Growing Healthy Families

While many working moms might be accustomed to receiving afternoon text messages from their children about homework or a planned sleepover, when Gloria Jimenez hears her cellphone ping, it’s more often a reminder from her 10-year-old son, Eduardo, to pick up some avocados or tomatoes at the grocery on her way home.

“My son always checks now to see how much sugar is in something, especially in drinks,” Jimenez laughed. “If it’s too much, he won’t drink it. He’ll drink water instead. And he’ll tell me, ‘Mommy, please don’t buy this one. It has a lot of sugar.’ For me, that’s amazing.”

While Eduardo is hypervigilant about the family’s diet, his younger sisters, Sophia, 8, and Andrea, 6, are just as likely to pipe up with advice about making smarter food choices.

“My little one, Andrea, remembers even more than her brother,” Jimenez said. “She talks about healthy foods a lot, and she keeps me straight. She says, ‘Mommy, I like broccoli,’ or ‘Don’t put in too much salt!’”

Jimenez said she and her children have benefited tremendously from programming offered through the Nashville Collaborative, a unique academic-community partnership between Monroe Carell Jr. Children’s Hospital at Vanderbilt, the Division of Academic General Pediatrics, and the Nashville Metropolitan Board of Parks and Recreation. The Nashville Collaborative’s mission is to develop and test innovative, potentially sustainable, evidence-based, family-centered, community-based programs that measurably improve child and family health, prevent chronic disease and reduce health disparities.

There have been more than 40 journal articles based on the Collaborative’s work, including in the Journal of the American Medical Association (JAMA), Pediatrics, and the Journal of Obesity, and team members have presented at international and national meetings, earning awards from the International Child Health Congress and the Tennessee Chapter of the American Academy of Pediatrics.

Jimenez and her children have been participants in the Nashville Collaborative through its largest project to date — GROW (Growing Right Onto Wellness). GROW began as an eight-year trial, which included more than 600 families with preschool-age children and received funding from the National Institutes of Health’s National Heart, Blood and Lung Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

GROW was designed as a “pragmatic randomized controlled trial that tests the efficacy of a family-centered and community-based behavioral intervention to prevent childhood obesity among preschool-age children.”

For the participating families, GROW meant building skills to better use local community recreation centers and public libraries, learning about better nutrition and increasing their physical activity, and connecting with other families with young children in their neighborhoods to support behaviors that strengthen family health. The underlying goal was better overall health for both parents and children.

“I’m new in this country — I came here just five years ago from Mexico,” Jimenez said. “We didn’t know how to use the library, and we didn’t know if we could use the community center, so we learned a lot. There are many opportunities through the public library to learn the English language. It’s my second language, and I’m trying to speak it fluently. So, this program has helped me, too — not just my children.”

By focusing on family-centered projects that actively involve both parents and children, the Nashville Collaborative hopes to encourage different generations to learn from each other and to drive positive change that will have a ripple effect through the family and the community, especially when it comes to fighting obesity and chronic disease. Their family’s behavior now at the dinner table is proof that just that type of transformation can happen, Jimenez said.

“Growing up, my mom would tell me, ‘You need to eat all your food on your plate,’” she said. “I started doing the same thing with my children. Now, because of this program, I learned that when they stop eating, it’s OK. They’re full, and their bodies told them they’re full. This is a big change for us.”

The results of the GROW study were published in JAMA in August 2018. While the three-year intervention improved nutrition behavior (so that intervention families were consuming about 100 calories fewer than the control families and sustaining that improvement over three years) and increased the use of the community recreation center for family physical activity, it did not result in a difference in child body mass index. The Collaborative continues to build programs and projects, drawing from the successes of GROW.

“We gave out 550 new library cards to families that had never had a library card,” said Shari Barkin, MD, MSHS, executive director of the Nashville Collaborative, chief of the Division of Academic General Pediatrics at Children’s Hospital, William K. Warren Foundation Professor and primary investigator of the GROW trial. “And we built sustained use of existing community resources such as community centers and libraries. That means that both the child and the parent are still accessing those resources. These are now default behaviors that can support both learning and health throughout childhood.”

The Nashville Collaborative is Barkin’s brainchild. When she was recruited to join Children’s Hospital 12 years ago, she planned to replicate a community-based partnership she’d been successful with while a faculty member at Wake Forest University School of Medicine. There, she partnered with the YWCA and secured funding from the Doris Duke Charitable Foundation to support the development of communities centered around family-based recreation and health programs that brought measurable change. Before relocating to Nashville, Barkin witnessed the opening of a new 90,000-square-foot YWCA sports and wellness center in the heart of Winston-Salem, North Carolina, an improvement that was a direct result of that partnership.

While seeking a partner with a similar objective, Barkin heard about then Nashville Mayor Bill Purcell’s goal of doubling the number of community centers in the Metro area, with a focus on offering family-based health and recreation programs that were easily accessible to the metropolitan area’s growing population.

“It was perfect timing for me,” said Barkin. “One of my goals as a primary care provider is to measurably improve the public’s health. I recognized that what we do in the hospital and in the clinic is important, but health typically happens in families and health happens in communities. I met with the Nashville Metropolitan Board of Parks and Recreation, and they told me, ‘We don’t know how to do this, but we know it’s the right thing to do.’ That’s what partnerships are all about. You’re not supposed to know everything; you partner with people because you make each other stronger.”

And the Nashville Collaborative was born.

“The core foundation of the Nashville Collaborative is to measurably improve family health in the communities in which we live,” Barkin said. “We don’t look at this as one child at a time. We look at it as families living in communities. That means we strive for two-generation solutions. We want to improve both the health of the parent and the child. If you do that right, you can amplify health throughout the family.

“We operate on four key principles. We are a learning lab, so we develop and test programs that are measurable. We address sustainability on the front end, and our programs have to be family-based and community-centered.”

More than a dozen organizations are now part of the Collaborative’s programs, including Nashville Public Library Foundation, the Governor’s Foundation for Health and Wellness (Healthier Tennessee) and Second Harvest Food Bank. Organizations represented on the Community Advisory Board include Metro Nashville Public Schools, Head Start, Conexión Américas, YMCA, United Way, the office of Mayor David Briley and the Tennessee Department of Health, among others.

The group’s first project was a study named Salud con la Familia, or Health with the Family, that was supported with funding from the State of Tennessee’s Project Diabetes and the Vanderbilt Institute for Clinical and Translational Research.

“We wanted to show that we could develop and test family-based interventions for parent-preschool child pairs,” Barkin said. “We focused on Latino families because also at that time, we saw that there were disproportionate poor outcomes in this population. That study, Salud con la Familia, taught us how to be partners. It taught us what we were each good at and what we weren’t good at so that we could really understand how to function in effective ways together.”

Based at Coleman Community Center on Nolensville Road, the study showed that overweight/obese Latino preschoolers who participated in a 12-week skills-building program were twice as likely to achieve a normal body mass index compared to a control group over a three-month period.

“This is one of the only studies that has demonstrated a reversal of early childhood obesity in preschool children, and because of that, the project was selected for an international award,” Barkin said. “We were also given a special achievement award from the Tennessee Chapter of the American Academy of Pediatrics. That was our very first Nashville Collaborative project.”

In 2018, the Nashville Collaborative launched its 11th project, Teaching Kitchen Outreach (TKO), an expansion of an educational program piloted in four Metro Parks and Recreation community centers. Centered around 20-minute, hands-on healthy cooking skills building for children participating in after-school programs, TKO will now be offered in more than 20 of Metro Parks’ community centers based in urban population centers throughout Davidson County.

During the short cooking lesson, school-aged children are guided by Metro Parks staff through the preparation of a dietitian-tested and approved snack or a meal that can be easily completed in less than 30 minutes, that has less than 10 grams of sugar, more than five grams of fiber per serving and costs between $1 and $3 per serving. The staff instruct the students on how to complete every step, from safely chopping up ingredients to properly using a stovetop or oven.

TKO is the direct result of the generosity of an anonymous donor who wanted to support a Children’s Hospital program that had the potential to directly impact childhood obesity, particularly among children in minority populations.

“This is the first philanthropic gift that we’ve received, and it has really jump-started our ability to spread and scale up our programs,” Barkin said. “We are so grateful. My wish list is for sustainable infrastructure funding for the Nashville Collaborative, because when you’re an innovation lab, you need to maintain momentum and have the ability to try new things. You want to be able to connect with new partnerships, build policy and practice and ensure financial sustainability. To date, the way I’ve kept the Nashville Collaborative going is by writing as many grants as I can.”

What keeps those grants flowing and what Barkin hopes will drive further philanthropic support is the long list of evidence-based practice and policy recommendations that have already resulted from the Nashville’s Collaborative’s first decade of work. Among the group’s many findings:

• A 12-week skills-building program aimed at improving both parent and preschool child health reduces short-term pediatric obesity;
• Preschool-age children from low-income families are more likely to be physically active if parents increase activity and reduce their sedentary behavior; and
• Most preschool-age children manage to get enough recommended daily physical activity, but how they move varies with noticeable differences between boys and girls. The Nashville Collaborative has recommended that this should direct practice and policy for preschool-age children.

Recently, Metro Parks employees who lead TKO during the after-school programs met for booster training as the program was being rolled out to all the community centers, and Program Manager Juan Escarfuller, MDiv, MA, one of Barkin’s first hires to implement Nashville Collaborative initiatives, spelled out the need for the program’s expansion.

“Why TKO?” asked Escarfuller. “Tennessee is now the worst — at No. 1 — when it comes to obesity among children. Thirty-eight percent of our children are either overweight or obese. In the Latino community, it is closer to one in every two children is overweight or obese. What’s happening? It’s getting worse, not better. With TKO, we’re trying to make a difference in the family and in the community.”

Jai McCrary, a Metro Parks staff member at the Southeast Regional Community Center in Antioch, Tennessee, started teaching the TKO program to her after-school crowd in April, and the biggest hit has been assembling healthy zucchini pizza boats with marinara sauce.

“We had a lot of children who said they had never had zucchini, but we also had children who said they’d tried zucchini before but never in that way,” she said. “They, of course, love pizza, so to be able to do something similar with healthier ingredients was great.”

Leslie Martinez-Garcia, an employee at Coleman Community Center where the teaching kitchen concept was piloted, said the children in her program are always excited for kitchen time.

“It is so important to introduce healthy food to children early on,” she said. “Even for myself, I’ll admit, I tried eggplant for the first time today. When I’m introducing these foods to them, I always make sure I share important facts about the ingredients and why they’re so healthy. These children are our future, and we want to see them thrive.”

Barkin said she’s thrilled to watch TKO take off in the Metro Parks community centers, but she’s also eager to scale the Nashville Collaborative’s work throughout the state and even throughout the nation so the benefit can reach more families.

“We strive to create programs that can be exportable,” she said. “We are very practical people, and we are about practical science. Since Parks and Recreation is an existing infrastructure, we hope to export tested programs that are poised to scale up across our state and the country to improve the public’s health.”