Pulse
Beyond Gym Class
A physician-run fitness clinic helps kids struggling with their weight and health.
Like many teenaged girls, Monica Twaroski wants to lose weight. But Monica isn’t just concerned about her looks; she worries about how her weight is affecting her health. Although she swims competitively and exercises regularly, the 16-year-old from St. Paul is insulin-resistant and at risk for prediabetes.
Last fall, Monica and her parents turned for help to the Institute for Exercise Medicine and Prevention (I.EM.PHIT), a new clinic that opened in October 2009 and is run by a husband-and-wife team of physicians. Located in a one-story commercial building just off of Interstate 35E in Little Canada, I.EM.PHIT offers a physician-supervised fitness and nutrition program for children and adolescents struggling with weight and health issues including asthma and other pulmonary diseases, autism spectrum disorders, cardiac disease, cancer, depression, developmental issues, diabetes, obesity, chronic pain, and fatigue.
The only clinic of its kind in Minnesota, I.EM.PHIT is modeled after Children’s Hospitals and Clinics of Minnesota’s exercise medicine program, which closed in 2008. Cynthia Garr, M.D., a pediatrician at Pediatric and Young Adult Medicine, and her husband, Michael Garr, M.D., a cardiologist at St. Paul Heart Clinic, founded I.EM.PHIT as a stand-alone, nonprofit clinic to fill the void.
Having referred patients and their families to the exercise medicine program at Children’s, Garr says she was impressed with the way it sought to augment medical treatment with exercise and nutrition. So were the patients and parents she sent there. When it closed, she says, parents were at a loss. “These kids, most of them, are chronically ill along with being obese and have the potential for type 2 diabetes, coronary artery disease, high blood pressure, and other issues,” Garr says. “They can’t really go to a general workout facility because they are under 16 [most fitness centers don’t allow children younger than 16 to use the equipment], and they have a chronic illness. So nobody really knows what to do with these kids.” I.EM.PHIT provides them a place to improve their overall health and wellness and build their confidence and self- esteem in a safe environment, she says.
Patients are referred to the clinic by a physician, nurse practitioner, or school nurse, and they come with a variety of concerns. Some need to lose or gain weight; others need to build strength or endurance after a major illness. Some patients may never have exercised before. And many are also struggling with emotional and family issues.
Chris Coffey, clinic director and lead exercise physiologist at I.EM.PHIT and the former lead exercise physiologist at Children’s, says overcoming the mental and emotional barriers is sometimes the biggest challenge for kids. Some patients are embarrassed by their bodies or their lack of physical ability, while others with asthma and other illnesses are afraid to exercise. “We have a lot of kids who are very apprehensive,” Coffey says. “They’re getting their toe in the water, and they don’t want to go in.”
A Family Affair
I.EM.PHIT looks like a smaller version of a typical fitness center. Treadmills, exercise bikes, elliptical machines, and weight-training equipment are lined up along the perimeter. A mural depicting active, happy kids decorates one wall and floor-to-ceiling windows along another look out onto green space beyond the parking lot. But one of the most important rooms in the clinic has no fitness equipment, just an oblong conference table with chairs. It is the first stop for patients and families, Coffey says.
When a child is referred to the clinic, Coffey reviews his or her medical, social, and nutritional histories and speaks frankly. If the patient has significant health issues, Garr will sit in on the consultation as well. Coffey tries to be up front with families about the changes they will need to make in order for the child to achieve his or her goals. It isn’t always an easy conversation, and some families aren’t ready to have it, he says. Those families don’t usually come back.
“It has to be everybody,” Coffey explains. “The whole family has to change. The parents have to take initiative, they have to be assertive, and they have to carry on what I’m trying to teach the kid.”
After the consultation, patients go through a physical evaluation that includes a handgrip strength test, a vertical jump test, a skin-fold measurement to determine body fat and muscle mass, spirometry to evaluate lung function, a metabolic VO2 test to assess oxygen consumption, and a sit-and-reach flexibility test.
The clinic accepts patients as young as 3 years of age, but the program is designed more for children 8 and older, who are big enough to ride an exercise bike and run on a treadmill. Increasingly, however, the clinic is receiving referrals for younger and younger kids, a trend mirrored by national health statistics. According to the Centers for Disease Control and Prevention, the prevalence of obesity has increased among children 6 to 11 years of age from 6.5 percent in 1980 to 19.6 percent in 2008. Among adolescents aged 12 to 19, the rate of obesity has increased from 5 percent to 18.1 percent.
After the evaluation, Coffey develops an individualized exercise and nutrition plan. He says some kids progress quickly, while for others, progress is measured in small increments.
Exercise programs are designed not only to accommodate a child’s health problems but their physical environment as well. Many patients come from low-income homes that don’t have access to fitness equipment or even outdoor play areas. To those children, Coffey teaches simple exercises such as push-ups, sit-ups, and pull-ups that don’t require special equipment, as exercising at home is a major component of the program. “This isn’t meant to be a long-term membership,” he explains. “It is a place where kids should learn to take care of themselves.”
The cost of the program is covered by a number of insurers including HealthPartners, Medica, PreferredOne, UCare, and Medical Assistance. Blue Cross and Blue Shield of Minnesota is developing a two-year pilot program with the clinic.
For Monica Twaroski, one of the biggest benefits of I.EM.PHIT’s program has been the one-on-one support she receives from Coffey and assistant trainer Steve Daugherty. “Chris and Steve work with you and modify the workout to fit where you are,” she says. “I definitely don’t think that I would have the knowledge that I have about what workouts are more effective to burn fat or gain muscle if they weren’t here,” she says.
She’s also been diligent about sticking with her program and has seen improvements on all clinical measures except her weight (she is now seeing a specialist to look for a medical cause for her inability to lose weight). “You have to answer to Chris,” she adds, grinning. “Chris is a very big guy.”
Research and Results
Patients’ progress is charted, and at the end of four months, they are re-evaluated. Garr says the clinic is establishing research protocols and collecting data on the program’s outcomes. She hopes the program ultimately will lead to reductions in patients’ need for medications, hospitalization, and emergency room visits. Because I.EM.PHIT is less than a year old, Garr can’t yet document success beyond that of individual patients. “The feedback we get from the parents, the patients, and the doctors has been very positive,” she says.
Although I.EM.PHIT currently has only four paid staff members—Garr and her husband volunteer their time—in the long run, she hopes to find enough grant support to make it a national program and to bring it to schools. Currently, I.EM.PHIT staff members visit schools upon request and do presentations at student assemblies, during staff training, and at parent events.
Coffey recently spoke with a group of school gym teachers about the special challenges obese children face. “I give them tips from what I see in my gym and what they can see in theirs,” he says. He and Garr have spoken to parent groups about the importance of physical fitness and nutrition for all children, and especially those with special needs.
“We do this all on a volunteer basis because we feel that it is so critically important,” Garr says. “Especially when you read statistics that our children’s generation will live shorter lives than my generation and yours.” –J. Trout Lowen