Fresh Start

This late afternoon the Coleman Park Community Center is brimming with children and the laughter, shouts and pounding feet that they bring.

 

The dribble of a basketball and the squeak of tennis shoes compete with the back-and-forth of a ping-pong game and the echo of water splashing from the pool down the hall.

Yesenia Mota’s two children, Ariana Nataly, 5, and Manuel de Jesus, 4, participate in the center’s activities as part of a program called the GROW trial, to learn how to be more active and eat better. They also take part in a class that gathers in one of the center’s community rooms, where a partnership between Monroe Carell Jr. Children’s Hospital at Vanderbilt and Metro Nashville Parks and Recreation is hoping to reduce childhood obesity by influencing families to live healthier lives.

“I come from a family where we eat a lot of fat,” Mota says, speaking in Spanish through an interpreter at the Coleman Center, located near the intersection of Nashville’s Thompson Lane and Nolensville Road. She notes that in her home country of Mexico, foods such as meat, soft drinks and snack foods are looked upon as status symbols, signs that a person is doing well financially and can afford such foods.

“I’m really happy for the program, for teaching my children to eat more healthily. Now they know they don’t have to eat chips,” she says with a smile.

For the past five years, the Children’s Hospital has partnered with the Parks and Recreation Department in a community-based effort against obesity, the Nashville Collaborative.

Such an effort is especially needed in Tennessee. According to the 2007 National Survey of Children’s Health, 36.5 percent of children in Tennessee are either overweight or obese, and the state now has the eighth highest rate of childhood obesity in the United States. Almost one in four preschool-age children is already overweight or obese. As these children grow into adulthood, this makes them more likely to suffer from diabetes, heart disease and a host of other ailments.

Based on the data and obesity trends, experts have noted that for the first time in generations, children born in the year 2000 will have a shorter lifespan than their parents.

The GROW trial is funded by a $12 million, seven-year grant awarded in 2010 by the National Institutes of Health (NIH). The formal name of the program is “Growing Right Onto Wellness: Changing Early Body Mass Index (BMI)

Trajectories,” and the study’s primary investigator is Shari Barkin, M.D., William K. Warren Foundation Professor of Medicine, director of Pediatric Obesity Research at the Diabetes Research and Training Center at Vanderbilt and director of the Division of General Pediatrics.

“My purpose in life is to measurably improve child health outcomes,” she says. “If you can change something as complex as childhood obesity, even in small ways, you can change their health for a lifetime.”

Barkin’s office, located in the Doctors’ Office Tower at Children’s Hospital, is just steps away from one of the pediatric clinics that children and their parents pour through daily and the staff of pediatricians treats everything from minor illnesses to major diseases.

As the director of the Division of General Pediatrics, Barkin has thousands of children in her care and in the care of the physicians she oversees, and says she has been troubled throughout her career by the health challenges faced by children struggling with obesity.

As laudable as helping children, one at a time, is, Barkin says that the GROW trial seeks to address underlying systemic issues to influence the health of populations. The Collaborative and the GROW trial are ambitious, maybe even audacious, attempts to find a way to systematically affect one of the most stubborn public health problems in the country.

“Anytime you build something, you want it to make a difference in a way that is measurable, meaningful and sustainable,” she says. “We’re developing new ideas and testing them. Then it’s about spreading them and making them available.”

The effort has the full attention and support of Nashville’s Mayor Karl Dean, who also has created several healthy eating, active living programs in the metropolitan area.

“Teaching children and families about healthy eating and active living is important as our city works toward improving the well-being of all its citizens,” Dean said. “We are expanding our greenways, building community centers and enhancing other services of Metro Parks to make it easier for residents to be active. I am proud that Metro Parks and an outstanding research institution like Vanderbilt University are partnering in this important study.”

Making Changes

Participants in the GROW trial are registered in parent-preschooler pairs, or dyads, and come to one of two Metro Parks and Recreation Community Centers to attend educational sessions, including cooking classes and parent-preschool child exercise activities. These classes closely follow a defined curriculum for research purposes, and are designed to give participants the tools they need to make changes for both young children and their parents—although, of course, the effects spill over to the entire family.

The GROW trial, which is explicitly designed to prevent childhood obesity, seeks to have 600 participants who stay in the program for three years, during which, in various program phases, they will have classes in nutrition, physical activity, good sleep patterns, controlled use of media, and use of their environment to support a healthy lifestyle. There are two options for the courses of learning: “healthy growth” or “healthy childhood development for school success,” which have different points of emphasis to help researchers learn what approaches are most helpful to participants.

All of the children are at-risk for obesity, but not yet obese, since GROW is a prevention trial.

The participating families get a membership to the community center for the period of the study, both while they are in classes and afterward, and they can do a range of sports and activities. The community centers are basically sports buffets, offering basketball, swimming, ping pong, a walking track and more.

Classes at the Coleman Park Community Center are conducted in Spanish, in recognition of the large Spanish-speaking population of the surrounding neighborhood. Classes in English are taught at the East Park Community Center on Woodland Street in East Nashville.

Talk to the participants in the trial, which on a recent night was meeting for its sixth session out of 12 in the study’s first phase, and it’s easy to begin to believe Barkin’s assertion that a solution is possible.

Many things are different in Rosa Maria Osorio’s life since she began participating in the GROW trial a few months ago.

“This program has completely changed my life,” she says through interpreter Anne Crook, research field collector for the GROW trial. Osorio was concerned about the health of her older son, 7-year-old Brian Alvarez, and four months earlier had talked to his Vanderbilt pediatrician, Adriana Bialostosky, M.D., about what she could do.

“My son was depressed, he didn’t want to play, he wanted to watch TV all the time,” she says. “Now it’s different—he wants to be [at the community center] every day. He is always wanting to get vegetables, fruit, water. Before, it was chips and hot dogs.”

She says her son Brian has dropped from size 12 pants to size 8 in the few months she has been in the GROW trial. And, tellingly, Brian is not even the child she is matched with for purposes of the program; the other half of her dyad is her younger son, David, 6, who was a preschooler when Osario entered the program.

“I have suffered discrimination because of my size. Now that I know what’s healthy to eat, I don’t want my children to suffer the same thing,” she says. “[Session leader] Juan [Escarfuller] is an incredible teacher—he motivates me.” Escarfuller is an interventionist for the GROW Program.

Sitting beside Osario in the class is Yesenia Mota. Like her classmate Osario, Mota is grateful for the information that is helping her family have a healthier lifestyle.

Mota says that her family especially enjoys fruit and yogurt, and have fun making fruit kabobs—an idea she picked up at one of the classes.

“I’ve never made anything fun [to eat],” she says, with a clear sense of pleasure at having learned something useful and new.

A few miles away at the East Park Community Center, another class of GROW participants meets for the program.

One of the participants who recently finished the 12-week phase of the program, and who asked only to be identified as Angela, has five children, ages 13, 9, 7, 3 and 2. For purposes of the trial, Angela is matched with her 3-year-old daughter, but she is quick to say that what she is learning in the program benefits her whole family.

“[We’re] just being aware of what we eat and trying to change what we eat,” she says. “And being more active as a family. [The program] motivated me to try to lose weight and get more healthy.

“I get up and walk now—I wasn’t doing any of that.”

Angela says she is much more aware of reading labels on food, and that she now makes a list before going to the store to stay on track with her shopping.

“I know I wasn’t eating like I should. The GROW program made me want to make changes,” she says.

Seeds for success

So far, there have been a dozen journal articles based on work of the Collaborative, including in Pediatrics and the Journal of Obesity, and Barkin has presented at the International Child Health Conference and at the National Parks and Recreation annual meeting in Salt Lake City.

Among the early findings in the published research: First, a culturally tailored and family-centered 12-week program can change early growth patterns back to normal among Latino preschoolers, especially those who are obese; second, two-thirds of Latino families who attended culturally tailored programs continued to use their neighborhood recreation centers for at least the following year after the program ended, boding well for sustainability of health changes; and third, these programs build new social networks that tend to form among mothers who perceived their children to be of similar body types.

The GROW trial has also won two awards: In 2011, researchers presented at the Global Congress for Consensus in Pediatrics and Child Health in Paris, France, and won the award for best scientific abstract. That same year, the program won a Special Achievement Award from the Tennessee Chapter of the American Academy of Pediatrics.

It is the connection with Metropolitan Nashville Parks and Recreation that provides one of the most unusual features of the Collaborative and its GROW program, and, Barkin says, one of its great strengths. “By using an existing infrastructure intended to support health, once programs are tested and found to be effective, they can easily be exported.”

Paul Widman, assistant director of the Recreation, Cultural and Wellness Division of Metro Parks, says his department is an enthusiastic partner with the Collaborative and the GROW program.

“The Collaborative is a great partnership for Metro Parks,” he says. He notes that one of the key elements is bringing people into the facilities who might not otherwise be aware of all that community centers and parks have to offer, even though they have geographic access.

“I thought the program was very ambitious, but we know there’s a need in the community,” he says. Speaking of the work of the Collaborative that preceded the GROW trial, he draws a line from the beginning of the Collaborative five years ago and the success the GROW trial is having now.

“The strength of this is that we evaluate one project and we work on the next one,” he says. “A lot of energy has come out of each one, and we put it back to work.”

If the vision of the GROW trial comes true, a workable, scalable prototype could be spread nationally through Parks and Recreation departments. The seeds for that success are already being planted.

Widman says that his colleagues in other Parks and Recreation departments around the country have taken notice of the success that Vanderbilt and Metro Parks have achieved.

“There’s not many weeks that go by that I don’t hear from someone [from another city],” he says. “Most of the questions I get are about the partnership itself.”

“Part of what we’re testing is how to use existing infrastructure to benefit health,” Barkin says. “National parks and recreation centers reach more than 230 million Americans, and have the potential to utilize existing resources to support health.”

“Meaningful, sustainable and important” are three of the signposts of the program from Barkin’s point of view. Anyone talking to her for a few minutes about her work senses a burning intensity to help families live better lives.

Even earlier in her career, during a fellowship at UCLA and a previous faculty position at Wake Forest, Barkin has worked to influence health in the communities in which her young patients live.

“There are a lot of wonderful ideas, but they’re difficult to test,” she says. “Your lab has to be the real world. These are big public health problems and you can’t think about them one at a time.”

And it takes a lot of planning and a lot of people to work on a project with this many moving parts, too. There are research coordinators, dietitians, bilingual research assistants and data collectors, session leaders, and students, among others, who are involved in making the program a reality.

Barkin says she is proud of the influence working with the Nashville Collaborative has had on medical students. Some have chosen careers involving community-based pediatric research as a result.

“It affected the way they understood health, and for some of them, it affected their career path,” she says.

She can’t help but smile when she talks about the end result of the effort that she and those working with her on the GROW trial are achieving: “There are families engaged in healthy activity—not because somebody told them to, but because they want to.”

–written by Wayne Wood
The project described was supported by Award Number U01HL103620-03 from the National Heart, Lung, And Blood Institute, the Eunice Kennedy Shriver National Institute of Child Health and Development and the Office of Behavioral and Social Sciences Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung, And Blood Institute or the National Institutes of Health.