48. Cherie Chu, MD: Lifestyle Medicine & Wellness in Pediatrics

Hello everyone, I'm Dr. Darsha, and I'm Dr. Altamash Raja, and welcome to Medicine Redefined. A podcast where we will explore the often overlooked but necessary components of health, what we consider to be the fundamentals. We will investigate topics and practices that can give you and your patients the best chance to optimize a healthy lifestyle. It's time to move the needle forward and put the health back in healthcare. John F. Kennedy once said that children are the world's most valuable resource and its best hope for the future. I couldn't agree more, especially if we're able to keep our children healthy and teach them about healthy interventions in their lives. Our guest today is Dr. Shari Choo. She's a board-certified pediatrician who is a certified diplomat of lifestyle medicine. She is a native Californian receiving her bachelor's of science degree in biochemistry and cell biology at the University of California, San Diego, and her medical degree at the University of California, Irvine. She completed her pediatric residency at UCSF. She currently practices outpatient pediatrics in a large multi-specialty medical group located in San Diego. She incorporates her knowledge of lifestyle medicine into her daily interactions with her pediatric patients and their families. She is also the founder of the website, Wellness Pediatrician. In today's episode, we delve into all things lifestyle intervention for children. Now throughout all of our episodes so far on medicine redefined, our focus has really been on adult medicine. But finally today, we have brought on an awesome pediatrician to talk about all those things that we want our children to learn at a young age. We talk about optimization, prevention, how we can have children develop the way that they need to. We talk about what plant-based diets might mean in children as well. We also talk about what parents can do, right? What are some of those common pitfalls that they may make while they parent and how we can avoid those? How can we incorporate better habits for our children to follow? And then near the end of the episode, Dr. Chu shares many good resources and books that she recommends for her parents and patients as well. Enjoy the episode. All right. Dr. Chu. Welcome to the show. Hi. Thanks so much for having me. So so excited for this conversation. It's been coming for several months now, right? We try to really connect on all our schedules, of course, while I'm busy. But so excited to finally have you here. You're doing so many cool things. We're going to dive a little bit into the pediatric specialty today because that's what you do day and day out. So I'd love to start with your journey kind of into medicine and really picking the specialty of pediatrics. What was the motivation or inspiration behind that? Well, apparently I actually wanted to be a pediatrician since I was like in fourth or fifth grade. I found some old essay I wrote way back when I had forgotten about that. So when I went to med school, I actually thought I was going to go into OB or family medicine and I even put my P's rotation last because I was like, Pediatrics is just colds. I don't want to do it. So I went through my rotations. And then during my OB rotation, I kept wanting to follow the baby. I didn't want to stay in the room with them while I kept wanting to follow the baby. And then I realized I'm like, oh, I think it's actually Pediatrics I want to do. So I got to my pediatric rotation realized, no, it's not just cold. I mean, that's a part of it, obviously, but it's not just colds and I loved it. I love kids. I love getting kids fresh from the start and kind of being able to start without any preexisting things going on with them. And then the other part of Pediatrics I really love is working with families. I mean, you just form this connection with a family and you get to watch their kids grow up. And I mean, I've been practicing long enough that some of my patients that were teenagers when I first started are now having children. And so I'm not taking care of their children. And then one of the older physicians in my practice got to the point. I think he took care of three generations, which is pretty cool. So yeah, so I love all of that about Pediatrics. You know, it's really funny that I think one of the knocks on Pediatrics is usually saying that, hey, you have two patients in the room, right? You've got the actual patient, right, the child or teenager, whoever it might be. And then there's one parent, maybe two parents, so. And I also find that to be the case with geriatrics, right, because it's full circle. So as parents get older, you know, you're really kind of providing care for the whole family. You're making sure you're addressing at least a good clinician is you talk a lot about or you have your own company called, is it wellness pre-dirtition, right? Wellness pre-dirtrition. Mm-hmm. What's that? What's that about? So I kind of had a journey into lifestyle medicine and I think your listeners might be familiar with lifestyle medicine. But I found out about it a few years ago. So kind of how it all started is I had twins about 10 years ago. And it was around a time that I had lost my mom to breast cancer, just really like less than a year before they were born. So my journey into motherhood wasn't easy. And I was working full time in Pediatrics, trying to manage the babies and not sleeping. And it was rough, it was really rough. And honestly, I kind of got to a place where I started to feel some burnout. And it let me down a road into learning a little bit about culinary medicine. I went to the Healthy Kitchens, Healthy Lives CME. And that was the first time I kind of learned about this whole concept of food as medicine. And I loved it. And interestingly, I was never somebody who really cooked that much prior to having children. And I knew that when my kids were starting to eat solids, I'm like, I want them to eat healthy foods. I didn't really know that well like how to prepare the foods. And so the culinary CME was great because it taught me like how to prepare food that I wanted to be feeding my kids. So fast forward a few years, and I learn about lifestyle medicine from all places from like a physician Facebook group. And then I learned all about it. And I'm like, oh my gosh, this is actually how I want to practice medicine. I mean, immediately I looked into certification as soon as I learned about it because it was just such a great fit with how I want to practice medicine. And so I got certified in Lifestyle Medicine in 2019 and really realized like with Lifestyle Medicine, I'm in the member interest group for pediatrics for the ACLM. But like the content in the certification and all of that was, and at the conference honestly, like really adult oriented. But the truth is is that these habits have to start when you're a kid, right? Like we're habits you have as a child carry with you when you're an adult. So I started the Wellness Media Church in as an outlet to help both pediatricians or just any health care provider who takes care of children. And also parents like have resources and information about specific lifestyle medicine and how that contributes to wellness and children. And also I just wanted to place this in my patients too if I said like, hey, there's a recipe. I want you to try, go to my Instagram or go to my website and you can find it. And so it's been kind of a nice thing to have on the side as a way to really just put lifestyle medicine and pediatrics out there. Yeah, absolutely. You know, if you take a look at all of our guests, you know, that do lifestyle medicine, I think all of them have a story that they can connect to, you know, at least with why they go into lifestyle medicine. You know, whether it's burnout in your case, whether it's a family member being sick, whether it's their own personal journey with, you know, losing weight or just wanting to get more healthy. So, you know, that's definitely something common that we're seeing amongst people who really want to go into lifestyle medicine. And a lot of the times when I talk to my premed students or medical students, they want to be in a position of healing, right? And you kind of mentioned, you know, oh, this is the way I want to practice, right? And I think we lose that art and science through medical school training, you know, because we're just so busy learning one system in one way that we often forget that, oh, wait, this is truly what I want to learn. But it's so awesome now that at least there's a college of lifestyle medicine out there that can, you know, provide this network, provide this curriculum for us to go into. So I want to transition now into you as a pediatrician and the way that you practice, right? You're from the lifestyle medicine perspective. When do you have a child coming to you? What is it that you're typically first looking to do? You know, is it to optimize their health? Is it looking from a point of view of prevention or are you just looking at healthy development? I mean, obviously, I'm sure all three of those things come up. But from your framework, what is it that, you know, you kind of hone in on? Yeah. Well, you know, I start the nice thing about what I do is I start my relationship with my patients from day one. And so that relationship is really with the parents in the beginning. And the framework I kind of set up for them is that, hey, you know, I want you to know that optimizing your lifestyle habits or your child's lifestyle habits in the areas of, you know, for example, the nutrition or the way we exercise, the way we manage stress, the way we sleep, all these like lifestyle habits will carry on to create habits as an adult. And so my goal is to help to teach you, how to teach your child, how to grow up with healthy lifestyle habits. So I kind of set the stage that way. And at each of our wellness visits, and so PhDs, we have these routine wellness visits, where obviously we're doing the basic things like we're talking about growth and we're talking about sleep and we're talking about what they're eating. And that's not different than what I ever did prior to doing lifestyle medicine. But the way I present it, I think, is different than what I used to do. And I think that's what's made all the difference. And so, you know, I think that something I've been doing probably more recently is, you know, when you're a pediatrician, you're taking care of, like you mentioned before, the whole family unit. And so really having a conversation with parents right in the beginning that, you know, it's important for you to take care of you too. And as parents, we often very much self-sacrifice ourselves and our health and our sleep. And you know, I'm talking to newborn parents about, like, this is how we can help you teacher child, how to sleep. And so that you can get sleep that you need for your health as possible. So that is kind of my focus, is I set the stage that my framework is like to have a healthy lifestyle habit. But now, let's say you have a patient come in, and honestly, I don't start with all my patients at day one, some of them transfer from other medical groups and they're already older or they already have, you know, not the best eating habits. So I try to kind of meet everyone where they're at. And so some people are in a place where they don't want to do anything different, and that's okay. And I might just give you information there. Some people are in a place where like, I want to make some changes, but I'm not sure how, or I'm not quite ready. My child is really picky, or the kid comes in going like, I'm picky. What can I eat, right? And so some of it is about like coaching the family or coaching the child about how do you move the needle closer to having a healthy life, healthier lifestyle habit. And so that's some of the stuff we learned in lifestyle medicine, right? How to like coach someone to do that. Yeah, you know, it's funny because I feel like a lot of medical students love pees, right? I mean, if you're taking care of children, I think a lot of people want to do that. But then the thing they realize sometimes is, oh, wait, it's a, you know, it's, it's it's the common joke that they say it's actually the patient, or it's actually the parents are better the patients, but you kind of flip the script, right? And you said, well, I'm taking care of the whole family in a way, and if I can use the parents to my advantage, then I can, you know, use them to help the actual patient, which is the kids. And by default, you're making everyone healthier, right? So you're kind of, kind of making everyone good like that. Right. And you know, from, it's an interesting, that's interesting thought because, you know, oftentimes, you know, parents aren't as motivated for their own health to change their eating habits. But if I'm telling them, hey, your child needs to change their eating habits, but they need your support. And I think parents will do anything for their kids. And so I'll find that when, you know, I have a motivated teenager who like wants to change their eating habits. And the parents are obviously the ones cooking and providing food. The parent often will change their habits. And so I've had, I've had families where my patient was a teenager, but the whole family like had improved health because they all start hiking together or they started cooking together. It's wonderful to see. Absolutely. I think there's, there's so many awesome things that you, you said in there and I, we often talk about the stat that, you know, about 43% of Americans are obese, right? And, and we know that over the last couple of years, I mean, childhood obesity is on the rise. We also know that parents who are obese are more likely to have obese children, right? I mean, so this comes back to the concept that you're talking about treating the whole family. How critical that is, right? It's going to be, it's going to be an uphill battle if you're only treating one and you're not getting the other person healthy. But I want to explore this concept of creating habits at a young age, right? We, Darce and I, we've had some guests for the listener, I refer you to episode 38 with Dr. Janika Benoit and follow episode 40 to talk about instilling good habits into our practice, whether it's for exercise, food and that kind of stuff. But what everybody, no, I shouldn't say everybody, what most of us know is that kids, their brains are malleable, right? So whether it's learning a scale, piano, instrument, whatever language, if you start in early age, it's going to be much easier to develop that and keep that long term. And so I really like that idea and I want to explore this a little bit further. You mentioned that there's really no age, it could be newborn, right? Parents that you're having these conversations with. So I'd love to hear a little bit about what does that look like? Like what are those conversations if you could use some specific examples with the parents that you're having? How might you care for them? Maybe, you know, initial visits, subsequent visits, that kind of stuff. And then as a follow up, maybe when you can actually have conversations with children, how older they, you know, how is that process look like for you? Yeah. I mean, as soon as I'm able to have a direct conversation with a child, I do it. So I mean, even I'm talking directly to like three, four year olds and I'm not talking to them necessarily about like how to have a healthy life, so how about it. But I'm talking to them, you know, I'm talking to them. And I asked them like, do you have any questions today? And so I really try to help my patients take ownership of their own health. And especially, and I think that the line where I really, really almost talk exclusively to the child is at age 10. Because at that point, they're making a lot of their own choices when it comes to eating what they choose to eat. A little kid, the parents are still doing a lot of the choosing. But like older kids, you know, I tell them like, you know, you're older now, I'm going to talk to you directly, but with this like older age and maturity also comes responsibility. And part of your responsibility is keeping your body healthy. And so my job really is to give you information. It's your job to decide what you're going to do that information. We choose to take it. We choose not to. My job is not to make you do it. My job is to educate you about doing it. And I think that approach really works better in that age group. Because now, you know, I'm telling my patients, I believe in you. I know you can do this. And it's not the same thing as telling you what to do, because they don't respond well to them. Of course. You know, I think about one of my attendings in the past, I've never fact checked her on this, but you know, she mentioned that, you know, children love sweets, everybody are well, most people love sweets, right? And you see all these Instagram clips or whatever clips of kids for the first time when they taste birthday cake or whatever on their first birthday or second birthday and their eyes light up because they get this sugar rush, right? And I wonder, I want a backtrack. So you said 10 is a good age where you can have these not necessarily in depth, but complete conversations with children. But maybe earlier than that, like, when kids are starting to actually eat, like solid foods, what are we talking eight months, maybe, or exactly, we actually say it's okay to start between four and six. Right. So six months, right? So when their parents are trying to start introducing foods, one of the challenges I'll hear from new parents is like, okay, you know, some parents will say, oh, my kids eat in broccoli. That's others will say, well, that doesn't happen. All we're doing is mac and cheese, right? That time, right, between six months and ten years, that's a long time, right? So developing a palette is really, really important with these, for adults, for children, for everybody. When you're counseling parents, right, and about plant-based diet, or just introducing more plants and diet, broccoli, if you will, how are you telling them to introduce that into their children? Okay, that's a great question. So let me backtrack just a little bit. So what I was talking about 10, that's kind of when I'm talking drug into the patients and really telling them, like, you're responsible. I do talk to my patients pretty much starting three, four and having these conversations one on one, like, what can you do? What will you try? Because it's really up to them, right? But so, yeah, so I think we can start talking to them pretty young age. But as far as, like, the babies, obviously, I'm not talking to them directly in regards to what they're eating. But what I counsel my parents is that, you know, as you mentioned, we all, I mean, innately, we are born to, like, the flavor of sweet, breast milk is sweet, right? And so, but it's a learned behavior to be able to eat something better. And there's a window between four and seven months where babies are a little bit more open to trying different flavors. After, as they get a little older, they become pickier. And it can take more tries to introduce something new. So I like to counsel my parents that it can take 20 times of trying something before a child will take to it. Each time parents stop trying is three. They'll say, oh, my kid doesn't like broccoli. They try three times, right? So you have to keep trying it and trying it over and over. And I think that the strategy I like to teach my families is those early months when you're starting thoughts, whether it's four months or six months, it's certainly a parent choice. The idea is you're not necessarily giving large volumes of food, but you're creating their palate. This is the palate they're going to have the rest of their lives. And you have a unique opportunity. Their reality is whatever you make it. So if you act like broccoli tastes great and kale is part of our daily life and kale of tastes yummy, that's their reality, right? And you know, an interesting story of my, so with my own kids, we did a lot of veggies early on. And they liked vegetables. And so when they got to kindergarten, so my kids like salad, and I guess that's weird, but they like salad and I packed them salad for lunch and their kindergarten teacher came up to you. She's like, this is the first time I've ever seen any kindergarten or bring salad to school. Like my kids like salad. So I just thought it was kind of funny, but my kids didn't actually know that kids didn't like vegetables until they got to school. And I think the teacher is reading some book about how kids think vegetables is yucky. And they didn't understand. They like came back home like, mom, what do people think vegetables are yucky? I'm like, okay. Well, let's have a conversation here. But the truth is, is that I think that you can create whatever reality you want. And so I often counsel my parents in those early months, get those green vegetables in so they can taste them, taste kale, taste swish chart, taste all the different vegetables. And really early on, I like to try to have families give their kids what they're making as a family. Because if you teach your kids to eat the flavors of however you cook, then it makes it easier down the road that you're not having to make a separate meal for them, which makes your life easier down the road, right, if you can all eat together. So that's kind of the strategy. I also recommend introducing different flavors in their food, introduce them. You know, I think historically we've done very bland foods for our babies. And some of that came from the thought that there was a higher risk of developing food allergies if you introduced foods too early. But after the study called the Leap Study a few years ago that showed that introducing these allergens earlier actually, so specifically that was for peanut protein that introducing it earlier reduced the chance of food allergies. It really opened up the possibilities of what you can, you know, offer to your child early on. So in other countries do this, like they introduce ethnic, well, what we can say ethnic foods, but they're normal for their kids and it's just considered normal. But I think in our country, like if you look at the, it's better now, but at least when my kid were babies, like the baby food, I was like pureed peas and pureed carrots and grape groans. It was just like one single ingredient, no flavoring in it. And that's what they grow up with. And then they get to the point where they're picky with eating around like one. And then you're like, okay, real food. And their kids are like, oh, that chili is too spicy. That's what it is. Too spicy. That's, I think that's kind of how a lot of families end up down like mac and cheese and chicken nugget road is that kid, quote unquote, kid foods. But I think our expectation for our kids is not that they have to have separate foods and they have to have kid foods. If our expectation is that you're just going to eat with us, whatever we eat, then that's what they grow up knowing, right? Yeah. I mean, I think that that's truly awesome. You know, that's that of 20 times before they can, I mean, I'm sure like, you know, some are very, very lucky and five times is enough. But I find that interesting as a newly minted father, I have a true sense of appreciation of, you know, what it's like when you're sleep deprived. As you mentioned, when you had twins, I can't even imagine that. And so I can appreciate the frustration the parents might have after trying it three or four times. And it's like, okay, it's just easier to give the chicken nuggets, right? Or the mac and cheese or the juice or whatever, right? This would be juice. I'm wondering though that let's just say if it is 20 times that you mentioned on average, right? Does that have to be just like kind of right up front like 20 times over a week or can it be spaced out over like a month or something like that? Like what is that data? Oh, yeah. Well, I wouldn't say 20 times on average, but it can take up to 20 times. Oh, I see. Yeah. And I think just what I would do is space it out because you're probably not going to eat that same food 20 times in a row in your house anyway. True. You know, if you're serving something that has broccoli in it and you serve it a few times a week or a few times a month and then offer it to your kid and they see you eating it at the same time, I think they're more likely to want to eat it if it's not 20 times in a row. They don't like it, you know, maybe try again another few days or a few weeks. No, absolutely. I mean, I think the increased exposure, I mean, just like any habit you're trying to instill in your life, right? If you have, if you're averse to something and you just get more and more exposure, you're less likely to be over time, I want to double click on this, this idea that you had where your kids are taking salad to school, right? One of the things that we talk about good, you know, habit formation or limiting bad habits is you want to create friction, right? So for instance, if you don't want to eat pop tarts, don't have pop tarts readily available in the cabinets, right? And the same thing for ice cream or whatever, insert your favorite guilty pleasure food. And I think that's the same case for children. That being said though, you know, it's one thing that we instill these good habits that hey, where your kids are like, okay, real food is salad or, you know, whatever we have good quality food. But there is a reality that they go to kindergarten class or they go to first, second grade and they have birthday parties or they go to their friends homes and there's juice and ice cream and they open their fridge and all kinds of awesome, yummy things available. How do you have the conversation? Maybe even with your children, because they're the ones eating salad is hey, like it's okay to quote unquote indulge every now and this to have a healthy relationship with food, but that's not the standard. Yeah, that's a good question. I mean, I think that you don't want to overly restrict those things and that was something I definitely struggled with. I think when my kids started school because there were definitely parties, especially those early years and very highly sugared parties. So obviously it's not my preferred thing for them to eat, but the same time they have to live in this world. And I think the fact that the way the style of eating that we did early on, so that we really got the ability to eat healthy foods, that they had the ability to also limit themselves when it came to the sweet. It wasn't like so overly restrictive that they never got to have it that they were like, okay, I can't wait till I get to indulge here. But it was more, you know, I told them like I trust you to what's enough and to eat till you're satisfied. And they just seemed to do it, but I think that they also, it was funny because they went to a birthday party in one time and there was a lot of sugar at the birthday party and they came home afterwards and they told me they're like, mom, I didn't eat my whole birthday cake. It was too sweet. It was too much. I'm like, okay, good. Yeah. You know how to stop yourself. Yeah, I think, you know, Ben Greenfield, the biohacker talks about this. I think he has teenage kids and on his podcast, he always says that he just educates his kids in terms of the why, right, like why you don't want to have three slices of pizza where you can have one. But he'll let his kids choose and he's found that that approach in terms of trusting your child, giving them the information and then letting them choose makes them more autonomous, right? And we all hate control, right? I mean, if you tell a child to do something, they're probably going to want to do the opposite. So it's really interesting, but, you know, I want to transition out into talking about veggies and plants, right? I mean, one of the components of lifestyle medicine is to become a little bit more plant forward, right, that we know there's benefits to this. So obviously, I think parents are becoming, I would hope, a little bit more open-minded, right? I think social media. There's so many accounts now talking about how to incorporate more veggies. What is your approach to patients, or at least parents, in terms of them getting more veggies, not only into their diets, but also their children? Yeah. Well, you know, because we have these wellness visits and pediatrics, I know predictably no one I'm going to see my patient next. And so I kind of have these canned talks I do at specific ages. So at my foreman visit is when I start having conversation about solids. And that's the first time I kind of really talk about there's benefits to eating plants in our diet. You know, plants have six categories, and I go through the six categories. So fruits, vegetables, nuts, seeds, beans, and whole grains. And so then I'll say like, you know, there's a benefit for your child to learn how to eat these foods. And by introducing these foods now, they'll make it easier down the road, right? So I've kind of set the stage that I like for you to eat some plants. I'm not saying exclusive plants, I'm just saying, I have the plants in because they're good for you. And then as we get into the older ages, the conversation usually shifts a little bit because what typically comes up is the child at this point is potentially, they're like, usually they eat fruit fine, they usually like carbs, great. Sometimes the parents say, oh, they don't like meat. So they all suggest, well, do they like beans? And a lot of times they do. And I'm like, okay, so maybe you can do, because the parents always where they're not getting a protein, I'm like, well, you can get protein from plants also, but especially beans are high in protein. So maybe look up recipes for someone who's on a plant-based diet because there may be some recipes in there that incorporate the kind of protein that your child eats and then you'll feel better about that they're getting the nutrition they need. And then I think the other thing that sometimes comes up is just with just kids in general, they will often come and say, like, oh, I don't like vegetables, right? And so, but a lot of times they like at least one. And so then we'll talk about, well, how do we make that one available for you? And how, like, can we keep that in the freezer? Can we maybe prep some on the weekends so that even if your family makes a vegetable, you don't like, can you grab the one that you do like and just eat that instead? So then we're talking about, like, how do you add those plants in onto your plate? And then fast forward, and now let's say there's a patient who actually really wants to add more plants into their diet, like they're actually motivated to do it, then we kind of talk about, like, portion of your plate and maybe you make half your plate plants. And then, and kind of go from there. So there's just, it's different conversation, depending on, you know, the state. Right. It's like a multimodal approach, you know, depending on the patient. Absolutely. But I also want to talk about the opposite side of that spectrum. So when I shadowed a functional medicine doctor, I mean, he would see some children. But typically, I mean, if you're going to go see a functional medicine doctor, most of these patients are well aware of lifestyle medicine, you know, functional medicine, the supplement, like everything, right? They're, they're super hyper aware and optimizing. And I'm sure you may, you may have had some parents who are just overly controlling almost in terms of their kids' diets, in terms of hyper optimizing it. Every single thing has to be, you know, perfect. What type of conversations do you have with those parents? Because I mean, of course, they want the best for their child. But, you know, as Ultraman has kind of talked about, it's not really setting up but probably a healthy relationship with life itself, right? With all the different elements. Yeah. I mean, I can't say I've had a patient who's down the functional medicine world, where there's like supplement and very specific macronutrient macronutrients. I see where you're getting at though. But I think probably something that's related is, I'll sometimes have parents who are pretty restrictive because they're worried about their child's weight and calorie counting and being very restrictive about. And sometimes the kids on board that sometimes they're not. But I think that can be a little tricky because with kids, especially, we have to be really, really careful about what is the goal of our eating habits because if you are making the goal, okay, you need to lose weight to like this way. It's different than adults because kids are still growing, you're getting taller. So you can't necessarily say like, I want you to lose 15 pounds, right? And that's not the goal anyway. The goal is not shape size. We're all different body shapes. The goal is you want to make your insights healthy, right? And so that's what I try to shift the conversation more towards is that, the reason we're doing this, the reason we're recommending that you eat whole foods and eat more plants is because it will help you feel better. It will help your mood be better. It'll help you, you know, just feel better in general on how and and I think that I try to separate that conversation between body shape and size and BMI with kids because sometimes I worry a little bit about like, is it going to trigger like eating disorder, can't be here. Gotcha. I sorry, if it's appropriate, you know, this is an important question that I do want to explore a little bit further, right? I think we asked one of our early guests, E.C. Sinkowski, who's an amazing nutritionist about whether it is appropriate to do calorie counting as an approach in children. And I think that, you know, her response and in most people that I've talked to said, no, for all the reasons you mentioned, I'm wondering though, like in adults, sometimes somebody like, for instance, we just talked about this a couple of days ago that somebody who is extremely analytical, right? We know that a, you know, a caloric deficit, as I said, can be a reasonable approach if weight loss is the goal. That's a big hit, right? Understanding what you just said with respect to developing, you know, disorders, eating disorders and whatnot, is there ever a time where you feel comfortable maybe having a conversation with a teenager or maybe close to adulthood, right? Seventeen, still teenager, but still where calorie counting can be an option. I mean, I've seen kids just on their own do it and be successful with weight loss by using, you know, like an app to calorie count, for example, I don't think I would personally recommend it, I would send you to a nutritionist and if they recommend doing calorie counting, and they're like, they're, they're really working closely with this patient, then I think it may be appropriate, but it has to be like the right patient, because sometimes the, the kids who are very overly analytical about it, I really worry about this kids going down the eating disorder road. And so I think like they need to have someone who's really watching closely who know exactly what they're doing, and I can't be that person to be with you day by day doing that. So it's not really a approach. I think I would recommend directly to a patient. That's a fair point. No, I love that. I mean, I think context is everything. I think that if there's one word that's kind of more than ever on this podcast, it's that right there, right context. Let's shift gears. Let's talk a little bit about exercise, right? That's another pillar of lifestyle medicine, right? Movement, healthy movement doesn't necessarily have to be structured exercise, but we know that's important, right? And today, today's day and age where screen time is just unavoidable, right? Everywhere you go, there is a screen where we're all sitting behind one now. And video games and everything as awesome as they are. And you know, I see in my world, I'm a sports medicine fellow, as you know, and I take care of children in middle school, high school, and they'll tell me, yeah, you know, I ask them if they need clearance for for Jim. It's like, oh, no, I have Jim next semester. What do you mean you have Jim next semester? Like Jim, you know, I'm Jim every day. And so that just baffled me. I just heard that last week. And what I'm getting at is we're not moving enough in school. And surely kids aren't moving enough as they were maybe 15, 20 years ago. Talk to us about your conversation about incorporating more play as a component of daily, you know, daily life. Yeah, I mean, that's a tough one. I mean, some kids are naturally inclined to just move all the time. And whether they're doing like something organized, like a sport, or they just like on their own, run around the house, some kids just do that. Some kids prefer to not do that. They're the ones who like to draw or who like to read. And those ones are a little harder because they're not as naturally inclined to move. I think a lot of parents, at least where I practice, have their kids enrolled in different types of sports programs. So that that certainly helps to some degree for like whatever is not being done at school. But to be honest, like that's not every kid and not every kid wants to be in sports. That's not, doesn't fit with everyone's personality. So like, how do you get those kids motivated to move? And that's a little harder, I think. I think that when you can get families to do it together, there's a better chance of it happening. I mean, I know I can speak personally because I am an athlete. And an exercise, they have all the pillars of lifestyle medicine, exercise, if I'm being totally honest, is my hardest one. So during the pandemic, actually, like for my family, we picked up hiking. And it's something that we've all grown to love and it's keeping us active, which is great. And so I think like, movement doesn't always have to be something that is, you know, you're enrolled in baseball or soccer, but it can mean lots of different things. It can mean you do, you know, a video at home if you can't get out of the house. It can mean you're doing chores at home, vacuuming takes, takes, is like exercise, right? But I think when you can do things together as a family, like that's, that's one way to get around the, like, not getting, not staying active at school. But yeah, I think one of the tough things that I'm seeing, especially because you're mentioning about screen time, is especially for the kids in like the middle school, high school years. A lot of them use screens to socialize. And it's particularly like in the framework of playing video games and they're like, well, I play video games with my friends online, right? And so parents, especially during this is during the pandemic, they're really hesitant to limit that screen time during that time. This is their only social outlet. Oh, my, okay, I get it, right? That's how they communicate. So that's been a little bit of a harder struggle because, you know, we do recommend limiting screen time recreational screen time to no more than two hours a day in that age group. But, um, but if that's like, if all their friends are together doing it, and their friends aren't out playing outside, and then if you're limited to two hours, and then you're not, you're now not socializing with your friends, like, what does that mean? So it's, it's definitely a tough world navigate these days. I mean, even more than like 10 years ago, I love that. I thought that's such a thoughtful approach to this. I mean, I think that, you know, when you would just take a simplistic approach to it, it's just hard cutoffs, right? Just limit screen time at 9 p.m., or, you know, if you're going to bed at 10 p.m. And it's an absolute, if we live like that, it's just going to be really hard. But, but that, you're coming right there about the social aspect of it. I mean, I think about, you know, playing Halo when it first came out, and we would just play online all the time. And that was so much fun, just, just the bonding with your friends. And so that, that's really important. I'm not really sure I appreciated it from that context. But to your, to, you know, to your thought about getting the whole family involved again, coming back to that concept. I mean, we know that one of the best ways to, again, instill good habits in our children is modeling good behavior, right? And so if they're going to see you get out and exercise, right, they're more likely to do that. I mean, they, especially at certain ages, I mean, all they do is just imitate their parents. And so that's such an important point that you make. And I really love that. Thank you. Oh, sure. Yeah, that goes with eating too, right? They see what you eat. They'll, they'll be more likely to eat it. Yeah. Sure. I also want to touch on stress, actually, because I think this is also important, especially right now with COVID, right? I, when I was rotating at least, I don't think I got the sense that parents understood the increases stress levels that kids and teenagers now have in today's world. You've been practicing for some time now. I mean, what, what have you seen kind of as the trend of stress in that early age group? I mean, have you seen an increasing? And if so, maybe kind of what is contributing to that? And what can children really do? I mean, stress relief isn't really a topic. I feel like we think about until we maybe hit our 20s, right? We think about meditation and mindfulness and, you know, onwards, but. Yeah, that's good. Well, I guess it's a multi tiered question. So as far as, yeah, I've been practicing for 17 years. And I definitely see a big difference in the kids now compared to the kids 17 years ago. I do see more stress, I do see more anxiety, I see it starting a younger age. I think that some of this, I guess one other thing I'm also seeing is this attention, like the ability to, the ability to be bored and the ability to pay attention and be mindful and not constantly have to have something stimulating you that, that is harder to come by than 17 years ago. Because we just have these constant stimuli, like all the time, right? And it starts at a really young age. So, you know, I have a conversation with my family's at six months. So again, I talk to these little can talk. So my, my, my talk at six months is like, how do you maintain your baby's mindfulness? And the way I frame this is that, you know, usually the baby is in the room, I mean, obviously the baby is in the room and they're like playing with their blanket or they're looking at me talking or they're playing with their rattle, something like that, right? And I'll point out to the parent, I'm like, look at your baby. Your baby is very mindful about what what he or she's doing right now. Like she's playing with this rattle and she is into it, right? And she's focused. Okay, so we are born mindful. We are born with the ability to like be present and be in the moment. And how, and as we see in the course of years, a lot of kids lose this. And how often do we go to a restaurant and every single member of the family has a technology in front of them, a screen and they're, you know, the kids are watching, I pad about they're eating their meal at the restaurant. And the truth of the matter is that I don't think most parents who kind of find themselves there plan to get there. But the conversation relates about like, well, how can I prevent from getting there? Because I think that that is actually the path of least resistance. So, um, so then I'll kind of talk about, well, so you have a choice as far as what you choose to entertain your child. Like you can choose to entertain them with what I call like low stimulation toys. So like a book or a rattle or blocks, right? And then on the flip side, you can choose to entertain them with something on the screen. And if your child's baseline of like what I consider fun is the screen, which has lots of color and lots of movement and lots of sound and lots of, oh, lots of everything. And this screen is like feeding your child entertainment. They're just receiving it. They're not even taking active part in it. If that becomes their like baseline of like this is what I consider fun, then it becomes harder for them to play with what I would consider something low stimulation. And it becomes harder for them to be bored and to be creative. And there are studies that show that, um, toys that I have like, you know, that are not electronic, increase your chances or make your speech development better. And so like there is some developmental advantages. Your brain is still developing a lot in those first five years. And so you have a choice of how you want to choose to entertain your child. And so, um, and I kind of point out that it's, it's important for your child to learn how to be bored. It's important for your child to learn how to entertain themselves. And it's a skill that they can learn when they're young. That's going to actually help you in the future because then as they get older, they'll know how to go play on their own without needing you to constantly entertain them without them begging you to turn on the TV or begging you for your phone, right? And so then I, but then the next question is like, you know, this is not meant to be judgmental or shaming in any way because we all live in this world and I'm guilty of it too, right? So then the question is, well, how do we, like, why do we do this, right? And so I think the reality is that we're just all tired. I mean, you know, you have a baby and you're not sleeping. And what, what do we do when we're tired? We kind of like turn our brain off and what do we do when our turn our brain off? We're on our phone and we're scrolling, right? And so then when we're on our phone and scrolling and the baby, especially at six months, they're like looking at your phone like, ooh, that looks really interesting, right? Then you're like, okay, I just need to finish my meal here. Take my phone and it occupies them for like five minutes. You can finish eating and then then it starts, right? And then they want it and then they keep wanting it and then they keep wanting it. And then you get to the point where your kid needs to have the iPad when you're at the rush hour. So I kind of like frame it out that way. And I'm saying, and I again, I'm not doing it to like say you have to do this, but I'm saying it more like you have a choice. And I'm not going to lie. This is the harder choice. Like entertain your child with non electronic things is the harder choice. It's going to involve you more. It's going to involve more energy from you. But the work you put up front right now is going to pay off in long run. Wow, that's truly amazing. And it hits close to home with me. I, you know, I actually, the other thing else is, I mean, we talked a little bit about modeling before, but this concept of the choice that we have, right? Or that we can give our children the choice of how we're going to influence their behavior, if you will, for lack of a better word. But a, I think it's a gif that comes to mind. No, it's not a gif. But whatever a picture that comes to mind, there, there's two people kind of sitting on a bench and one of the parents is reading a book and their child is reading a book. And the other parent is on their phone or whatever and their child is playing on iPad. And the parent with the phone, their hand turns over to the other parent and asks how do you get your kid to read? And I always find that to be really interesting. It also makes me think, Darshan, I always go back and forth. This is, you know, we both read decent amount of books. Darshan loves to actually read books. I love to listen to audio books. And I think about this is, you know, my child grows up. And, you know, of course, there's a lot of great things I have from screen time, right? So we don't want to demonize. I'm a lot, lots of the work is being done. But children, maybe they don't have that, the insight of like, what's the good deck income from it, right? You mentioned all the different colors and stuff, right? Rewiring the dopamine patterns and pathways. And that's all those are the pleasure senses. How, or maybe at what age or how are you communicating maybe with your children? Hey, there's actually a lot of great things that can come from a computer. Your phone and stuff like that. But, you know, let's use it appropriately. And like, what age did you have those conversations with them? Yeah. I mean, I'm not sure if I actually had that conversation, but I think they know that there's lots of interesting things you can get on the screen. My kids really, like, again, I'm not saying you have to do what I do, but like, we really didn't have them do screen until they went to school. Because this is the thing. So the AAP recommends, at least at that time, and I think they kind of age a little younger now, but we, as a whole, try to recommend waiting on screens until their kids are two years old. And this does not count like video conferencing. Like, so if you're talking to grandma and other state on the screen, we don't count that. But this is really like, you know, programming on, you know, YouTube or whatever. And so, so we recommend waiting until two years old and minimum 18 months. But with 18 months, you want to be like next to them and pointing things out and using it as a developmental tool. Like, oh, what do you see on the screen? Do you see the dog? The dog just one of the cave, you know, and like narrating it. Because that's developmentally appropriate to help with their like language development, right? Um, but after that, so over to, I think an hour is appropriate if you wanted to use the screen, um, I think that something that a lot of families and them think is, if I don't introduce the screen early, my child's not going to know how to use their computer. Are they not going to, and then when they start school, they're going to be behind. And so like, I've heard that sometimes as like a motivator to introduce the screen, like in those toddler years. And so my argument to that would be like, it doesn't take long for them to figure out and for them to get better than you. And they can, they, it's kids are smart. They can figure it out. And so, but you can't get that time back. Like, you can't get that time where they're not using screens back. Because once you start it, like, it's hard to stop it. And so, um, I think at least for my own kids, because we didn't, it was never the standard to have the teeth on. And let me just preface this by saying like, like, my husband and I were TV watchers. Like before we had kids, it was on all the time. It was like that, that was our habit. And we, we purposely made a change when I, I remember when my, I have a picture of it actually on my phone, I was watching something on TV. My kids, I had them turned around because I don't want them watch TV. But I think they're maybe like four to six months old and they heard the TV behind them. And they're both like their heads, like straining all the way backwards to see the TV. And I'm like, okay, time to turn it off. And so, and so we made a very conscious choice at that point. Like, okay, we don't want them to watch TV. And so we stopped watching TV when our kids were awake and we just did it in the evenings when they were in bed. Um, you know, my husband likes to watch basketball. And so that was another thing that came up. Well, how, how do I watch the game? We don't want to have the kids watch, right? And so there was a compromise there. So we decided that like we, it was fine to watch the game, but we'd posit during commercials because the commercials were all like, we don't really want them to invest to anyway, but like the commercials were all like lots of movements happening anyway. So, so we still, I mean, the kids are older now. These, we still do that. Um, but the nice thing about not having the screens as like our standard of what we do normally as a household is that it then didn't become something that they ask for. And so we, we do watch things together now, but it's never really like an expectation. We don't, we don't have to argue about it, you know, it's not something you have to even set limits on because we don't really, like it's not part of our routine. Um, so I mean, does anybody can do this? Like it's not like, it's not like we were not TV watchers before. I mean, I still have my shows. I watch, I just watch them, you know, not with the kids. Um, yeah, so I mean, a lot of what you're talking about is mindfulness and parents, right? And so I want to transition that into mindfulness during appointments. I mean, I remember seeing parents blaming children for having too much earwax in their ear and being like, told you you need to clean your ears, born, the pediatrician will be like, whoa, this is, this not his or her fault. Like, you know, some children just have too much earwax. Um, but I think parents listening to this would benefit from at least understanding what are some helpful tips that you could give them for when they are with their child at appointments? What are some things that they should be mindful of? Well, I, I like for the phone not to be on. It's just so distracting. Sometimes they, they're worried that the kids going to run around. So they'll have the kid running around or sitting down on the table, like watching a show, but it sounds like on. And so it's hard to talk is, you know, there's like movie going the background. You're trying to talk to the parent. Honestly, I wouldn't much rather have the kid running around the room without the phone on. Can I expect that I'm a pediatrician? Like that's, that's a normal thing. If you're kids running around the room, that's fine. Um, so I think I'd love the phone not to be on. I think another thing is, um, don't tell your kids that if they do something bad, they're going to get a shot because then, then you're demonizing shots. And we know shots help keep us healthy. So, um, oh, yeah, they'll say like, if you don't sit still, you're getting a shot. I'm like, they don't, don't say that because they might get a shot anyway, because they're supposed to, this, this, this, um, so yeah, that's another thing. Um, the third thing I would say is, again, going back to the whole body image thing. I think sometimes they stay a little bit of shaming with body shape size. And oh, I told you you shouldn't have eaten all that stuff and look at your weight now. So again, I think that that doesn't do anybody any good. We had to like focus on like being healthy, staying healthy, making healthy choices. And whatever happens, the way it happens with the weight, but like we need to make healthy choices. And that's what we should focus on. That shot one's interesting. My wife is also a pediatric resident. So I'll have to ask her about that if she's, um, part of that or experienced that. Um, so I know we're coming up on time and, and you got to run. Uh, so it's just two, two more questions for you. Um, we, you know, parents, parents, patients, everybody will listen to this. And, and of course, they'll benefit from your knowledge and they'll want to maybe learn more. Um, so of course, we know resource number one is, I think wellness, pediatrician.com, right? So we'll point them there. Uh, but what are, what are some other good resources? Maybe books, podcasts, websites that that you recommend that parents can kind of dive a little bit deeper into this and get some of these, um, awesome tips. Yeah. Um, so there's a few books that I like. Uh, there, there's one that was published, I think it was last year called Nourish. And the authors are Dr. Raish Masha and then Brenda Davis. Um, so for families who are looking into eating more plant-based and kind of knowing like, the very specifics about like, you know, how much protein, how much, of the micronutrients, like, it's all laid out in there and it's, it's a good resource. So there's that one. Um, I also like, I don't know if you've ever had Dr. Yami because they're a landcaster on your podcast, but she's, she's a podcaster for a veggie doctor radio. Um, and she wrote a book called A Parents Guide to Intuitive Eating, How to Raise Kids Who Love to Eat Healthy. So that one's, that was a great book. I like that one as well. Um, and then I, you know, I, I post also on Instagram. I'll put up recipes of things that I make in my own home with my kids and, um, so that's also resource as well. Awesome. Cool. Well, we'll link all those in the show notes. We'll link your Instagram, your website. Um, I know you're going to be starting a, uh, a, uh, a doctor mom physician group as well. So we'll, we'll throw that in there. Um, but the last question we ask all, uh, all our guests is, how do we put the health back in healthcare? Start the kids young. Start them on a path of wellness right from the very beginning. And then by the time, and that's the gift, we'll give our adult medicine doctors, is that they'll have adult patients who are already healthy and exercise and sleep. I love it. We have not had that answer yet. So it's a, it's a beautiful close. I love it. Thank you so much, Dr. Chu, for coming on here. Um, I think our listeners' parents will, will gain a lot of benefit from listening to this. So we can't wait to publish. Thank you so much for having me. All right. What an awesome episode. I really hope you enjoyed that with Dr. Sherry Chu, the wellness pediatrician. Now, whether you're a parent to be parent or you're in the health care field and you're an aspiring pediatrician or you even take care of children, I think it's safe to say that understanding lifestyle medicine and wellness within the pediatric realm is super vital. Obesity rates are going through the groove. Chronic conditions are at a pace that we haven't seen before and it's safe to say that we all want children to grow up as healthy as possible. Now, if you have the opportunity, please take the time to rate and review this podcast. Also, if you're enjoying this and you think others will enjoy it, please share it. And if you haven't already, subscribe to the medicine redefine podcast. Medical disclaimer, everything in this podcast is for educational purposes only. It does not constitute the practice of medicine and we are not providing medical advice. No physician, patient, relationship is formed and anything discussed in this podcast does not represent the views of our employers. We recommend that you seek the guidance of your personal physician regarding any specific health-related issues. See you next week.