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Hello everyone out in video land this is Alex Adams we're going to get started on our webinar today understanding and supporting our children pediatric overweight this webinar came about because we realized that providers and others who are working with families in rural and native areas in Montana needed extra information and so this is going to be maybe a little bit more basic and then we're going to ask you some questions at the end about what you might want to hear in future and dr. Ruth and I are going to be talking about this together and she's going to take over about halfway or just a little bit further through so just a quick background on me I am a family medicine physician I practiced for nine years of the pediatric obesity treatment physician at the University of Wisconsin and a theatric Fitness clinic their work so the objectives for today are to talk about how common childhood obesity is and why we should be worried about this and then really to kind of get down a little bit into the weeds about why the kids gain weight so fast and why are they different than other kids some of the newer thoughts on why that is and then what we as providers or people who are working in communities can do to help those kids so it's important to understand that pediatric obesity is most rapidly increasing pediatric health issue there are a number of studies showing this we do have some plateauing in some areas of the country and not in other areas but I think it's really important to understand that most of the kids that are overweight are going to become overweight adults and it's not something that kids usually grow out of which is very often a parental misconception rural and low income and minority populations particularly native populations are more at risk for obesity and much higher risk for complications such as hyperlipidemia or fatty liver syndrome and we'll talk through that tiny bit today so is a map of obesity rates for use again this is kind of lumping everybody together so this doesn't have the race/ethnicity pieces in here or rural-urban yet and you can see Montana's in that set of 10 to 14 a 15% range in that 10 to 17 year old age group so when we look at rural areas large rural areas are smaller layers you can see that that actually has a much higher rate than for urban areas and the reasons for this are complex and ever-changing but we'll talk through some of those I think some of them we understand and some of them were just beginning to understand of course some of them are very obvious like food deserts and lack of accessibility for exercise here are some Montana data and this is for adults kind of that kid range and then WIC age kids 2 to 4 and you can see that we are lower except for our WIC kids in the percent obese sort of compared to national norms but we're still very high if you look at this this is the majority of the of the adults in the state are either overweight or obese and a large percentage of kids if we went into minority groups you see these numbers sometimes triple so it's really important to understand this is again a combination of kids so we're going to talk a little bit about how you'd address this clinically and what you would do as a practitioners and some and then Breanna is going to get into some resources so I toes the 30 minute well child visit because this is kind of a typical visit that you might see a child that is overweight or obese in and one of the things that it's important to remember is that because our mindset has shifted into what is overweight or obese just because we see kids all the time and because I think all the sizing on things has really greatly changed so that I have I have two boys 10 years apart and I can tell you that the size 10 genes from 10 years ago are very different than the size 10 genes today and so it's really important to understand that some of the things in the environment are not helping us realize that kids are gaining weight so the first thing to do is to look at the BMI and then ask if parents are concerned about that child one of the ways you can kind of help understand this is if there's a family history of type 2 diabetes hyperlipidemia high cholesterol any obesity in the fan Lior history of eating disorders those are really important to understand and when you show them the child's growth chart I think it's really important to have an open discussion on the way trajectory of that child so if the the child is coming off the chart or they look like they've been gaining weight recently it's important to understand why and we'll talk through some of the really common reasons why that might be happening and then once you use a physical exam if there's any particular physical exam finding some of them which we'll go through it's important to mention those and to talk through whether those are weight related or not and maybe family history related and then for for a lot of kids they need to have lab schedule so they would need a lipid panel fasting lipid panel liver enzymes ast alt and a insulin if you can get them with follow-up and then obviously follow up with some brief motivational interviewing about getting that kid back into the office to have some discussions and we'll talk about some of the resources and some things you can do so I'm going to go through an example patient and this of course is a fictitious patient but kind of gives you a general idea 11 year old is a typical age range that I would see in my clinic and I think it's because people think in the earlier years oh they're going to grow out of it and by 10 11 12 for girls people are thinking oh they got to enter middle school and they're not growing out of it I need to come in boys sometimes we're seeing a bit later but Sally here is an 11 year old girl she has a BMI of 25 which as we know is normal for an adult but if we look at her growth chart puts her at the greater than 90 5th percentile for a kid which of course is in the obese range she we've gotten labs for this particular kid to example she has height rigs and low HDL which is a very common combination that we'll see and her insulin level is borderline meaning it's over 25 and probably in the 25 to 28 range and she has to make an ptosis which is that dark line on the back of the neck it's often second skin in minority children and have darker skin it tends to be much darker in white kids it tends to be either a reddish line or this kind of brownish like this sometimes it's just a thickening and that's early but that's important to point out because many many many of the parents I saw in my clinic we're trying to scrub that dirty neck off and that's obviously not possible so some other concerns for her she's sitting on the exam table she's got really poor posture and you can see she's got low muscle tone when you talk to her she sounds really sad interesting a lot of emotional eating she may have some knee pain and she obviously has low fitness levels without any after-school activities and she's got a cell phone and she's on the phone to 11:00 p.m. these are again really typical things and sleeping poorly because of that so if we ignore these things in a typical pediatric eleven-year-old visit which a lots going on and there's a lot to talk about and there's vaccinations but she's going to continue to gain weight and she's going to get more complications and she's going to get increasingly socially isolated so really important to address this now and hopefully earlier if possible but this is a pretty common age for parents to get worried I wanted to show a typical BMI chart these often don't come color coded but they really should because it's so nice to see that what you can see here is that a 15 year old boy with a BMI of 23 is in that normal range but the same BMI of 23 in that 10 year old boy is in the obese range so you really can't just look at the BMI is you've got to plot them on that BMI percentile chart and if you have an EHR this is often done for you but if you don't you need to get that chart out and actually plot it and I've had parents that sort of don't understand that 95 is a bad number they fit 95 is like we want to be high and really trying to help them understand that they need to be trying to keep their kid in a more normal range or at least keep them flat so that they're not increasing rapidly on that growth chart so here's some of the many many myriad influences on pediatric obesity so that we don't get into that blaming the kid or the parents for the whole issue right so there's many things in our environment that make it really hard we talked about food a little bit food production and being out in rural areas is really complicated really complicated to try and get healthy food sometimes being active in a rural environment when there's just highways to be on or a lot of terrible weather is also a really difficult there's of course genetics and individual biology there's a psychology of eating and then there's a lot of societal influences in terms of what's being fed in the school school breakfast lunch and availability etc so I think so here's some determinants of weight gain these are things like go through in my head when I'm going through why a kid might be sitting in front of me and I'll show you something that I've used to actually show parents and explain to them what we can worry about so we just talked a little bit about the biology piece while this is a big piece it's not the only piece and it has a lot more influence early in life than later in life being premature is a risk factor not having been breastfed mother with gestational diabetes or risky behaviors during pregnancy is important and then of course any kind of adverse childhood experiences are really important and that things such as divorce sexual abuse trauma parent incarceration those can really affect weight trajectory and then of course family risk factors so these are important to kind of go we're not going to be able to address those we might think that they're important you deal with them but we don't address them the things we can address are what the family's doing and I mean the whole family is doing in terms of their diet if they have food insecurity that can be a really big risk factor for waking what the exercise and physical activity is like in the family and mutter screen and sleep rules in the family stress and mental health again those aces are really important and then if there's any disordered eating going on and then medications and many of the atypical antipsychotics fallenness and can really really significantly increase weight gaining kids time okay so here's what I say to parents is with these are the things we can't change we're not going to blame you're saying people about having done these things are not done these things these things that we can modify are important and each kid is going to be different in terms of what the particulars are in terms of that particular kid so getting to that is really critical to understand how we want to treat each child as an individual and each family and their own issues here are some complications I've seen all of these in my clinic you may or may not see these but one of the ones that's the most overlooked I think is liver fat fatty liver and I'm not even so the Seattle hip hopera Titus or fatty liver syndrome super super common particularly in Latino children there's a couple of genetic variants in there that caused that to be a bad thing dis leva D Mia again very very common and kind of the poor self-esteem and depression also very common so this is what we're going to look at the tipping point of personal susceptibility genetics lifestyle with what the environments been promoting in our country and so that's where we can make a difference as providers as well I'm going to show this because I think it's important to understand that small increases of calories or decreases of calories can make a big difference in waking over time and often I'll see kids when they're here instead of when they're over here coming off the growth chart and I'd much rather see them at age 4 to 6 then at age 16 when they're already you know 99th percentile so I just want to kind of put a plug in for limiting or eliminating sugar particularly high fructose corn syrup which is in sugar sweetened beverages a lot of a lot of the beverages that kids really like to drink sodas and other kind of sugary drinks so getting rid of that makes a huge difference we can do that and here are pictures actually taken by middle school kids honey Photovoice project to show things that were unhealthy in their community but that they wanted to eat this is inside of somebody's refrigerator this is availability in a building they had access to and this is a store that they like to go to so you can see that this kind of stuff is what I would like to call things you can eat that aren't food so that's in that category so I'm gonna let dr. Reece go through this but I'm current dietary recommendations I'd say if you can get people eating a lot of colors on their plate that's the easiest thing to do you can buy divided plates and choose is a really easy nice site to get into for everyone with lots of good tips and we'll go through some of those at the end as well so recommendations for physical activity are 60 minutes per more many of our schools have that in it in Montana we're kind of lucky but some of them don't and so you need to ask your kids about that and whatever you can get them doing outside of that is great and then here's a really really hard one with all of the video gaming and phones is the less than two hours a day this is a struggle in my house and it's a hard thing but it's really critical where are we so sleep this is something I saw again very common sleep deprivation in all of us particularly in late school age so I would say middle schoolers are where they start to limit their sleep and in teens they're either up late on the phone or gaming or they're up late because they're doing homework and they need a lot more sleep than adults need so while we can get away with seven to eight hours a night most kids especially the school-age are needing that 10:00 to 11:00 the teenagers really in that's it at eight to nine range and that is really hard to get they're often not getting that I've even seen toddlers in our studies that are up till midnight eating and of course then they're going to be cranky and irritable and driving their parents crazy so sleep is really critical and what we don't realize is that when we're trying to stay awake think back to maybe taking some exams when you want to stay awake you often eat in order to kind of be alerting and chewing is alerting and act so that's a really big problem so getting that sleep in is also going to switch the there's two hormones that regulate appetite ghrelin and leptin and those will get the ratio will be distorted if people are not sleeping enough and that will increase appetite as well so sleep is underappreciated as a real cause of significant weight gain sometimes both in adults and kids so other reasons I wanted to go through for ED normal weight gain because we we tend to still have the mindset of it's all that exercising it's all about diet but we forget that the stress hormones cortisol can really make a big difference as well as some of the other pieces so very often I would see a kid's growth chart going up and I would say to the parents why do you think this growth chart is suddenly heading up like what happened here that made the growth chart go here and they would say oh that's when we got the divorce or that's when we moved to this new town and he wasn't quite sure of himself at school or he's being bullied at school or there's some kind of significant food insecurity issue and so kids are then eating whenever they can as much as they can because they're not sure where their next meal is coming from and then don't forget about physical and sexual abuse because those are significant causes of increased weight trajectories we talked a little bit about sleep and screen time and those are significant especially my teenage gamers that's a big one and then what we haven't talked about yet is sensory issues and kids that have any kind of spectrum disorders autism Asperger's often have these issues and even normal kids that have sensory processing issues will often be using their mouth as a way to control their emotions and their sensations if they can't handle things they will be using chewing or sucking as a way of self calming very primitive mechanisms we all use them only for infants and these are kids that are still doing that because of that so we need to get those kids off and into occupational therapy to help kind of calm that stuff down and then we get the mouth Hunger down you can also by get them to chew on other things that are not but you know these are often kids at you on clothing queue on their nails twirl their hair these are kind of kids like that so think through other ways to get them sensory input then there's eating disorder kids that have food addictions my favorites are flamin hot cheetos and what's the other one Oh Mountain Dew those are very very addicting I saw high fat high sugar high caffeine so those need to be limited and or eliminated sometimes slowly sometimes rapidly again emotional eating regarding all of these issues is important nighttime eating again to stay awake a lot of the gamers will be eating while they're gaming and stay up and then of course there's anorexia bulimia and that those are much more serious but the kids I saw in the obesity clinic often are the bulimic kids because they're not purging and then lastly some of the psychiatric medications the two the two that really are the worst are abilify and geodon but any of the atypical antipsychotics can cause weight gain I saw kids in my office of anywhere from 30 to 40 pounds of weight in a year just starting those drugs that had nothing to do anything else and I we often had to taper those drugs in conjunction with their psychiatrist and think about other reasons that kids are needing those psych meds so some steps for providers I think we're going to go through some of where you can find better information but look at some current pediatric nutrition parenting and behavior change recommendations obviously you're probably already doing some of this and your clinics are ready but there's some really nice materials out there that you can get your hands on and we'll show you that I think it's really important to set small goals and really avoid that shaming blaming is not a particular person's fault but everybody in the household has to change it can't single out this one kid as we've got to change you know Sally's eating habits and not mom and dad and I would have parents say to me oh well we we don't want to give up our soda and I'm like guess what you got to give up your soda so that's really important because they have to be role models and then we're going to talk a little bit about other referrals and how you can advocate statewide for this Thank You next so I'm gonna let you take over and thank you so hi everyone my name is Breanna Ralph as Alex mentioned and so I'm going to share with you some of these resources that we've alluded to throughout the presentation as well and it's a little bit about me and my background I'm a new to Montana I am a food and nutrition extension specialist and a professor in Health and Human Development and my background is in public health nutrition I'm a registered dietician and I also have experience in Health and Human Development as well and so I just wanted to share with you some resources that we have an extension as well as other resources that you might have access to around the state that can help you as providers but that can also you can share them with families that you might be working with as well so we have to go this little thing and then go down its existing okay um so and this I just wanted to share with you this is our resource list that we've put together along with links to all of these resources and this will be something that will share with you after the presentation but I just wanted to give you a little visual so you could see what exactly you might be expecting and again we have resources for u.s. medical providers but also resources that you might suggest as well as share with families and so some of the resources that we have online for providers I wanted to just talk through a little bit of those with you so you know what to expect we do have some resources with some of those current recommendations that Alex mentioned in terms of what the research the most recent research says are different nutrition guidelines that we should be following different family practices that might contribute or prevent and promote healthy behaviors as well as what things you might do in the clinic and what those recommendations are so we have a couple of resources from the Academy of Nutrition and Dietetics which is the National Organization for registered dietitians and they also have some resources from the Academy of Pediatrics and so of these again we have nutrition guidance we also have recommendations for prevention but these also can help with reduction of childhood obesity as well and then guidelines for weight management as well as guidelines in the clinics that you might be able to use in your practice and these again are based on research they provide the research about what these recommendations about why would have these recommendations as well as some practical tools that you can use them in your practice we also have some resources that might help you in assessing and talking with families as Alex mentioned there are a number of different lab tests and things that you might run as well as different family history things but we also wanted to provide some resources in terms of how do you talk about weight in general it can be sometimes a tricky subject to talk about with families and we want to approach it in a way that doesn't cause additional complications in addition to the obesity that you might be trying to reduce but we also have a online assessment tool which I'll share a little bit more with you about in moment and then there's a diabetes self-management education and support website which is through our very own Montana Public Health and Human Services program and they have listed on that it's a lovely map that you can find where are their diabetes education classes in your area you can food resources as well as what kinds of physical activity opportunities there might be in your community and then we also suggest the idea of again normalizing this discussion about weight and about promoting healthy foods and one way that you can do that in your clinic is to have some of these materials on display and so we provided a couple of different websites that are USDA government websites research-based and have some really great not only handouts and flyers that you can give to families directly but also they have really great posters that you can post in your office as well and so I also wanted to go back to thinking about what kinds of community referrals you can make you have a limited amount of time in a clinical setting but what are some ways that you can continue to support these families one option is to connect with your local registered dietician nutritionist and there are many around the state but you want to connect with whoever might be local to your area as well to see what kinds of language they might need in terms of billing in order what kind of language they might need in that referral for billing and then another option that is kind of new and in the works and they're still working out some of the kinks too but is telehealth and there actually is a pediatric dietitian at Billings Clinic that is going to be starting telehealth consultations around the state so this might be another option and I also have her name and contact information on the resource list so you can connect with her to see if that might be an option for some of your patients as well and then the other community referral that is really important and I highly recommend it might be a little bit biased but I think with their really good resource is our community Extension agents and snap-ed educators there we have agents all around the state and some in many counties are specifically focused on things like families and health and nutrition and they're providing research based programming to meet community needs so they need to know about what needs you're seeing in your community but they may already have program that's under way that you can refer clients to but you also may be able you may be able to work with them if you have a need that they're not currently meeting that they could be meeting as well and this includes things like physical activity programming cooking classes basic nutrition information things that can really help support people as they're trying to make some of these behavior changes and then I also mentioned that we have some resources for parents and again these might also be resources that have some helpful information for you too one big resource that I want to point out with food assistance programs there's often a lot of stigma and people that might be eligible that aren't seeking out these programs this would be things like sat snap which is a Supplemental Nutrition Assistance Program formerly called food stamps which is what a lot of people will know it by WIC women infants and children fdpir which is on reservations and TANF which is cash fund to support needy families and in these programs as a really respected member of your community and as someone that these patients are often looking to for where they should go for assistance it's a really great thing if you can suggest that they look into these resources as well so that they can have support to make some of those healthy food choices when they otherwise might not be able to for financial or excess reasons additionally I put in our Minnesota our Montana excuse me extension resources and again we have our snap education program which specifically works with folks who might be eligible or receiving SNAP benefits we also have our local agents in counties our extension agents and then also myself as a specialist I am a resource to you as well and so if you do have resources that you're looking to have in your clinic whether it's a handout that you don't have or some sort of information that you'd like to be able to provide to families that's also something that you can reach out to me and we can hopefully work with you to provide that as well and then in addition there are plenty of great resources online some of which you might already be familiar but I wanted to point them out and suggest a few more that you might not be aware of but these have not only tips for parents and tips for kids about small changes that they might be able to make but they're often presented in a way that is at the very basic level they don't necessarily need all the research background and to why they why X Y or Z behavior is something that we might want to address but they want to know how they can do it and so these resources things like the eat right org which again is the Academy nutrition and dietetics webpage MyPlate the CDC has some really great resources and then let's move also still have some really great resources that you might be able to share with families and so I mentioned a moment ago that there is a family nutrition and physical activity online survey and I wanted to share this with you it might be something if you have times that you could use in the clinic visits but it's also definitely something that you can suggest to parents who might be wanting to know what they can do in their family to really promote that healthy behaviour because as Alex mentioned is a whole family issue and it really does take the whole family it takes parents being engaged it takes the child being engaged but it also takes things like siblings being engaged or other adults in the household to really be on that same page in terms of promoting healthy behaviors and so this online survey is again it's questions developed from the Academy's evidence library and these are it's asking simple questions about different household behaviors related to food individual child behaviors things like physical activity screen time sleep as well and so it's meeting a lot of the areas that we've already discussed today and when they take this survey if I give them an immediate response which i think is one of the really helpful things about this they can get specific recommendations based on the answers that they selected and so I have one example here about reward and restriction which are two areas related to food that we really want to avoid if at all possible we don't want to have food as a reward and we don't want to necessarily restrict some of those really high palatable foods that kids often like to eat but we do want to maybe reduce their availability in the home and promote some of those healthier foods and so this provides some recommendations that are really tangible things that parents can then do and try try out in their home as well and this is another tool that can also help if you're trying to set goals with families and they're having trouble thinking about what a goal might be this kind of a tool might be able to help you as well and again we have the link to this assessment online in the resource page as well and then so before we move on to just some general questions and seeing what questions you might have we also want to talk about what parents can do so when you're working with parents those are often who's coming in with the child but any parent or guardian as well as I have their additional family members we want to emphasize to them that they can really be those they really are the role model for what is healthy so anything that they're doing the child is also seeing and might then want to emulate so we want to promote those healthy behaviors for all family members in the home and then we also want to build a healthy relationship with food so sometimes when we go down the path of focusing on obesity we talk a lot about again that restriction of different foods and things which is a component we do need to reduce those quantities but still promoting that healthy relationship with food so it doesn't swing in the opposite direction of disordered eating or not necessarily the opposite direction but doesn't swing towards disordered eating or cyclical dieting and other long-term health complications that might come along so we want to think about what are those healthy relationships with foods and ways that we can promote those in the home whether that's reducing the amount of times that we're going out to eat reducing the amount of sugar sweetened beverages in the home promoting trying different foods in the home and really promoting that cook once cook one meal and have everyone eat together which is another component that really can be helpful similarly family meals and having family meals without things like the TV or screen time I have research has also shown that that can be a helpful preventive measure and it also helps with other areas including things like academics and then also exercising with kids which this is something that a lot of times you'll have some resistance to or wondering what exactly we can do but anytime that the family can exercise together whether that's going for a walk after dinner or even I've had families that are really excited about doing dance videos together so thinking about what kinds of exercises you can do as a family so it really normalizes that physical activity come opponent as a everyday practice and then avoiding regularly speaking about your child's weight as well as then focusing on the promotion of those healthy behaviors as a family and so again this goes back to that healthy relationship with food and really thinking about what kinds of words and language are we using in the home oftentimes you'll see we've seen that if one child says I don't really like this food the other child might say well I'm not going to eat that and so the words that you're saying and the way that you're interacting with your food are also important so we don't necessarily want to focus on the negative and the behaviors that we don't want to do but really promoting those behaviors that we do on it what do we do want to see so praising things like physical activity or trying a new vegetable for example are really good ways to help parents to think about what are ways that they can promote those healthy behaviors well not necessarily focusing on some of the negative behaviors and so with that we wanted to ask you guys a few questions to see what might be some of the next steps in terms of additional networks webinars that we might want to happen so we're going to try something out so bear with us for a moment um we're going to first might work we're working on some wonderful technical things over on this side just because we're using this new system but we're really appreciative that you were able to join us today and our first question we just want to know who out there that has joined us today is a provider and so I believe that in a moment this will pop up in a poll question for you we should get out there is it a little punishment or not stay in it but it doesn't mean it's not up if you're seeing a poll question right now feel free to respond if not by seeing any responses no so just um I will enter it in chant and P perfectly so we're just going to type in our questions here into the chat function and if you wouldn't mind taking a brief moment to respond to them in the chat function on your lower on your lower right hand side I believe and so our first question is are you a care provider are you seeing patients currently and if you can go ahead and just say yes or no that would be great and then our next question so you can think about it here for a moment is our next question what kinds of topics would you like to see related to this so thinking about pediatric obesity what kinds of further information would be helpful to you we went over a lot of information today very briefly and we can go into a lot more depth but we wanted to give you this overview first and see what those next areas would be helpful most helpful for you in the future so you can also put that into the chat box now as well and then similarly if you do have any questions for Alex or myself please feel free to put those in the chat box and we're happy to take a few minutes here to respond to any of those questions new questions coming how to use the chat maybe okay yeah and so I think that we are going to also be posting this on the care website yeah care that the care website which is on your screen but you can't really read it so sorry about that so that is ww-want an AED you backslash care cai rhe we'll have this posted on it and we'll send that out to everybody who that's on the webinar today so you have the link and then of course if you have any fault questions that you think of it's you know feel free to email briana or me let's see okay here we go questions that for some reason we can't see but we got on a different screen okay they're coming in fast and furious right here this is this is from someone about sensory disorders we are provided information that but have not received much information on the sensory disorder aspects and we talked a little bit about that being a fairly complicated topic but one that's I think very overlooked I found anywhere from ten to thirty percent of the kids in my clinic that we're overeating words sensory processing kids some diagnosed and a lot that we're not diagnosed so that may be a topic that we deal with a separate piece but I think it's important to sort of understand or look at if kids are doing a lot of non-nutritive eating as well you know like in other words too in clothing or read a lot of other sensory issues this is a really big clue to why they may be overeating so I think that's an excellent question and it's a big topic and I'd love to talk further so again I can do that offline with the person that asked if you want to email me but we might use that as a separate topic I think there's another question coming in - yes and so the next question that we had was related to farm firm kids and that they usually have a lot of work to do but it's not always necessarily the best in terms of actual physical activity as it may have been yep in the past and so I'm thinking about what kinds of recommendations we might have for how to be physically active and what kind of fun positive physical activity we can suggest and encourage like if you have almost art and then maybe you can go I think this is a really tricky question I got um I worked in Wisconsin where we had a lot of dairy farm kids and now here or you have a lot of ranch farm kids as well as other farming kids and I think it is tricky because they do have chores but often those tours are not as active as they should be and it also makes it really hard to get outside because they're in really remote rural areas so anything you can do together as a family looking into some of the resources we've had in terms of home physical activities enough people often ask about wheeze and those kinds of things and while they're not as active as having like an exercise bike or a treadmill they're better than nothing so they're better than sitting gaming sitting so but I would say and then families doing stuff together is really important that that helps get kids to be active using specific suggestions that's what I was saying in my farm yeah I would I would echo that that any time the family can do that physical activity together there's a lot of resources online on YouTube specifically and that's also if you have kids that are really excited about the the online and those types of Technology resources there are a lot of resources out there that have different physical activity ideas that are things that you can do in your own home regardless of whether also we do have some wonderful opportunities here in Montana and I think that really kind of the culture of outdoor physical activity in the state is a real benefit that we have so that's another area and then I will also put in a little plug that we do have a new health and wellness specialist Michelle grouchy and this is an area I know she's looking at what types of physical activity and things that we can promote so there might a new resource coming out at some point in the future that would have some potential ideas and suggestions so I would also recommend that anytime you're looking for resources feel free to stop by our extension webpage to see what we have available and if you don't see something that you would like to have definitely let us know because we again are looking to meet the needs of the state with some research-based resources so two more things coming in one is implementing the healthy stores campaigns and communities and taking the community environment obviously super critical right if we don't have healthy foods people can choose it's really hard to eat well so I love that suggestion and maybe that person can email one of us or we can find that and put it on one of the resources the other one person is loved to share this provider this webinar with providers in eastern Montana thumbs up on that this is why we did it so forget it a link once we get it uploaded on to the care site and then it will have both that resource guide as well as the webinar and then and I would also say in terms of thinking about and I didn't touch on this very much in the resources but really thinking about what kinds of activities you can do or promote in your community that can help the environment to be a place where people can have access to those healthy foods easily it's really a great thing and again this is an area where your local Extension agents or snap fed educators can help out we are doing work for example we're working in food banks to go through a checklist to see what kinds of research-based practices they're doing in what ways they might be able to get there so thinking about how can you promote those activities that might be happening sometimes it's a policy thing sometimes it's community education types of things so there's a lot of different opportunities for how you can promote not only in that individual clinic setting but just in your community in general and maybe I give just a couple of examples of that so one of the physicians that I work with back in Wisconsin actually did a little quick cookbook that she made four things you could buy in your community to the farmers market that they then put in the clinic and that was really helpful on others have gone to their local community grocery stores and said please stock things that are better and I think there's a lot of there's also a lot of moms out there that are doing amazing work trying to promote this so I think that don't underestimate the power of active mothers either to get things done so here's the question does USDA Extension have programs for farm gardens or canning sometimes the gas station was the only place to buy groceries in frontier rural communities given that gas station usually has very bad things I think those are excellent suggestions and I'm going to turn it over to yes because of course they do yes you can tell you that yes any of you we have programs like master gardening which is a really great way to help people understand gardening and what kind of things and a lot of communities are really working on community gardens so if you're not aware of a community garden in your area do some connection with some of those referrals that I suggested as well because they will likely know about what community gardens are available sometimes you can even have a plot in those community gardens and additionally relate to the canning we definitely have canning resources we have tons of canning resources whether that you want to watch a video or you want to read a pamphlet on it or you want to actually go to a class and learn how to can that is definitely something that we have in extension and that is another opportunity to connect with your local agent to see what those classes are and when they might be available in your community all right next question is with limited resources in some counties as far as health care providers as we know very thin out in eastern Montana especially how should Extension agents approach families with this type of information I think we both answer that I may start my experience with families and children that are either becoming overweight or already overweight or obese is that it's best approached as a let's try to be really positive about what are the strengths of this child in this family and how do we promote wellness and again no blaming shaming for the family or the kid but really treating it as something that's really important for their future health and so I think coming at it from this is an everybody issue you know this is United States issue this is not necessarily your family or my family issue but that all kids need to eat healthily have good sleep having you know less screen time and exercise regardless of their weight there are kids that are doing those things all wrong and so I think that's probably the safest and easiest way for people that are not health care providers doing specific treatment to approach it as a more like this as a wellness piece that's my sense for that and then there's so many resources there's a couple more that we didn't show that I think after you answer this also these other resources yeah and so I would just say um as extension one opportunity we have is also to connect with those healthcare resources that we do have as well to again facilitate that partnership because I think that when we can partner then it really allows our resources to spread further extension has a really great opportunity to reach more to reach more families and to really promote some of these healthy behaviors so that maybe we can prevent obesity in some of these families earlier and so I think that really viewing all nutrition types of work that you might be doing as a potential for preventing further challenges in the future is a really great approach and something that we can capitalize on as well yep so there are two books that we I'm not sure these are in our resource list but we'll add them so this is the first one is called pediatric obesity and we think that the new version is just coming out by Sandra Hesselink and this is more of a provider version kind of all about strategies for treatment and prevention and interventions very nice and well done book the second one a little higher reading level for parents but probably one of the best books out there for parents is again from the American Academy of Pediatrics which is called a parent's guide to childhood obesity a roadmap to health so again this is for parents that already have kids that are struggling with this but I think well-done book reasonable things to do but a little bit high reading level so maybe not a starter place site and one more research that was just mentioned on here that I should also share is thinking about some of the work that actually snap-ed and our farm school programs are really doing nearly work in the schools whether that's things like nutrition education thinking about eating local foods as well as things like taking part in school wellness policies and that's something that anyone can do see if they have them in your community see if you can get involved and again they really like that outside input even if you're not even if you don't have children in the school or aren't connected that these are really great opportunities to understand what's happening in your community already but also see how you can again be engaged in that yeah and I think we did not set this webinar around sort of those community pieces on purpose yes there's a very extensive network of things happening in every state and in Montana as well in the communities through a variety of different mechanisms and that might be a separate topic entirely I think ever we were trying to address more towards what might you do faced with this in your office versus the other piece but do feel free and you have ideas or if you'd like more information on any of these topics that we talked about today please do let us know in the chat box and we hope to do more with these in the future with you yeah thanks another way any other questions I think we're probably um kind of almost out of time I don't see any other okay I think yes I think that we've gotten about all of the questions here so we have if anybody has other suggestions for things here's one coming in have we heard of dr. young from Virginia she developed a non-profit to help kids parent learn how to cook - pediatrician um I haven't heard of that particular one but there are many out there just like her and apparently her website is dr. young org yeah and there's no end of resources now out there about these kinds of things so I'll take a look at that with Breanna later but I think um that's a good suggestion yeah yeah and I think that as I'm sure many of you know just being ensuring that when we are looking at resources because there are so many out there make sure that they have a solid background in terms of what research they're citing or how they've tested these programs as well right um yeah and I one of the questions we didn't get into or talk about and I think this is really important is some of the sort of fad diets out there paleo keto you know you name it whatever is the latest thing those are really less appropriate and probably not appropriate for most growing children and so and they're also way too complicated and require far too you know calorie counting and things that really should not be happening in the home that is going to just set kids up for failure and for eating issues disordered eating issues so really thinking much more clearly about let's just have lots of colorful foods and healthy foods and trying to get rid of some of these other trigger foods that are going to be bad for kids guts and you know cause waking a lot of the sugars and saturated fats need to go we didn't get into anything like you'll make it through read I mean there is a huge list of stuff but we didn't have time today so again send your suggestions to us and we can think about these things in the future what would be useful maybe like that thanks so much everyone everyone I think we're going to say goodbye this is going to unplug us okay and you'll be getting an email from us with that list of resources and a link to our website so you can then further this out in your communities and we would love to hear from you if you do that about how you're doing that because again that's really helpful to us to know where people need things and how we can be of use to you guys so thank you for your time and attending with us today.