 Good afternoon, everyone. Health and Human Sciences researchers are taking great, giant leaps to improve lives in Indiana and around the globe. Thank you for joining us for the second in a series of HHS Learn and Launch presentations during Purdue's 150th anniversary year-long celebration. The College of Health and Human Sciences is grateful for the HHS Alumni Board's contribution to this program. I am pleased to introduce today's presenters. Angie Abbott is an Assistant Dean of the College of Health and Human Sciences and the Associate Director for Purdue Extension. As a registered dietitian, she is also an extension specialist in the area of nutrition education programs that targeted limited resource audiences. She has professional experience in the areas of education, research, community, and clinical practice. Tim Gavin is a professor and head of the Department of Health and Kinesiology and a fellow of the American College of Sports and Medicine. His research focuses on the effects of exercise in chronic diseases such as aging, obesity, and diabetes on skeletal muscle health. Together, they have focused their efforts on two Indiana counties with over 40 percent adult obesity rates and with a combined population of approximately 90,000 residents. In collaboration with local partners, their goal is to build sustainable health-oriented coalitions focused on identifying areas of community need and implementing evidence-based strategies to increase access to healthy foods and opportunities for physical activity. We hope you will enjoy this presentation. Thank you, Emily. Just so we're clear, I'm Tim Gavin, and we're excited to have everybody here today. Well, we're going to talk to you about some efforts that we've worked together on to look at how do we reduce obesity in a couple of counties in southern Indiana. So as we start to talk about it, what we were looking at was really a community approach, and we can talk about how we address obesity in multiple ways. We can discuss what happens at the cellular level. We can talk about how we make food choices. We can talk about what happens when you exercise. And what we're going to talk to you about today is how do we work with communities? How do we get communities to recognize the challenges they face and what might be effective solutions to get them to try and address those challenges? So very conversational. Angie and I wanted to be very conversational. I know I'm happy to take questions as we go along. And I will be honest, too, as I started to build the presentation, I got into my science mode and I got into statement of the problem. What's the background? What did we do? And I realized that's not where I wanted to go. So hopefully you'll see, too, very conversational in how we're going to approach it. So really, what's the problem? I'm going to give you some data. We hear about this all the time, just to get us on the same page. So obesity rates have tripled over the last 30 years. And the prevalence of obesity in the United States right now is approaching 40%. I always tell the students, think about that when you walk past someone on the street. Two out of every five people you will run into will be obese. Okay? Indiana struggles with many areas related to obesity, overall health, physical inactivity, access to healthy foods, and our public funding. Four efforts in these areas is among the worst in the United States. So we face very severe challenges here in Indiana that many states don't face. I think most frightening probably for those of us who talk about the impact of obesity is what's happening in our children. Okay? So what we see is that close to 14% of our two to five-year-olds are obese. Currently, if we look at our kids, it is currently projected that these rates continue. 57% of the U.S. population will be obese by their age of 35. That if a child, now we now can start to predict based on a two-year-old, if you have a two-year-old who is obese, they have a 75% chance of being obese when they become an adult. These are staggering numbers and the health care cost associated with these will be staggering as well. Current estimates is that we spend almost 20% of all of our medical dollars on obesity-related diseases or over $190 billion a year related to obesity. So it's not just the health problems but it's the financial side. So one of the things that Angie and I, we're interested in, is talking about how do we prevent this. We're not going to be able to treat our weight out of this. We will have to find ways to prevent these events from happening. And it's not just the medical cost. We lose almost $8.5 billion a year billion with a B in absenteeism for obesity-related issues. That's worker productivity that all of us, whether we're here at Purdue or whether we're working in industry here, Alcoa, what have you, those are going to be things that are going to have to be figured out. Alright, so one of the things we'll talk to you about some and if you know these counties, these counties are Jackson and Lawrence counties in southern Indiana, they're rural. One of the things to keep in mind is Indiana is a rural state. On average, we're more rural than the average U.S. state by about 5%. So we have about 20% of our population live in rural communities. And when you live in rural communities and we don't think of it this way, we think of people farming out on the land doing these kinds of things. However, when you live in these rural communities, you can face serious health disparities. And when we talk about health disparities, what we're discussing are things that may be different because of who you are. One that we talk about a lot is, for example, race. We know there are health disparities based on different races. Here what we're using is rural as also being a health disparity. And in part, that's due to the fact that you get geographic isolation. So we've been to county, we've been around the counties and we went to Midora, Indiana. Anybody ever heard of Midora, Indiana before? There we go, handful, alright. I hadn't. Midora hosts the smallest school corporation in the state of Indiana that has pre-kindergarten through 12th grade of 233 students in their entire school corporation. That is a and it's a relatively large geographic area. So these are some of the issues that we face. We can also face poverty education losses and access to physical activity and fruits and vegetables. And these disparities are also associated with low socioeconomic status and they can create food deserts places where we either cannot get healthy foods or the cost of those foods is so high and we've worked some to try and address that in these counties and also inability to access to physical activity. Typically, these will be things like rural roads. No shoulders, clearly no sidewalks. It's very difficult in rural communities to just walk outside your door and get physical activity. So they really face some challenges that are unique and even if we look at obesity rates, urban levels of obesity tend to be lower in part because in an urban setting, especially the more urban it is, city like Chicago has lots of walking around. You walk from your home to the bus stop from the bus stop to work so you get a lot of informal activity. So what we know we know that reducing obesity is, takes everybody to be involved. It requires environmental changes, policy changes, systems changes and we have to approach it from multiple perspectives. We know too that when we look at interventions it has to include everybody. We cannot do these types of interventions in isolation. We cannot just focus on schools. Last time I checked five-year-olds don't do a lot of grocery shopping. So we really have to address families in this and we have to bring everybody together, our communities, our public offices. That's the only way we're going to be able to see long term sustainable changes. And if we want to address it we're not going to go in and we were there for two years. We're not going to make people reduce the obesity levels but we want to put things in place. And so in 2016 the CDC, the Centers for Disease Control and Prevention put out a call and they were looking for partners and they said we want to partner with people we want to tackle obesity in these counties that had adult obesity above 40%. Right now the obesity, the adult obesity rate on average across the United States is about 32%. So these are very high percentages. In particular these are Lawrence and Jackson counties and the other piece was they said oh yeah, and we want you to work with extension. Now I'm lucky because I know people in extension. I know that's a big thing. So that helped us tremendously in being able to approach this problem. So what do we do? Well, we partnered with the CDC on a $1.15 million grant and this money went into the counties. We engaged with local community stakeholders and we used evidence-based approaches, behavioral approaches environmental approaches to try and impact these communities and probably what really was attractive to the CDC for us is we used a coalition a health coalition based model so what we really wanted to do was build teams. We really wanted to build teams in these counties that could help solve their own problems. But the very first thing we did was we formed our own team and I cannot tell you how important it was to get good people on board. So one of the first things we did was Angie said you should talk to Donna Vander Graf. It's like Donna who? Oh, I know Donna. Yeah. Donna it did a wonderful job. So here's part of our team here. Lindley McDavid, Karen Dubaugh Ellie Brottin, Donna Vander Graf, Molly Marshall Chris Meyer and Tonya Hall. Bringing Donna on board was tremendously helpful. She was wonderful to work with and there's no way we could have done it without. I couldn't imagine doing this without her. And then we did a couple of other really smart things because Donna told me to do them. One of the things Donna told me to do was make sure we got Lindley involved and Lindley did all of our evaluation. Being able to identify what was working in the communities and help us track our progress. The other thing Donna told me to do was she said you know we're going to build some champions, get these community champions. They're going to be advocates and help organize down in the counties. We should really get people who are from there. So Karen is from Lawrence County and Chris is from Jackson County. And by having people who know the communities already was a big win. Now I grew up in Indiana and I've lived in the northern part of the state where I was born and went to my early schooling and I lived in the southern part of Indiana where I went to college at another Big Ten institution that like Lord Voldemort will not be named. However, I hope you notice some of us are wearing appropriate attire and some of us struggle with it. So I've seen in actually where we went to school is very, is adjacent to some of these county areas. So I'm very familiar with them in what we did. The other pieces Molly is from Jackson County as well and then the last piece and what I thought was just wonderful ideas that we got when we sat down together and really started to think about how we wanted to attack this problem ENG said well what about community development? What about an economic community development officer? And I said what? She said we do this. Purdue Extension works in communities and they help build economic development. What about if we start to use this model? And that's what we did. And we got Tanya who is an economic development person and an expert in building coalitions. Do you think that sounds pretty easy to do? We're going to get a group of people in the room they all live around here they all know these are problems and we'll just figure it out. Oh. Having someone who can manage because you start to see when we get in these rooms you start to see how different personalities interact and having someone who can do that was wonderful to have happen. So what were our goals? We wanted to increase knowledge about healthy eating and physical activity across the lifespan. We wanted to build these community coalitions. So that they can help us identify the needs identify the solutions and be part of the solutions. And we wanted to increase access to healthy foods and physical activity. So what was our approach? This is based in community development. I can't take credit for it. Just Donna and Angie mentioned it to me and the only thing I did was go that sounds like a really good idea. So I always think and I'm sure you do too work with really good people and it makes you look good. I cannot tell you how this project did that exactly for me. So what do we do? So the five principles of this development is collaborate. So we built healthy coalitions so that we can get people across the spectrum community, public offices, schools, local healthcare hospitals would have you build it across the community. So what we're really trying to do was get everybody we could think of at the table. This is where Karen and Molly and Chris said, oh, you've got Joe and Sue and Bob. All right. Well, you need Carol. Carol's not here. We got to make sure we get Carol. Having those local people who could call and say, hey, we're doing this. We need you to be part of this was critical. Then we train the community champions. We learn how to do environments and how to act like a coalition. We then ask these coalitions. We empowered these coalitions to assess what the problems are. We went out to hospitals because we know they have to do needs assessment. Let's get their reports. Let's get the other reports that have happened around the counties and let's bring those together. But we test the coalition with doing it. Not Angie, not Tim, not Donna. The coalitions were responsible for it. Then we asked the coalitions to develop the strategies. What are the priorities? What are the things we should do in your community? And we would not do anything in the community until we had sign off that the coalition said this is what we want to do. We had people come to us and say, hey, we'd like to do this. And our very first question back to them was, what did the coalition say? If we circumvented that, we would have not empowered them to be the change implementers. And then the last piece, and this will take time to figure out if it works, is trying to make it sustainable. By building this coalition by empowering them using some of the funds we got from the CDC for successes to implement the things we'll show you, some examples here in a sec, to implement those ways for them to show that they're making a difference in impacting communities to empower them. And then trying to transfer the activities we did to the local communities. So this community development also is based upon a belief that the solutions are in your communities. You know your community and you can be the change maker. You can be the people who help us solve it. You know what would work here and what won't. I can tell you growing up in Indiana, no one likes to be told what to do. I can't tell you why that's true here, but it sure as heck is. And we know if we went into those communities and say, oh, you should do ABC they will just look at us like you don't even know who we are. We want to do XYZ. How do you not even know that? So by knowing the solution lies in those communities and working with them was fundamental. Then we had community networks sharing information amongst themselves. Not allowing people to be siloed with that information. Trusting each other. You go into communities and there can be a lot of distrust. Big Town in the county is distrusted by the smaller towns. How do we get those small communities to participate? We've got to build a common vision. When the coalition says this is what you wanted to implement, that's our common vision. And then we identify what our assets are that we can use to try and implement these changes. And then we use some good, good practices. Mentoring. And this is where Tanya, and there's a picture of Tanya leading some of our group discussions. Just a wonderful job taking it. And we sometimes, truly, you get a group of people. It can get pulled by one or two people into directions you don't need to go. And Tanya just was able to really do a great job of bringing everybody. Letting some of those ideas come on the table. Making sure people are heard, but still bringing it back to where it needs to go. Fundamental. And then show, teach, build capacity. That is what we plan is our plan for sustainability. And so this is kind of that community development where we do assets, we look for wins, we look for community partners, try and build common vision, try and get together regularly. And we just need someone in the county, too. It's like, don't forget, monthly meeting, Monday, two o'clock, community center, everybody be there. Someone has to send that email out. It's easy for everybody to look and think, oh, Angie's going to do it. Angie's like, no, Tim's going to do it. All right. And then trying to be this change agent to help maintain these efforts. So what were our successes? Here we've got a short video. Last I checked it does work. No promises. When we learned about the obesity rate in adults and the younger population, teenagers and younger kids, it was, it was shocking. It's an obesity grant with the two counties in Indiana that were above the obesity rate and Lawrence County, Jackson County were the two counties in Indiana. The Purdue Extension kind of walked us through the process and helped us out tremendously with getting all the exercise equipment signage for our blue jacket trail and they've been a tremendous help. The jacket trail has primarily two pluses. One is the physical activity and the bonus of being able to reconnect with people that I haven't seen that are now on the trail. So it's a, it's used rather frequently by a lot of people of a wide range of ages. Our individual projects in Parker Rec were everything from menu boards at our parks. We bid out that process to concessionaires so we wanted a policy change that said if you get this contract you have to serve so many healthy items. A big portion of it was our bike lanes and trails, the paint for the roads and lanes, that was a part of that and they helped us with the 40 signs that were a part of that and then you can see behind me the big addition is the fitness court in our community and they were a major sponsor with the fitness court. For years boys and girls clubs were kind of seen as an after school program so we're so much more than that, we're trying to become a community hub for a lot of things going on and so one thing we did through the grant the coalition is we started making healthy choices in our vending machines. We haven't completely taken out all of the bad choices but getting those healthier choices we see kids that will actually take advantage of them. We wanted kids to learn that no matter what town you can grow your own food grow your own healthy food. So we did start with the help of the grant we started our summer garden and taught kids how to plant tomatoes and cucumbers and peppers and then with the ninja warrior course we originally had that intended just for our preschool kids and early elementary but it's actually worked out for all of our kids. We opened a taught indoor playground that allows six months to five years come and use our facility in the morning when it's not being used so those kids can use that for healthy play. We're already seeing over 40 families involved with that program and that they come on a regular basis so when it's rainy and cold they can come inside to the boys and girls club and find healthy outlets to continue to be active. Personally I think it's a step in the right direction it's not the positive news that you hear when you're one of two counties that has you know an obesity rate that's a concerning and when you see steps being taken to improve that in a group or an organization that's willing to get involved and help you resolve that or help you make positive strides that becomes that's a very positive feeling from that standpoint. For the coalition and if it wasn't for Healthy Jackson County and the CDC grant through Purdue Extension I'm not sure we would have made these changes as quickly but having Healthy Jackson County in their support our healthy lifestyles really just we pushed that up a lot quicker. With the relationship we've developed with Purdue Extension and the city park board there and all the efforts from Purdue Extension we have seen a larger number of people outside using the bluejacket trail going to the parks they take breaks on the benches that were also part of the grant by cracks and we just hope that number continues to grow. So I get the opportunity to talk about a lot of the great you saw in the video a lot of the successes that the community has decided and I want to make that very clear we didn't go in and say you need to do this you need to do that. After they looked at their needs assessment as a community coalition they made decisions about what sort of things they wanted to implement in their community and we we went with whatever they said they wanted to do and a lot of cases we use some of the money from the CDC to make these things work but in some cases we looked at what other assets or volunteers or things there were in the community that helped them make the decisions about which opportunities we were going to take advantage of. You heard on the video both of the communities did this healthy vending or concession stand things which I thought was really interesting if you think about where families go when they're not at home and they're not at school right and the coalition said we spend a lot of nights at at a concession stand at a baseball game or at a basketball game or you know we a lot of times we're busy in the evenings and that's where we're at and sometimes you know think about what are the options when you go to a basketball game at the concession stand so they said if we had healthy options we're not going to take away the other ones that would be great if we had options to choose from and I really liked it that they both decided to do their vending process where they put out bids and they would only accept bids from people that included healthy choices back and so you know that was a good policy system that they made and they did that with their parks department they did that with their schools the athletic departments were involved the PTOs all sorts of groups that were involved in concession stands so that was and then they used some of the CDC resources to make signage to sort of highlight what the healthy menu options were that were available and in Lawrence County they needed signage and information to help the community understand about their blue jacket trail as Tim talked about you know you can all think about the country roads in Indiana and I don't know about you but if you've ever tried to walk on run on them of course they went the water so they kind of got this slant you know that goes down and so anyways they have this trail in Lawrence County but a lot of people didn't know about it didn't know which way they'd be on the trail and you know you'd go so far and then they're not sure if the trail stopped here or do I turn will I come back to where I started so again signage and things like that to promote that trail in Lawrence County was an option that one of the communities chose another one of the communities chose safe routes to schools so you know the young people again when we were thinking about this grant we weren't necessarily focused on that 40% of adult obesity that were already obese right we decided to think about prevention strategies headed forward and you can imagine these communities didn't necessarily like getting the phone call from me at Purdue Extension like guess what you qualify for a CVC grant because you're one you're the two counties that are 40% like you win you know that's not a fun phone call to get you don't want to be on that list right and so so thinking about with those communities how do we look at what our assets are these communities have great assets how do we look at those assets and turn them around to help sort of prevention strategies so they had they did have some sidewalks and stuff just not the signage and the crosswalks and stuff to help people think about this is where you cross the road if you lived in the community down this sidewalk your kids could walk to school and here's the crosswalk so the signage and the crosswalk didn't exist and so those are the types of things that the communities decided if we had these things more kids would walk to school one of the communities I thought had a really clever idea and they developed this and I'm going to think about what the name is or I'm going to get it right help me Tim what's the name of that the the Mitchell inclusion garden that's what they called it the Mitchell inclusion garden and they got a whole bunch of volunteers a lot of supplies were donated and they created this garden in Mitchell in one of their parks that were designed for people in wheelchairs so it was raised beds they had the raised beds built so that people who could stand up you didn't have to bend over to get to your garden the garden is all up and then they made nice paths and things around them so you could easily get a wheelchair around and through the park and still participate in the gardening program and so again they very if any I'm not even sure that any of the CDC funds were used for this project it was all volunteer and donations from the community of coming together and deciding this is one of the strategies that they wanted to implement I thought this was a really creative way that the music was a creative way to sort of bring attention to the crosswalks in their community so that was fun and both of the communities worked with the different youth serving organizations to start gardens in various youth serving organizations so lots of community gardening type of work as well so those are some of the successes so let me talk a little bit about what worked definitely what worked when you give the community the information they can make the decisions about what's going to work in their community so even all of the control over to the community worked and that's something that we're going to continue to use through cooperative extension flipping the challenges into goals so I talked about identifying those assets in the community they had some great things working but they also had some challenges and gaps what we did what we help them do through the community development process is looked at what their challenges were and said how about if you turn those challenges into your goals right so instead of looking at them as a negative let's turn those into that's what we want to change so we flipped those into goals building health coalitions unique to each community Tim sort of alluded to the fact that you know you go into a community and CDC defined what the geographic region was right they said it's based on county well we know not necessarily all communities identify with county right but that's what CDC said so that's what we had to work it with but we did have one of our communities had these sort of two sort of cities that were like no what's going to work for that town isn't going to work for our town we're in the same county but we do things different and so that idea of thinking about the stakeholders defined community right and so letting the stakeholders define what their community is and letting them make the decisions based on how they defined community so that was you know that's one of the things that comes with these funding opportunities the funding was use it for this county but in reality that's not the way necessarily the world works and then within these health coalitions they formed committees and then those committees identified what their top interventions are going to be and one of the things that we started working on from the very beginning and this is as you see here in second when I talk about where we're needing to go thinking about building community leadership all these people that are involved in these health coalitions have other jobs they're volunteers like we hired people through the grant to sort of be the leaders but we knew after two years that money was going to run out and they were going to go away so how do you start to build leadership and community capacity so when that grant money runs out the work can can keep going and so that that's a constant sort of struggle especially in these small communities you know the all of them have multiple jobs and there's very limited volunteers so those are things that we have to think about as we work in communities so areas that we're needing attention they struggled if whatever the seed of the county was or the big city is usually where the activity started it's usually where the extension office is the Purdue extension office is located so sometimes it was hard to get participation from those other small towns because they're like yeah whatever they're going to do it's going to be for Seymour right because Seymour is the seed and they always get all the resources so we had to deal with a little bit of that no probably shocker in this room they weren't real interested in strategic planning so anyways that was something that there wasn't a whole lot of interest about what they were more interested in were these sort of one off events right let's host a 5k let's have a health fair right they didn't want to think about what are some bigger things that we can do those were easy wins and so sometimes it was hard for us to get them past that sort of easy win thinking and then again the idea of transferring this leadership to community agencies right when the money runs out to pay for this champion that we were paying for with the CDC funds who's going to be the leader of this group who's going to send the email to tell people to get together who's going to push their colleagues to keep these interventions moving forward and so that is actually there's lots of good data that shows that's one of the struggles with community based health coalitions is the leadership if you don't have someone leading it it falls apart real quick and so leadership is an important piece that needs to be thought about and that goes along with long term sustainability leadership is key to the long term sustainability so what's our next steps we know that moving forward if we do this work which we will continue through Purdue Extension to do this work in other communities in Indiana is you let the stakeholders define the community the stakeholders define what the geographic boundaries are going to be and we need to build and support community capacity and leadership within rural communities one of the things is they just need to know they can do it right I mean sometimes it's like so overwhelming you look at the data oh my goodness 40% of us are obese like how are we going to turn the ship around and so part of it is just looking at we're not going to fix everything let's choose a couple of things small wins and get those moving and that's what happened you start small and then they're like oh we did that now we can build an inclusion garden or we can write a small grant and get money to do signage for our trails and so you start out with the small wins and then start to help them see that there are bigger things we really want to continue to help communities to think about using data to drive their decisions as one of the mayors said on the video like I couldn't even believe our county was 40% or more obese right so there was a local elected official that didn't even know that there was this health issue okay so using data to help the communities make decisions using the health needs assessment and things like that and then you know always trying to connect the these communities to additional resources many of those resources we have expertise on this campus that can help help these communities answer some of these difficult questions so helping communities get connected to Purdue but not only Purdue there are all sorts of resources across the state and across the nation and so helping them then get connected to those and so with that we want to stop and open it up for questions and if I recall we'll need to wait for the microphone to get to you it won't you won't hear the volume it's just for the camera so with that we'll open it up to any questions you might have. Well to wait for our first question one of the things I learned and this is the only place I've worked in the land grant institution I cannot tell you what an absolute pleasure it was getting to know extension much better. Extension at Purdue and the trust the communities have with extension at Purdue is outstanding and if you're thinking about ways you want to be in rural communities or communities across the state I don't want to speak for you but I'm sure she would say well give me a call. Absolutely absolutely so we have a health and human science extension educator and other extension educators that cover ag community development and 4-H youth development in all of the 92 counties so we have resources and people there that can get connected so lots of opportunities and our boss has a question so I think we should call on her. Thank you for a really outstanding presentation that was just wonderful and I love the pairing of the scientific perspective and the stress of the importance of working with the community and taking the ideas from the community I have a very basic question about sort of the science of obesity and then how you communicate that to the public so I understand that it matters how much we move and it's very good for us to exercise and exercise helps to prevent obesity I also understand that we need to make healthy choices about eating and not eat too much I know the public health message must be that both matter I accept that is it not the case that what we eat is a little more determining of obesity or is that true I mean if you had to say which is most important in preventing obesity and in reducing it if you had to pick you got the nutrition person and the exercise person you all could take it out well I go for it I mean even if I had to pick I'm not sure that I could because I think both of them are so so important and sort of the message we usually give is working with communities to make the healthy choice not focusing on food or physical activity making the healthy choice the easy choice that's really the way we communicate with communities is how do you how do you make you know if you got to make a choice right that it's easy so if you're at the vending machine or you're seeing that the concessions stand with your kid you know and if there is no other choice besides candy and pop and you're hungry you're going to choose candy and pop there are other choices it's easy they're there we can make that choice if we want so when we look at the scientific data when you look at it from an energy perspective you can change energy balance equally with both systems you see similar kinds of problems with both systems in how people lose and the biggest issue is you have to I would say you have to clamp if you're going to study one you can clamp the other so if you're going to have people who are reducing their caloric intake it's easy for people to stop being active you have to maintain their activity similarly if you increase someone's activity you have to clamp how much they're excess eating because clearly they can eat their way so it looks like a net balance so when we look at just the energetics of it all they're very similar because we're talking about the same amount of energy difference you're welcome well I was going to ask a question but I think based on the energy balance one quick thing is it's actually interesting when you get to the energy balance unfortunately a large amount of that research has actually been funded by Coca-Cola and so I think as you're taking a look at research literature you should be careful in terms of who published that work but I think even irrespective of whether obi physical activity or nutrition is most important I think the interesting thing to think about is that we know that physical activity is an independent risk factor for a large number of health outcomes and there's a lot of work that was done in the 80's and 90's looking at how cardiorespiratory fitness is associated with different health outcomes especially if you're looking at you could be obese but still have a high level of fitness level and would still have certain protective effects so I think whether you're looking at whether one is more important than the other I think looking at the literature that shows that physical activity is definitely offers a lot of independent risk reduction but I think back to my question though I think working with communities is really really difficult and when you start working with I think rural low-income communities and racial and ethnic minority populations I think hopefully everyone in here has gone through city training that you learn about a lot of the horrible atrocities that have taken place and potential mistrust with certain communities potentially having fears of partnering up with communities and then I think related to that is just the fact that a lot of low-income are just swamped by you look at how many communities in either are in Indiana and then you look at how many universities there are doing research in Indiana and I think a lot of them are just swamped with a lot of different requests and that highlights some of the issues that you ran into related to trying to work with communities I know you highlighted a little bit about that talking with some of your community champions and working with people that were part of those communities but I don't know if you could highlight a little bit more of that work Sure, so we have extension educators that have been in the community they're there and they're embedded in the community so they know the partners so before we actually even applied we went down and had our local extension educator bring together groups and we had a conversation with both communities and kind of said what do you already have going on maybe this isn't needed I mean maybe this isn't a good time for your communities and so we had conversations before we even applied for this grant with the communities that we were talking about if it was the right thing our extension staff do a really good good job in my opinion of helping try to balance that lots of people coming in and wanting to help or wanting to collect data or whatever it is they do a really good job of trying to balance that of course they always want to encourage it but there's a balance I think I've even shared this example with you particularly in the situation in Lake County a couple of years ago when they had the lead poisoning going on in Lake County we had several people not only on produced campus but other campuses contact our extension office and our people that work in low income communities they are specifically that community that was affected by that situation and you know our extension educator said the community doesn't want all this they don't want that anymore they don't want that anymore and so having those champions and those people that work and live in the communities were able at least they knew us well enough at Purdue to say no we're done and so that's hard for us in an academic community when we want to collect data and we want to help but the community knows sometimes when that stopping point is well and there too I'm not an extension Purdue extension and I can't speak to other states Purdue extension is well trusted in their communities exactly because the kind of example Angie gave which is they have the communities best interest in mind in the communities know that I was horribly impressed as I got to see the health educators in the counties working with their communities because when in so many times there's not so fantastic job and we hire people who live, work, play and pray in the communities that they serve and we do that for that very reason thank you again this was very very informative if I were to take home messages I guess the first one that I heard is getting the right people in the community to provide trust and empowerment I think that was the first part and the second one was almost like a paternalistic approach or nudging towards the right decisions make the choice available and then in a very seamless passive way just nudge them so that they don't have to really choose they just do it what I didn't hear, here's my question is whether there was an information gap I'm an engineer I tend to think that I need to tell people about the data and I didn't hear that you guys had the challenge with that I guess was there a challenge people already know in just a matter of implementation or there is also an information gap that you have to address yeah that's a really good question and actually I didn't talk about we had a success that was more of an information so in both of the communities we implemented evidence based nutrition education and physical activity curriculums in their school systems we did some in the youth based boys and girls club and things like that and as a part of the school based work that particular evidence based program that we used had a parent component to it that we used but that's a small sort of snippet of getting them information but as a part of this grant there was some of that helping educate people about what are the right decisions and then part of it was getting the environment set up so they could make that choice there's piece two that I thought really is by empowering the communities the communities know what works and what doesn't work they know where their errors are they know the data and we can look at the sheet of data they know the data from seeing it in real life they can tell you we go around with their health educators oh I can tell you this county has this this opportunity and not that one so we had that data in the community on the sides of the community were discussing really knows what's happening there they really did need us to talk about and I would say understanding that healthy eating and physical activity we really didn't have to tell anybody about that like we didn't have to show them a whole lot of data because they already know about the problem although certainly I think still areas for improvement because we saw leadership elected officials that didn't really know the data so there's still lots of opportunity yeah so to kind of dovetail off of that question is so how did you guide well you know it is important to make the community make their own decisions on what interventions they want to put into place but I guess my question was how did you guide or did you guide them in making decisions that would be the most impactful because I'm sure there are some people that wanted to you know build a new restaurant or I mean I don't know some something that may not been as impactful as you know the the bluejacket trail or something like that so we partnered with our community development colleagues who are all trained in facilitation which was key as Tanya Hall was is trained in facilitation skills and so and they use lots of different processes of which I'm not an expert in and helping people get to what are all the ideas and then how do we prioritize those and how does that match up with our needs assessment data that we had so they spent a lot of their coalition work getting those sorts of pieces together and then ultimately they were making the decision but they were making decisions based on lots of different pieces of information right like like maybe this was our highest priority to do I don't know safe routes to school right but in this community we couldn't get through the streets department approval to do it right so it's going to take us more work to get through those political barriers so let's go to this one so they did a lot of that like thinking through or in this community we want to do this but we really it's going to take some grant writing to bring in some other resources so let's go to this one because we feel like we can get that until we can get a grant written for this does that make sense okay we had two pieces to one was each of these the communities had already tried some of this having coalitions and they all fell apart so really trying to bring someone in who can facilitate it really brought them back together the other piece that we didn't show in here was we also brought in experts from outside we brought an expert on physical activity in the built environment and we had them come in and just you could see when they would put ideas on the table they said so here we are we're walking with the police and the police chief and the fire department chief and the principal of the school and one of the the thoughts was well wouldn't you like then the principal said we would like a connection between this community a sidewalk or something and our school so our students don't have to go on busy roads and the expert said looked at the police chief and the fire chief and said would you like something that's a little bit wider so in case there is an incident at the school you have a back entrance to get in and you don't have to fight all the parents coming in and they said we've always wanted that so could we build a sidewalk that facilitates the kids so having people who could facilitate those conversations and bring in the communities the one thing I remember hearing about bringing this expert in was the community said that's the first time somebody in here who didn't tell us we had to spend ten million dollars to get started they said you know you can just do this put some planners along here to limit cars getting in and out of this parking lot just paint some stuff here make these kinds of changes that bought us a lot of goodwill and went a long way instead of saying you know you need a hair consultant you know that's going to give you a report that says for ten million dollars you can transform this community right well and these are the solutions too are and you have it in every area oh as soon as someone goes well you're going to have to contact the State Department of Transportation and everybody's eyes glaze over they're like oh my gosh it will take forever and it's going to cost us a lot of money but when he says oh you know you could just paint a line you could just paint a line down here and make a bike lane because it's wide enough and so what we would do is we buy the paint and the communities would provide the labor and they would put them so like this the crosswalk we bought the paint they provide the labor to put it all together great thanks everyone