Active People, Healthy Nation℠ seminar

Okay, let's go ahead and get started. So, I'm so pleased to welcome you all to the Division of Nutrition, Physical Activity, and Obesity Seminar Series. This is our second in the reboot that we've done of our seminar series, and these will be posted eventually online, so you can watch it again and check it out. I'm your moderator today. I'm Janelle Gunn. I lead the Office of Policy, Partnerships, and Communications in the division. So, thanks folks who have been on and filled out the poll, and we'll kind of get started here. So, just a little bit of housekeeping as we get started. So, first, this Zoom seminar call is being recorded, so if you're not comfortable with being on a recorded call, we ask that you disconnect at this time, and you can always watch it on playback later on our website. To have the best experience, we encourage you to use the Zoom webinar app or website to view slides and to participate in today's meeting. All participants have been muted. Following the three presentations, we will have a Q&A, so if you look on your Zoom and on the bottom, you see the Q&A box, that's a great place for you to enter the questions that you have for our speakers, and we'll get through most of those at the end of the session. So, at any time, when you kind of think of your questions, go ahead and put it in, and we'll be queuing those up for the Q&A portion. So, I'm really excited to be joined today by three great speakers, and they have a whole afternoon focused on, or morning, depending on where you're joining us from, focused on physical activity. So, our first speaker is Dr. Jeff Whistles, and he leads the Epidemiology and Surveillance team within the Physical Activity and Health Branch at CDC. Jeff holds a master's degree in Exercise Physiology and a PhD in Epidemiology from the University of Texas System. He joined CDC as an EIS officer in 2013, and his research interests include health impacts of transportation-related physical activity, the environments that support walking and bicycling, and public health surveillance and physical activity. Our next speaker will be Ken Rhodes. Ken is the chief of our Physical Activity and Health Branch in the Division of Nutrition, Physical Activity, and Obesity, which we call DNPAO. So, if you hear DNPAO throughout the seminar today, you'll know what that is. Ken has extensive experience in policy systems and environmental support for physical activity and managed the creation of Active People Healthy Nations. You'll hear more about that today. He directs the branch of scientific and partner strategy and has a 25-year career at CDC, holding multiple leadership positions in the agency. And lastly, I'm really pleased to join Armand Turner. He's the Physical Activity Program Manager at the YMCA of Coastal Georgia. Here Armand is working with African-American people with lower incomes within the county to improve their ability to live healthier and more active lives. As a professional in the recreation field, Armand works to provide quality recreation and wellness betterment opportunities for all populations, including but not limited to people with and without disabilities, youth, adults, young adults, and seniors. So, our agenda for today, as I just shared, we'll have the three speakers and some Q&A. And what we'll be doing is we'll be walking through recent research on the benefits of and barriers to physical activity, looking at physical activity trends over the past 20 years, hear about some new resources and tools from Active People Healthy Nations, and lastly, how the YMCA of Coastal Georgia, Healthy Savannah, is creating activity-friendly routes to everyday destinations. So, very exciting. I'm really excited for the focus on physical activity today. Regular physical activity is one of the best things we can do for our health. And we know that only about half of adults are meeting physical activity recommendations, and even fewer are meeting the additional recommendation of muscle strengthening activities. Here in DNPAO, we aim to increase equitable and inclusive access to safe places to be physically active. DNPAO utilizes a broad evidence base to improve population health and promote health equity with strategies from the Community Guide, the Physical Activity Guidelines for Americans, and the Surgeon General's Call to Action to promote walking and walkable communities. So, let's dig into the benefits of physical activity. I will now pass the virtual microphone over to my colleague, Dr. Jeff Whitfield. Jeff? Hey, thank you, Janelle. Appreciate it. Thanks for the opportunity to talk today. I'm going to start by saying that physical activity is one of the best things that people can do for their health. Many people are aware of the long-term benefits that you can see on the right side of this graphic, including prevention of heart disease, diabetes, and several cancers. But physical activity also has immediate benefits that can be enjoyed after just a single episode of physical activity, including improved sleep, reduced anxiety, and reduced blood pressure. And the bottom line is that physical activity is an incredibly powerful tool for improving health and well-being. In 2018, a group of experts reviewed and summarized the science on physical activity and health to determine the amount and types of physical activity that improve health. And the end result of this process was the Physical Activity Guidelines for Americans Second Edition. And I'll point out a couple of highlights on the screen here for the various groups. For youth and adolescents, daily physical activity is important. And some of that physical activity should be at vigorous intensity. Also, muscle-strengthening and bone-strengthening activities are important for youth and adolescents. For adults, the guidelines recommend at least 150 minutes per week of moderate intensity aerobic physical activity, plus muscle-strengthening activity on at least two days per week. And then for older adults, the recommendation is the same for adults, but it adds balance exercises. So those are the amounts and types of physical activity that are important for maximizing health benefits. Unfortunately, many people don't get the levels of physical activity they need to achieve health benefits. Only about one in four adults and one in six high school students fully meet the Physical Activity Guidelines. And about 37% of adults age 65 or older are inactive. That is, they report no leisure time physical activity. In addition to the benefits noted before, there's emerging evidence that physical activity improves immune function and may prevent severe outcomes for people diagnosed with COVID-19. What you see here is an excerpt from one of those studies. This study, in particular, looked at almost 50,000 people with COVID-19 who also reported their physical activity levels at least three different times in medical visits that occurred before they were diagnosed with COVID-19. And the researchers then classified these people into three categories. Those who were inactive, so they consistently reported little to no activity. Those that were inconsistently active, so sometimes they reported activity. And then those who were consistently active, that was the most active group that always reported being physically active at those visits. What you see on the screen here is that among the most inactive patients with COVID-19, 10.5% were hospitalized, 2.8% went into the intensive care unit, and 2.4% died. Now, when we add in the inconsistently active, remember they did some activity, we can see that they were slightly less likely to have each outcome. And then when we add in those who were consistently physically active, we can see that they were much less likely to be hospitalized, be admitted to the ICU, or to die of COVID-19 than their less active peers. And it's important to note also that in this study and in others, even after adjusting for things like smoking, past medical history, age, etc., this effect was still present. In fact, being inactive carried a similar risk for severe outcomes from COVID-19 as other well-established risk factors for severe COVID-19, like diabetes or even having had an organ transplant. So physical activity protects against severe COVID-19 outcomes. But there is evidence that some U.S. adults have gotten less physical activity during the pandemic. For example, this study or this report from CDC shows that in June of 2020, nearly one-third of U.S. adults reported decreased physical activity levels during the COVID-19 pandemic. Compared to white people, decreased activity was more likely among Black and Hispanic people, who are also known to be at risk for severe illness due to COVID-19. And have higher rates of chronic diseases. Notably, these groups may not have adequate neighborhood supports for physical activity. So this finding really speaks to the urgent need to make sure everyone has access to safe and convenient places for physical activity. As you may imagine, the health benefits of physical activity can add up to considerable healthcare savings. In an analysis spanning 2006 to 2011, CDC authors estimated that about 11% of healthcare expenditures among adults, or an amount equivalent to $117 billion per year, is associated with inadequate physical activity participation. Additionally, a recent study from the NIH, the National Institutes of Health and CDC, looked at the physical activity history of over 20,000 AARP members and their Medicare expenditures later in life. They compared people who became active as adults to those who were consistently inactive throughout their life. And found substantial cost savings of $800 to $1,800 per person per year. Where early adoption of physical activity in adulthood was associated with the larger decrease. And the important takeaways from this study were, number one, if you're physically active, stay that way. And number two, adults can benefit from becoming active later in life. And the earlier, the better. So it's very clear that physical activity improves the health of individuals and groups of people. But activity-friendly communities experience additional benefits beyond personal health. The types of changes that make a community activity-friendly, so think about sidewalks or walkable or bikeable main streets, that kind of thing, can also bring economic improvements, safety improvements, and increased productivity. All right, so we've established the health and other benefits of physical activity. So now let's take a look at how physical activity participation is changing in the U.S. And if anyone's interested in a deeper dive on this subject, I'll refer you to the supplement mentioned at the bottom of the screen here that contains 13 different papers on this subject that are all freely available on the internet. Okay, so we're going to start with physical activity among adults. And we'll start with the National Health Interview Survey, which consistently assessed leisure time, aerobic and muscle-strengthening activity among adults from 1998 to 2018. And during this time, the proportion of adults that reported meeting both the aerobic guideline and the muscle-strengthening guidelines, so fully meeting both guidelines, increased, albeit somewhat inconsistently, from 14% in 1998 to 24% in 2018. And importantly, in this paper or in this analysis, a really key finding was that these increases were evident in all the subgroups that we looked at, including by age, sex, race, ethnicity, and education, which I think we can all agree is great news. However, despite these widespread increases, some important differences remain. And what you see on the screen here is a deeper dive into the proportion of adults who meet the aerobic guidelines. So we're focusing in on that aerobic guideline now. And we've separated it by income and race ethnicity at the same time. And there's a few important takeaways from this analysis. The first is that regardless of income level, non-Hispanic white people are more likely to report meeting the aerobic guidelines than are non-Hispanic black or Hispanic people. And this means that black and Hispanic people at high income levels, that's the far right side of the screen, have similar activity levels to white people at moderate income levels, that's in the middle of the screen. And black and Hispanic people at moderate income levels, so now in the middle of the screen there, have similar activity levels to white people at lower income levels. These analyses also show that some of these differences by race, ethnicity, and income have in fact narrowed over time. But important work remains to ensure that everyone has the opportunity to be physically active. Now, there's likely many reasons for these persistent differences. And Ken is going to talk a little bit more about how to address those in a few moments. But as I mentioned before, differences in access to safe and convenient places for physical activity are likely a key factor. Now, keep in mind that the previous slides showed physical activity in leisure time. And think about going for a walk or playing basketball, jogging, et cetera. But physical activity occurs in other contexts as well, including during work time, during household upkeep, and during transportation. Now, the National Health and Nutrition Examination Survey, so we're changing data sources here, and we're looking at something else. The NHANES, as we call it, has asked adults about these different types of physical activity since 2007. Overall, and after some ups and downs, the proportion of adults who meet the aerobic guideline, when combining all of these different contexts of physical activity, it has increased slightly, but significantly, from about 64% of adults in 2007-2008 to 68% in 2017-2018. These data also suggest that although non-Hispanic white people report more physical activity than non-Hispanic black and Hispanic people, differences in recent years are smaller than differences early in the monitoring period. These data also show that physical activity during transportation is a potentially underutilized source of physical activity among U.S. adults. And then I'll close with a couple of remarks on youth physical activity. So, every two years, the Youth Risk Behavior Survey asks high school students about their past week's physical activities, and that includes both aerobic and muscle strengthening activities. The results over the past several years are concerning, with decreases among both boys and girls. The decreases were particularly evident in 2019, which is obviously before the COVID-19 pandemic, which raises concerns about the potential for further decreases during the pandemic and the associated disruptions. So, that concludes my remarks on monitoring physical activity. I'm going to pass it over now to Ken to talk about Active People Healthy Nation. Thank you so much, Jeff. I appreciate your great presentation there. So, today, I am going to talk about Active People Healthy Nation, our work to get 27 million people more physically active by 2027. I'm going to provide an overview of Active People Healthy Nation, what DNPO supports, highlight some recent data related to our strategy to support that work, and then review some recent resources as well as some hot off the presses Active People releases. So, as you can see here, Active People Healthy Nation supports a set of seven evidence-based strategies that work for increasing physical activity. It's critical to note that equity and inclusion should form the foundation for all of this work. If you go to our website, you can find additional information and resources about each of these strategies. Today, I'm going to talk a lot about our work to make safe and convenient physical available to everyone through a strategy of what we call activity-friendly routes to everyday destination. So, as Janelle started our remarks, DNPAO is our division, and so I'll refer to either DNPAO or our division to reference the work that we do within our part of CDC. As Jeff briefly mentioned in his presentation, we support work to increase physical activity through walking in support of the Surgeon General's call to action to promote walking and walkable communities, which recognizes that walking and rolling are the most approachable forms of physical activity. Walking is also the most common physical activity people report doing. For example, data from the National Health Interview Survey shows that three out of four U.S. adults who meet federal physical activity guidelines report walking for transportation or leisure. Our work seeks to integrate opportunities to walk into daily living through a strategy we call activity-friendly routes to everyday destination. It focuses on creating safe and convenient routes, like sidewalks, to places people typically go, like parks, schools, or stores. And it recognizes the importance of improving safety for people walking and reducing the distance with which they must walk to reach destinations. But it addresses, it is important to understand that these are fundamental problems in this country. Our strategy addresses the lack of access to safe streets. And for example, in one national sample, and these are data, just a sample of data that support the strategy that many may not have seen already. For example, in one national sample, only 30 percent of people reported that they had access to safe streets. And only about one in seven, or 14 percent, reported that they had access to both streets that make walking safe and easy, safe streets, and safe and convenient access to locations that support walking, like walking trails or parks and recreational facilities. And it should be noted that these data were roughly consistent across race and ethnicity with Blacks reporting slightly higher access to what we call safe and convenient locations, which implies something else is at work there. So, in another national sample, only 33 percent of people reported that they lived in neighborhoods where drivers actually followed the posted speed limit. And we all know that sometimes speed limits are maybe too high for the environment they need to be in. And I should also say that these data were roughly consistent across race and ethnicity. And almost half of parents reported dangerous traffic conditions as a barrier for letting children walk to school. People who reported being nonwhite reported this barrier at slightly higher rates than people who reported as white. And you'll note here that distance also was reported as a significant barrier to walking to school. So, traffic congestion is often cited as a rationale for creating these dangerous traffic conditions. But when we asked in another national sample, over 80 percent of adults reported favoring or strongly favoring safer street design, even if it made driving slower. And it should be noted that Black respondents reported this support at even higher rates. The data analysis we supported with Smart Growth America showed that these perceptions are all too real. In a report published by Smart Growth America using these data called Dangerous by Design, they showed that people who are walking are much more likely to die, the faster cars are able to travel on the streets around them. And that too many people, and especially too many people of color, are being killed while walking. So, it's important to note that while perceptions generally perceive these dangers equally or at similar levels, the danger is actually disproportionately impacting communities of color. And it is why we focus our activity-friendly route to everyday destination strategy in those communities, because it improves these safety conditions and protects human life today by preventing traffic-related injuries and deaths, but it also promotes quality of life and prevents disease by providing access to physical activity and its profound health benefits. So, the NPO funds over 60 recipients in state and communities across three key programs to promote these strategies. State Selectivity and Nutrition Program, the High Obesity Program, and Racial and Ethnic Approaches to Community Health. Many of you probably represent those programs on the webinar today. Some examples of the work conducted by these partners include citywide comprehensive plans that support walking, adding more sidewalks and multi-use paths in communities, adopting and implementing complete streets policies, and improving park access. Our last speaker, Mark Turner, will talk about a local example of how they have used Active People Healthy Nation to support this critical work in Savannah, Georgia. In addition, we've been working with a wide range of national partners to advance the science and practice to promote this strategy. As recent examples, Smart Growth America worked with us to publish a decision support tool for local policymakers that they can use to estimate the positive health and other positive impacts of implementing complete streets policies. The National Collaborative on Childhood Obesity Research worked with us and other leaders in the field to identify 10 key economic measures to promote and evaluate the benefits of our built environment strategy. And we are currently working on a complementary piece of research with the Physical Activity Policy Research and Evaluation Network to highlight possible policies that decision makers can consider to prevent and mitigate gentrification concerns. I encourage you to visit our Active People Healthy Nation National Partner Network website to learn about the range of work that national organizations are doing in this area. So we are also evaluating approaches to address other barriers to physical activity specific to communities of color. Examples often reported include community safety and fear of police. As one example, we are currently conducting a rapid review of published evidence on over policing, physical inactivity, and health. We are also exploring ways to modernize our data so that we can acquire and analyze data for decision making more quickly with greater geographic precision. As one example, we are exploring ways in which we can better measure walking by using big data process from GPS-enabled devices. So this highlights new releases for Active People Healthy Nation. On this slide, but to reach a goal where everyone can be physically active, regardless of age, race, socioeconomic status, disability status, and geographic location, we have to create the supportive environments I've discussed. But we have to do so much more than that. It means we have to engage other sectors to support all of the strategies that work I mentioned at the start of my presentation. We have developed sector-specific strategies, real-world examples, and resources listed in color here, and more are coming later this year. I really encourage you to check these out. They're new on our Active People website. They've got some great suggestions for these sectors and just really great work from folks on staff at CDC. One example taken from the government sector is the Active People Healthy Nation Proclamation. Pictured here are examples of proclamations cities and states have already adopted to support Active People Healthy Nation. Draft language for this proclamation is on our government sector webpage, and states and cities can adapt it for their own unique needs. So far, proclamations have been adopted to cover over 5 million people in the United States. The Maricopa Association of Government, representing the Phoenix, Arizona region, was the first place to adopt one of these proclamations, followed by Buckeye, Arizona, Decatur, Georgia, the state of South Dakota, and Kent County, Michigan. We cannot wait to see who from this webinar will be the next place to adopt one of these resolutions. There are many resources that can help you with your work to support Active People Healthy Nation, including fact sheets, print and digital advertisements, and social media posts shown on this slide. In addition, you can look up physical activity indicators in a variety of ways at the local state and national level on the data trend and map section of our website. If you haven't joined Active People Healthy Nation yet, scan this QR code to stay in the loop about what we're up to and how you can join Active People, how you can join this Active People Healthy Nation national movement. By joining, which is really simply just entering your email address, you are saying that you believe physical activity is important, and you support the goal of getting more people active in this country. You will also receive early access to resources and information through a monthly Active People Healthy Nation newsletter, and you can connect to a network of others supporting Active People Healthy Nation at the national, tribal, state, and local level. You can join as an individual influencer, a professional who works for an organization doing this work, or if you are a state or local policymaker as a community champion. And now I'll pass this over to Armand Turner, who is an incredible leader in our field. And he's just doing amazing work in Savannah, Georgia. Take it away, Armand. Thank you so much, Ken. Good afternoon, everybody. I'm extremely excited to tell you all what we got going on here in Savannah. Yeah, so this is Active People Healthy Savannah. I'll explain a little bit later how we came up with that name and why it's so cool for us to use. So a little bit about the Reach Savannah and Savannah in general. So Savannah is pretty cool in that it's known as America's first planned city. And this is because in 1733, when James Oglethorpe founded the state in the city of Savannah, he used a sort of blueprint to guide them. And this included creating these squares, which were green spaces in which housing and retail was all built around them. And obviously, it allowed for easy walkability within the city. And even today, 22 of those original 24 squares still stand here in our downtown area. And because of that, our downtown area is still our most walkable portion of the city. How we came about Reach was through a collaboration with the YMCA of coastal Georgia and a local nonprofit called Healthy Savannah in order to address a lot of the health disparities that we're seeing throughout the city. Because though our downtown is extremely walkable, the same can't be said about many of the other neighborhoods and communities throughout Savannah. So now we're in year four of our Reach grant. And we've done some pretty good things thus far. So some of those health disparities, one of the major ones is our lack of sidewalks. So here in Savannah, only 70% of our streets actually lack sidewalks on either side. This makes obviously getting to places that people need to get to extremely difficult. 35,000 Savannians live a mile or more from a grocery store. So that creates these food deserts, or as we like to call them food apartheid throughout our city and county 29% obesity rate, and 19 and 26% of adults and children don't have a reliable source of affordable food or nutritious food. And so these are things we saw. And these are the things that prompted us to really go after this Reach grant so that we can start addressing them. One of the things that I've been able to sort of oversee is the physical activity portion of our grant. And that includes creating those routes to those everyday destinations. Some cool examples that we've done include our price street bike lane, which is that picture on the right. We just had that installed about a year and a half ago with the green paint, which was a very big deal for us at the time. And it's getting used constantly. Also to the left is a picture of our Truman linear park trail. So this portion right here is part of a three mile stretch that leads from one of our major parks to a very popular school in the area. And it's all off road and used heavily by people of all races. And we've done the surveys to really verify that. So it's been a great success thus far. So both of those portions that I just showed you are actually a part of a much larger, larger vision. So what tied the town is, is a 30 plus mile walking and biking trail network that we want to see built for the city of Savannah, that will eventually stretch out to the surrounding cities within Chatham County. The Truman linear park trail is the very first segment of this larger network. And right now it's three miles, but we are expecting an additional three miles to be built within the next year. Also, we've been able to get approved for $1 million in funding through our city's special purpose local option sales tax. And we're hoping to basically leverage those funds for a little bit more funding down the road. We're estimating that trail of this magnitude will come around 25 to $30 million to see fully come into fruition. Once completed, we expect for it to, we expect for it to touch every single automatic district within the city and connect our neighborhoods, especially those pivotal neighborhoods in which our African American and our low wealth population resides to the places they need to go, such as school, work, church, the grocery store, the corner store, and so forth. One of the major parts of this whole idea and vision and work that we do includes neighborhood and community outreach. So one of the big things that we want to address and be sure to do ahead of time is really talk to the communities and explain what Tide to Town is and what the health benefits actually are. So what we do is we team up with local community members and community leaders, neighborhood associations and other nonprofit organizations. And basically, we set up events in which we can meet with them. Socially distance and walk their neighborhood with them. So through these walks, we identify what barriers exist. What issues are they seeing? What issues are they hearing from other community members? And how can we address this through partnerships with the city? So getting those issues to the city so they can begin addressing them, but also getting that information back to the community members. So one of the cool ways that we've sort of progressed this is through an app that one of our partners, Bars Design, helped develop. And this app is basically taking that biking and walking audit forms that we usually see and usually get filled out with tons of data and putting it into an easy to use app. And so we asked our community members that we're partnering with to download this app and they can identify the barriers that they're seeing directly onto the app and we get that data back in real time. It works great because it allows us social distance because these community members can go off and do it at their own leisure, or they can do it while they're already walking to school or to the bus stop and so forth. And so far, we've met with two different communities and it's been a huge success thus far. Some other work that we've done include updating our zoning ordinance. So the new zoning ordinance goes by new zoning ordinance and basically allows for more walkable neighborhoods. It allows for increasing mixed use within our neighborhoods and a higher more appropriate density as well. We also work with the school system and the Associated Police Department to really establish walk in school buses so students can walk to and from school in large groups chaperoned by adult volunteer. And our main focus with those school buses are with our Title One schools. So the ones who need that type of infrastructure and programs in their neighborhoods the most. And lastly, we've done a great job at partnering with Chowme area transit, which is our local bus system. A cool thing we've done with them is we basically partnered to have the signs installed inside every bus in their fleet. And these signs have a QR code that one scan actually takes the scanner to a web page that lists all of our nutrition destinations as we like to call them. So the local farmers market that we partner with the farm truck, the corner stores that actually have healthy and nutritious food within them. They can see that full list right on that web page and get from that just by scanning while they're already riding the bus. So our idea is that while they're on the bus, they can begin, you know, mapping out how they'll get to these locations using the bus system that they're already used. Yeah, and so finally, while all the work that we do and all the material that we produce, we're able to put the Active People Healthy Savannah or Healthy Nation design element onto our work. And basically, this came about through a collaboration with the CDC who helped us sort of transform the design element to better reflect the city of Savannah and the work that we already do. As I mentioned earlier, one of the organizations that received the REACH grant is called Healthy Savannah. So it was a no brainer to put Active People Healthy Savannah so that people see that color, they see the name Healthy Savannah, and they can instantly recognize the work that we've already done and done for years and associate with these great physical activity programs and initiatives that we're pushing throughout the city today. And one of the things that we do with the design element, we've added it to a backdrop for taking pictures at some of our larger events like our annual meeting, such as this, which was in 2019, as well as putting it on stuff like our centerpieces at those meetings. So we try to get real creative. Of course, we use it all throughout our social media. But these are some of the other more creative ways we've been able to implement the design element in our everyday use. So I look forward to answering some of you guys' questions later on. And with that, I'll hand it back off. So thank you, guys. Thank you, Armand. We're now reaching the point of our seminar today for Q&A. I have some questions here in the Q&A box. If you haven't submitted your question yet, there's still time to do so. If you click on the Q&A, we'll try to take as many as we can. And I struggled a little bit with the poll at the beginning, but I got the highlights of the results. So the first question was, what motivates you the most? 80% of you all said improvement in quality of life. The second polling question was, what type of activities do you generally do to be physically active? And walking and hiking ranked number one. And the third was, what gets in your way of being physically active? And maybe not surprising, but 71% of you said time as a barrier. So thanks for filling that out. And we'll jump into the questions. And Armand, the first question is for you. The question came in that the app that you shared is pretty cool. So is it just for your area, or is it open to other people? Yeah, so that's actually a common question that we get. So at this very moment, it's just for the area in which we're using. And that's simply because the organization or the company that we partner with doesn't currently have the manpower to do it nationwide. But it is something that they are exploring in the future. So once we do reach that point, I'll be sure to share that as much as possible, because we do want people to use the app. And it has been helpful thus far. Thank you. Jeff, the next question is for you. And someone, I think, who understands their surveillance. So the question is, if you can speak to the change in collecting physical activity data in BRFSS, the change of cycle from two years to four years. And what do you think practitioners should use in lieu of that data? That won't be coming every two years. Yeah, always a good question about changes in surveillance systems. We know that's a tough topic. Having not been personally involved in the change with BRFSS, I can't speak too much to it. I would refer folks to the Division of Population Health here at CDC that administers BRFSS. But I think more generally, we're constantly in the surveillance world, especially in questionnaire-based surveillance. We're constantly wrestling with respondent burden and just the amount of time that it takes to complete a questionnaire. So I think we're all familiar, or many of us will be familiar with the problems of response rates that have been decreasing over time. And so trying to reduce the burden on respondents is a key factor. Unfortunately, sometimes that means that we reduce the frequency of questions or reduce the number of questions asked per year, and that can create some gaps. And so I think that speaks also to a larger problem that we're trying to address with our data modernization initiatives. So I'm looking for these other data sources like GPS-enabled devices that we can use to augment those regular data collections. For other data sources that people can use in the interim between those four-year periods of assessment in BRFSS, I would point out that the physical inactivity question is still going to be asked every year. So that one is still usable. And then there are some other data sources. I'm thinking primarily of the American Community Survey that provides some information on walking and bicycling to work at the state and local level. And that is administered by the U.S. Census and is done annually. So a couple of options there. But I would also just stay tuned to the field in general as we move forward with these modernized data measurements or modernized measurement sources. And I think there's a lot more to come in that area. Ken, the next question is for you. I'm going to pair a couple of questions together. So the first question is, what role do you see coalitions playing in Active People Healthy Nations? And then related, what role do you see partners playing? Well, certainly partners and coalitions are really part of the same continuum. We can't do this work by ourselves. There's no way that our little initiative at CDC is going to do this alone. It absolutely requires partners in the public health sector. And as I mentioned in the slide set, a lot of other sectors. And not only that, it requires coalition building at the local, state, and national level. To promote physical activity. And to be honest, at the end of the day, if it is something that is going to support physical activity, but the message needs to be different, whether it's an economic message or some other type of message, coalitions know the best answer to that question. What is going to work in their own environment to speak to decision makers? So that's why I think coalition building is so important, along with certainly cultivating partners at the local, state, and national level. Thank you. Armand, has COVID changed how you work with your community? Oh, dramatically. Early on, we were able to, of course, meet with people in person. And with a lot of our communities, especially our neighborhood associations, for example, they have a much older population within them. And so once we had to start switching to online, there was a gap in which it was sort of difficult to maintain those links that we had with a lot of community members. But as time went on, I think we found that a lot of those same people learned to use things like Zoom and these online platforms. And they also began exploring other things such as these large just conference calls. One quick example is, so a community who hasn't been able to meet, we want to tell them a little bit more about Tide to Town and give our usual presentation on it, but we couldn't because we couldn't meet with them in person and they weren't using online. And so what we began to do is start printing out, creating and then printing out basically short presentations on paper, and then we'll give them to the addresses of that neighborhood association, the executive board, and then we'll hold a phone conference to really discuss the material that they've read. So it's become a little more difficult, but it also, I think, has expanded our reach because a lot of people can't show up to a neighborhood meeting at, you know, 5pm if they're dropping off kids, I mean, picking up kids from school and coming off of work and whatnot. By having these more flexible online meetings, we have been able to reach, I think, more people in the long run. Jeff, questions for you. You covered some of the surveillance data for the past 20 years. Did anything in the data surprise you? Yeah, I think one of the surprises for me was the consistency of increases that we observed in the National Health Interview Survey. So that was the survey that covered the big 21-year span from 1998 to 2018. And just to see such consistent increases across, you know, every way that we sliced and diced the data, we saw these increases in reported physical activity. So I think that was one of the more encouraging findings. But, you know, I point out that those findings were limited to adults, and we weren't quite so lucky among youth. Thank you. Ken, so many of the obstacles described are consequences of focus on vehicles and mobility planning and construction. How can the best practices of road design and traffic flow expectations that are baked into urban planning to adjust to provide for safety of walking and biking? Sorry, that was a full question. You're on mute, Ken. Maybe you could ask me again? Sure, no problem. So it's describing that some of the consequences or the obstacles that were described in the presentations today are a result of kind of a car-focused world that we're in or country that we're in. So the question is, how can some of the road design and traffic flow expectations marry our interest in safe pedestrian and biking? Yeah, so I think that, well, a lot of people in the transportation and land use world that support our work would say that road design hasn't caught up with public opinion. And certainly, in places where people live, people want safer roads. And so I think it means then that we have to really understand and appreciate the broader perspective of what people do in those neighborhoods and from a transportation engineering perspective, really push for what they call context-sensitive design. So anybody that is in a public health coalition showing up at a local meeting to talk to transportation engineers really, I think, should come to the table pushing that concept. We need roads that what they call context-sensitive design, which basically just means accommodating the people that live on either side of that road and in that community in a way that that road isn't a barrier that goes through their community at best and at worst, something that comes through their community that is killing people. And so that's, I think, the short answer. I mean, I could, this is, as you know, Janelle, I could talk about this for the next hour. So I will stop now. Thanks, Ken. I appreciate that. I think we do have time for one last question and then time to adjourn and give everyone just a few minutes before the next meeting. So Armand, the last question is for you. Can you explain more about some of the zoning changes around mixed use in neighborhoods? Yeah, so with the new zoning ordinance that was sort of voted in, before that, I think the last time any changes had happened to our zoning ordinance was in like 1963. So that was a lot of work to do. The main point with the mixed uses, it increased the areas within our city that were allowed to sort of rezone to have a more mixed use within it. So for example, a building could now have a corner store or restaurant at the bottom or barbershop like which exists up the street from mine and housing above it. And so what the new zone really did as well as make all of these changes and how to go about them a lot more transparent. So for people who are coming up to the NPC with these concerns or requests, they actually understood how to use it or how to request certain changes. And it also put it online and able to be searchable online, which was a big deal. So a lot of changes came with that. But mostly, it increased the ease of use for regular people to really understand it and know how to navigate it. How important. Thank you. Well, I want to thank all the audience that joined us today for CDC's DNPAO seminar series. I appreciate all the Q&A. A special thank you to Armand Turner, who joined us from the Savannah REACH program, and to my colleague, Jess and Ken, for their presentations today. We appreciate all. And maybe everyone can have a moment to have a quick physical activity break before they do their next meeting. Thank you all.