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Dr. Jones: When parents are faced with the diagnosis of cancer in a child, they are overwhelmed with the fear of losing their child. Overwhelmed by the medications and the surgery and the testing and the last thing on their mind is thinking about their child as a future adult with hopes and dreams and children of their own. But what are the options for fertility preservation?

Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.

Dr. Jones: Over the last 40 years the survival rate of childhood cancer has gone from 10 percent to almost 90 percent. In years past, our goals in the treatment of childhood cancers were just to get kids past the crisis of diagnosis to survival for five years and now we're thinking about long-term survivorship to adulthood with what a full life means for these children. This means thinking about these kids having kids. These are decisions made often by the parents because the kids are often clueless about having kids.

So, today in The Scope studio we are joined by Dr. Douglas Fair and Dr. Joe Letourneau. Dr. Fair is an oncologist at Primary Children's Hospital and co-director of the Huntsman-Intermountain Adolescent and Young Adult cancer care program. And Dr. Letourneau is a fertility preservation specialist at the University Center for Reproductive Medicine at the University of Utah. And thanks for joining us.

Dr. Fair, how do we approach parents and children about fertility preservation? They got a really sick kid, and they just want their kid to live to Christmas, but we want them to have a whole life.

Dr. Fair: I think you said it well in that. Unfortunately, at the time of diagnosis because of the intensity of a new diagnosis, the workup, the planning, the discussion in referral for fertility preservation can be forgotten or minimized. And I think additionally, fertility preservation counseling is complicated, it's nuanced, it's consequential. And particularly, for women, it can involve an additional procedure, and it can delay the initiation of cancer therapy and, in some cases, particularly for women can be costly.

So, it's a lot to know and it's a lot to talk about. And really it was with my own ignorance that I realized that I in my training, which is not different from other pediatric or adult oncology training, didn't get a lot of understanding about what the fertility preservation process is, not to mention, all of the different nuances of having that conversation with a child, with a teenager or with a parent. So, it really is a really difficult conversation.

And what we are finding out from data and what we can also say by intuition it's a super important conversation that parents really care about and they just sometimes don't know where fertility lies in importance when their child is diagnosed with cancer and it's our job as oncologists to bring that up and to describe that.

Dr. Jones: Right. Well, I remember in my own clinic when I'd see adolescents and I'd be approaching them and when the mother's in the room, the adolescence got her arms crossed and her eyes are rolling even though she's pretty sick. When her mother is out of the room, then I can actually have a conversation with her but it's complicated on this issue even talking about fertility or sex. Are the approaches different depending on the ages? Can you actually do this conversation and have technology for four-year-olds or is it mostly for teenagers?

Dr. Fair: It's a great question. I'll take the conversation piece first and I would just echo your hint that it is tailored to the patient. And that certainly includes age, maturity, but also the family dynamics and where the patient is and how well the patient feels.

And that's where it's just really important to be nimble and to be flexible but knowing that it's a super important topic that even if the parents or the child don't really want to talk about anything, certainly not cancer and not fertility or sometimes awkward things like eggs, testes, ejaculation, fertility preservation. These are really important topics that they will care about in their survivorship. And so I think that's a really important thing to state.

And to your other question about just the technology and what can we do now for patients, we typically break patients down into prepubescent or pubescent. So, meaning patients who have gone through puberty which is usually somewhere between the ages of 12 to 14 when patients go through puberty and then so older or past puberty or before puberty. And I'll let Joe talk a little bit about the options that we have for prepubescent patients.

Dr. Jones: Yeah. Joe, let's talk a little bit about let's say a 12-year-old or 10-year-old boy. So, he hasn't really developed or matured yet. Is there much we can do in that particular situation?

Dr. Letourneau: Well, one of the hallmarks of puberty is the maturation of the sperm and the eggs and the ability for them to eventually create a pregnancy. So, with young children, it can be difficult because we hope in the future that we can mature sperm and eggs from very young gonads but at this point, that remains an experimental process. It seems achievable but at this point, the gametes or the sperms and eggs that we can get from prepubescent children would not be likely to make a pregnancy so it would require a technology that can achieve that maturation outside of the body.

The sperm stem cells and the eggs that we are born with are not necessarily able to create a pregnancy, they don't have a fertilized ability in a sense. And that's a gap in our technology and research that we hope to close particularly for young patients who are prepubescent.

A lot of our focus in counseling is on education. We want people to know that even if there's not a proven treatment now, the door is not closed on family building in many ways. We don't want people to grow up and wonder if they can ever have a partner, wonder if they're good enough, wonder if they'll live a normal life. We want them to know that they have a lot of options, a lot of normal options to build a family. And sometimes that includes considering fertility treatment in the future, sometimes that includes considering donated eggs or sperm in the future, and sometimes it may include considering adoption as a very normal way to build a family.

Dr. Jones: Well, there are somewhere close to 400,000 survivors of childhood cancer living in the U.S. now, and they're trying to live their lives in ways that they now are survivors, hopefully, putting that thing in the past, "Oh, that happened to me in the past." So, that's really encouraging that we're doing so well these days.

The other encouraging bit is that really young kids, their ovaries and their testes are a little bit more resistant to chemotherapy. So, the younger the kids are the more likely they are to actually make it through with some eggs and sperm left. Do I have that right?

Dr. Letourneau: That's correct. A lot of what makes the sperm and egg cells susceptible to chemotherapy is the fact that later in life they, or the supporting cells around them, are rapidly dividing making them susceptible to chemotherapy, which targets rapidly dividing cells. Early in life when they're quiescent or sleeping, chemotherapy is a bit less likely to see them in a way.

Dr. Jones: So, I have some questions, of course, on the larger issues. But what have I not asked you about kids in the program, the oncofertility program for younger patients? Is there often a debate between the mom and the parents or are the kids mostly going along or the kids have questions too?

Dr. Fair: I think what is surprising, at least that I've found anecdotally, is that, well, once you break the barrier of talking about an awkward or difficult topic, families are super happy that you brought up that topic even if we are talking about a patient that doesn't have good fertility preservation options like we're talking about prepubescent males and females. And I think there's a couple of reasons for that and data support that. So, patients have told us in studies, in surveys that after they have been done with their treatment even if they haven't preserved their eggs or sperm, they feel that they were taken much better care by their cancer team if fertility preservation was brought up.

And to emphasize a point that Joe mentioned, just because we can't preserve eggs or sperm before cancer therapy doesn't mean that fertility preservation or oncofertility or thinking about family building is not an important part of their care and in survivorship. And that's again on oncologists to really realize that this is a really important feature of patient survivorship. And so as Joe said, there can be important timing considerations and different physiologic considerations to seeing a fertility specialist like Joe after they've completed therapy to see where exactly where are their fertility preservation options and having that conversation again even if at the beginning before therapy they couldn't preserve.

Dr. Jones: And I think that's been one of the unique things about the Huntsman Cancer Center is trying to look at the patient and the family in a really big way rather than just, "Oh, you have this cancer and you are your cancer." It's "You are this person, you have potentially this future, you are this family." And the Huntsman has done a really great job and the oncofertility consortium and the oncofertility program here has been trying to think big.

Dr. Fair: They really have. They've been incredibly supportive in adolescent and young adult cancer medicine which this falls is a big part of that with survivorship, which fertility preservation and oncofertility is a big part of that and then directly oncofertility. The University of Utah and the Huntsman have really just been super supportive since Joe and I started this program and it's really just been a series of yes, yes, yes that sounds like something that patients would really benefit from. How can we be supportive?

Dr. Jones: I think helping parents and their kids think about these options and providing access to fertility preservation technology is part of our mission. And I thank you both for being here and I thank everyone for listening to The Scope.

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Dr. Gellner: Kids, technology and obesity. What do these three things have to do with one another? I'll talk about kids using technology to help childhood obesity and if it's a good thing or not on today's Scope.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kid Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Childhood obesity is a significant issue, with the Centers for Disease Control reporting 12.7 million children and adolescents between the ages of 2 and 19 years being obese. It's no secret what the long-term effects of obesity are. With how prevalent it is in children, it's even more important to find ways to get kids active and help them take charge of their health. One way adults do this is with fitness and calorie counting devices, like a Fitbit for example. More and more children are starting to use these devices as well.

The primary goal of using technology like these devices is to help children do self-monitoring. It's actually a sneaky way of changing their behavior. Kids are naturally competitive, so by letting them track their activity in the form of number of steps taken or time spent on a certain activity, it encourages them to keep going and meet milestones. Kids get immediate feedback on how they're doing, another aspect that kids love about technology, and finding out how they are doing at any given moment is huge to kids.

Some fitness trackers even make it more fun for kids by giving them examples of how far they've walked, like telling them they've walked the entire length of the Eiffel Tower. It gives them a visual reference that they can understand and help shape healthy behaviors.

Using technology like this also allows parents to have the conversation with kids to emphasize healthy behaviors. Many kids use technology to sit and play video games, but when you use devices or apps which encourage kids to be active, it helps remind them. Think about Pokemon Go for example. It's a video game, but kids have to do a lot of walking to get to poke stops, to get more poke balls, to catch more Pokemon. Kids will walk for 30 minutes or more and not even realize how far they've walked or how much exercise they've gotten.

A lot of parents think that kids get a lot of activity at recess at school, and in some cases that's true, but for other kids they may just be sitting on the ground socializing and not being active at all. Kids need to have fun to keep active. When parents try to increase physical activity for kids, it often backfires. Putting a kid on a treadmill isn't as exciting as encouraging them to go out and play games they really enjoy.

The bottom line here is there are a lot of different technologies out there that can help your child meet their fitness goals and needs. What works for one child may not work for another. The most important thing to remember is to make whatever your child does fun. That's the main way to keep them active.

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Dr. Gellner: Kids pick their noses. It's gross, but it's normal as well. What can you do if you have a nose-picker in your house? I'm Dr. Cindy Gellner, and we'll talk about that on today's Scope.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kids Zone, with Dr. Cindy Gellner on The Scope.

Dr. Gellner: Nose-picking appears to be a habit that, although it usually begins in childhood, may actually linger into adulthood. If you find that hard to believe, consider that a study of adults in the 1990s found that 91% pick their noses regularly, and about 8% of them reported to eat what they pick. Parents are often horrified when they see their child pick their noses, or eating the boogers, or wiping the snot on anything nearby like their sleeves or your pants. It's socially unacceptable and unsanitary. I know, I'm a parent.

While you may not be able to stop your child's finger from digging for gold in their nostrils, you can teach them to be more discrete and to put their boogers in a Kleenex by the time they're ready for kindergarten. Nose-picking can also cause nosebleeds and introduce cold viruses directly to where they will end up having symptoms. Frequent nose-picking can even cause sores that will irritate their noses, and their fingers will go up their noses even more.

Kids also think gross things are cool. So if you tell your child, "That's nasty," they might actually do it more because it gets a rise out of you. If the nose-picking starts causing a lot of problems, such as nosebleeds or skin infections, talk to your pediatrician about things you can do.

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Interviewer: How to help your young child after a traumatic event. We'll talk about what you can do next on The Scope.

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Interviewer: Dr. Katherine Rosenblum is the director of the infant and early childhood clinic at the University of Michigan. When scary things happen to young children, we're talking about infants, toddlers preschoolers, what can you do to help them through that? Is this something that a lot of parents don't recognize first of all?

Dr. Rosenblum: I think it's something that people often overlook because we think young kids are really little, maybe it won't affect them so much, maybe they won't remember things that happened, and also because it's hard for them to tell us what they're thinking and feeling if they don't have the words for it yet. But in fact little kids are affected by scary things that happen in the environment or that happen to them. So we often think about how young kids actually do experience trauma or stress and what we want people to be thinking about is how we can help them to manage those feelings. I think how we can help them cope.

Interviewer: How do you define trauma or stress to that age group?

Dr. Rosenblum: Little kids deal with little stresses all the time. For example, starting at a new school, Mom or Dad is going to work and we have to adapt to separations. It's hard but kids can learn to manage that. It's a stress and it helps them learn I can manage little stresses.

Trauma, in contrast, is something that's so big that actually it overwhelms the individual's ability to cope effectively, and especially for little kids. When they're faced with something that is traumatic or really, really distressing, then what they need is a lot of help to be able to figure out how to recover from that and to be able to recover from that. It really requires additional support from outside.

Interviewer: So are we talking about emotional trauma exclusively or physical trauma as well?

Dr. Rosenblum: Actually, it can be a whole range of things. One of the most common traumatic experiences for young kids is accidents. They get injured or hurt. And that can be really scary and overwhelming and parents might see that after an accident they're afraid, they're more fearful, they're more clingy, that sort of thing, dog bites, things that can happen in the environment.

Interviewer: Falling off of a play set maybe even.

Dr. Rosenblum: Absolutely right. If it was really a scary experience, maybe they had a broken arm, or they had to have some sort of a medical procedure, those things can be really distressing. But with support they can really recover from that.

Big traumas are things that are just told really overwhelming to to the child. It might be witnessing someone being seriously hurt or injured, or really scary events that happen in the community. Those are things that we really think of as true traumas. They overwhelm that young child's sense of, "I can I can cope." It really creates a sense of intense fear or threat, danger.

Interviewer: Seems like we're talking about a wide range of things like from separation anxiety because a parent is going to work versus a traumatic accident. Are they all kind of dealt with the same way or do they require different strategies?

Dr. Rosenblum: The one thing that's sort of common across all of those things for young kids and the number one thing that young kids need when they're managing things that are challenging is the support and help of their primary caregivers, what we think of as their attachment figures, their parents. Young kids are totally dependent on their caregivers to help them navigate life's challenges, and whether those challenges are small or big they're turning to their primary caregivers for help with coping.

Interviewer: I'm sensing here as a parent a little bit of a struggle because on one hand, I don't want to over . . . because a little bit of stress and that sort of thing's good so I don't want to maybe overprotect or over . . . I mean how do you decide how much?

Dr. Rosenblum: It's really important to on one level follow your child's cues. So your child is going to be showing you, :I need you in some way," and parents have an intuitive sort of sense often of, "When my child needs me, I'm going to go to them and help them." Doesn't mean that you're going to prevent them from having to face challenges. Normative things like going to school, that's really important and you're helping them learn how to balance. But when young kids are experiencing something that a parent knows is really really stressful, then I think it's actually really important for the parents to sort of say, "Hey I'm here. I'm here with you. You're safe right now. I'm going to take care of you. I'm going to protect you"

Interviewer: And what does that interaction look like? Say a child falls off of a play set. You can tell the over the next couple of days there is a big fear there. My dad was a rancher. He'd say, "You get bucked off the horse you get back on". Is that the approach you take or is there a better approach?

Dr. Rosenblum: Let me sort of step back and share something with you that's sort of interesting. We often have people who sort of say, "Hey, I'm worried about spoiling my child. If my child is crying and I pick them up, is that going to spoil them?" What we actually know from the research is that when kids express feelings like being afraid or sad and they have parents who pretty consistently and reliably go to them and help them with those experiences, they actually end up as they get older being more able to cope with life's punches if you will, the hard things that come in life. They can sort of bounce back get up and do things better on their own as well.

So I think two things. One, we want kids to be able to try to sort of manage small things on their own. If your dad saw you sort of fall down and bump your knee, it might be totally appropriate to take a moment, sort of look and say, "Hey, wait a second, is he really hurt? Is he really distressed or is he going to be able to sort of bounce back from this on his own?" That's totally appropriate. But if he sees that you're really crying, that you're really hurt, and you're looking up, that's a time where we really hope a parent is going to say, "Hey buddy. You know I'm here for you. I've got your back. Come here and let me help you."

Interviewer: With an adult I might validate somebody's feelings a bit. "I totally understand why that was a scary experience." Do you do the same thing with kids?

Dr. Rosenblum: Absolutely. "That was really scary. But you know what? I'm here. I'm going to help you and you're going to be okay." Little kids really like to know that someone's there, someone's got their back, someone's going to scoop them up, give them a hug and then help them be able to sort of do that bounce, get back into normal daily routines and experiences. That's another piece that's really important here. I think the other part of your question was, "I don't want to over react." I don't think it's overreacting to really be asking how is my child managing, am I seeing . . . If something scary, something really big happens, use your child as your guide. Look at your child's behavior. Is your child looking more fearful, having trouble sleeping, a little bit more clingy? If all of those things are true then that's a time to give a little bit more. But if your child seems to be doing okay, all right, be a watchful observer. Use your child to help you determine what your child needs.

Interviewer: Would there be a point where you'd visit a counselor?

Dr. Rosenblum: Absolutely. So if your child is continuing to persist in showing more clinginess, looks very fearful, can't sort of do the normal routines, seems really distressed or you're just really concerned about them, trust your gut, talk to the primary and pediatricians are a great resource. They can help you sort out is this something that we can sort of wait and see and sort of watch and wonder? Or is this something where it might actually be helpful to get some extra help?

Interviewer: Do you have a resource if a parent's listening right now on their like, "This is great. I'd like to learn more"?

Dr. Rosenblum: There's a really wonderful website called the National Child Traumatic Stress Network and they have a website, NCTSN.org, and that provides wonderful resources for parents, for teachers of young kids about how to help kids manage really scary or big things. For smaller sort of things, the more every day sorts of occurrences, there are a number of resources that are available as well. The American Academy of Pediatrics has a website dedicated for parents and there's also a wonderful resource called Zerotothree.org. Again, lots of resources to help parents navigate life's challenges with young kids.

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Dr. Gellner: Playtime is fun time and there's a reason why it's important for development. I'll discuss the magic of play on today's Scope. I'm Doctor Cindy Gellner.

Announcer: Keep your kids healthy and happy. You're now entering "The Healthy Kids Zone with Doctor Cindy Gellner" on The Scope.

Dr. Gellner: We all remember a time when we had few obligations, we could play dress up like a princess or a superhero and spend our days creating our own magical universe. Then, life gets in the way. Those preschool years are called the magical years for a reason. That's when a child's brain is developed enough to imagine amazing stories, but not yet complex enough to understand reason and ask, "Can that really happen?" See, in their world of imagination, anything can happen.

Babies use their senses to explore their world. As they develop, they learn to understand how things work. "If I push this button, the cow comes out of the barn. Wow, I did that!" Now, as preschoolers, they take this knowledge and combine it with a growing imagination to come up with some fantastical ideas about why and how things happen.

Pretend play, like being a superhero, allows kids to learn problem-solving and the all-important skill of learning how to share. Self-control is a tough skill to learn and pretend play helps kids practice it as well as play out the frustration it creates. So how can you, as a parent, help encourage imaginative play? Rule number one, be a big kid and play. Go along with anything they come up with and keep away from those electronics. Let them play the old-fashioned way with dolls and blocks and trucks and anything that requires them to be creative. I personally am a Little People fan. Give them the chance to free time play all by themselves as well and with friends.

Reading to your child is a great way to get kids thinking, "Hmm, what comes next in the story?" It also promotes language skills so don't surprised if your preschooler becomes a little chatterbox; that's a good thing. The day will come when the magic ends. The princess tiaras sit on the shelf, the superhero action figures stay in the box. It's a bittersweet moment. Your little one is growing up and your child's brain is developing, as it should.

This time in childhood, sometimes called "the age of reason," is also when kids begin to form a conscience, differentiating between right and wrong and not just acting on impulse but because something is the right thing to do. So be sure to enjoy the magic while it lasts and have fun playing.

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Dr. Jones: The United States has an increasing rate of childhood obesity, so why can't we seem to improve on this problem? I'm Dr. Kyle Bradford Jones, family physician at the University of Utah. We'll talk about this next, coming up on The Scope.

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Dr. Jones: Childhood obesity has long been a significant concern in the United States. The rate of childhood obesity has increased three to four times in the last 30 years. Approximately one-third of kids are either overweight or obese.

So this impacts multiple areas of health, both short-term and long-term, for these children such as impacting their heart, their lungs, their joints, and the possibility of developing diseases such as diabetes. It impacts their mental health as well as many other things.

Now, over the last few years there has been shown to be some mild improvement in the rate of obesity among young children age two to five years, so there is some bright side coming with hope on the horizon. However, a recent evaluation shows that the United States has the fifth highest rate of childhood obesity in the world. Now, in markers like this we tend to be number one in the world. However, I think this really underscores the problem. If we are number five that means this is a really big issue across the world and it's not just us.

So why is our rate so high? There are multiple factors. We're going to touch just on three.

Number one, our culture. It's changed a lot in the last 30 years. Our kids and adolescents and us as adults participate in a lot of screen time; so television, computers, video games, phones. Many households have more screens than people. So spending so much time in front of a screen leads us to be more sedentary and leads our kids to be more sedentary and not getting the activity they need.

When you combine this with concerns about safety outdoors, as well as the availability and cost of healthy fresh food, this can be a very important thing that leads to obesity. Soda and junk food tend to be ubiquitous and extremely damaging to our health. They are all over.

Number two, and this can be a little more controversial, but advertising to children for junk food. Young children cannot tell the difference between an advertisement and a show, and small children are often unable to understand good food choices. Now, advertisers have been shown to very carefully study what are the most effective ways to target children to get them to take these products and that seems to be having a big impact on childhood obesity.

Number three, school lunches. This is something that we're getting improvements very slowly but are getting some improvements, big efforts by people such as Michelle Obama to continually improve the health of school lunches. Now, this can include many different forms such as eliminating vending machines, decreasing the amount of fatty food, increasing options that are healthy. But this is a big contributor to the problem of childhood obesity.

Childhood obesity continues to rise in the United States, making us one of the worst in the world in this marker. Our culture, certain advertising methods, and food exposures at school among many other factors all contribute to the problem. So let's hope we can make some changes as a society to improve the health of our children.

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Dr. Cindy Gellner: Hi, I'm Dr. Cindy Gellner. I'm a pediatrician at the University of Utah's Westridge Health Center.

Interviewer: Let's talk about childhood obesity for a second, one of your passions.

Dr. Cindy Gellner: Right.

Interviewer: Why is childhood obesity one of your passions?

Dr. Cindy Gellner: Just because I see a lot of it. It's a big, growing problem nowadays. We see a lot of kids who are overweight and actually kids that are normal weight seem really, really skinny but they're actually normal. We have such a high prevalence of childhood obesity now that it's just something I started doing routinely and then I did a project about it and it's just been something that I've been the specialist for at this clinic for the past three years.

Interviewer: Childhood obesity. Do you think that's one of the most important things facing our children today?

Dr. Cindy Gellner: It's one of the biggest problems that we're facing in child's health, yes.

Interviewer: Why is that?

Dr. Cindy Gellner: There's a lot of theories going around. The biggest one is you don't have PE in school as much as you used to. In neighborhoods there's a lot of places where kids can't go and play as much as they used to. Foods, obviously there's a whole lot more variety for foods out there and quite often it's expensive to eat healthy. So a lot of people can't afford to eat a lot of the healthy foods that would be better for the children.

Interviewer: We know childhood obesity, for those that have it, it's a threat. How prevalent is it among our children?

Dr. Cindy Gellner: A lot of kids. I would say in my patient population there's probably about a third of my patients who actually meet the criteria for childhood obesity.

Interviewer: Have you noticed that increasing over the years?

Dr. Cindy Gellner: I have, yes.

Interviewer: How do I know if my child is obese? Is there a definition?

Dr. Cindy Gellner: There is. The hard thing is, when you think about adults you think about obesity as having a body mass index of 30 or higher, and a body mass index is actually a math formula that takes height and weight into consideration and so for kids you can't just say a body mass index over 30 because it's going to change based on the gender of the child and the age of the child.
So on the graphs that we do for all children over age 2, there's a body mass index chart when we do a visit and we check their height and we check their weight. If a child is between 85th and 90th percentile on the body mass index we start talking about how their weight is starting to creep up there. Let's talk about ways that we can bring it down into a more healthy range.
Kids that are in the 90th to 95th percentile or even the 95th to the percentile we're like, okay, we really need to start talking more seriously about it because they are getting into the overweight categories. Children who have a body mass index above the 99th percentile for their age and gender technically meet the criteria for childhood obesity.
Genetics plays a big part of it too. You've got to figure out is the child obese because that's their genetic makeup, or are they overweight and they just have other risk factors like too much television, things like that.
So it's not as cut and dry as just saying, yes, your child is overweight and this is what we need to do. But we do have a lot of things that we can tell them that these are things that you can do to help increase the chance that your child is going to be a healthy weight and to help your child be healthy on the inside as well, which is what we strive for.

Interviewer: All right. So let's talk about this for a moment. A parent brings a child in and you determine that they're obese. What's the first step then?

Dr. Cindy Gellner: In the program that I do we have a very long conversation about weight. They'll actually come back for a consult with me, and if the child is old enough, usually we say over 10 but I've done it in younger kids as well, we'll check for their cholesterol, we check their sugars, we check their thyroid, although it's very rare that the kids actually have a true thyroid problem, and we just check to see what their overall health is. I've caught kids who have liver abnormalities because there's fat in their liver already.
So we do that and then we sit down and we find out: what is your lifestyle like at home? What are your eating habits? Do you eat regular meals or do you graze all day? Does your family eat together? Do you eat enough fruits and vegetables? You're supposed to have five servings of fruits and vegetables a day.
Do you watch a lot of television? You should have two hours or less of screen time, and that includes television, computers, video games, Facebook, things like that.
There's a lot of kids that are emotional eaters. They get stressed out or they're bored and they will sit and just eat even though it's not meal time and they're not hungry but they're bored so they reach for something to eat.
Then kids don't get a lot of exercise. During the summer you have a lot of outside things that they can be doing and during the school year a lot of them have PE or they'll walk to school, but they should have a cumulative of one hour of activity a day.
Then the biggest thing I find is kids are just shocked when they find out how many calories are in juice in soda. I actually have a chart that I give them where a soda and juice are actually called liquid candy because a 20 ounce regular soda has as much calories and sugar as a candy bar.
So they don't realize all this stuff. They don't realize the portions they're eating and they don't realize this until you sit down and you talk with them about their individual habits at that time and then they're like, "Oh, wow."
We just choose one small change to make at every visit because it takes about a month of them doing a particular change before it actually becomes part of their routine and then we just slowly see how they're doing. I do pick up a lot of kids that have insulin resistance where they have a lot of sugar in their body and their pancreas is just overloaded.
They can't make enough insulin for their body to use to get all the sugar that they eat turned into energy and whatever sugar is left over gets turned into fat. There's a lot of kids that have that. There's a lot of kids I find with high cholesterol at a young age, so we do have a lot of discussions about all that.

Interviewer: So it's more than just being overweight. You need to eat less, you need to get out and move around more. There are a lot of other factors it sounds like.

Dr. Cindy Gellner: Exactly, there are.

Interviewer: That's kind of an old-fashioned way of looking at it.

Dr. Cindy Gellner: Right.

Interviewer: All right. So after that first consultation, how often do you see those steps solving the problem, letting them know how many calories they're actually consuming, looking and seeing if they're stress eating, how much screen time they're getting?

Dr. Cindy Gellner: Right. Again, the child comes up with one goal. They can ask for my input, they can ask for their parent's input, but the bottom line is they're in charge. Giving them the autonomy to make these choices actually helps improve the outcomes.

Interviewer: So you give them that one goal and you see them a month later?

Dr. Cindy Gellner: Yes.

Interviewer: And then, generally, 90 percent of the time the problem is solved?

Dr. Cindy Gellner: Nope. No, no, no. We see them every month and if they have a slip-up, it's like, okay, don't get discouraged. Let's see where we can tweak things. We keep on them because quite often just having that reinforcement of, "You're doing a good job," or, "You know what, it's okay. It's the holidays. We all understand," and just say, "Okay, how can we get you back on track?" just having that support system there, the parents and the kids really respond to.

Interviewer: All right. So what are some other factors and we'll talk about these in future podcasts that might play into it? Kind of tease us, if you will.

Dr. Cindy Gellner: Genetics is huge. There is a lot of diabetes, high blood pressure, heart disease, things like that going around.

Interviewer: That you might miss in the first initial screening?

Dr. Cindy Gellner: Well, actually, we talk about that in the first initial screening. We ask about family history because that is such an important thing. You can change your eating habits, you can change your activity, you cannot change your genetics.

Interviewer: Okay.

Dr. Cindy Gellner: As much as some of us would like to, we cannot change that. But there are ways that by doing things on a more healthy level you can actually prolong or reduce the chance of you actually having those chronic diseases.

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