cholesterols, the liver tests, the diabetes, the high blood pressure. And then the third is the mental, is there stress is there anxiety? Is there emotional eating? Is there teasing and bullying? Because those to me, are the complications related to weight. And sometimes they experience them in just that stage one obesity, but more often we see more of these, the higher the weight range goes. So it's important that if they're there, consider referring to a referral center. If they're not there, but the weight is still severe and the parent is concerned, say, I would like to be able to help you more. And by doing it, let's connect you with, and I would reach out to your local children's hospital, regional children's hospital or pediatrics department, see if they may have a specifically identified weight management center. They may do it in a different department, like the GI department also sees kids for weight or endocrinology will see kids for weight. So you kind of have to know as a primary care provider what your environment is. And as a parent, you want your primary care doctor hopefully to lean on for advice of where to refer. Just like if your child had asthma or allergies, where would you refer them to address those issues? It would be a similar approach. Dr. Sarah Stombaugh: Absolutely. When I think this, so my listeners know I have three young children and one of my, as I've grown into motherhood, I've recognized one of the most important things for me is how do I advocate for my children? How do I show up as the best advocate for my children? And that can be in the healthcare setting, but in the rest of their environments as well. And so I think we're encountering a lot of situations in schools and sports and churches or other activities that our environments can be challenging as well. And so thinking too about advocating within a healthcare system, but in other places as well, are there other places where we need to help support changes? I'm always surprised the number of candies and cakes and everything is a holiday in really young schools. Even my preschooler, for example, I'm like, how much candy do these kids get sent home with? And so as a parent starting to recognize too, there's a lot of other factors. Certainly there's things that are within your own family, there's other factors that are out of your control, but starting to pay attention to. Are there other places too that I can advocate? Can you speak on that piece a little bit? Dr. Stephen Cook: Yeah, absolutely. I mean, like any chronic disease, any disease that has a genetic component as well as an environmental component, there's ways to advocate. So it may not be as straightforward as cancer care and supporting research for cancer in a regional cancer center, but it can be if there is a large children's hospital, what weight services do they have? And asking them, do they provide these services? Do they have doctors who are familiar with this or training and getting exposure to do that, to provide that care if needed? We have a lot of long-term data on surgical options for teens with severe obesity. We have growing information and data on obesity medications. There's approximately five medications that are FDA approved for children. When I say that to pediatric groups and they're shocked, I'm kind of like, yeah, that's really the case now. I don't want everyone thinking they can start prescribing them right away. It's not that simple. But the reality is that we do have evidence of what to do. But everywhere in the life of a child schools, daycare built environment, are there adequate parks and recreation facilities? Are they safe? What is school policies around just snacking and food and chips and things like that? What is the school's meal plan? Honestly, things that don't sound off the bat to be maybe not significant for weight, but I would argue that anything that's good for overall child health and development is going to be great for a child, regardless of their body size, but definitely for weight. So instead of punishing kids by taking away recess, let them have recess, let them get out and burn and be physically active. So having schools using, not using withdrawal of recess as a form of punishment, have something else. Not being reliant on screens and phones and tablets and devices in schools. There's a number of books that have come out recently that are very good talking about this and the social science and behavioral science showing how much childhood has changed. And Jonathan ha's book, the Anxious Generation, and I think his previous book discussed this. We've gone from a play-based childhood to a screen-based childhood, and that has so many bad implications for kids across the body size, but children with higher weight too. So looking at schools, not relying on, well, every kid has to have a phone because they have to have a group text so they can get information from their classes, from their teachers, whatever. My wife's a teacher. She was always in communication with parents, whether they called or sending out a newsletter, even the teachers having a classroom page where they can post assignments. There's a number of tools that exist that use technology, but don't require a child to have a telephone. Don't require a child to have a smartphone or a tablet. And I think that's just another area you can look at. What are the routines and policies and practices in childcare centers? How much outdoor time do they get not having screens around in those settings, what type of snacks are available? And understanding are they calorie dense foods? Are they appropriate? Mix of healthy foods in those settings is also very, very important. Dr. Sarah Stombaugh: Absolutely. Dr. Stephen Cook: Oh my goodness. I'm sorry. I just was thinking weight is a chronic disease and condition, and it's the one condition that we still stigmatize the most. So if you had a child with cerebral palsy or some type of intellectual disability or autism and they were at school and they're like, oh, that's the stupid kid who's autistic. We would not tolerate that for a moment. But kids who are teased and bullied about their weight, schools, any setting kids are in, if they're working in an afterschool job, that is a form of discrimination and harassment, and that has to be addressed, and schools have to be on that, whether it's teams or in the classroom or other settings. So it's another area of advocacy that I really try to point out. Dr. Sarah Stombaugh: Yeah, absolutely. Well, and I think that working on how we as a society talk about people's bodies, and I talked to my own kids about this too. There's people who are tall, there's people who are short. People's bodies are just different sizes, and our bodies all do different things. And so really, yeah, that's such an important piece. Dr. Cook, I think we could talk all day long about these things. This is so wonderful. Tell me, so we got connected through the OAC and I know they have a big conference coming up at the end of July. The Obesity Action Coalition is celebrating 20 years. They have an annual conference and you are going to be presenting there. Tell me a little bit about OAC as an organization, as well as what you'll be presenting at this upcoming conference. Dr. Stephen Cook: Yeah, so the OACs, Obesity Action Coalition, as you mentioned, it is the only, or one of the most significant, I'll say, patient advocacy organizations that helps people who suffer with obesity to advocate for care, coverage of care, as well as for against discrimination, either in work sites or jobs or any setting. And they have taken that realization that it's not just for adults. I mean, their main focus when they had started was around adult care and adult harassment in advocating for those patients. And now they have said, we really actually have to get on board with helping adolescents and children, to what extent surgery and medication options maybe facilitated that because you have very effective medications that can be used, but you have insurance companies that want to carve out the coverage of those. So they've advocated for their coverage for adults, and now they're saying, we have to do this for children, but in a well-informed way because they listen to patients and the patient voice, the patient's lived experience. And so now they're addressing and trying to create an adolescent focus group. So they're bringing in teens with their parents or caregivers to the conference this summer to try to get that momentum around what are teens experiencing, what are the things they need? And honestly, they may not be nearly as focused on the medical side that we might think of as providers. It may be far more on the social, the school, these other settings that they may help advocate for. So who knows, they may help advocate for much stricter anti-bullying and teasing legislation in schools that may arise from this, from the patient experience. So I'm really excited. When I first got involved with obesity medicine, I had seen this evolve and was a fan from afar, and I've gotten involved more over the years. They were a great partner with us in a large research study we did where we trained behavioral specialists and embedded them into primary care setting. And the CEO of OAC, Joe Nadglowski served on our steering committee and advisory board chair for the patient experience because he had seen this evolve in research with adults and said, this is what you may want to think about with kids and teens. So they've been a great resource. I was able to connect one of our families to their advocacy team to help them try to navigate the insurance system for coverage for their child to get bariatric surgery because of just the game insurance companies play. So this is an organization that is a patient advocacy organization. They're trying to help people with this disease get the appropriate care and not be stigmatized, not be ostracized by society and being treated just like anybody else. Dr. Sarah Stombaugh: I love that. And this year's conference is in Washington DC I understand. And so any of my listeners who are local to me, I'm in Charlottesville, Virginia. It's not too far away. And I think one of the things that's really unique about this organization is it is so patient centric. Many organizations are focused on providing education for physicians or other providers, but the OAC, while there is educational component, it's really designed for how do we help the general public? How do we help patients and families who have been struggling with their weight, struggling with advocating for themselves and connecting them to the resources or building broader advocacy? And so the conference is open for patients as well as other providers. Dr. Stephen Cook: Yes. It's actually, it's probably mostly, I believe this conference is mostly really the patient conference. The other great resource I remember from OAC C with you talking it reminded me, is they have a media page of how to appropriately present patients, people with obesity in the media. And it's the classic example. Next time you watch a story about obesity or exercise or nutrition, what do they do? They show people in large body sizes from behind and headless. They cut 'em off from the shoulders, Or they show them eating fast food at a restaurant, and they may not show their whole face, but you can see them taking bites and stuff and how stigmatizing that is. And so they actually have media outreach materials, and I have done that. When I've done stories for local news or other areas, I'll say, can you please use some appropriate pictures? Here's a link to the OAC webpage. I believe the Yale, or not the Yale, the Rudd Center University of Connecticut also has appropriate media images that you can use, whether it's still photos or video clips. So even that subtle type of thing isn't so subtle and how important that is in OAC C, bringing attention to that and bringing answers to the table, not just don't do it here. Here's a better way to use to show people with obesity as part of a story. Dr. Sarah Stombaugh: Absolutely. Oh, that's a really neat resource. I was actually not even aware of that. So I'll go take a peek at it after our recording. Well, Dr. Cook, this has been really wonderful. Thank you so much for joining me on today's podcast. Dr. Stephen Cook: No, thank you very much, Sarah. I really appreciate it. Dr. Sarah Stombaugh: Yes, absolutely. And to my listeners, if you were interested in learning more about OAC, we will have links to that in the show notes. You can definitely check them out there, and we will all see you all next week.