Let’s talk about weight

Measuring growth in children is an important part of a health check-up, as it enables early recognition of unhealthy weight trends.  It can also enable regular discussions around healthy behaviours.  Feeling comfortable to integrate routine growth assessments into clinical practice can feel routine, but what do you do with these measurements once you have them? In this episode, host Dr. Sam Manger and guest Dr. Danielle Carter discuss how to navigate those conversations with empathy and practical solutions. 

Dr. Danielle Carter is a GP with an interest in Public Health and was the Founding President of a grassroots health promotion charity in Toowoomba called Flourish PYO. Danielle is passionate about preventative health and lifestyle modification, Indigenous health, and public health initiatives focussing on nutrition and food security. She has now relocated to sunny Townsville and enjoys organic food growing, running, and spending time with her family. 

Transcript

[Upbeat music]

Transcript

Health and Wellbeing Queensland acknowledges the Yuggera and Turrbal people, the traditional custodians on the lands on which this podcast was recorded and the traditional custodians on the lands and waters on which you are listening.  We pay our respects to the Aboriginal and Torres Strait Islander elders, past and present, for they hold the memories of the traditions, cultures, and aspirations of Australia's First Nations people.

[Upbeat music]

Danielle [Speaking over music]: People just shut down. They don’t want to talk about that. There is too much baggage, so to speak, attached with that kind of terminology.

[Upbeat music]

Sam: Welcome to the Clinician’s Guide to Healthy Kids, a podcast series for health professionals brought to you by Health and Wellbeing Queensland's Clinician’s Hub.  I'm your host, Dr Sam Manger, and in this series, we'll be diving deep into the topics that matter most in childhood weight management.  We'll be talking to Queensland experts across a variety of topics, including sleep, disordered eating in higher weighted children, prevention, and healthy growth with healthy diets. 

Let's get started!

[Upbeat music]

Sam: Today we are deep diving into conversations about healthy growth.  Research tells us that Healthcare Professionals feel confident to take a child or adolescents weight or height but aren’t always sure how to then talk to the patient in a way that brings about effective change.  As professionals, we don’t want to damage our relationships with our patients or cause unintended harm.  But we also know that the earlier these changes are discussed and integrated into a family’s life, the more likely the child might avoid acquiring chronic health conditions later in life.  

To help us tackle this important topic today, we have Dr Danielle Carter joining us.  Danielle is a GP with an interest in public health and was the founding president of a grassroots health promotion charity, in Toowoomba called Flourish PYO. Danielle is passionate about preventative health and lifestyle modification, Indigenous health and public health initiatives focusing on nutrition and food security. She's recently relocated to sunny Townsville and enjoys organic food growing, running, and spending time with the family. Sounds like a kindred spirit, thanks so much for joining us, Danielle.

Danielle: Thanks Sam.

Sam: So please tell us a little bit about yourself and why you're so passionate about all of this great work that you do.

Danielle: Sam, I’ve been a GP for a number of years, and I've worked in a variety of different practices, from private billing through to Aboriginal medical services and then other bulk-billing practices that served other people in population groups such as people from refugee backgrounds, university students, and then others from a lower socioeconomic background as well.  And I think during this time I saw the gross disparities that income makes to people, that education makes, so a lot of those social determinants of health, and then, that's prompted my interest in public health and what things can be done at a broader level to, kind of, influence people’s ability to access healthcare and all of the tools that they really need to live a healthy life. 

We've started a free open access community garden that people can access seven days a week at any time to improve their diets. And then there's also been initiatives as well with that, of educational cooking classes with children and adolescents doing things such as character book readings that involve some food or different colours, and incorporating that within the garden itself so that kids are not afraid of green foods or they're not afraid to try things that might smell different to what normally comes in a packet. So, trying new things to kind of break down those traditional barriers that people have to healthy lifestyle is something that I'm really interested in.

Sam: I'm inspired already. My first question is as a GP, what do you see as your role in healthy growth, but already I can sort of see the context of your answer, where clearly, you're an individual GP and you're optimising and developing your skills right there. But you clearly think also systemically in the sense of the microenvironments, and whether it's, you've mentioned the communities and schools and gardening programmes, and also for public health macro level, so you're clearly thinking at each tier, which is wonderful and trying to intervene in each tier, which is where a GP actually can do and be quite creative in that.  So excellent! But what's your formal answer to that question?

Danielle: Well, I think as a GP, we're really privileged to be in a position where we can walk through life with families and that role is really holistic. I think we make our best impact when we're focusing on the person as a whole and understanding the context in which these families operate as well. And yeah, our  goal really is to encourage every person within that family to be in the best state of health that they can be. And that's done through prevention, I believe, because through that early intervention, and having an approach to that physical, psychological, social, spiritual, and cultural wellbeing of a person, we can then work with them. It has to be collaborative, where you are developing solutions that they themselves feel that they have some control over and moving away from that very paternalistic, prescriptive type of healthcare.

Sam: Yes, absolutely. No, you're right that collaborative and whole of person approach is one of the great rewards of what we do. But also as you said, it's not necessarily having to focus on one specific thing but looking at the whole person and seeing positive, enjoyable, beneficial change then begets other positive and beneficial change. So, well done! However, many clinician’s can struggle with some of these topics we're discussing today around raising the topic of weight, for example, in consults. So why do you think that is, and how do you approach it?

Danielle: Well, I think, generally health professionals by nature are empathic, and they're a compassionate bunch. So really, I think it's that fear of causing hurt or harm to children or their families and disrupting any relationship that they might have had with them in the past. But I suppose there's also not feeling ready for that conversation, not feeling like they have the skills to be able to take that conversation to the next level. 

And for some, it might be a small proportion, but for some there's also just a feeling of hopelessness, like there's not really any point in trying, because the problem's too big or they've tried it before and it hasn't made any difference to a family, so feeling like there are roadblocks along the way that are just too hard to overcome. 

Yeah, and I guess all of us go through those, have those experiences that we refer to and that makes us fearful that even wanting to try again, which I guess is for families as well, they may have been through this journey or had this conversation with someone in the past that didn't go well and they're dreading being put on the scales or dreading that conversation being brought up again. So, I think it comes from both sides and from the clinician's point of view, we need to acknowledge how we're feeling about that because often if we don't raise the topic in a sensitive way, and we don't assist the families in making those changes, or helping them in their next step along thinking about those changes, then we're also doing harm by not raising that. 

Sam: Yes, absolutely. And there's two elements to this; one is on the patient side of things, and the other thing is on the clinician side. 

To start with the clinician side, just because you mentioned there that we can become, I don’t think you used the word, jaded, but that was the sense of it, is that we can sometimes not get the response we were hoping and we can become, have less hope over time or hopeless as you said.   So, what's your antidote? Because you've obviously been sitting in this area, been reflecting, been practising this. Like everyone you would have interventions and experiences where patients haven't turned out in the inverted commas, way you had hoped, but you still remain hopeful, proactive, passionate, clearly. So, what's your philosophy that helps you through?

Danielle: The evidence tells us that if we don't do something, then the outcomes are poor. So, we have a responsibility to continually try, and I believe that everybody is capable of change over time but there are so many things going on in people's lives that we need to be aware of that as well, and but just not give up hope because at some point they might change their mind. At some point they might have an experience that actually crystallises the fact that they…they may need to change, or that they may need to assist their child to change, whether that be someone in the family is diagnosed with diabetes and you can, I guess, find a common ground in concern for wanting to stop this happening to other members of the family. 

It really just comes from a genuine concern for patients as well and raising the awareness within themselves of a concern that maybe they're not acknowledging.

Sam: So, humanity, empathy, duty of care, as you said, and being inspired by the by those wins that we do get along the way. 

We’ll be back after this short break.

Community message [narrated by woman]: Deadly Choices empowers First Nations people to make healthy choices for themselves, their families, and communities – to eat good food, exercise daily and to stop smoking. 

Deadly Choices also encourages First Nations people to access their local Community Controlled Health Service and complete an annual Health Check – normalising the idea of seeing a doctor not just when sick, but to remain healthy, access support, and prevent or better manage chronic disease.   Find out more at deadlychoices.com.au

Sam: And now back to the show. 

Now this brings me to the patient side, because in our first episode our guests discussed how we can complete accurate and routine growth assessments and the importance of BMI trends to identify healthy and unhealthy growth. So, when it comes to a consult, how do you embed these growth assessments as routine practice in your own clinic?

Danielle: Well, it comes from, I guess it’s made easy for us in some ways, right from the beginning, where children are attending for their vaccinations and the height, weight, head circumference, those kinds of things are a routine part of what's done. And very important during those first couple of years. 

To continue that, I think, as the child ages and they they're not coming in for those routine vaccinations, but they're attending with a sore ear or a cough or something like that, that as soon as they come in through the door, you're doing those routine height, weight measurements as well, so that families feel like, oh, this is just what happens when we come to see the GP. And so, we're normalising that rather than stopping and only starting when we see that that there may be a concern with weight coming through the door. I think then if we're if we're only doing it when we see that there might be a problem, that's when stigma starts to come into it. So doing it right from the word go, every appointment, adult, child, whoever it might be, if you haven't seen them for a while, doing those regular checks is really important. 

Sam: So, as you're saying, normalising it, making it sort of default practice; there's no difference between you or any other person but this is just what we do. And as I've heard multiple times over my career in making weight a vital sign, you know, just as we would take a blood pressure, we do weights just normal, there's no judgement or association connected with that. 

So, you, you clearly do your growth assessments as a part of routine health assessments for children. So, are there any other aspects within those routine health assessments that you would do? And in specific, if a child is living with a higher weight; is there any other assessments you might complete?

Danielle: Yes, so the other things that that I would routinely do would be having a discussion with the parents or caregivers about other parts of healthy growth and development as well, that, have they noticed any issues with their vision, with their hearing. Asking questions about behavioural concerns that the parents might have, about sleep, physical activity, all of those general things that are kind of, you know, the snap for adults, but for kids, just so that you can get a bit of an understanding about what life is like for this family and for this child, and then that can just highlight areas that you might need to ask more sensitive questions about, at another time or later in the consultation.

Sam: So you frame it around obviously what is the medical needs and the medical indications and then the lifestyle factors. So obviously there's the food, the movement, the sleep, and then there's the social components of the network, which they exist in family, et cetera, the dynamics and the and the culture obviously that they may be part of. 

So, I'm curious now to go down the clinical path to think about the causes and consequences for a higher weight so given our listeners are clinicians and GP's and other health professionals, what do you consider when it comes to differential diagnosis when you have either child or adolescent present to you with a higher weight?

Danielle: Yes. So, the vast majority of children, as we know, it's likely going to be an imbalance in their energy input and their energy expenditure as well. So that's going to be for most children. However, there are some medical conditions that are associated with childhood obesity, whether it's causative, or may sort of be the result of an undiagnosed condition that we need to be aware of. 

So, there can be the chromosomal abnormalities, that most people know about, like Prader-Willi syndrome, children with Down Syndrome. But then there's some of the endocrine causes; Cushing syndrome, hypothyroidism, gonadal deficiencies, issues with growth hormone deficiencies as well. Some medications can also cause weight gain, so medications used for migraine therapy, antihistamines, antiepileptic medications, sedatives, haloperidol, risperidone, tricyclic antidepressants, all those medications which probably more apply to adolescents, but something definitely to keep in mind. 

And then there's some of the psychiatric issues as well; disordered eating patterns, depression, psychogenic polyphagia, conditions such as that, that just lead to disordered eating. 

They are more prone to slipped femoral epiphysis, so if they're presenting with the knee pain or hip pain, that's definitely one of the differentials to consider. It can cause type 2 diabetes, early puberty, polycystic ovarian syndrome, and earlier, so earlier growth spurts as well. We've got all the cardiovascular complications, which are fairly obvious, similar to in adults such as hypertension, hyperlipidaemia, early heart failure.  

There are the hepatic consequences as well, such as fatty liver disease, gallstones, all of those things that we associate with increased triglycerides are an issue, and then we've got the psychological and social problems that stem from being above a healthy weight as well, such as impaired confidence, lower educational attainment as well is actually an outcome of childhood obesity, which is really sad when we know about the long term implications of lower educational attainment as well and what that means for the next generation. And, of course, we know that for children who are above a healthy weight earlier in life, they have a much greater chance of being overweight in adulthood as well when a lot of the problems sort of compound themselves and start to show up in symptoms and conditions that could have been prevented.

Sam: Thank you for that thorough list. And as you say, some of those can be quite insidious because, for example, you mentioned sleep being impacted there and clearly sleep can be both a cause and consequence of weight changes but in particular, if we look at higher weights leading to things like obstructive sleep apnoea, which then can lead to things like fatigue during the day and...and that can present as poor concentration, behavioural concerns, and so people might actually be presenting with psychological concerns, but we need to sort of follow that thread and look at the whole person and say, ‘okay, well, how's your sleep’ and how's the other aspects and that may end up taking us to a conversation around healthy weight. And likewise, it may not. But a good thing to do is to do that thorough assessment and consider those differentials within that. 

And coming back to the conversation, how would you approach the conversation with a family? If you can see the child is gaining weight too rapidly or they have a weight in the high unhealthy weight ranges, how do you broach that and commence that?

Danielle: It's always important to start with asking permission from the parent or the carer to discuss their child's growth and perhaps lifestyle as well. So, normalising the weight and height assessment as being part of that standard approach, which we've already talked about, and focusing the communications on the benefits of healthy lifestyle behaviours for the whole family rather than on the weight of the child or the adolescent. So, you might say something like, ‘Part of my role as the GP is to ensure that your child is growing well and is in the best state of health that they can possibly be in. Do you mind if I assess your child's growth and development today and this might involve taking their height and weight and plotting it on a chart, and then maybe having a discussion about some of these things that will help your child to be in the best health now, but also in the future. Is this something that you would be interested in?’ 

So just those open-ended questions that give you permission, avoiding discriminatory terms or stigmatising terms, such as overweight, obese, or too heavy. Those things in the literature have shown that people just shut down, they don't want to talk about that. There's too much baggage, so to speak, attached to that terminology and so we need to move to a more positive framing of those conversations and that in some research has shown that families are much more comfortable and accepting of terms such as above a healthy weight, and that's one that I like to use because it's focusing on the healthy side of things, not the negative connotations associated with terms that we might have used in the past.

Sam: We’ll be back after this short message

Community message [narrated by man]: Unhealthy weight is one of our greatest public health challenges. Two in three Queensland adults, and one in four children, live with overweight or obesity. We need to shift the dial. That’s why Health and Wellbeing Queensland has created Clinicians Hub for you, our clinical workforce. Clinician’s Hub is a digital ecosystem of initiatives, resources, and tools, including this podcast series for multi-disciplinary health professionals to support best-practice prevention, identification, treatment, and management of overweight or obesity and it offers a variety of clinical tools and training to help you transform health for children, adults, and families.  Find out how Clinician’s Hub can help you at hw.qld.gov.au/hub

Sam: And now back to the show.  

Okay, so given that we're focusing on health gain and not weight loss, as looking at the whole person, and obviously weight loss may still be part of that.  What about for adolescents that have, say, extreme higher weights that we would classify as morbidly obese, do we still, are we still just aiming for health gain or are we going to be more direct about that?

Danielle: Yes. So, suppose for children who are above a healthy weight, but it's not sort of in the extreme categories, we focus more on weight maintenance rather than loss, and that's recommended for all children and adolescents, with the plan that if they're not gaining weight over time, that their BMI will normalise as they grow. And so, trying to introduce those lifestyle changes with frequent check-ins, you know, at least every three months with health professionals, and a team of people, if that's something that's available to people. 

And so, for those who are in those extreme higher weight kind of categories, and particularly those who have some of those secondary complications of overweight or obesity, and they are post-pubertal adolescents, then, if the usual lifestyle interventions, referrals to, you know, dietitians, psychologists, even paediatricians, have not been effective, then more intensive interventions can be considered. Things such as the low energy diets, particular medications, or drug therapy and you know, in the worst case scenarios, bariatric surgery.  Those things are the very last option for what's recommended and that would need to be everything else has failed.

Sam: Do you ever find that parents or families get defensive when you start raising these topics?

Danielle: I mean, there's always the risk of that happening, particularly if you don't have a long-standing therapeutic relationship with the family. If they don't trust you, and you, you don't have the times where they know that you that what you've done has worked for them, in terms of improving their health.  

But I think if you approach it with compassion and understanding, without bias and you genuinely are communicating concern, and you're choosing terminology that focuses on partnership, and overall health and wellbeing, not just on the weight, then people, they are always far more receptive to that. They can see that you're trying really hard not to be offensive or negative about this, and that you actually care and are wanting to make life better for them.

Sam: And given the limits of being a GP, we're both a GP sitting here, we’ve got, we're lucky to have some time today to talk, but typically that's not something we've got in huge amounts. So, if you've only got a short consult booked, would you try and discuss your weight concerns then? Or do you get them to come back another time? How do you practically incorporate it into your day-to-day work? 

Danielle: I think if you've identified that there's definitely a need to have that conversation in future, assessing the family’s kind of receptiveness to that or their stages of where they might be in that stages of change, kind of flow diagram, and raising it as something that you would like to be able to discuss with them in future and why that would be. Then having time set aside where they're coming prepared to maybe have some of those conversations is definitely worthwhile. But I think it does depend on the family as well.  If you know that there's someone who engages well with healthcare, and you've got the privilege of being able to have them back then yes, you do that. There are some circumstances where you think, we only see this family once every 12 months, what can I possibly do that might make a small change today, to send them away with, in the hope that, you know that they would come back for another appointment.

Sam: And a little bit of nuance here, but do you, do you leave the child in the room to discuss these things or do you find you like the child to be absent during these sort of conversations that may be more sensitive, and you obviously don't want that flowing on to the child, but at the same time we’ve got to involve them. So how do you, how do you balance that?

Danielle: Yes, I think I'd probably look for feedback from the parent when you're starting that conversation. But if you're being really respectful in the terminology that you're using, and you're not focusing on the actual weight itself, but more on the solutions and the lifestyle. I think getting the child involved with those conversations is really important, and then you can kind of try and encourage that, I guess, relationship and, what's the word I’m looking for; accountability, perhaps, between the parent and the child. You know, if you, you've asked the child what sort of activities you love to do or do you get to go to the park very often, and they say no, but I could do it on Wednesdays. You know, you then look to mum and say is something that might be possible and make a bit of a plan that way to even just add one activity in once a week as the beginning of starting that process. Yeah, I don't think I've ever asked a child or an adolescent to leave the room when talking about weight with a parent.

Sam: And it's about normalising that too, and by normalising it, we're reducing the stigma in the process as well. And as you said, it’s a collaborative, management plan, you know the good old, shared management plan terminology, but you can check it off with most, as we said smart goals, specific, measurable, achievable, realistic and timely. You can say, well is this, achievable, is this realistic, when are we going to do this, with everyone in the room, then you're much more likely to get genuine buy-in as opposed to faux agreement.

Danielle: Yes, completely agree.

Sam: And now the flip of this and I think we kind of answered it, but I'm curious nonetheless, do you sometimes get the parental carer to leave the room and just talk to the child or adolescent by themselves?

Danielle: No, not really, unless I'm sensing that the adolescent is not being completely open or honest or might not be willing to share something. If I'm getting that vibe, then I will just politely, again normalise, and say to the parents ‘look, so and so is now at an age where they might really appreciate some autonomy in discussion, and I just feel it's really important to have a chat with them by themselves. Would that be okay, and yeah, and then ask any questions that I do feel they may not be openly answering honestly once the parent has left the room.

Sam: I guess that’s the art of medicine really isn’t it, and it's an art of what we do, is being able to sense the shifting dynamics in the room, the relationship between different people in the room and say, OK, I'm getting a sense here that I'm not getting the full story and maybe then it would be good, especially with adolescents, and by that I mean those who are sort of 14 and onwards, who are feeling their own autonomy, wanting to express and challenge, perhaps authority in some degree, which is their parents and find new peer circles. Then it can be helpful sometimes to hear what they've got to say when they're not being watched. 

Danielle: Yes.

Sam: And sometimes it can be, their relationships can be very open and that's not necessary, but sometimes it could be useful to, to hear what they've really got to say.

Danielle: Yes. And I think too, being able to pick up on some of the dynamics between adolescents and parents as well, in terms of are their false agreements that they hold or are they myths that they kind of share around food behaviours or the physical appearances or things like that.  Sometimes it's really important to be able to pick that up because I think changing the way that we speak about weight is really important and if parents are using negative words or negative phrases with their adolescents, being able to just sort of gently correct that or change that, how that conversation goes, can definitely make a difference to how they feel and the way that they speak about this at home in terms of what's the goal. The goal is not just weight loss. The goal is actually for us to be healthier, to be feeling happier in ourselves and having better mental health that comes from healthy diet and exercise, to be feeling more energetic, to be feeling more confident within ourselves, all of those things tend to be probably more outcomes that teams are more focused on rather than the weight as such.

Sam: Yes. So, making those outcomes relevant, and personalised to the person, to the family that you're working with.  Now, when we look at some of the literature here, some of the concerns that health professionals raise is that there's a fear that the family will disengage with them, or as a clinician, or maybe the medical practice, or even sometimes, you know, western medicine, because of being challenged around some of these points we're talking around here, so sort of, narrow focus on weight, for example. So how do you try and make sure that doesn't happen?

Danielle: I think we've sort of discussed really our approach is what matters the most in that, finding those common goals. Enhancing understanding, and the importance of why we've raised the issues that we have. 

Highlighting some of the myths that are out there as well. There's so much on social media that’s...that's rubbish! There’s all of the fad diets and those things that people may have tried and feel that that they've made no progress with them, and actually highlighting why they don't work, that the gains are made through these small changes that we can incorporate into our lives. And we do what we can now and then when that's our normal, we add something else in and then that becomes our new normal, and very slowly over time we start to transform our lifestyle and our behaviours. But it hasn't felt like it's been really hard work. And that might look like changing your white bread to brown bread and that's it for a month or so. And then once you're doing that off the grocery shelf without even thinking about it, you might start grating up a carrot and putting that into your normal spaghetti bolognese. Once that's your normal, you add one more vegetable, just slow changes that don't cost a huge amount to implement and don't take a whole lot more energy because families are under immense stress these days. You know, both parents are working or they're single income families. 

There's mental health stuff that's going on, there's just so much pressure on them, that the last thing they need is a major prescriptive list that adds more pressure and guilt if they can't do it, to the struggles that they're already carrying. And so, if we can make it as simple as possible and they can go, actually that's achievable. I can do that then if we're changing them feeling like they can't do anything to actually starting to empower them to make some changes that are going to impact themselves and their children's long-term outcomes.

Sam: So, from your experience, those easier, you could call them small, but that's all relative, but easy wins, and early wins, are quite important so that people get a taste of that, inverted commas. And then are engaged with the process as opposed to having the bar set too high; it’s unrealistic, it's unachievable, and then just that spirals on the feeling of well, what's the point, I'm just going to disengage.

Danielle: Yes, absolutely. I think finding one thing that they can go away with and change that they've selected, with your input, is the beginning of something really, really good.

Sam: Yeah, wonderful. Now my last question is; now when it comes to management, it's very important for us to remember that, for those where we are aiming for weight loss, as you said sort of say, post pubertal adolescents for example, where that modest weight loss can make a considerable difference, you know, we're not aiming necessarily for 30-40% of weight, you know, excess weight loss, we're looking for 5 or 10% of weight loss, can make a profound difference to peoples cardiometabolic risk profile, improve as you said, their blood pressure, and sugar and insulin sensitivity and fatty liver improves. So, it's important to remember that when we're aiming for these things, a realistic and achievable goal is actually a very healthy goal. And I wonder with you, when you're considering management and this intention, what's your overall framework or principles of management that you remember in your mind in clinical practise?

Danielle: I think going back to the basics of the 5A's, gives us a really good structure to work with, with any consultation and it applies here as well. So, ask, you know, do your history examination, maybe ask them whether this is something that they're aware of as well, that might be an issue for them and their family. Or assessing their…Assessing is the next, so doing that thorough physical examination, is there a need, asking yourself is there a need for further investigation in this case? Do we need to exclude some of the medical causes of overweight and obesity? And do we need to go looking for some of those complications, those metabolic risk factors as such. Then moving on to the advise stage, we're educating them about the benefits of these lifestyle changes, not just for weight but for all of those other things that you've mentioned. 

And then assisting them to develop a plan that will work for them, as we've mentioned earlier. And then arranging, so do they need referrals, do they need a chronic disease management plan to make access to allied health more affordable for them, arranging review and monitoring, and making sure that they're on board with this whole process as well.  It's a complex problem and there are so many aspects to it, which is why it's good to have that multidisciplinary team as well to make sure that all aspects are being covered.

Sam: I like the use of the 5A's there; the ask, assess, advise, assist, arrange. The way I think about it definitely falls into that too. The ASK is a great, as we've said numerous times throughout our conversation today, is a good basis of all curiosity and rapport and relationship building, and that therapy relationship makes a difference for multiple reasons.  Then, as you say, assess; consider those differentials, consider those causes of what we're dealing with, and then consider the potential consequences which can be biopsychosocial. 

That then leads us to investigation if it's necessary, and we want that to be rational, of course. And then moving on next, you said, with advice to management, that's lifestyle, and you touched on mindful eating there, and other aspects. So clearly psychological care, it can be a huge part of this, as both the causative or consequence to consider and then as you mentioned earlier, around potentially pharmaceutical, or procedural processes. 

And then Assist; so, refer and that can be in allied health direction; psychology, Dietitian, Exercise Physiologist, all those excellent experts. And also thinking about the whole person, so we often talk in adolescents around the HEADS acronym, you know, home, education, activities, drugs, sexual activity, safety and those things. So, considering the whole person might be a good opportunity.

And then, as you say, arrange to arrange follow up, which is really important for all of these healthy lifestyle behaviours because people will often need regular touch points for support, but also just to know that we're there to help them problem solve if that's necessary. 

So, I like that! Using the 5A's in that regard, I think that's really practical, really useful.  Right! Well, thank you so much for your time and expertise today. It was much appreciated and continue the great work!

Danielle: Yeah. Thanks Sam.

[Today we've been talking to Dr Danielle Carter. For more information on today's topics, visit the Health and Wellbeing Queensland website at www.hw.qld.gov.au. We'll see you next time on the Clinician’s Guide to Healthy Kids.]