Okay, let's get started. We are so happy that you have all during this this afternoon for the DNPAO Seminar series. Today's seminar will discuss priority strategies for improving health and reducing chronic disease.

My name is Eileen Bosso, and I am the lead for the Policy and Partnerships team in the Division of Nutrition, Physical Activity and Obesity, or DNPAO, as you'll hear it referred to you today. 

I'm going to be your moderator for today's session.

In case you missed it, the CDC released annual obesity maps this week. This new release covers adult obesity prevalence in two thousand and twenty-one. Nineteen states and two territories have at least thirty-five percent of residents with adult obesity more than doubling the number of states with high obesity prevalence in two thousand and eighteen. Combined data from two thousand and nineteen to two thousand and twenty-one. So, the number of states and territories with high obesity varies widely across race and ethnicity. I think this new data really highlights the importance of the work that you're going to hear about today. If you want to learn more about our obesity maps or see what your state looks like, you will see the link in the chat.

A few housekeeping items before we get started. This zoom call is being recorded. If you're uncomfortable being on a recorded call, we ask that you disconnect at this time. A recording of the seminar will be posted on the DNPAO Seminar Series Web page. You can find that link in the chat as well. To have the best experience, we encourage you to use the zoom app or website to view the slides and to participate in today's meeting.

All participants will be muted. However, following our presentation, we will have a question and answer session. The Q and A box is open now, so feel free to drop in a question at any time. If you're using the zoom app or website, you can type in a question by clicking on the Q A icon. We'll get through as many questions as we can in an hour.

For those of you who aren't familiar with the division. You can see our vision and mission on this slide. You'll hear more about the strategies and efforts of the division to achieve this mission in today's presentation.

Before we jump into today's presentations, I want to introduce our four amazing speakers.

First, we have Terry O’Toole. He is the Chief of our Program Development and Evaluation Branch in DNPAO. And Terry provides leadership and subject matter expertise to state and community-based programs, national partners and health organizations focused on program efforts to promote good nutrition, physical activity, and obesity prevention.

Next, we have Steph Leonard. She is a Built Environment Coordinator at the Colorado Department of Public Health.

Steph works with local, regional and state partners on policy and built environment change to promote access to safe spaces for physical activity and prevent chronic disease in Colorado.

Thamara Labrousse has been the Program Director for Live Healthy Miami Gardens since 2014. She excels in bridging partnerships that bring together grassroots leaders with professionals, and policymakers to improve the city of Miami Gardens Community. In July, Thamara received CDC's twenty, twenty two REACH Lark award for advancing health equity.

Finally, we have Anu Pejuvara. Anu is the lead for the Program, Evaluation team in DNPAO. She employs a utilization-focused, evaluation approach to provide guidance and technical assistance to seventy-one state and community recipients to improve their physical activity and nutrition environments.

Here’s a quick look at our agenda. You'll hear more about our five action steps to reduce chronic disease, followed by examples of physical activity efforts in Colorado. Nutrition efforts in the city of Miami Gardens, and then we'll wrap up with some of the successes we've seen in our SPAN, HOP, and REACH recipients. After that we'll have some time for Q and A.

With that I'm going to turn it over to Terry to discuss the five action steps to reduce chronic disease through physical activity and nutrition. Terry.

Thanks so much Eileen. Welcome everyone. It's pleasure to be with you.

More than half of all Americans live with chronic disease, at least one chronic disease, such as heart disease, cancer, type, two diabetes and obesity.

Chronic diseases are leading causes of death and disability, as well as drivers of health care costs and drivers of low work or productivity.

On the bottom of this slide, you'll see DNPAO's strategic priorities that we use and employ to combat chronic disease, and how we help all Americans get a healthy start and stay healthy throughout their lives.

Adequately addressing risk factors for chronic disease needs to consider the long-standing systemic, social, economic, and environmental inequities which have resulted in inadequate healthy and safe food access as well as physical activity access. Often the most underserved groups are racial and ethnic groups that have historically suffered these risk factors disproportionately.

And alongside our partners, we work intently to achieve health equity by lifting up community assets, lived experiences, and removing those environmental and systemic barriers to health. Through our State Physical Activity and Nutrition program, known as SPAN, our High Obesity Program, known as HOP, our Racial and Ethnic Approaches to Community Health,  or REACH program, we provide financial and technical support to states and communities to implement a variety of these evidence-based strategies and policies to promote sound nutrition and safe and calming access to physical activity.

It's important that I underscore to you that context and community voice really matters, and that our funded states and communities have the flexibility to tailor interventions that meet their local context and needs and assets. Bottom line up front, we know what works to build healthier communities. We use information from evidence-based interventions, expert recommendations, practice and based and lived experiences to determine what state and local public health actions are feasible and impacted.

This slide depicts the five specific population-focused public health actions that work to reduce chronic disease through improved physical activity and nutrition, and I'll take a minute to just describe each one.

Action item one, make physical activity safe and accessible for all. Being physically active is one of the most important actions that people of all ages and abilities can take to improve their help, now and in the future.

People generally report that they lack this time in safe places for physical activity. So, to support this action item, we provide funding to states and communities and provide technical assistance to improve safe access and convenient activity-friendly routes to every destinations, essentially making it easier for everyone to walk to school or bike to the store, to roll to work or play in the park.

Action item number two, make healthy food choices easier. You know that people make hundreds of decisions every day about consumptions of foods and beverages, and if you had a chance to tune into yesterday's White House Conference on Hunger, Nutrition, and Health, we learned that when healthy items are not readily available, many people settle for unhealthy foods that are high and added sugars, sodium, and starches, thus increasing their risk for chronic disease.

States and communities have a variety of levers to improve access to healthy foods, such as bulk food purchasing, nutrition standards and food pantries, and school food environments and implementation of school foods and of food service guidelines. We provide technical assistance and funding to states and communities to assess their needs around healthy food for all.

Action item three, make breastfeeding easier to start and sustain. Human milk is the first food provided to most infants born in the U.S. And delivers not only needed nutrients, but numerous health benefits for the child and mother. We know breastfeeding initiation, and duration is influenced by many factors, including unsupported work policies, lack of parental leave, cultural norms, and lack of family support. We support our partners and SPAN recipients to work with hospitals to safely implement the Ten Steps to Successful Breastfeeding, a set of evidence-based maternity practices to promote and support breastfeeding. And after leaving maternity care settings, ready access to continued and culturally tailored breastfeeding support is needed in the workplace and community, and our DNPAO recipients have successfully implemented a variety of continuity of care interventions, including developing communication and referral systems between hospitals and community support groups to make it easier for moms to breastfeed.

Action item four, strengthen obesity prevention standards in early care and education settings. Early childhood is an important period of growth and development of health for our children. About twenty-one million children, the age zero to five, and not yet in kindergarten and in care outside the home at least once a week with center-based care being the most common. And infant infants and toddlers, within ECE centers spend an average of thirty-one hours a week in center care. So, we know the ECE settings can really help many children establish healthy behaviors. To support this action step, we provide funding and technical assistance to state and local recipients to develop action plans that can use system and policy levels to improve nutrition, physical activity and breastfeeding environments in ECE facilities, using CDC's spectrum of opportunities.

Action item five, spread and scale family healthy weight programs. Childhood obesity is putting millions of America's children at risk for poor health. Many factors that drive excess adiposity, unfortunately, disproportionately impact children from low-income households, and racial and ethnic minority groups. We know that intensive family-centered lifestyle programs can promote children's health, including quality of life and reduction in excess adiposity for children with overweight or obesity. And here at CDC, we work with partners to address state and policy systems and supports to facilitate local level spread and scale of family healthy weight programs.

Now you might be wondering what states and communities need to implement the five action steps. We know that state health departments and their committee partners need focused and specific expertise to tailor these and implement these five actions, and it takes specialized staff in state health departments and community health departments, including physical activity specialists, public health nutritionists, evaluators, policy experts, communication experts, and a dedicated program manager.

As I mentioned earlier, our current resources enable us to support sixteen states through SPAN, and we know the need exists across all fifty states. And we currently support forty organizations through REACH, and we know the need exists in at least two hundred and fifty more communities across the U.S.

So, if you're wondering what's one thing you can do. You can go to our website and join Active People, Healthy Nation initiative where you can learn more what you can do to help our goal to get twenty-seven million more Americans, more physically active by two thousand and twenty seven. And if you tuned into yesterday's White House Conference on Hunger, Nutrition, and Health, you heard that it will take all of us to make it easier for people to be more physically active. So please join us in Active People, Healthy Nation to create a more active America together.

Thank you so much, and it's my pleasure to turn it over to Steph Leonard.

Thanks, Terry. Hello, everyone. My name is Steph Leonard. And as Eileen mentioned, I am a Built Environment Coordinator at the Colorado Department of Public Health and Environment, or CDPHE, as we call it. And thank you to DNPAO for inviting me to participate today. And many thanks to each of you for tuning in.

So, I'm going to present some of Colorado's strategies to promote physical activity and reduce chronic diseases through our SPAN program and Active People, Healthy Colorado efforts.

So, on this slide, the physical activity in Colorado's slide. As background, so the data shows that show that more than fifty percent of children and forty percent of adults in Colorado do not meet the CDC Physical Activity Guidelines. The proportions of for this metric are greater than the state average among communities of color and older children. Forty-five percent of African-American adults, and fifty four percent of Hispanic adults, and fifty-two percent of high school students reported that they do not meet the CDC guidelines. Of note, reported physical activity within all population groups in Colorado is decreasing over time.

Since the origination of Colorado's SPAN program in two thousand and eighteen, we've made significant progress towards increasing activity-friendly routes to everyday destinations. This table highlights the sum of Colorado's reporting throughout years one through four. The first row shows numbers of potential miles and destinations called out in new plans or policies, and the second row shows numbers of actual miles and destinations that have been installed as a result of existing plans or policies.

One-way Colorado has promoted physical activity is through the development of Colorado Downtown Streets Guide. CDPHE partnered with the Department of Local Affairs and the Department of Transportation to produce this guide to help support effective planning and promote coordination between technical professionals and local leaders, as well as community members to create better streets for people walking and biking. One strategy called out in this multi-agency guide is the use of quick-win projects to rapidly enhance local streetscapes and promote active transportation. Pulling from the Colorado Downtown Streets Guide, Colorado has used SPAN funding to support quick-win projects that promote activity-friendly routes to everyday destinations. quick-win are low-cost, locally-driven projects designed to promote safe physical activities. Often, quick-win projects help provide essential streetscape components that may get value-engineered out of larger-scale improvements. While these projects may be small-scale or temporary, they can have large impacts on promoting physical activities, while also providing momentum toward or helping to implement long-term policy changes that promote healthy built environments. Some examples of funding quick-win projects include adding bike boxes at a busy intersection in Lakewood, shown on the left, and the addition of bicycle racks and fix-it stations outside of a food kitchen and near a popular transit stop in Durango, shown on the right. To highlight a few more quick-wins, the photo on the left shows high school students working on a trail crossing improvement near a school in Delta County. And on the right, you'll see two artists that design benches for the town of Hotchkiss Main Street. Hotchkiss has a vision to be more walkable and socially connected for the growing senior population. And benches were installed after learning that older adults would avoid Main Street because there wasn't a place for them to sit.

Over the last four years, Colorado has committed funding to forty-two community-based quick-win projects throughout the state, as shown on the map here. We opened our application for year four in April, and received sixty-three applications, requesting over two hundred and sixty thousand dollars in funding, which is highlighting a clear need for these types of funding opportunities. While we initially budgeted only thirty thousand dollars, we were able to leverage additional funds from the Colorado Comprehensive Cancer Control Program to fund twenty-three quick-win projects in total. To evaluate the applications, Colorado uses equity-centered variables in the scoring rubric, including comparing county-level health disparity index rankings, which is a metric we've developed at CDPHE, and assigning a higher score to projects that help improve activity-friendly connections for priority populations like lower-income communities, youth, and vulnerable roadway users. Building on principles within Colorado downtown streets and the momentum gain from quick-win projects, the Colorado Department of Transportation recently launched Revitalizing Main Streets to help communities implement transportation-related projects that improves safety and yield long-term benefits to community main streets. For this funding, Main Street is defined in a context-specific manner to be inclusive of rural and frontier communities that may not have traditional main streets. This program was originally funded by the Colorado State Legislature through the COVID-nineteen recovery plan, and developed in partnership with CDPHE and the Department of Local Affairs. CDPHE provided guidance on the request for application language, and project scoring criteria, as well as its own monthly application review panel. Revitalizing Main Streets is a dynamic shift for Colorado, as it is one of DCOT’s first opportunities, aside from safe routes to school, to focus on active or funding active transportation. And to-date, around one hundred and forty projects, totaling nearly ten-point-seven million dollars have been funded to promote activity-friendly routes to everyday destinations and revitalize Colorado's main streets.

Thank you again for your attention. I look forward to answering any questions during the Q and A session. And now it's my pleasure to hand it off to Thamara, to share about the city of Miami Gardens REACH program.

Thank you so much, Steph. Good afternoon everyone. As mentioned, my name is Thamara Labrousse and I am with the city of Miami Gardens. And I serve as a Program Director for Live Healthy Miami Gardens. I am really pleased to have some time with you this afternoon. This afternoon I will present on three current projects that reflect areas of work that are consistent with the CDC's priority of reducing chronic disease through physical activity and nutrition; and in particular, this work reflects work that is aligned with action items two and three which Terry have already covered.

Just in terms of background, Live Healthy Miami Gardens was started in two thousand and fourteen through a health foundation of South Florida Healthy Community Partnership grant, which was a six-year, three point seven-five million-dollar grant. The city of Miami Gardens was selected as the grantee to implement this new initiative and service the backbone organization. Overall, the goal is to strengthen community capacity, to collaboratively plan and collectively carry out strategies to improve health outcomes in the city. And this initiative is part of the city's strategic and systemic effort to reduce poor health outcomes by engaging community residents to improve identified, selected public health indicators. We are a Collective Impact initiative which is really an essential and intentional way of working together and sharing information for the purpose of solving complex problems. Collective Impact is carried out within a broad and diverse network of community members, organizations, and institutions. Our Collective Impact initiative is currently made up of sixty-eight organizations and about one hundred individuals, and the conditions for collective impacts are reflected here. Our theory of change helps to guide our work and keep us keep us focused. The theory of change is a comprehensive, descriptive and illustration of how and why a desired change is expected to happen in a in a particular context, and it really reflects the desired long-term goals and outcomes. Live Healthy Miami Gardens focuses on five health impact areas, alcohol, tobacco and other drugs, mental health, primary health care, nutrition, and physical activity.

Today, I will present on these three projects our Breastfeeding Project, the Healthy Corner Store Project, and our Healthy Out of School Time. So, our breastfeeding project offers education and training for providers. We also focus on policy development and implementation. We assess all the patients on knowledge, history, interest, and support needs. We refer to breastfeeding support services. We provide outreach to local businesses to help support breastfeeding promotion and workplace lactation policies, and we also provide outreach to local universities to encourage them to incorporate evidence-based, breastfeeding curriculum in their programs.

One of the things that I wanted to focus on is our Breastfeeding Cafe, which um went virtual because of COVID and since then we've had thirty-one virtual sessions. Of those who participated, fifty-six percent return for at least one additional group session. And there's been some major um lessons learned there. One is to be flexible in-regards-to the virtual space due to COVID. Another is the internal collaboration with clinic staff to ensure patients enroll for services is key, and we have five different clinics that we're in partnership with to achieve this and another is the collaboration with community partners, including WIC and Metro Miami Agency, to help promote the program to their client population.

Our Healthy Corner Store Project is designed to increase access to healthy food by assisting small neighborhood corner stores to stock and market produce. Currently, we're working with eleven stores. We also have a healthy recipe contest which takes place on a monthly basis. We have a healthy corner store designation policy, which was passed by our city council. We have a healthy retail committee, which also is made up of residents to help monitor what happens with the stores and support their efforts. We are currently working on a healthy checkout policy which hopefully will be going to council really soon. The project also includes a huge component focused on marketing and promoting the stores and making sure that residents know that the stores have these produce. We also provide technical assistance to help implement a work plan which is developed with each of the stores and reflect their individual needs and to help them achieve certifications.

And we also maintain a healthy retail website to promote fresh food access points and routes. And currently we're working on a community purchasing room which we hope will help our stores be able to get produce at a price point that makes it profitable for them. 

Our healthy corner store also has, we've partnered with the eleven stores. It's currently eleven. We just signed on one yesterday which have taken the pledge to increase access to produce within the city. The impact really what we're trying to achieve is to increase access to produce and we've been able to do this for about twenty-five thousand residents. And they're also major lessons learned that I like to cover. One is the important of strengthening relationships among the stores. The other is to build customer demand through interactive events which are held at locally at the stores. 

Our Healthy Out of School program it provides assessment of after school settings, technical assistance where we also develop a wellness plan and work with individual organizations to implement their plans. We provide a small ten-thousand dollars, up-to ten-thousand dollars grant to support action plan implementation and also to help the sites develop in strategies for adopting the national HEPA standards. I just like to add that since we've been doing the host project, which has been in the last five years, we have thirty host providers that are meeting an average of eighty-two point five of the HEPA standards and this has been a really huge accomplishment for these organizations.

Thank you so much. I look forward to your questions. And now I’d like to pass it on to my colleague Anu.

Thank you, Thamara. I'm Anu Pejavara and as Eileen mentioned, I lead our division’s program evaluation efforts. I get the extreme pleasure today rounding out our presentation with a celebratory message. I will share the collective progress of our SPAN, REACH, and HOP recipients. As of three years into their five-year corporate agreements, our recipients have made tremendous progress in such a short period of time; and have demonstrated such a commitment to making a difference in our country's efforts to improve places to make the healthy choice the easy choice. We have been truly wowed by them so I’m proud to get to share a little bit about their work. As Terry mentioned, and, as we heard further described in Steph’s and Thamara’s presentations, SPAN, REACH, and HOP recipients work on a variety of funded strategies which you can see here. Some of which are specific to certain cooperative agreements like food systems for HOP and REACH, and early care and education just for SPAN. We ask recipients to report progress to us in two categories: the number of settings that provide increased access to opportunities to make healthy choices; and the number of people potentially reached through those efforts. We have more data than we have time to cover today. But I will highlight just a few examples of each. This is a depiction of the summary of progress made across the strategies in just three years’ time. Isn’t this impressive? Let's talk a little bit more about each of these. Starting with the first two circles related to physical activity. As we heard from Steph earlier, SPAN, REACH, and HOP recipients work on policies and plans to support improvements in activity-friendly routes to everyday destinations, and they made great progress in this area. Recipients collectively built or installed over two thousand miles of activity-friendly routes, such as sidewalks, bike lanes, and connections to public transit. These are actual routes built out that you can physically see in communities right now. And because the High Obesity Program, or HOP, recipients work in primarily rural areas, they have built fewer miles than SPAN and REACH, but they are no less important. In fact, much of this work is occurring in underserved communities with the highest need. Recipients collectively created or enhanced four hundred and sixty-nine everyday destinations by year three. These were places for living, working, or playing. Some of the common destinations recipients worked on included parks, playgrounds, community centers, and recreation centers.

Now let's touch on the two nutrition strategies. For healthy nutrition standards, recipients work in settings where food is served or sold to increase the number of healthier foods offered. Recipients are working in over seven hundred sites, and the potential impact in just three years’ time is a whopping four million people. Some of the most common sites implementing healthy nutrition standards are work sites, hospitals, government agencies, food pantries, and faith-based organizations. Now let's look at the progress made by HOP and REACH recipients charged with working on the food system strategy. Recipients work with new or existing food outlets for the strategy. They work with partners to increase the number of places that sell or distribute healthy food in a community such as farmers markets, food pantries, or mobile markets, or by enhancing transportation options to food outlets, such as by increasing public transit routes or sidewalks to access grocery stores or markets. Recipients also work with existing food settings to accept food incentive vouchers, such as SNAP, the Supplemental Nutrition Assistance Program or WIC, the Women Infants and Children program. They collectively reached over one point seven million people through these efforts in over six hundred places. Some of the most common places where recipients are doing this kind of work are farmers markets, food pantries, mobile markets, and faith-based organizations.

Taking a look at the bottom row of circles from the earlier graphic recipients have made impressive strides with millions of people nationwide to support breastfeeding and early care and education. 
Breastfeeding continuity of care is achieved by consistent, collaborative, and seamless delivery of high-quality services for families from the prenatal period until no longer breastfeeding. Recipients are working with a variety of new or existing places to enhance lactation support such as clinics, hospitals, community centers, libraries, work sites, and even online lactation support. SPAN and REACH recipients have made tremendous progress on this strategy potentially reaching over one point four million people. SPAN recipients are also working to increase implementation of physical activity, nutrition and breastfeeding standards and practices in early care and education programs. Through these efforts they have reached over one point nine million children.

Now let's talk about how COVID nineteen impacted this work. Since the pandemic started two and a half years ago, we have heard about recipients’ creative pivots to continue important chronic disease work in their communities. Some of those pivots turned out to be fortuitous. Now recipients discovered new ways to support the communities they serve. In the business and innovation world, you may have heard the term stickiness. It refers to ideas or methods that have a lasting impact. We ask recipients to share examples of their creative pivots that have staying power, and which they plan to continue beyond the pandemic. Allow me to share just a couple. Similar to the example that Thamara shared earlier of Miami Gardens virtual breastfeeding cafes, several recipients shifted from an in-person to virtual format of their breastfeeding lactation support so they could sustain the offering during the pandemic despite facility closures and physical distancing measures. They found in fact, that this virtual format helped overcome barriers some families were facing with in-person attendance such as those that might not have had childcare or transportation to attend an in-person support group. Doing these classes virtually has been so popular that many recipients have said that they plan to continue offering it to families post-pandemic. Recipients also conducted a number of innovations around food security and distribution that may have some staying power. To avoid in person contact, some recipients used a drive through model to distribute produce at food pantries. They noted that clients like this model, plus it increased efficiency for the pantry. So it allowed them to serve more clients, and so they plan to continue beyond the pandemic. And this just scratches the surface of recipients’ progress and innovations. To summarize, we have been truly wowed by all that our recipients have accomplished in just three years’ time. All made even more remarkable, knowing the added challenges none of us could have predicted with the pandemic. SPAN, REACH, and HOP recipients have been transforming their communities in many ways, and we feel proud to bear witness to that work. I'll now pass it back to Eileen.

Great. Thank you, Anu. And, thanks to all our speakers for those great presentations. On your screen now you'll see several DNPAO online resources, including our Data, Trends and Maps, State and Community Health Media Center, our website and our social media. The links for all of these will be provided in the chat. Also, if you're interested in receiving the latest news from DNPAO, please use the QR code, or the link in the chat to subscribe to our listserv. You will receive the DNPAO Insider, our Research Roundup, and announcements on future DNPAO Seminar Series. Once you register your email address, you'll see all of the CDC listservs and you'll want to subscribe to the one that's nutrition physical activity and obesity. If you have other questions about the division, you can contact us at DNPAOPolicyatCDCdotgov. And with that I think we can open it up for Q and A. Terry. I think I'm going to kick it off with you. Earlier we mentioned the latest obesity map release where we see rates continue to climb. Could you talk a little more about what type of investment is needed to really move the needle on obesity?

Yeah, absolutely, thanks, Eileen. So while DNPAO's current work through our seventy-one public health practice recipients SPAN, REACH, and HOP really adds tremendous value, as you saw, and have heard from from Steph and Thamara, and Anu, lots of great successes, improving health. So, there's some great work being done there. However, the current resources dedicated to funding states and communities and land grant universities to implement what we know works these five actions. It's really quite limited. This is related to the level of available DNPAO investments, not the demand of the field. As I mentioned earlier, DNPAO resources equivalent to about thirty-two cents investment per American, per year, is unlikely to prevent obesity among at-risk Americans nor reduce the racial and ethnic disparities and in the national burden of obesity. So, we really need more commitment to adequately spread and scale what we know works, and what we know is needed for chronic disease prevention. I mentioned that, for example, we fund sixteen states, and we know fifty states plus DC can really benefit from that. And you know we have forty REACH recipients currently, and we know that there are three to four hundred communities that could benefit from that work. Thanks, Eileen.

Great. Thank you, Terry. Anu, another related question for you. One of our um registrants asked: what are some of the ways we can measure success for obesity really looking beyond just the BMI?

That's a great question. You know Terry described this earlier that you know we do have a good bit of evidence that shows what works as well as practice-based wisdom. So really the evidence and the practice show that that multi-prong multifaceted approach to obesity prevention is what works best, so that's policy change systems, environmental changes to ultimately make the healthy choice the easier choice, so that we can see an increase in healthier behavior. So, looking at measuring progress in healthier behavior, such as physical activity. You're also looking at um measuring progress through impact for policy changes, but those can all help illuminate progress being made. Something else to think about as we're talking about measurement and looking at progress. It's important to consider prioritizing underserved communities that have the highest obesity and those that have been disproportionately impacted by obesity, and maybe have received fewer resources in the past and opportunities in the past. So, I feel like all of that kind of fits under the umbrella of measuring progress. It's not just about looking at BMI change, but rather the entire systems changes that we want to be seeing in the communities with the highest.

Thanks so much Anu. And Terry, I know these are these are her questions. So, appreciate all of the thought and efforts that you all have put into this. Steph, I'm going to have the next question for you. How has Colorado promoted the Colorado Downtown Street Guide and its guidelines for the for better streets, for people walking and biking.

Thanks, Eileen. Ah! So, this guide has been out for several years. It was actually published before COVID. And so we, when it was initially ah launched, we traveled throughout the state, our our team, as well as with partners, with the Department of Local Affairs and the Department of Transportation to host workshops with community members and leaders who are interested in learning more about how to create healthier streets and safer streets. So, there was this again: multi-agency promotion through in-person interaction. So, we can answer questions in real time and provides context-specific direction. And then we continue to um share this resource as much as we can when we're providing technical assistance with communities. Most recently, and a recent example was, we are providing technical assistance in one of the counties in in Colorado, with our Public Health Department, where the Public Health Department is actually participating, was asked to participate in a master planning process. So, providing this resource as guidance to the public health leaders who are then able to more thoroughly interact in that master planning process, and have some context that might not be as readily available to them, since they are public health professionals. So those are a couple of ways that we've been able to promote it.

Great. Thank you, Steph. I appreciate you highlighting the partnership component. I think if we, as we know, these are really complicated issues, and and they're just not things that we can do in a silo or on our own. It really requires partnership across federal, state, and local levels. And so, hearing these examples of how the partnerships come together, I think it is really helpful too. Thank you.
Thamara. The next question that came in is for you. Can you talk a little bit more about the Healthy Checkout policy?

Sure, the Healthy Checkout policy is our latest attempt to really make the healthy choice the easy choice. I think all of us have had the experience when you're waiting to check out, these stores intentionally put things right at that right at the checkout line, just to temp you and to get you to make those last minute, very compulsive kind of purchases. Usually, those items are the are not the healthiest items. They really, you know the best the bathroom, and they're very sensing and um, and they're just not what we want people to be, you know, making decisions around when they're making their purchases. So the Healthy Checkout policy will change what the stores are able to carry and display in that area in those areas within the store, so that when you are standing there and you're kind of just trying to pass time where you should check out what's going to be reflected. There are the choices that are a lot healthier for you. So if you are tempted to make that last minute kind of compulsive, impulsive purchase, that you're actually now, you know, having um the healthier item. So that could be, you know, water versus sodas, and maybe fruit snacks versus you know, potato chips and things of that nature. So, we're working right now with our city council, obviously, to get something like this off the ground requires part of it, education, and really a shift in culture and thinking. So we've been doing some, some pre work with our city council, our city manager's office, and our city attorney to get something in writing that um that they can support. That will eventually go to the city council, and then we'll be working with our partners to help implement that policy in my regards.

Great. Thank you, Thamara. I think we've all been leaving the grocery store in the checkout line hungry, and seeing all of the candy options, and knowing how tempting it can be. So, it's, I think this is a great example of how these little simple design changes can really make a difference every day for people. So, thank you for that example.

I also see a question about the obesity maps, and whether we have data on kids as well. So, these maps are only for adult obesity prevalence in two thousand and twenty-one. But we are going to put a link in the chat where you can find national data on childhood obesity. All right.

Anu, the next question is for you. Are there any examples of SPAN, HOP, and REACH activities that you've been able to leverage that could also contribute to addressing behavioral mental health issues based by children, and students?

That's another great question. You know, I think we all recognize that health is not silo, right? We want to treat people as whole individuals and parts of communities. So, um yeah, there's amazing examples of this with our SPAN, REACH, and HOPs recipient. Um! They have done a great job of, you know, with our community clinical linkages, that providers clinical providers are not just referring patients to uh needs related to hunger or chronic disease prevention and management, but also basic needs, mental health services, housing, job assistance, things that really do affect a family's overall well being, able to thrive and survive. Um, even beyond just the nutrition and physical activity space. I think also our our recipients do a great job of connecting with local leaders and community members to learn what is, what works on the ground, what matters people in the community the most, so that again the efforts aren't siloed, and we treat people as whole individuals beyond just a physical health, but mental and behavioral health as well.

Great. Thank you so much Anu. Steph, another question for you. How does Colorado structure the quick-win funding, and what are the project parameters?

Thank you. So, we have, we've structured the Quick-win projects to be on a reimbursement model, so we um, for previous years, it's been that communities could apply for up to five thousand dollars to purchase equipment that could be used for promoting physical activity and active transportation. So, we can't for things like installation, construction, staff time or incentives, but the direct equipment purchase um! And when in our application, within the most recent year year four, we asked community members to talk about how this project would address existing community needs and barriers, and and to show that, show the need and barrier through the use of data. So, citing local plans, any kind of walking on it results or survey results, we wanted to make sure we were working in populations that you know, trying to target some priority populations. So, asking folks to identify who this project was intended to serve, and and the estimated reach for that, and showing a clear connection with local governments. So, we open this up to, you know, libraries or school districts or nonprofits. But often, these projects get installed on public land. So, making sure there's a close relationship with local governments to make sure that um the equipment can be installed in the proper and speedy method as well. And this year, in our application, we also asked folks to identify how this project will help it advance equity in the community. So, we provided a definition that CDPHE uses for equity, and explaining how achieving equity requires eliminating barriers and transportation systems. We have highlighted transportation systems in this project specifically. But that was a key component of the scoring criteria, as well as trying to prioritize communities where there might be a disparity in healthy eating and active living throughout Colorado. So, those are some of the key components of the equipment projects. Thank you.

Thank you so much Steph. Tthat's actually a perfect lead into this next question, which I think, Terry, I'll start with you, but then I'll open it up for the group, because I think this is something that everyone everyone can weigh in on. How do we address social determinants of health and health equity within our five action steps and strategies, particularly around rural and urban population and individuals with low income and vulnerable population? So, I think that's just some great examples of of health equity, and the work that that group is doing here. Can you talk about this a little bit more broadly? Anu, maybe share some data on how we look at this in terms of evaluation. And then Thamara also, please jump in with your thoughts.

Yeah, thanks, Eileen. I'll just. I'll just start by saying through our current program work through SPAN, REACH, and HOP, our the recipients really work to focus on the disparities related to inadequate nutrition or physical inactivity. And we know these disparities as we've discussed can stem from a variety of factors, race, ethnicity and geography, mobility, limitations, intellectual disability, etc. And we also encourage our recipients to design culturally tailored interventions. You heard a little bit about that as well, and I'm sure that Thamara and Steph can talk more about that across the across these priority actions that states and communities can take. The other thing I'll say at a broader level is, you know, community of orders matters and so we encourage the use of a community-based participatory approach, where the local coalition can really be active, into driving the work that that we do that they do to address some of these health disparities and drivers that have social in terms of health.

Sure, I like to jump in. I think a couple of things that Terry mentioned are so critically important, and it is reflective of the experience that we're having in mind regarding, for example, Miami Gardens is like eighty-seven point five, you know, like African American. But our Hispanic population is change. This change is growing. So that's a shift in our demographic, and we've had to really be much more intentional to being of that um segment of our population. So, we're getting ready to roll out an entire campaign that is, uh promoting physical activity that is promoting all of the amazing parts and green spaces that we have all of the activities that our residents have access to. And in doing that campaign, we're now, for the first time, having conversations and having to um allocate some aspect of our budget to having everything translated in Spanish, so that again, we can. So, we've never had to really consider that in Miami Gardens and um, and it's not something that we've done in other areas of work with the city. Obviously, health and wellness is not a typical municipal function, but we've had to really play a role as an initiative of the city to really push this message and encourage the city to be much more inclusive in other areas of work as well. So, that's a really important piece the other piece that he mentioned that we're also trying to focus on this idea of but being intentional about having folks who are representative of the community being involved in the work. So, we're using community liaisons and actually hiring people from the community to play the role of, you know, help champions, and really be at the very best level, engaging with with residents, and demonstrating, you know, doing demonstration projects and kind of displaying and showing our community what is possible, as it relates to physical activity. And both of those focuses have really been working well. And we feel good about this new kind of approach in terms of being much more inclusive.

Great. Thank you so much Thamara. I think you know equity is really foundational for the Nfl's work, and so it's great to hear how it's embedded in the work, and how our recipients are implementing this. Anu, I'm going to turn it back to you. Can you talk a little bit about how evaluation plays a role in equity?

Yeah, Thamara really touched on what I was thinking of, which is engaging community members in the entire process start to finish whether it's program, design and implementation or evaluation. And so, we've seen a lot of success with our recipients engaging community members to collect data or conduct evaluation activities, building that capacity, the community level and engaging those community members It just is a win-win all across. But they know the community well as well as building a strength and an asset in the community. So just wanted to underscore that point that Thamara made, and that Terry made about community-based participatory approaches. I think that's what we love to see with program evaluation. As well.

Great. Thank you so much. And we do a couple of minutes left. So I'm going to try and get through a few more questions. Thamara, nother question for you. This one around the virtual Breastfeeding Cafe, and I see a couple of different questions on this, so one, it looks like the virtual option was really successful. Do you see this as replacing in person? Do you see a hybrid approach moving forward, and then for these Breastfeeding Cafes?

Sure um! We've been having that conversation. I think probably every organization, every business, you know, is having a conversation in terms of what does it look like. In regards to either maintaining some virtual presence, or being all virtual or in person, I think, in order to again to be as inclusive as possible, we're going to be looking at a hybrid. I will say, however, that we were able to make the shift very quickly to virtual, and it's actually paid off in great dividends. We know that for some people, the option to participate virtually has really worked out. And when we talk about, you know, social determinants of health and all of the barriers that some folks in our community face on a daily basis, in regards to, you know, rather as transportation or not, having, you know, adequate support in terms of daycare and those kinds of things. We know that more people are participating as a result of being virtual, but we also know that we love the interaction and the face-to-face time with our clients. A lot of people need you know much more support than maybe we're able to provide on the on a virtual basis. So, we're definitely looking to do some hybrid. But we can't imagine looking forward and not having that option, you know um for residents to participate virtually because the feedback that we've gotten have really been positive, and that’s not just across the Breastfeeding Café, but across all of our other projects. So, we definitely will be doing a hybrid. And I'm. So, thank you so much for your question. Eileen, did I answer?

Yeah, yeah, thank you. I was just going to say, so one of our other participants is asking how the ethnic distribution looks at these breastfeeding cafes.

We have been trying to be really a lot more intentional in making sure that our residents, our black and brown residents are being engaged in breastfeeding. We know that there's a disparity where that is concerned, and we um we've been trying to get the message out there in in terms of the importance of this, and trying to build the support that is culturally relevant and conducive to engaging in work folks that are wrong, and we've seen an increase, but that is concern. Obviously, Miami Gardens is predominantly African American, as I mentioned earlier, and there are some major challenges where that is concerned. But we are seeing a shift. We're seeing a cultural shift, and we're seeing a lot more acceptance, not just in terms of our residents, but also the city and other businesses that we've been working with who are, you know, willing to talk with us, and have conversations about how they can much more supportive in terms of the policies and the in the programs that they put in place to support this very important function. We're also doing a lot more focusing on the person who is nursing and their support system, whether that be a mom that is helping or partner a husband, or whatever the case may be to be much more inclusive, so that we're building an entire support system for that individual to make sure that they're successful. So as a result of quite a bit of effort, we are seeing a bit of a shift.

Great. Thank you so much. All right. We're getting close to the end of time but there's one more question that I do want to address the idea coming in, and a couple of different ways. A lot of excitement around these programs here. Can you tell us in one minute or less how people can get involved with these programs?

Yeah, absolutely. So, first of all, check out our state and local programs link that has been shared, and you can see on that site you can see the program information that's available through SPAN, REACH, and HOP, each one of those programs.  Well, if you're in that state that has that program, we'll have a contact name, feel free to reach out to that person to learn more about that particular program, and absolutely do check out our forecast information that we shared in the chat about future funding. And we'll be having an information call in early twenty-twenty-three about those SPAN, REACH, and HOP future funding opportunities. So, we'd love to have you tomorrow.

Thank you so much, Terry. Thank you all again to all our speakers for this great presentation. This is going to be our last seminar series for two thousand and twenty-two, but we'll pick you back up in the new year. So please keep an eye out for invitation for invites. Thank you again to everyone for joining, and again thank you to our speakers. Have a great afternoon.
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