Rob Steele, MD (Host): Welcome to Pediatrics in Practice put on by Children's Mercy Kansas City. I'm Dr. Rob Steele coming to you from Kansas City at Children's Mercy. I want everyone to remember to claim your CME credits after listening to our episode, visit cmkc.link/CMEpodcast and click the claim CME to get your credits.

I am excited because we've got not just one, but two fantastic speakers here. Dr. Michaela Voss and Dr. Sarah Hampl, both of whom have done incredible things here at Children's Mercy, and we're going to talk about that. Let me introduce you first to Dr. Voss. She is the Medical Director for the Eating Disorders Clinic.

She received her medical school degree at the University of Kansas and did pediatric internship and residency at the Children's Hospital of Wisconsin and then went on to fellowship in adolescent medicine at Seattle Children's. Dr. Hampl is Weight Management Pediatrician and holds the Kemper Endowed Professorship for Healthy Lifestyles.

She received her degree at the University of Missouri Kansas City School of Medicine and residency right here at Children's Mercy Kansas City and is also Board Certified in Pediatrics. Also interestingly is Dr. Hampl was the lead author in last year's Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity published by the American Academy of Pediatrics.

And that is a great segue into what we're going to talk about, which is really about weight management and obesity, particularly in, in adolescence. So welcome Dr. Voss and Dr. Hampl.

Sarah Hampl, MD: Thank you.

Michaela Voss, MD: Thank you. Glad to be here.

Host: It's great to have both of you. So, why don't we start not so much into the weeds about weight management, but really more about how you address weight management. You know, let me start with Dr. Hampl, how does one address weight and health in a non-biased way with patients?

Sarah Hampl, MD: Well, I think that it's important to address it in the context of whole child health um, that weight and BMI are really only one or two indicators of a child's health. There are lots of other health indicators as well. We do definitely need to pay attention to it. Just as pediatricians, we're looking at height and weight and how they change over time.

And kids, that's one of the things that we do from infancy on. But if weight starts to trend up or BMI starts to trend up, it's really just more of a signal to us as pediatricians that more evaluation should be needed. So thinking about how to discuss it with families, I think it helps to try to certainly not use the term obesity, but really talk about it in terms of that child's overall health.

And also just, I just plain old tell my families, it is hard to be a healthy weight these days. We know that. There's so many different influences that impact children's weight and that health is more than their weight. We want to learn about you as a whole person in the context of your family. And is your shape or weight worrying you or stopping you from doing anything that you want to do, just kind of helping to see what type of impact their extra weight may be playing in their life.

Host: Yeah, that's a great approach. Dr. Voss, you know, on follow up to that, Dr. Hampl mentioned, not focusing just solely on one metric, you know, BMI and those, you know, you really have to look at the entire picture. Do you find that the adolescents, do they do that or will they tend to focus in on BMI or one number in particular?

Michaela Voss, MD: I think it really varies depending on the culture that they live in, as well as the diet culture in the home and what's influencing the reason that they're coming into the weight management clinic. Unfortunately, I do think a lot of kids are focused on a number and get really worried about their weight, shape, or size.

And so, one of the things I think we do at the Eating Disorders Center and the Weight Management Clinic, together is like Dr. Hampl said, really focus on all those other factors. So a lot of times, it's us needing to bring out what those factors are and make them and their parents aware that health has a lot of different indicators and weight could possibly be one of many.

Host: Yeah, great point. As a general pediatrician myself, my experience is that those are really hard and fairly lengthy conversations to have because as you know, it's a dynamic, not just with the adolescent, but the whole family in doing that. So, with that, Dr. Hampl, what practical advice can you give to the practicing pediatrician about implementing these new obesity practice guidelines particularly in a busy practice where they're seeing a lot of kids per day?

Sarah Hampl, MD: I think one thing I would try to remember is it's a marathon and not a sprint. You don't have to do all the things that are recommended at once. In fact, really a slow, carefully thought out approach is recommended. And so, thinking about, what aspect of care and what aspect of the recommendations might you be interested in or your partners or your other clinic staff might be interested in taking on first?

And a lot of times it does start with how do I sensitively talk with a patient and family about their weight? There are lots of different resources now available through the AAP. They're almost all free, and they can really help you learn how to talk about it. And honestly, the more that you apply a more patient centered motivational interviewing approach, it's going to become second nature to you, and you're going to find yourself applying it for, you know, a lot of health conditions in addition to obesity.

So, taking advantage of what the resources are. I think the one stop shop for a of these uh, resources is www.aap.org/obesitycpg. And you can find everything from motivational interviewing to checklist for your practice to assess your capacity, there's a capacity checklist, actually, that goes through different domains.

Staff training, is your office environment sensitive and able to sensitively accommodate patients of a larger size? Who might be able to do what in caring for patients with obesity? Do you have an EHR that is set up to help follow patients regularly? Do you know where the community resources are to help families who might be interested in taking the next step?

What is your subspecialty network? And some of those things. So that's available there, as well as a lot of other tools to help guide your next steps. But I would say consider it's a marathon, not a sprint. See what you and your practice are most interested in addressing first, and know that there are a lot of supports for you to be able to improve your care of kids with obesity.

Yes, Michaela.

Michaela Voss, MD: So, Dr. Steele, what you're hearing from us is a lot of conversation, and I just want to pull together the concept of looking at the full person in the context of these guidelines and setting that stage up front. It's very important when you do your follow up visits that you also hold yourself to those guidelines, and you are not looking at just weight.

When pediatrician or primary care provider focuses just on the number and the change in that number, that's when the eating disorders can start to creep in and other unhealthy behaviors get missed. So, looking and discussing about how they're losing or maintaining weight, how they are changing their eating habits, what their exercise looks like and if it's appropriate or not, and what their body is showing, vital signs and any symptoms they're having. And so putting that together holistically at every single visit will help your patient succeed as well as prevent eating disorders.

Host: Yeah, so fantastic advice. And actually is a really good segue into that conversation about disordered eating. Dr. Voss, can you follow up on that, particularly with regard to the population of patients that experience disordered eating? Undoubtedly that's not even across different populations. I imagine there are disproportionate affected populations that have disordered eating. Can you expand on that?

Michaela Voss, MD: Yeah, definitely. When we're looking at those with more of a binge focus, so bulimia nervosa or binge eating disorder, we do see a higher rate in female Latino and African American females, especially with bulimia nervosa. We also know that anyone that's a gender or sexual minority, so that LGBTQ+ population is at risk for all mental health disorders, including any eating disorder.

Um, if there's a family history of an eating disorder, if there's someone who focuses in a weight focused sport, so like gymnastics or ice skating or wrestling; those kids are going to be at greater risk. If anyone's been bullied about their weight, they're going to be at risk for an eating disorder. And then kids that have a history of trauma are also at risk for eating disorders, including binge eating disorder.

Host: Yeah, great. Dr. Hampl, for the practicing pediatrician, a lot of times these kids are coming in for other reasons. They're seeing their pediatrician. What cues should the pediatrician be looking for that could indicate that a patient might be susceptible to a disordered eating process?

Sarah Hampl, MD: Well, I'm glad you asked. I think assessing for disordered eating in kids with obesity needs to happen. As Dr. Voss said, it really needs to happen at all follow up visits. And so clues that might indicate that, certainly if you see unexpected weight loss, even if a child is working toward getting to a healthier weight, we wouldn't expect a weight loss any greater than two pounds a week.

And as she said, you never want to validate or really congratulate a patient on weight loss until you find out how they are losing weight. So probing more, asking about, you know, looking for any skipping of meals for instance, or looking for excessive physical activity, asking about those things are really, really important.

There is somewhat of a challenge in primary care to find a short pragmatic tool that can be used, but there are some questions that can be asked to help you make sure that they're not going down the wrong track.

Michaela Voss, MD: Yeah, there's the binge eating disorder screen. There's also the SCOF, which is a longstanding classic screening tool. And there's a couple of newer ones too. There's the eating disorder screen for primary care physicians, which is validated in 18 and up and they're working on validating it for younger.

I really like that tool. And then for those of you that have heard of SPERT, there is an SPERT for Eating Disorders online, actually through the National Center for Excellence for Eating Disorders that can be utilized. So, yeah, there's a couple of different tools out there, but nothing that's quick that captured everything, but I agree with you, Dr. Hampl. I'm checking that growth curve and if they're losing or gaining weight that seems pretty fast and they're not in a weight management program or they're not seeing a nutritionist or registered dietitian, then I would really start probing.

Host: Yeah. Great. So, you know, I learned long ago, 90 percent of the diagnosis is made by history, but that means there is still 10 percent on the physical exam. Are there any specific physical exam findings that we might want to clue in on?

Michaela Voss, MD: Yes. And I think if I have to make one big point, it's that eating disorders come in all shapes and sizes. And so what a person's BMI is or what their weight is, is not indicative of an eating disorder. And so although the rate of weight loss could be a clue, the weight itself is not. So more importantly, whenever you go into starvation mode, you are going into a hypoactive state.

So, everything shuts down. So, your vital signs are going to look worse. You're going to have a heart, slower heart rate, a lower blood pressure, a lower temperature. Your GI tract is going to shut down. So, they're going to come in with lots of abdominal pain and reflux and constipation. They're going to get cold extremities because their blood flow isn't going to be good.

They might have worsening anxiety or depression, lack of focus, more tired. If they're doing any purging behaviors, you might see some breakdown of skin over their hands or some enamel breakdown, some sores in their mouths. I always check the spine as well. Sometimes if they're doing frequent exercise, they might be hitting that spine frequently enough to get bruising or on the bottom of their feet if they're exercising by moving their feet a lot through walking or running. Another quick tip that I often hear is that parents will come to me saying that their plumbing gets clogged a lot. So, and in that case, I really think a lot about vomiting. Either in the shower or something. And then if they're doing, if they have more binge eating behaviors, parents will often say that they find that foods are going missing quickly.

Maybe they go to their big box store and buy a huge thing of Little Debbie cakes. But something that normally would last a month is now only lasting a week, or they'll go into the bedroom and find wrappers hidden underneath the mattress or in the trash can. Those are also concerning behaviors.

Host: Yeah. Great pearls of wisdom on that one. That's great. Question for either one of you, maybe we'll start with Dr. Hampl is the family dynamic. So with regard to the, you know, we're focusing in on the adolescent and the patient, but there is a family dynamic. How does one address that family dynamic around food and also just around that child and how the parents are looking and trying to help the child? How do you approach that?

Sarah Hampl, MD: Yeah, and you're talking about a child with obesity that you're meeting for the first time, or even if you've known him for a while; the role of the family, even for an adolescent, can't be under emphasized and they can't make health behavior changes in isolation even if they're a teen.

It really is important to have that family support. So, also at the same time asking and respecting the family's cultural values related to food, related to family gatherings, body size, acceptability, role of physical activities. Those things are also important to understand. And, really ask is there anything that you as a family think that you would want to address first?

Again, the child in the context of the family. And so when we provide treatment, it's always in a family based context, whether that be in our clinics or in our group behaviorally based programs.

Michaela Voss, MD: Dr. Hampl, you bring up a really good point about being really inclusive with the family. I'm also wondering if there's anything that offices can do to be inclusive within their office.

Sarah Hampl, MD: Definitely. I'm glad that you asked. So, going back to what is the environment that the family walks into when they come into a primary care provider office? Is there adequate seating for instance, in the waiting room? Magazines are maybe becoming kind of a thing of the past with the electronic means. But do you have a bunch of teen magazines that depict unhealthy teens in them? What kind of message are you sending with that when they're seeing that in your office? Is your front desk staff welcoming to families of all shapes and sizes? When you go to get into the exam room, is it necessary to have a gown on, or is it okay for kids to be able to wear their clothes still?

What about weighing? Is it in a private location? You're not you know, announcing the weight to somebody else that is writing it down. So those are just a few of the things that could help families feel more comfortable and more accepted in the primary care provider office.

Host: Great advice. Drs. Voss and Dr. Hampl thank you so much for all that you do for the kids and families here in Kansas City. It is such an important subject both in clinical and in research. And so we thank you both for everything you do. I have one last question. As long standing Kansas Citians that you both are, I have two adolescent boys. They like to play this game called Would You Rather. I don't know if you're familiar with it or not, but we're going to play one round of Would You Rather. So you can only pick one. You're only allowed one. Would you rather only go to Chiefs games, only go to the Royals, only go to sporting KC, or only go to the KC Current? You can't go to any of the other three. You only get to pick one. Dr. Voss.

Michaela Voss, MD: KC Current. I got to support my women.

Rob Steele, MD (Host): There you go. All right.

Michaela Voss, MD: I love their new stadium.

Rob Steele, MD (Host): Dr. Hampl.

Michaela Voss, MD: And their food's cheaper.

Sarah Hampl, MD: Oh, good point. I'm going to choose the Royals. I'm a longstanding Royals fan. And yeah, that they've got my heart.

Host: All right. We'll pull for both of them this season. Very good. Thank you again, Dr. Voss and Dr. Hampl.

Sarah Hampl, MD: Thank you.

Host: That concludes episode here at Pediatrics in Practice. I want to remind everyone that you can claim your CME credit for listening to our show today. Visit cmkc.link/CMEpodcast and then click the claim CME.

Thank you again.