By Sarah Ovaska
On a rainy, cold and dark winter evening, several dozen children from age 5 into their teenage years gathered in the courtyard of a Durham Parks and Recreation building, counting out stretches, jumping jacks, lunges and leaps in unison.
“1-2-3-4-5 …”
Between the numbers were shouts relaying the rules of Bull City Fit, an innovative community-based program focused on reducing child obesity, particularly in low-income children: Play hard, play fair, play safe and play as a team.
The nightly activity at Durham’s Edison Johnson Recreation Center is a partnership between pediatricians at Duke Children’s Healthy Lifestyles Program and the city of Durham’s Parks and Recreation Department. Children struggling with obesity have been referred by their health practitioners to a year of the no-cost, organized sessions that are available six days a week. Bull City Fit has two locations in the city. The one at Edison Johnson is for children ages 5 to 18. The other, at W.D. Hill Recreation Center, focuses more on pre-teens and teens in the 11-18 age group.
The program is the brainchild of Sarah Armstrong, a pediatrician at Duke University Medical Center, and her colleagues. Armstrong, who has dedicated much of her professional life to the growing epidemic of child obesity, routinely sees young patients presenting with conditions that used to be reserved for later in life: 8-year-olds with Type 2 diabetes and in need of daily insulin shots, 10-year-olds on blood pressure medicine.
Growing problem
Overweight children aren’t served well by concentrating solely on diet and calorie intake, a method more effective with overweight adults, she said. Concentrating on what an individual child can control – their activities and being open to healthy habits – can help build self-confidence and instill healthful behaviors that can continue into adulthood.
“In kids, it’s helpful to focus on the physical activity side of things,” said Armstrong. “Being active is inherently a kid thing.”
At Bull City Fit, children get their choice of rotating activities each night, from dance classes, track events, Capture the Flag games, basketball, tennis and more. Each offers an opportunity to try out new sports and activities in an environment where everyone around them is facing the same challenges.
There’s also a twist to how Bull City Fit works — it’s not just the children referred by the doctors who are there.
The program requires a parent or guardian to take part in physical activities while there as well. Adults can either join their kids in what they are doing, work out in a small gym with exercise equipment or take such Durham Parks and Rec classes as Zumba or Spin offered at the same time. Older and younger siblings also are welcome. A highlight of Bull City Fit is weekly cooking classes on Tuesdays, in which families learn new ways to prepare healthy foods.
The Durham-based program is a small but strong stand against the scourge of child obesity in the state, where an estimated 13.5 percent, or one in every seven North Carolina adolescents ages 10 to 17, are currently defined as obese, according to an annual survey put out each year by the Robert Wood Johnson Institute.
Turning research into reality
Though the number is higher than child health advocates would like, the 13.4 percent child obesity rate lands North Carolina in the lowest third of states. Faring worse are states such as Mississippi (25.4 percent), West Virginia (20.9 percent) and Kentucky (20.8 percent) at the top.Utah (8.7 percent) and Minnesota (9.4 percent) have the lowest rates in the country. The trend follows through to the youngest children, with 14.2 percent of children in North Carolina ages 2 to 4 who receive WIC supplements considered obese in 2016.
And while there’s been no shortage of research into the epidemic of obesity in general, and child obesity in particular, the large-scale solutions continue to be elusive, with incremental public health victories.
“We don’t have soda machines in schools and, by and large, recess is required every day in North Carolina schools,” Armstrong said, about those public health wins. But, “we haven’t really seen the comprehensive changes that make a dent in the epidemic of childhood obesity.”
Part of the challenge is that childhood obesity is often framed as a failure of some sort, either on the part of parents or the children and not seen through the lens of the health condition that it is, Armstrong said.
“There’s blaming of the parents for not regulating their children’s well-being, there’s blaming of the children themselves, there’s blaming of the school system for not feeding them the right food,” Armstrong said. “All of that blaming is not getting us anywhere. We have to remove the shame and stigma of what essentially is a health condition.”
Tasking a community with change
That’s exactly what Bull City Fit is trying to do, by getting rid of the stigma and building support on the community level to support largely low-income families as they face childhood obesity issues.
A study of Bull City Fit published in JAMA Pediatrics in early 2018 has shown that the community approach to child wellness is working, perhaps without dramatic weight loss numbers but in ways that showed promise through increased activity levels. A randomized clinical trial followed nearly 100 children, 70 percent of them living in impoverished homes, who spent six months with Bull City Fit. The trial didn’t show reductions in BMI over that short period of time, but it did indicate there were significant improvements in quality of life and activity levels.
Now, the Bull City Fit model is being recreated in seven other counties around the state – Cumberland, Montgomery, Moore, Richmond, Rowan, Wake and Wayne, with assistance in funding from the Duke Endowment. [Disclaimer: N.C. Health News also receives grant funding from the Duke Endowment, but the foundation has no input into editorial decisions.]
Open-ended participation
Crysta Hilliard has already come on board with what Bull City Fit is aiming to do, just a few weeks into her family’s participation. Her son Kaden, 7, joined the program earlier this fall at his pediatrician’s suggestion. Hilliard is planning on making it two to three evenings a week, a big commitment given the family is coming from Hillsborough, about 15 miles away.
“Our main goal is to have him lose weight and make him as healthy as possible,” she said.
Only a few weeks in, they already have made changes. Weekends have shifted to limit computer time and instead include family walks. Kaden, typically a bit shy, has been outgoing and excited to try new things and connect with other kids. His mom signed up for a spin cycle class, a challenge but one that’s making her feel good about her own exercise.
He used to complain about running, telling his mom he was too slow. But after trying it out with Bull City Fit crew and staff, he’s enjoying the activity and proudly telling his mom how fast he is getting.
Kaden was selected as the program’s “Kid of the Week” in early December, reporting that his favorite healthy food is now broccoli and that you can have fun if you are kind and try hard.
Mother and son also really enjoy the regular Tuesday night cooking program, making zucchini noodles, broccoli tots and parsnip fries on a recent evening, things they had never tried before.
There are no requirements about how frequently families need to attend Bull City Fit. Some will come a few times a month while others may come a few times a week.
Elser Aguilar comes every night with his 6-year-old son, Elser Jr., and daughter Catalina, 4. The time at Bull City Fit is not only a positive way to instill healthy habits, but it’s also important family bonding time.
Aguilar works a full-time job at a grocery store before going to another job cleaning offices in the evening hours. The hours the trio gets to spend together at Bull City Fit are valuable, Aguilar said.
Nights at home aren’t as productive, he said, with him getting tired from his long days and nights of work, and the children then gravitating toward sedentary activities like video games. At Bull City Fit, the whole family can play, bond and be active.
The idea is to build up the whole family to address the effects of obesity, by finding ways to get kids excited about playing and moving, and cementing that parental support as well, said Rachel Fleming, the Bull City Fit program director who first connected as a volunteer when she was an undergraduate at the University of North Carolina at Chapel Hill.
“We really want to encourage families to do what’s realistic for them,” Fleming said. “Whatever they do, we want to celebrate that.”
Approach spreading beyond Durham
The Bull City Fit model is one that people across the state are also getting excited about.
The program also has received attention for the way it links community parks departments with medical providers, connections that don’t necessarily exist otherwise. In 2017, the program was recognized for a National Partnerships Award from the National Recreation and Park Association.
Michelle Wells, the executive director of the N.C. Parks and Recreation Association, is a strong proponent of what Armstrong and Bull City Fit are doing. She’s had Armstrong come speak at the annual conference her group holds for city and county park departments around the state.
Every year, people leave excited about the program’s approach to obesity and families and begin looking for ways to replicate it in their communities.
It’s not only participants in these programs who benefit, Wells said. Once those connections are made through programs like Bull City Fit, a doctor may more readily talk to other patients and their families about the greenway systems in a community, available swimming pools and lessons, or low-cost or free sports and recreation programs that are available.
Child obesity, after all, isn’t a problem that one person or one pediatrician or one recreation director is going to solve on their own.
“It takes lots of partners in that community to combat all types of issues,” Wells said. “No one group has all the answers.”
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