Fifteen-year-old Danielle stands five feet four inches tall and weighs more than 300 pounds. She also suffers from asthma. Fortunately, Danielle is participating in B'N Fit, one of many Einstein outreach programs that are helping her and other children who are this country's future.
Danielle lives in the Bronx, the poorest urban county in America. It also has the highest percentage of children under the age of 18 of any county in New York State. Like any American urban area, the Bronx has neighborhoods with tidy homes, strong families and involved citizens who have pride of place. But in other Bronx neighborhoods, kids are living in substandard housing where the air is dirty, and crime and drug abuse are a daily reality—plus they're confronted by all the other problems associated with poverty, including poor schools, limited access to healthcare and inferior diets. For these children, growing up healthy is far from a sure thing.
In many different ways, the researchers, clinicians and students at Einstein are trying to improve the health of these city kids. They're helping the children themselves and the adults they'll become. Obese teens such as Danielle, for example, have an 80 percent chance of becoming obese adults, prone to all the health problems that accompany obesity, including a greatly elevated risk for type 2 diabetes, hypertension, heart attack, arthritis, end-stage kidney disease, breast cancer, colorectal cancer and other types of cancer.
A recent study of Bronx adolescents found that obesity affects one in five girls and one in four boys—significantly more than the national average. Two Einstein pediatricians became so concerned about the problem that they developed programs to address it.
"I was seeing kids who were gaining more and more weight", says Jessica Rieder, M.D., assistant clinical professor of pediatrics at Einstein. "I'd ask them, 'Why don't you go outside and exercise?' and they'd say,'I can't go outside.' I'd ask, 'Who do you hang out with?' and they'd answer that they had no friends. They couldn't trust anybody."
So six years ago Dr. Rieder created B'N Fit, an after-school program for overweight Bronx children 12 and older that is now held at the Mosholu-Montefiore Community Center. The four-day-a-week program provides supervised physical activities for the kids and—with the aid of a social worker and a nutritionist—education and counseling aimed at helping them change their habits. There are also monthly family nights, a summer camp (last year's 40 campers lost an average of three to four pounds per week) and, in some instances, home visits.
The average B'N Fit kid weighs 240 pounds and has a body mass index double the normal level. Many already suffer obesity-related type 2 diabetes, nonalcoholic fatty liver disease and hypertension.
"I also see kids with obesity-related renal failure and hip and lower limb abnormalities and degenerative joint disease because of their obesity," says Dr. Rieder. "And we're seeing that in 15-year-olds."
Danielle, a B'N Fit participant since June 2008, says she is learning not to let her emotions — she mentions sadness and anger — control her eating. The B'N Fit summer camp motivated her to run or walk a mile a day, and she's eating more fresh fruit instead of the junk food she used to snack on at home. She lost five pounds in December. "It made me feel good, and I want to continue my weight loss," she said on a recent school-day afternoon. "Without B'N Fit, I'd probably be home after school eating."
Dr. Rieder spends half her time on B'N Fit and considers those hours her most rewarding. "Childhood obesity is not just the family's responsibility," she notes. "Nor is it the responsibility of the doctor, the nutritionist, the school or the hospital. The problem really belongs to all of us."
A second program brings the fitness and nutrition message into the schools. Created by Philip Ozuah, M.D., Ph.D., chair of pediatrics at Einstein and at Montefiore Medical Center, and his team, the series of 10-minute audio CDs called CHAM JAM (Children's Hospital at Montefiore Joint Academics in Movement) gets kids moving, dancing and motivated to be healthy right in their classrooms, with their teachers leading the fun. Some 4,000 Bronx students have already taken part in the pilot program; a new NIH grant will allow the researchers to extend their reach to 16,000 Bronx kindergartners through third graders. "We've received consistently positive feedback from schools, and our preliminary results are very promising," says Dr. Ozuah. "After 20 years of medical practice in the South Bronx, I've come to appreciate the enormity and complexity of the obesity epidemic. The impact of obesity on children and their health is devastating and demands to be addressed."
Danielle also exemplifies another notable Bronx health problem: childhood asthma. The asthma rate among Bronx kids is a whopping four times the national average.
"Asthma is one of the most common—and serious—problems that Bronx residents face," says Hal Strelnick, M.D., professor of family and social medicine at Einstein and director of the Bronx Center to Reduce and Eliminate Ethnic and Racial Health Disparities, also known as Bronx CREED. He notes that each year almost 9,000 Bronx residents—half of them children—are hospitalized for asthma.
Dr. Strelnick blames the polluted air in certain parts of the borough, pointing to the truck-laden Cross Bronx Expressway and diesel exhaust from trucks driving to and idling at the Hunts Point Terminal Market. He also cites the mold and vermin associated with inadequate housing and notes that nearly 20 percent of Bronx adults smoke cigarettes, exposing thousands of kids to secondhand smoke that can cause or worsen asthma.
Several Einstein medical students have responded to the problem of asthma in the Bronx by launching an innovative program to help kids with asthma and those at risk of developing it.
Although the Einstein Community Health Outreach Free Clinic (ECHO) serves only adults, two years ago, second-year medical student Thalia Segal, a community outreach coordinator on the ECHO board, helped launch Open Airways—a national asthma education program endorsed by the American Lung Association—in a local elementary school. She knew that the program needed volunteers to bring its message to Bronx children.
The first step was for Thalia and another Einstein medical student, Angela Lightbown, to undergo training with the ALA to become asthma educators. Then, beginning in the fall of 2008, they met weekly for six weeks with 10 PS 105 elementary school kids chosen by the school nurse. During the 40-minute Open Airways sessions, the asthma educators discussed common asthma triggers and how to deal with them.
Thalia recalls one particular session in which she asked the children to draw things that trigger their asthma. After one girl drew a cigarette, an ashtray and smoke, Thalia asked her to describe her picture.
"My mommy and daddy smoke and it makes me feel really sick and I start coughing," the girl said.
"Do you ever ask them to stop?" Thalia asked.
"They don't care."
"Do you ever ask them to go to another room?"
"No, I don't do that. Maybe I'll do that tonight and tell them how I feel."
The Open Airways course concluded with a graduation ceremony at which certificates and backpacks were handed out. "The kids were so sad it was over," says Thalia. "They felt it was this special club they were part of." She passed the Open Airways baton to a current second-year medical student who have continued the program.
Bronx CREED, the Einstein program directed by Dr. Strelnick, has launched numerous initiatives to improve the health of Bronx residents, of its children in particular. Three of these initiatives focus on improving children's nutrition, starting from birth.
Compared to the national average of 34 percent, only about 1 percent of new Bronx mothers are still breast-feeding at six months, according to data gathered by researchers from Bronx CREED and Montefiore's Comprehensive Family Care Center. So a lot of infants are missing out on breast milk's proven benefits. Breast-fed infants, for example, get fewer gastrointestinal and ear infections than bottle-fed babies do, and are less likely to become obese. How can more Bronx mothers be encouraged to breast-feed their babies?
That question is being addressed by a federally funded Bronx CREED study: a randomized, controlled trial of some 275 mothers directed by Karen Ann Bonuck, Ph.D., an associate professor in the department of family and social medicine at Einstein. In this study, lactation consultants are educating mothers about breast-feeding's benefits in a variety of situations—in clinic examining rooms at the Centennial Women's Center across the street from Montefiore Medical Center, as doctors make their hospital rounds, during office visits before a doctor arrives and through follow-up phone calls.
"As we compare breast-fed-educated with noneducated mothers, one thing we'll be looking at is the range of illnesses that their babies develop," says Dr. Bonuck.
A second Bronx CREED initiative — a collaboration with the NIH-funded Hispanic Community Health Study — looks at environmental influences on dietary choices and how people can be encouraged to adopt healthier diets. This pilot project involving 40 Bronx households is directed by Earle Chambers, Ph.D., M.P.H., assistant professor of family and social medicine.
"Whether people act in healthy or unhealthy ways is greatly influenced by their environment — their social networks, the apartments they live in, their access to certain facilities and resources," notes Dr. Chambers. "People in poor communities tend to have less access to recreational facilities where they can exercise or markets offering them healthy and fresh food. We hope that exposing people to healthier foods may lead to better food choices."
Fruits and vegetables are the focus of a third Bronx CREED initiative which is studying a sample of the borough's 150 community gardens—roughly half of them endangered—and how they enhance their neighborhoods and add vital nutrients to the diets of local residents.
In particular, gardens affiliated with local schools offer young "growers" a welcome respite from asphalt and concrete—and, it is hoped, an appetite for their crops. "Ideally, these communities are providing kids with a hands-on introduction to the bounty, taste and texture of fresh vegetables," says Yasmin Mossavar-Rahmani, Ph.D., R.D., an assistant professor of epidemiology & population health at Einstein, who is studying how urban gardens are influencing Bronx residents.
Many Bronx children are born to parents who don't have the parenting skills or financial wherewithal to assure their children's healthy futures. For these at-risk children, intervening early in their lives can make a world of difference.
"If you can shore up the parent-infant relationship and improve the quality of caregiving, you can foster a young child's cognitive, emotional and social development," says Susan Chinitz, Psy.D., associate professor of clinical pediatrics at Einstein, in explaining the reasoning behind Healthy Steps, an initiative for first-time mothers and their infants. It's a collaboration between Einstein's Children's Evaluation and Rehabilitation Center, where Dr. Chinitz directs the Early Childhood Center, and the Comprehensive Family Care Center of Montefiore Medical Group.
Healthy Steps can begin even before the child is born—about one third of families are enrolled in the mother's third trimester of pregnancy—or with the child's first well-baby visit, and it continues through age 3. So far, the program has benefited more than 300 new mothers, one in five of them teenagers and many from deprived backgrounds themselves. For example, 30 percent of the mothers were raised in foster care, 11 percent were physically or sexually abused and 36 percent were raising their children alone.
Healthy Steps uses a team approach to give parents the support that helps them become better parents. The program offers a wide array of services, including enhanced well-child care (which focuses on both parental well-being and the child's behavior and development), parent support groups and referrals to specialists for children and their parents. The team, which includes three psychologists, a social worker and a psychiatrist, also staffs a "warm" line weekdays during business hours, makes house calls on request and runs an extremely popular weekly parent-child play group.
"What's really exciting," says Healthy Steps Director Rahil Briggs, Psy.D., an assistant professor of pediatrics at Einstein, "is to look at the data on how the Healthy Steps children are doing at 6, 12, 18, 24 months out. We see that they're doing much better in social and emotional development than are the control-group children, even though the Healthy Steps infants started out with more risk factors against them."
Einstein and Montefiore programs are clearly making a difference in the lives of urban children. Ideally, like the children they serve, these innovative programs will grow and thrive.
Several of the programs described in this article are partnerships between Einstein professors and staffers at Montefiore Medical Center, the University Hospital and Academic Medical Center for Einstein. These programs illustrate the success of the affiliation agreement that Allen M. Spiegel, M.D., Einstein's Marilyn and Stanley M. Katz Dean, and Steven M. Safyer, M.D.'82, president and chief executive officer of Montefiore, signed in July 2009.
The 10-year agreement reinforced the mutual commitment of the two institutions—dating to the 1960s— to combine Einstein's strengths in research and technical expertise in research administration with Montefiore's stellar reputation for patient care.
The new agreement has strengthened both institutions' missions and core programs, making it easier for them to recruit outstanding faculty and clinical staff. This foundation will allow the two institutions to conduct new clinical trials in areas such as heart disease, cancer, neuroscience and pediatrics and—the ultimate goal— to advance the health of the communities they serve.