I'M KATHERINE LAW AND I'M THE DIRECTOR OF COMMUNICATIONS AT THE NATIONAL CENTER FOR COMPLIMENTARY AND INTEGRATIVE HEALTH. I'D LIKE TO WELCOME YOU TO THE 2020 STEPHEN A. STRAUS LECTURE. I WANT TO THANK THE AUDIENCE JOINING US TODAY ON VIDEOCAST. AND ALSO ON FACEBOOK LIVE. WE'RE GOING TO BE HAVING A Q&A SESSION AT THE END OF OUR LECTURE. AND THE VIDEOCAST VIEWERS MAY ASK QUESTIONS AS YOU CAN SEE ON THE SLIDE. YOU MAY ASK QUESTIONS USING THE FEEDBACK FORM AVAILABLE TO YOU DIRECTLY BELOW YOUR VIDEO ON NIH VIDEOCAST. YOU MAY ALSO SEND AN E-MAIL TO NCCIH EVENTS AT MAIL.NIH.gov. THOSE ON SOCIAL MEDIA ON FACEBOOK LIVE YOU CAN POST A QUESTION ON FACEBOOK OR USE THE E-MAIL TO ASK YOUR QUESTION. SO WITH THAT SAID, I WANT TO THANK YOU ALL FOR JOINING US ON BEHALF OF MYSELF AND ALSO OUR COLLEAGUES AT THE NATIONAL INSTITUTE OF NURSING RESEARCH. NOW I'M PLEASED TO TURN THINGS OVER TO DR. ALLEN LENGEVIN INTRODUCING OUR SPEAKER. ARE YOU AVAILABLE TO BEGIN INTRODUCTIONS? >> YES. CAN YOU HEAR ME? >> YES. >> GOOD AFTERNOON. THANK YOU FOR TAKING THE TIME TO JOIN US TODAY FOR WHAT I ANTICIPATE WILL BE A VERY IMPORTANT AND TIMELY TALK. WE AT NCCIH LOOK FORWARD TO THIS EVENT EACH YEAR AS A VERY SPECIAL TIME TO HONOR THE MEMORY AND LEGACY OF DR. STEPHEN STRAUS, THE CENTER'S FOUNDING DIRECTOR FROM 1999 TO 2006. STEVE WAS AN IMMINENT PHYSICIAN RESEARCHER TRAINED IN MEDICINE, IMMUNOLOGY AND WAS INTERNATIONALLY KNOWN AS A BRILLIANT RESEARCHER AND WAS NOTED FOR HIS COMPASSION TO PATIENTS. WE WELCOME TODAY, MS. BARBARA STRAUS, STEVE'S WIFE AND OTHER MEMBERS HIS FAMILY WHO MAY BE JOINING US ONLINE. I WOULD ALSO LIKE TO THANK MR. BERNARD AND MS. BAR RA -- BARBARA OSAR WHO MAKE THIS POSSIBLE THROUGH THEIR GENEROUS DONATIONS AND THANK YOU TO NCCIH IN THEIR CONTINUED PARTNERSHIP AND SUPPORT OF THIS LECTURE SERIES. I'D NOW LIKE TO INTRODUCE OUR LECTURER DR. STH SHANNON ZENK ON ALL HEALTH IS NOT CREATED EQUAL. WHERE YOU LIVE MATTERS. SHE'S THE DIRECTOR OF THE NIH INSTITUTE OF NURSING RESEARCH. SHE JOINED NIH IN SEPTEMBER OF 2020. SHE'S A REGISTERED NURSE AND LEADING POPULATION HEALTH RESEARCHER. PRIOR TO COMING TO NINR, DR. ZENK WAS A NURSING COLLEAGUE AT PROFESSOR AT THE UNIVERSITY OF ILLINOIS CHICAGO COLLEGE OF NURSING AND FELLOW OF THE UIC INSTITUTE FOR HEALTH RESEARCH AND POLICIES. HER RESEARCH FOCUSES ON SOCIAL INEQUITIES AND HEALTH WITH A GOAL OF IDENTIFYING EFFECTIVE MULTI LEVEL APPROACH TO IMPROVE HEALTH AND ELIMINATE RACIAL, SOCIAL AND ECONOMIC HEALTH DISPARITIES. NOW, PLEASE WELCOME DR. SHANNON ZENK. THANK YOU EVERYONE FOR THE INVITATION AND FOR JOINING TODAY. AS DR. LENGEVIN MENTIONED I JOINED NIH A FEW MONTHS AGO AND WHILE IT'S A VERY UNIQUE TIME IN OUR HISTORY AND LIVES, IT'S TRULY SPECIAL AND INSPIRING TO NOW BE A PART OF AN ORGANIZATION WORKING AROUND THE CLOCK TO HELP THE UNITED STATES AND THE ENTIRE WORLD NAVIGATE THIS PANDEMIC. IT'S ALSO INSPIRING TO LEARN THE STORIES OF THE AMAZING SCIENTISTS WHO HAVE COME BEFORE US AT NIH AND ONE OF THOSE IS DR. STEVEN STRAUS. I KNOW WHAT HE MEANT TO THE NIH COMMUNITY AND NCCIH IN PARTICULAR AND THIS LECTURE SERIES IS A FITTING HONOR TO HIS LEGACY. SO THANK YOU FOR ALLOWING ME TO BE A PART OF IT. COMMUNITIES VARY DRAMATICALLY. THEY DIFFER IN THE AVAILABILITY OF RESOURCES SUCH AS JOBS, GOOD SCHOOLS AND GARBAGE REMOVAL AND PUBLIC TRANSIT, ATTRACTIVE PARKS, HEALTHY FOODS, DESTINATIONS AND INFRASTRUCTURE FOR WALKING AND BIKING AND CLEAN AIR AND WATER. COMMUNITIES ALSO DIFFER IN HAZARDS SUCH AS THE AVAILABILITY AND TARGET MARKETING OF TOBACCO, ALCOHOL AND JUNK FOOD. MONITORING BY POLICE, FAST FOOD, POLLUTION AND TOXIC SUBSTANCES. THERE'S A SAYING THAT ZIP CODE IS MORE IMPORTANT FOR YOUR HEALTH THAN YOUR GENETIC CODE. IN FACT, THESE ASPECTS OF PEOPLE'S COMMUNITIES AFFECT THE CHANCES PEOPLE HAVE TO BE HEALTHY. DIFFERENCES IN COMMUNITY ENVIRONMENTS ARE THOUGHT TO ALSO DRIVE SOME OF THE LARGE AND PERSISTENT HEALTH DISPARITIES OBSERVED ACROSS OUR COUNTRY AND WITHIN OUR CITIES. FOR EXAMPLE, ACROSS THE CITY OF CHICAGO, LIFE EXPECTANCY VARIES BY AS MUCH AS 30 YEARS A FEW COMMUNITIES AWAY. AS SHOWN HERE, AVERAGE LIFE EXPECTANCY IS 90 YEARS IN THIS AFFLUENT COMMUNITY AND 60 YEARS IN A LOW-INCOME COMMUNITY. TODAY FIRST I'LL TALK HOW I GOT STARTED IN RESEARCH AND BECAME INTERESTED IN COMMUNITY ENVIRONMENTS AS A SOCIAL DETERMINATE OF HEALTH. THOSE ARE THE CONDITIONS IN WHICH PEOPLE ARE BORN, WORK, PLAY AND AGE AND I'LL SHARE SOME OF MY COLLABORATIVE RESEARCH FOCUSSED ON COMMUNITY ENVIRONMENTS AND OBESITY ORGANIZED AROUND THREE RESEARCH QUESTIONS. AS I DESCRIBED THE RESEARCH I'LL HIGHLIGHT HOW IT FITS IN THE BIGGER PICTURE OF SCIENTIFIC EVIDENCE. I'LL THEN TALK ABOUT THE RELEVANCE OF COMMUNITY ENVIRONMENTS FOR TODAY'S PUBLIC HEALTH CRISIS, COVID-19. I'LL CONCLUDE WITH SOME THOUGHTS ABOUT NEXT STEPS. SO I WOKE UP TO THE RELEVANCE OF COMMUNITIES FOR HEALTH WHILE PRACTICING AS A NURSE. AS A HOME HEALTH NURSE CASE MANAGER I WAS IN PATIENT'S HOMES TYPICALLY AFTER A HOSPITALIZATION. I WAS OFTEN THERE TO PROVIDE CARE AND HELP WITH PAIN MANAGEMENT OR COUNSEL THEM ON HEALTHY BEHAVIORS. SPENDING TIMES IN PATIENT HOMES IN DIFFERENT COMMUNITIES I WAS STRUCK BY THE TREMENDOUS DIFFERENCES IN THE HOME AND COMMUNITY ENVIRONMENTS OF THE PATIENT IN MY CASE LOAD IN TERMS OF PRIVILEGE AND POVERTY. I FOUND IT DIFFICULT TO TALK WITH SOME PATIENTS HOW THEY WERE EATING WHEN WHAT THEY NEEDED WAS MORE FEDERUNDAMENTAL, HAVING ENOUGH TO EAT, STABLE HOUSING AND ELECTRICITY AND A SAFE ENVIRONMENT. IT'S THE HOLISTIC PFKT -- PROSPECT AND HEALTH AND HEALTH CARE SINCE FLORENCE NIGHTING GAIL AND OTHERS THEY LONG REALIZED SUPPORTING PEOPLE TO PROMOTE AND RESTORE THEIR HEALTH MEANS PHYSICAL, EMOTIONAL AND ENVIRONMENTAL LEVELS. DURING MY Ph.D. STUDIES I SPENT A LOT OF TIME IN DETROIT, MICHIGAN. ONE CLASS I WORKED WITH A COMMUNITY ORGANIZATION THAT WAS MOBILIZING RESIDENTS TO BRING ABOUT CHANGES AT A LOCAL GROCERY STORE CALLED EXTRA FOODS. I WAS RUN DOWN AND SOLD POOR QUALITY FOODS AS SHOWN ON THE LEFT. I ALSO WORKED ON SEVERAL RESEARCH PROJECTS IN THE CITY. I LISTENED TO RESIDENTS DESCRIBE A SCARCITY OF FOODS AND UNHEALTHY OPTIONS AS WELL AS LACK OF SAFE PLACE TO ENGAGE IN PHYSICAL ACTIVITY. THESE EXPERIENCES RAISE QUESTIONS FOR ME HOW RESOURCES WERE DISTRIBUTED ACROSS COMMUNITIES AND THE IMPLICATIONS FOR PEOPLE'S HEALTH. AT THAT TIME, OBESITY WAS A RISING HEALTH CONCERN WITH THREE IN 10 U.S. ADULTS OBESE. SINCE THAT TIME THE NUMBER OF ADULT HAS CONTINUED TO CLIMB AND ALMOST ONE IN FIVE OF OUR YOUTH NOW MEET CRITERIA FOR OBESITY. THERE ARE LARGE DISPIRATE PATRIOTS IN OBESITY RISK -- OBESITY, 50% OF BLACK WOMEN ARE OBESE COMPARED TO THIS PERCENTAGE OF HISPANIC AND 40% OF WHITE WOMEN. PATTERNS LIKE EDUCATION AND INCOME ARE MORE COMPLEX AS IL ILLUSTRATED ON THE RIGHT FOR MEN AND WOMEN THE PREVALENCE OF OBESITY IS LOWEST WITH COLLEGE EDUCATION VERSUS LESS EDUCATION. THESE DISPARITIES IN OBESITY ARE SUCH A PUBLIC HEALTH CONCERN BECAUSE OBESITY INCREASE THE RISK FOR A WIDE VARIETY OF DISEASES. KEY SCIENTIFIC QUESTIONS THEN AND NOW ARE WHAT IS DRIVING THE HIGH PREVALENCE AND THESE DISPARITIES IN OBESITY AND WHAT CAN WE DO ABOUT IT? SO MY WORK AS A NURSE, TIME SPENT IN DETROIT AND THE RISE OF OBESITY SHAPED MY RESEARCH ON COMMUNITY ENVIRONMENT AND BEGAN LOOKING AT WHETHER THERE WERE SOCIAL INEQUITIES AND THE FOOD ENVIRONMENT ACROSS COMMUNITIES. MY COLLEAGUES AND I FOUND LOW-INCOME BLACK COMMUNITIES HAVE LESS ACCESS TO SUPER MARKETS WHICH TEND TO OFFER THE WIDEST SELECTION OF HEALTHY FOODS. FOR EXAMPLE, IN THE DETROIT AREA WE SHOWED SUPER MARKETS WERE LOCATED A MILE FURTHER AWAY FROM BLACK HIGH POVERTY COMMUNITIES THAN WHITE HIGH POVERTY COMMUNITIES. THIS WAS ONE OF THE FIRST STUDIES IN THE U.S. ON WHAT WE NOW COMMONLY REFER TO AS FOOD DESERTS. WE FOUND HEALTHY FOOD OPTIONS LESS AVAILABLE AT RESTAURANTS AND STORES IN COMMUNITIES OF COLORS AT OBSERVATIONS AT OVER 8500 STORES LOCATED ACROSS 46 STATES, STORES IN COMMUNITIES WITH A HIGH LEVEL OF POVERTY WERE 29% LESS LIKELY TO OFFER PREPARED SALADS THAN THOSE IN LOW POVERTY COMMUNITY. EVEN WHEN WE LOOK AT SUPER MARKETS, PREPARED SALADS WERE LESS LIKELY TO BE CARRIED IN HIGH POVERTY COMMUNITIES OF COLOR THAN LOW POVERTY WHITE COMMUNITIES. IN SOME BUT NOT ALL OF OUR STUDIES, WE FOUND HEALTHY FOODS ARE MORE EXPENSIVE AND LOW INCOME IN BLACK COMMUNITIES. IN THE NATIONWIDE STUDY I JUST MENTIONED, LOW FAT OPTIONS WERE MORE EXPENSIVE IN GROCERY STORES IN BLACK COMMUNITIES VERSUS WHITE. WE LOOKED AT THE AVAILABILITY OF UNHEALTHY FOODS AND THEY'RE MORE AVAILABLE IN LOW-INCOME AND BLACK COMMUNITIES. IN THE STUDY OF SECONDARY SCHOOLS ACROSS THE U.S. SCHOOLS IN HIGH-INCOME COMMUNITIES HAD SUBSTANTIALLY FEWER CONVENIENT STORES AND FAST FOOT OF RESTAURANTS NEARBY THAN THOSE OF LOW INCOME COMMUNITIES. WE'VE ALSO FOUND THE BALANCE OF HEALTHIER TO UNHEALTHY FOOD OPTION WORSE IN LOW-INCOME BLACK COMMUNITIES. IN CHICAGO, WE FOUND WHOLE MILK WAS AVAILABLE IN 83% OF STORES IN ENGLEWOOD AND SKIM MILK WAS AVAILABLE IN 9% OF STORES AND SAW IT ACROSS WHITE BREAD VERSUS 100% WHOLE WHEAT BREAD. IN THE NATIONWIDE STUDY, STORES IN HIGH-INCOME WHITE COMMUNITIES CARRY 25% FEWER HEALTHY OPTIONS. NOT A GOOD SHOWING BY ANY MEANS BUT THE SITUATION WAS WORSE IN STORES IN LOW INCOME BLACK COMMUNITIES WHICH CARRIED 35% FEWER HEALTHY OPTION. YOU MAY HEAR THE TERM FOOD SWAP PEOPLE USE TO REFER TO COMMUNITIES WITH A HIGH AMOUNT OF FAST FOOD AND JUNK FOOD RELATIVE TO HEALTHIER FOOD OPTIONS. IN DETROIT, CHICAGO AND NATIONWIDE, WE FOUND CONVINCING EVIDENCE THAT HIGH POVERTY BLACK COMMUNITIES HAD LESS ACCESS TO HEALTHY FOODS AND GREATER ACCESS TO UNTHEY WILL -- UNHEALTHY OPTIONS COMPARED TO WHITE EVIDENCE. NOT ONLY HEALTHY FOODS BUT OTHER RESOURCES SUCH AS SAFE PLACES FOR PHYSICALITY ACTIVITY AS WELL AS HAZARDS ARE UNEQUALLY DISTRIBUTED ACROSS COMMUNITIES. HIGH-INCOME COMMUNITIES TEND TO ACCUMULATE RESOURCES WHERE LOW-INCOME COMMUNITIES TEND TO HAVE FEWER AND LOWER QUALITY RESOURCES AND MORE HAZARDS. DUE TO THE HISTORY OF RESIDENTIAL SEGREGATION AND PRACTICES SUCH AS RED LINING, BLACK AMERICANS AND PEOPLE OF COLOR ARE MORE LIKELY TO LIVE IN HIGH POVERTY COMMUNITIES. ONE IN FOUR BLACK AMERICANS AND NATIVE AMERICANS LIVE IN HIGH POVERTY COMMUNITIES COMPARED TO 5% OF WHITE. SOCIAL INEQUITIES RAISE CRITICAL QUESTIONS ABOUT THEIR IMPLICATIONS FOR HEALTH AND HEALTH DISPARITIES. NEXT I'LL TALK ABOUT MY RESEARCH ON COMMUNITY ENVIRONMENT AND BEHAVIORS LIKE DIET AND PHYSICAL ACTIVITY AND OBESITY ORGANIZED BY THE THREE QUESTIONS SHOWN ON THE SLIDE. LET ME START WITH THE FIRST QUESTION. WHERE DO SOCIAL INEQUITIES LEAD TO BEHAVIOR AND HEALTH DIFFERENCES? TO ILLUSTRATE, TWO INDIVIDUALS MAY BE EXACTLY ALIKE. THE SAME EATING PREFERENCES, THE SAME GENETICS, IDENTICAL HEALTH INSURANCE COVERAGE AND FAMILY INCOME EXCEPT THEY LIVE OR SPEND TIME IN DIFFERENT ENVIRONMENTS. ONE LIVES OR SPENDS TIME IN COMMUNITIES WITH GROCERY STORES THAT OFFER HEALTHY FOODS SAFE AND WELL MAINTAINED PARKS AND FITNESS CENTERS AND A WALKABLE ENVIRONMENT WITH CONNECTED STREETS AND DESTINATIONS TO WALK TO. THE OTHER PERSON LIVES IN COMMUNITIES WITH NONE OF THESE RESOURCES AND IN FACT THEY MAY BE SURROUND UNHEALTHY FOODS AND AN ENVIRONMENT THAT LACKS SIDEWALKS. IT'S EASY TO IMAGINE INDIVIDUALS SPENDING TIME IN THESE DIFFERENT ENVIRONMENTS MAY HAVE DIFFERENT DIETS, PHYSICAL ACTIVITY AND YOU WILL MATLY HEALTH. WE'VE DONE -- ULTIMATELY HEALTH. WE DID A NUMBER OF STUDIES EMPIRICALLY TESTING WHETHER THIS IS THE CASE. THE FIRST STUDY LOOKED AT DIET AND WAS CROSSSECTIONAL AND LOOKED AT COMMUNITIES AND DIET AT THE SAME TIME. THESE STUDIES WERE WITH AFRICAN AMERICAN ADULTS AND SAMPLES OF AFRICAN AMERICAN, LATINEX AND WHITE ADULTS IN DETROIT. WE FOUND PEOPLE WHO LIVED NEAR A LARGE GROCERY STORE HAD HEALTHIER DIETS. WE FOUND ON AVERAGE, THEY CONSUMED MORE FRUITS AND VEGETABLES EACH DAY AND ATE SNACK FOODS COMPARED TO THOSE WHO DIDN'T HAVE A GROCERY STORE NEARBY. IN CONTRAST, THOSE WITH MORE CONVENIENT STORES ON AVERAGE ATE MORE SNACK FOODS AND THOSE IN A COMMUNITY WITH NO STORE CARRYING A GOOD SELECTION OF DARK GREEN AND ORANGE VEGETABLES GENERALLY CONSUMED FEWER. WE STUDIED PHYSICAL ACTIVITY IN MULTI-AMERICAN AND ETHNIC SAMPLES. IN DETROIT WE FOUND CROSS-SECTIONAL EVIDENCE THAT THOSE IN COMMUNITIES WITH BETTER SIDEWALK CONDITIONS WERE MORE PHYSICALLY ACTIVE WHERE THOSE WITH MORE PHYSICAL DISORDERS LIKE LITTER AND GRAFFITI WERE LESS PHYSICALLY ACTIVE. WE ALSO HAVE DONE LARGE NATIONAL STUDIES WITH MILLIONS OF AMERICANS FOCUSSED ON BODY MASS INDEX OR BMI WHICH IS ESSENTIALLY A MEASURE OF PEOPLE'S BODY WEIGHT ADJUSTED FOR THEIR HEIGHT. THESE STUDIES HAVE ALLOWED US TO LOOK AT NOT ONLY CROSS-SECTIONAL ASSOCIATIONS BUT LONGITUDINAL ASSOCIATIONS. IN ONE OF THESE STUDIES, CROSS-SECTIONAL ANALYSIS REVEALED IN EITHER MEN OR WOMEN THOSE LIVING NEAR SUPER MARKETS, PARKS AND FITNESS FACILITIES HA LOWER BMI AND THOSE NEAR A WAL-MART HAS HIGHER BMI ON AVERAGE. IN ADDITION, HIGHER PRICES OF CHIPS AND SODA AND FROZEN MEALS AND PROCESSED FOODS WERE ASSOCIATED WITH LOWER BMI. NOW, LET'S TAKE A CLOSER LOOK AT THE DATA POINTS TO GIVE A BETTER SENSE OF WHAT THESE STUDIES INVOLVE AND HOW THEY'RE CONDUCTED. THERE'S THE DATA LOOK AT MEN AND WOMEN SEPARATELY AND THE IMPACT OF LIVING NEAR FAST FOOD RESTAURANTS AND MASS MERCHANDISE STORES AND SUPER MARKETS. MEN AND WOMEN HAD HIGHER FAST FOOD AND THOSE NEAR A MASS MERCHANDISE STORE HAD HIGHER BVR BMI. FOR A NATIONWIDE STUDY SUCH AS THIS WE DRAW ON SEVEN YEARS OF DATA FROM ELECTRONIC HEALTH RECORD AND OTHER SOURCES FOR 3.2 MILLION PEOPLE. WE ALSO TOOK ON A BIG DATA CHALLENGE OF CONSTRUCTING ANNUAL MEASURES OF THE FOOD ENVIRONMENT NATIONWIDE. WE USED SPECIAL MAPPING SOFTWARE TO DIVIDE THE UNITED STATES INTO 30-METER BY 30-METER CELLS TO CALCULATE THE NUMBER OF FITNESS FACILITIES UP TO FOUR DISTANCES FOR SEVEN YEARS AND FIND INDIVIDUAL'S VALUES USE BASED ON WHICH THEIR HOME WAS LOCATED EACH YEAR THEY WERE IN THE DATA. AS WE KNOW, CROSS-SECTIONAL ASSOCIATIONS DO NOT ESTABLISH CAUSALITY. MORE VIGOROUS DESIGNS ARE NEEDED TO SUPPORT RELATIONSHIPS SUCH AS LONGITUDINAL ANALYSES. WHEN WE USED INFORMATION ON PEOPLE'S COMMUNITY ENVIRONMENT AND HEIGHT AND WEIGHT OVER TIME, IN THIS CASE SEVEN YEARS. WE FOUND ONLY WALKABILITY AND ULTRA FAST FOOD PRICES WERE RELATED TO BMI. ONE OF THE LIMITATIONS OF THE STUDIES I'VE JUST DESCRIBED IS THEY FOCUS ALMOST EXCLUSIVELY ON THE COMMUNITIES WHERE PEOPLE LIVE. A TYPICAL APPROACH IS TO STUDY THE ENVIRONMENT IN AN ADMINISTRATIVE UNIT SUCH AS A CENSUS TRACK. THIS SHOWS A CENSUS TRACK IN CHICAGO. TECHNOLOGY AND DATA EVOLVED SUCH THE FIELDS STARTED CHARACTERIZING THE ENVIRONMENT WITHIN A GIVEN DISTANCE OF PEOPLE'S HOME SUCH AS A HALF MILE AS ILLUSTRATED HERE IN MAGENTA. BUT IN NORMAL TIMES, PERHAPS NOT NOW IN COVID TIMES, MOST PEOPLE'S LIVES ARE CONDUCTED BEYOND THE COMMUNITY WHERE THEY LIVE. PEOPLE ARE MOBILE. FOR EXAMPLE, THEY WORK ELSEWHERE. THEY TAKE THEIR CHILD OR GRANDCHILD TO SCHOOL SOME PLACE ELSE AND WORSHIP IN YET ANOTHER LOCATION. AND IN THE COURSE OF THESE ROUTINE ACTIVITIES THEY'RE EXPOSED TO OTHER ENVIRONMENT. AS A RESULT IT'S POSSIBLE RESEARCH FOCUSSED SOLELY ON THE ENVIRONMENT WHERE THEY LIVE ISN'T CAPTURING THEIR ENVIRONMENTAL EXPOSURES VERY WELL. TO MORE ACCURATELY MEASURE ENVIRONMENTAL EXPOSURES WE WERE EARLY ADOPTERS OF GPS TRACKING USING WEARABLE DEVICES AND CELL PHONES TO MEASURE WHERE PEOPLE CONDUCT ACTIVITIES AND SPEND TIME. ON THE RIGHT ARE TIME-WEIGHTED MOBILITY PATTERNS FROM THE GPS TRACKING OF TWO ADULTS LIVING ON CHICAGO'S WEST SIDE. YOU CAN SEE THEY TRAVEL AND SPEND TIME OUTSIDE THE COMMUNITY WHERE THEY LIVE AND THEY USE -- UTILIZE SPACES CONSIDERABLY DIFFERENT FROM ONE ANOTHER AND THIS IS DATA WE FOUND IN LATINX IN CHICAGO IN DETROIT. WE LEARNED PEOPLE SPEND CONSIDERABLE TIMES BEYOND THEIR RESIDENTIAL COMMUNITY. HALF THE PARTICIPANTS IN OUR STUDY SPEND AT LEAST 44% OF THEIR WAKING HOURS OUTSIDE THEIR RESIDENTIAL COMMUNITY. WE'VE ALSO LEARNED THE ENVIRONMENTS OF PEOPLE'S ACTIVITIES SPACE AND RESIDENTIAL NEIGHBORHOOD OFTEN DIFFER SUCH AS IN THE DENSITY OF SUPER MARKETS. AS A RESULT, WHERE YOU LIVE IS A KEY DETERMINATE OR HUB OF YOUR ACTIVITY SPACE, WE CAN'T SIMPLY USE THE RESIDENTIAL COMMUNITY ENVIRONMENT AS A PROXY FOR PEOPLE'S ACTUAL ENVIRONMENTAL EXPOSURES AND FOUND SOME EVIDENCE OF STRONGER ASSOCIATIONS WITH DIET FOR THE ACTIVITY SPACE ENVIRONMENT. LET ME MOVE ON NO THE SECOND QUESTION. DOES THE AFFECTIVENESS OF HEALTH CARE AND OTHER MICRO INTERVENTIONS DIFFER ACROSS COMMUNITY ENVIRONMENTS? WE KNOW THERE IS OFTEN TREMENDOUS VARIATION IN THE EFFECTIVENESS OF HEALTH CARE TREATMENTS. TREATMENTS WORK FOR SOME AND NOT OTHERS. ONE POSSIBLE REASON IS THAT TREATMENTS MAY BE MORE OR LESS EFFECTIVE DEPENDING ON PEOPLE'S ENVIRONMENT. YET VERY LITTLE RESEARCH HAS EXAMINED THE CONDITIONS SUCH AS COMMUNITY ENVIRONMENTS UNDER WHICH HEALTH CARE AND OTHER MICRO TREATMENTS OR INTERVENTIONS ARE EFFECTIVE. WHAT DO I MEAN BY HEALTH CARE AND MICRO INTERVENTIONS. FOR EXAMPLE, AFTER LEAVING THE HOSPITAL AS I TALKED ABOUT EARLIER, WE SENT PEOPLE HOME WITH INSTRUCTIONS TO EAT HEALTHY, GET EXERCISE AND TAKE THEIR MEDICINE. BUT WE DON'T IN ANY SERIOUS WAY TAKE INTO ACCOUNT OR STUDY WHETHER THIS IS POSSIBLE GIVEN THE RESOURCES, OPPORTUNITIES AND ENVIRONMENT WHERE THE PERSON LIVES. SUCH RESEARCH CAN HELP TARGET INTERVENTIONS, IMPROVE INTERVENTIONS OR IMPORTANTLY -- [NO AUDIO] BEHAVIORAL INTERVENTIONS THAT EMPLOY VARIOUS STRATEGIES TO HELP PEOPLE CHANGE THEIR DIET OR PHYSICAL ACTIVITY BEHAVIORALS. -- BEHAVIORS. LET'S TALK ABOUT OUR EARLIER ILLUSTRATION IN WHICH WE CONSIDERED TWO INDIVIDUALS WHO ARE EXACTLY THE SAME INCLUDING IN THEIR MOTIVATION TO EAT HEALTHY AND BE PHYSICALLY ACTIVE AND LOSE WEIGHT. BOTH MAY BE GIVEN THE SAME INTERVENTION. THEY MAY BOTH BE INVOLVED IN A PROGRAM TO HELP THEM LOSE WEIGHT. HOWEVER, DIFFERENCES IN THE COMMUNITIES WHERE THEY LIVE OR SPEND TIME MAY ENHANCE OR IMPEDE THEIR ABILITY TO CHANGE THEIR BEHAVIOR AND LOSE WEIGHT INITIALLY PLAIN -- MAINTAIN BEHAVIORS CHANGES OR KEEP THE WEIGHT OFF LONGER TERM. IN ONE STUDY WE TESTED WHERE THE EFFECTIVENESS OF THE WEIGHT MANAGEMENT PROGRAM DIFFERED DEPENDING ON PARTICIPANTS, COMMUNITIES AND ENVIRONMENTS. THE DEPARTMENT OF VETERANS AFFAIRS, V.A., IMPLEMENT THE PROGRAM FOR VETERANS RECEIVING CARE IN MEDICAL CENTERS AND CLINICS NATIONWIDE. PARTICIPANTS IN THE PROGRAM RECEIVED PERSONALIZED TREATMENT PLANS AS WELL AS GROUP AND INDIVIDUAL COUNSELLING AND WAS A UNIQUE STUDY OF OVER 100,000 ADULTS WHO PARTICIPANTED AND OVER A 1 MILLION WHO DID NOT PARTICIPATE. WE LOOKED WHETHER THE EFFECTIVENESS OF THE PROGRAM DIFFERED DEPENDING ON THE AVAILABILITY OF FOOD OUTLETS. WE FOUND SOME EVIDENCE IT DID IN MEN. WE FOUND ON AVERAGE IT REDUCED BMI BY .7 UNITS AT SIX MONTHS AFTER THE INTERVENTION AMONG BOTH MEN AND WOMEN. HOWEVER, MEN LIVING NEAR THE MOST CONVENIENT STORES AND FAST FOOD RESTAURANTS LOST LESS WEIGHT AT SIX MONTHS THAN THOSE NEAR THE FEWEST OF THE OUTLETS. WHEN WE EXAMINED WHAT HAPPENED AFTER 24 MONTHS POST INTERVENTION WE FOUND NO DIFFERENCES IN BMI CHANGE ACCORDING TO PEOPLE'S FOOD OUTLET ACCESS. WHILE THE ENVIRONMENTS SEEMED TO MAKE A DIFFERENCE IN PEOPLE'S ABILITY TO LOSE WEIGHT INITIALLY IT DIDN'T SEEM TO A THE ABILITY TO KEEP WEIGHT OFF TWO YEARS AFTER INITIATING THE PROGRAM. AND WE LOOKED IF IT VARIED DEPENDING ON WALKABLE SPACE AND FITNESS FACILITIES BUT FOUND NO EVIDENCE IT DIFFERED IN THE ENVIRONMENT FOR MEN OR WOMEN. TIMELY, LET'S -- FINALLY, LET'S LOOK BEYOND THE INTERVENTIONS AND FOCUS ON THE MACRO LEVELS DESIGNED TO IMPACT AN ENTIRE COMMUNITY INCLUDING POLICY CHANGES AND COMMUNITY INVESTMENTS ON A BROAD SCALE. WHAT STRATEGIES AT THIS LEVEL ARE EFFECTIVE IN IMPROVING COMMUNITY ENVIRONMENTS AND ULTIMATELY IMPROVING HEALTH AND REDUCING HEALTH DISPARITIES. ADDRESSING THIS QUESTION IS CHALLENGING BECAUSE EXPERIMENTAL DESIGNS ARE OFTEN UNETHICAL OR IMPOSSIBLE. FOR EXAMPLE, WE CAN'T RANDOMIZE PEOPLE IN GENERAL TO DIFFERENT COMMUNITIES AND WE CAN'T RANDOMIZE OFTEN WHERE A PARK IS BUILT BUT METHODS TO EVALUATE SO-CALLED NATURAL EXPERIMENTS WHERE WE STUDY CHANGES IN POLICY AND ENVIRONMENT AS THEY OCCUR IN REAL LIFE ARE GROWING IN SOPHISTICATION AND RIGOR. TO UNDERSTAND THIS STUDY THINK OF OUR TWO INDIVIDUALS EXACTLY THE SAME BUT THIS TIME BOTH LIVE AND SPEND TIME IN ENVIRONMENTS NOT SUPPORTIVE OF HEALTHY EATING OR PHYSICAL ACTIVITY. SUPPOSE ONE OF THEIR COMMUNITIES CHANGES. FOR EXAMPLE, A NEW SUPER MARKET OPENS? WHAT WILL HAPPEN TO THEIR DIET AND HEALTH? COLLEAGUES AND I TESTED THE AFFECT OF DIFFERENT POLICY AND COMMUNITY INVESTMENTS THROUGH NATURAL EXPERIMENTS RELEVANT FOR DIET AND PHYSICAL ACTIVITY BEHAVIORS AND HEALTH. WE STUDY SEVERAL INTERVENTIONS TO INCREASE THE SUPPLY OF HEALTHY FOODS. ONE EXAMPLE IS THE 2009W.I.C. FOOD PACKAGE REVISION TO INCLUDE FRUITS AND VEGETABLES IN THE PACKAGE. PARTICIPANTS TYPICALLY REDEEM FOOD PACKAGES AT STORES YOU OR I GO TO AND RETAILERS HAVE TO MEET SPECIFIC STOCKING REQUIREMENTS IN ORDER TO PARTICIPATE IN THE W.I.C. PROGRAM. WITH NEARLY 50,000 RETAILERS PARTICIPATING AT THAT TIME, THE POLICY CHANGE HAD THE POTENTIAL TO IMPACT THE COMMUNITY FOOD ENVIRONMENT. AS A RESULT, WE EXAMINED PRE AND POST POLICY CHANGES AND THE AVAILABILITY OF PRICING OF FRUITS AND VEGETABLES AND SOUTHERN ILLINOIS AND FOUND SMALL IMPROVEMENTS AND MODEST REDUCTION AT VEGETABLE PRICES AT RETAILERS. THIS IS NOTEWORTHY BECAUSE THE FOOD PACKAGE REVISION WASN'T DESIGNED TO IMPROVE THE ENVIRONMENT BUT THE NUTRITION OF W.I.C. YET THE OUTCOME OF THE COS COST-NEURAL POLICY CHANGE BENEFITTED W.I.C. CLIENTS AND THE PUBLIC MORE BROADLY. STUDIES BY OTHER RESEARCH TEAMS HAVE GENERALLY FOUND CONSISTENT RESULTS AND SHOWN THIS POLICY CHANGE WAS ASSOCIATED WITH IMPROVEMENTS IN MATERNAL AND CHILD NUTRITION AND HEALTH OUTCOMES. OUR EARLY WORK ON FOOD DESERTS PROVIDED POLICY SOLUTION TO IMPROVE ACCESS TO HEALTHY FOODS IN UNDER SERVED COMMUNITIES SUCH AS THE HEALTHY FOOD FINANCING INITIATIVE OR HFFI. COLLEAGUES AND I HAVE SINCE EVALUATED THE IMPACT OF THE SUPPORTED SUPER MARKET OPENINGS IN LOW INCOME AND BLACK COMMUNITIES. A STUDY IN PITTSBURGH FOUND IT RESULTED IN POSITIVE CHANGE INDICTRY QUALITY AND CONSUMPTION OF CALORIES AND SUGAR. INTERESTINGLY HOWEVER, THE CHANGES WERE NOT SPECIFICALLY ASSOCIATED WITH REGULAR USE OF THE NEW SUPER MARKET. INSTEAD, THESE IMPROVEMENTS MIGHT BE A BYPRODUCT OF THE BROADER ECONOMIC DEVELOPMENT HAPPENING IN THE COMMUNITY RATHER THAN THE SUPER MARKET ITSELF. THE TEAM IS NOW TESTING THE HYPOTHESIS. WE ALSO TESTED THE AFFECT OF SUPER MARKET DEVELOPMENTS ON FOOD AVAILABILITY AT SURROUNDING OR NEARBY STORES. THIS IS IMPORTANT TO STUDY BECAUSE SUPER MARKET OPENINGS CAN SPUR OTHER STORES TO INCREASE THEIR OFFERINGS TO COMPETE OR STOP OFFERING HEALTHY FOODS ALTOGETHER. IN STUDIES IN PITTSBURGH AND ROCKFORD, A SMALL ILLINOIS CITY WE FOUND WHILE SUPER MARKET DEVELOPMENTS PROVIDED A NEW SOURCE OF HEALTHY FOODS FEW CHANGES WERE FOUND IN PRICES AND MARKETING IN SURROUNDING STORES. THE STATE OF THE SCIENCE ON HFFI IS MIXED WITH SOME FINDING THESE TYPES OF SUPER MARKET DEVELOPMENTS IMPROVE NUTRITION AND HEALTH AND SOME WITH NO AFFECTS. ONE SUSPICION IS IT INCREASES THE AVAILABILITY OF HEALTHY FOODS WITHOUT ADDRESSING UNHEALTHY SOURCES. AND WE STUDIED TAXES. SUGAR SWEETEN BEVERAGE TAXES HAVE BEEN PASSED IN NINE JURISDICTIONS IN THE UNITED STATES. PART OF THE IDEA IS THAT INCREASING THE PRICES OF SUGAR SWEETENED BEVERAGES WILL REDUCE CONSUMPTION AND IMPROVE HEALTH PARTICULARLY FOR LOW-INCOME INDIVIDUALS WHO TEND TO BE MORE PRICE SENSITIVE. AS PART OF A TEAM WE EVALUATED THESE TO UNDERSTAND THEIR AFFECT ON PRICING AND MARKETING AND IN RESTAURANTS AND WE TEST THE AFFECT OF THE TAX ON PRICE PROMOTION AND ADVERTISING. AND IT INTENSIFIES THE SUGAR SWEETENED BEVERAGE PRODUCTS AND ANY POSITIVE EFFECTS COULD BE REDUCED. BASED ON AN EVALUATION OF THE 2017 OAKLAND, CALIFORNIA TAX, WE FOUND LITTLE SHORT-TERM EVIDENCE THAT INDUSTRY INTENSIFIED THE MARKETING OF BEVERAGES AT STORES. THE IMPACT OF THE TAXES ON THESE INTERMEDIARY OUTCOMES AS WELL AS DIET AND HEALTH ARE CURRENTLY AN ACTIVE AREA OF RESEARCH. SO STAY TUNED. WE STUDIED THE SUPPLY OF OPPORTUNITIES FOR PHYSICAL ACTIVITY. ONE UNFUNDED EVALUATION FOCUSSED ON THE 606 A $95 MILLION, 2.7 MILE TRACK AND WE FOUND LATINX TRAIL USERS WERE MORE LIKELY THAN WHITES TO REPORT INCREASED PHYSICAL ACTIVITY. THOUGH WE WERE LIMITED IN WHAT WE COULD DO, IT SUGGESTS POTENTIAL BENEFITS FOR THIS TYPE OF COMMUNITY INVESTMENT FOR LATINX ADULTS SPECIFICALLY. AS MY LAST EXAMPLE IN A STUDY LED BY DR. SANDY SLATER WE TEST THE IMPACTS OF THE CHICAGO GLAZE INITIATIVE AN INVESTMENT BY THE CHICAGO PARK DISTRICT TO RENOVATE WHAT WAS ULTIMATELY 327 PLAY GROUNDS IN NEED OF REPAIR ACROSS CHICAGO. WE FOUND RENOVATIONS WERE ASSOCIATED WITH INCREASED ACTIVITY IN PARKS LOCATED IB HIGH-INCOME COMMUNITIES AND LOW-PERCENT COMMUNITIES. RENOVATIONS WERE ASSOCIATED WITH REDUCTIONS IN PHYSICAL ACTIVITY IN LOW-INCOME COMMUNITIES AND NO CHANGES IN PHYSICAL ACTIVITY IN BLACK COMMUNITIES. THIS STUDY SUGGESTS PLAYGROUND RENOVATIONS IN CHICAGO MAY HAVE BEEN UNINTENDED CONSEQUENCES, INCREASING COMMON RACIAL DISPARITIES IN PARK USE. FUTURE PLAYGROUND RENOVATION EFFORTS MAY NEED TO ALLOCATE MORE RESOURCES FOR RENOVATING THE BROADER PARK WHERE IT'S IN DISREPAIR. MORE INTENSELY INVOLVED COMMUNITY RESIDENTS IN PLANNING AND DESIGN AND EMPLOY COMPLIMENTARY STRATEGIES SUCH AS ADDITIONAL PARK PRASHGING TO ENSURE RENOVATIONS BENEFIT ALL COMMUNITIES. I NOW WOULD LIKE TO SHIFT FROM MY OWN RESEARCH ON OBESITY TO TALK ABOUT TODAY'S UNPRECEDENTED HEALTH CRISIS, COVID-19. AS OF YESTERDAY THE CDC REPORTS 14.8 MILLION TOTAL CASES IN THE UNITED STATES WITH 283,000 DEATHS AND THAT'S RISING EVERY DAY. AND COMPARED TO NON-HISPANIC WHITES AMERICAN INDIANS OR ALASKAN NATIVE TWICE AS LIKELY TO BE INFECTED. LATINX PERSONS ARE 4.1 TIMES MORE LIKELY TO BE HOSPITALIZED AND BLACKS ARE 2.8 TIMES MORE LIKELY TO DIE. AND COMMUNITY ENVIRONMENTS ARE RELEVANT FOR INFORMATION COVID-19 DISPARITIES AND ANTICIPATED LONG-TERM HEALTH CONSEQUENCES OF COVID-19. WASHING HANDS IS GOOD FOR STOPPING THE SPREAD BUT DUE TO LACK OF PLUMBING AN ESTIMATED 2 TO 15 MILLION AMERICANS HAVE NO RUNNING WATER. WORKING FROM HOME HAS BEEN A KEY STRATEGY TO PREVENT THE SPREAD OF VIRUS YET BLACK, LATINX AND LOWER WAGE WORKERS ARE MORE LIKELY TO BE ESSENTIAL WORKERS AND LESS LIKELY TO BE ABLE TO WORK FROM HOME. A U.S. STUDY SHOWED DURING THE PANDEMIC, INDIVIDUALS IN HIGH-INCOME COMMUNITIES INCREASED THEIR DAYS AT HOME AND REDUCED THEIR DAYS WORKING OUTSIDE THE HOME SIGNIFICANTLY MORE THAN THOSE IN LOW INCOME COMMUNITIES. HAVING SERVICES NEARBY TO GET WHAT YOU NEED FACILITATES STAYING CLOSE TO HOME AND CAN REDUCE COMMUNITY SPREAD. YET, AS A TALKED ABOUT EARLIER, TENS OF MILLIONS OF AMERICANS LIVE IN FOOD DESERTS. MILLIONS ALSO LIVE IN COMMUNITIES WITHOUT A PHARMACY. AS ILLUSTRATED BY THE MAPS OF CHICAGO, COMMUNITIES OF COLOR ARE MORE LIKELY TO BE FOOD DESERTS AND PHARMACY DESERTS. AS A RESULT, MANY LOW-INCOME AND PEOPLE OF COLOR HAD TO TRAVEL FURTHER FROM THEIR HOME FOR BASIC NEEDS LIKE FOOD AND MEDICINE. HAVING FEW BUSINESSES FOR BASIC NEEDS AND LOW-INCOME AND COMMUNITIES OF COLOR MAY ALSO CONTRIBUTE TO CROWDING AT BUSINESSES THAT ARE PRESENT. MOREOVER, WHILE MAKING COVID-19 TESTING AND SOON VACCINES AVAILABLE AT PHARMACIES IS POSITIVE OVERALL, THOSE LIVING IN PHARMACY DESERTS ARE AT A DISADVANTAGE. IN A TIME WHEN GETTING OUT SIDE FOR A WALK OR TO EXERCISE OR FOR FRESH AIR IS HELPFUL TO RELIEVE STRESS AND PROMOTE HEALTH AND MANAGE OTHER HEALTH CONDITIONS, ADEQUATE GREEN SPACE IS ESSENTIAL. RESEARCH HAS LINKED GREATER COMMUNITY GREENNESS TO LOWER COVID-19 INCIDENTS. FORTUNATELY, COMMUNITIES OF COLOR AND LOW-INCOME COMMUNITIES OFTEN HAVE SMALLER, LESS MAINTAINED AND MORE CROWDED PARKS THAN WHITE COMMUNITIES AND HIGH-INCOME COMMUNITIES. MOREOVER, BECAUSE OF CROWDING, MANY MUNICIPALITIES REMOVED AMENITIES LIKE BASKETBALL HOOPS, REDUCED HOURS OR CLOSED PARKS ENTIRELY DURING THE PANDEMIC. NOTABLY, INADEQUATE ACCESS TO THE COMMUNITY RESOURCES, HEALTHY FOOD AND ESSENTIAL MEDICINE AND GREEN SPACE MAY CONTRIBUTE TO OBESITY THAT INCREASE SUSCEPTIBILITY TO SERIOUS ILLNESS AND COMPLICATIONS DUE TO COVID-19. IMPORTANTLY, COVID-19 WILL LIKELY HAVE LONG-LASTING CONSEQUENCES FOR THE PUBLIC'S HEALTH AND HEALTH INEQUITIES. IN PART BECAUSE OF ITS POWERFUL EFFECTS ON SOCIAL S INCLUDING COMMUNITY ENVIRONMENT. ACCORDING TO DATA, 163,000 BUSINESSES HAVE CLOSED IN THE UNITED STATES DUE TO COVID. 100,000 OF THEM PERMANENTLY. LATINX AND BLACK-OWNED BUSINESSES HAVE DISPROPORTIONATELY IMPACTED. 11 MILLION JOBS LOST AND UNEMPLOYMENT HAS CLIMBED DURING THE PANDEMIC. AGAIN, COMMUNITIES OF COLORS HAVE BEEN SUFFICIENTLY -- DISPROPORTIONATELY IMPACT AND THERE'S INCREASED FINANCIAL STRESS, HUNGER AND THE WIDENING OF THE ALREADY EXTREME RACIAL WEALTH GAP ALL OF WHICH AFFECT PEOPLE'S HEALTH. EDUCATION IS A POWERFUL PREDICTOR OF MOST HEALTH OUTCOMES, YET MILLIONS OF U.S. CHILDREN HAVE NOT HAD ANY IN-PERSON INSTRUCTION SINCE LAST MARCH AND SCHOOL DISTRICTS THAT SERVE MOSTLY STUDENTS OF COLOR ARE MORE LIKELY TO BE OFFERING ONLINE LEARNING ONLY. THE CHALLENGE OF ONLINE LEARNING IS HEIGHTENED FOR STUDENTS LIVING IN LOW-INCOME COMMUNITIES WITH NO HIGH-SPEED INTERNET ACCESS. FOR THESE REASONS, CONTINUED DISTANCE LEARNING RAISE THE POSSIBILITY THAT AT-RISK STUDENTS WILL FALL BEHIND THEIR PEERS LEARNING IN PERSON AND FURTHER EXACERBATE EDUCATIONAL ACHIEVEMENT GAPS. SO WHAT DOES ALL THIS MEAN AND WHERE SHOULD RESEARCH GO FROM HERE? IF THERE'S ONE THING I WANT YOU TO TAKE AWAY FROM MY TALK IS NOT ALL HEALTH IS CREATED AS WELL BUT THERE ARE THINGS WE CAN AND MUST DO. THERE ARE DRAMATIC INEQUITIES IN THE CONDITIONS IN WHICH PEOPLE ARE BORN, WORK, PLAY AND AGE AND THE OPPORTUNITIES AND RESOURCES PEOPLE HAVE TO BE HEALTHY AND THESE INEQUITIES SHOW UP IN PEOPLE'S HEALTH. UNLESS WE RESPOND TO THE CONDITIONS OF PEOPLE'S DAILY LIVES AND THE OPPORTUNITIES THEY HAVE TO BE HEALTHY THROUGH EVIDENCE-BASED STRATEGIES, COVID-19 WILL JUST BE THE LATEST HEALTH CONDITION OF MANY TO APPEAR ON THE LANDSCAPE FOR WHICH DISPARITIES EMERGE WITH MORE INEVITABLY TO COME. THIS IS WHERE THERE'S A CRITICAL NEED FOR SCIENTIFIC EVIDENCE AND AN INTEGRATIVE APPROACH TO OUR RESEARCH AND LIKELY OUR SOLUTIONS. IN ORDER TO IMPROVE THE PUBLIC'S HEALTH AND ADVANCE HEALTH EQUITY WE NEED RESEARCH THAT IDENTIFIES WHAT FACTORS AT THE MULTIPLE LEVEL AND SOCIAL DETERMINATES AND WHAT FACTORS CONTRIBUTE TO HEALTH DISPARITIES. WE NEED RESEARCH TO ENSURE INVENTIONS AND TREATMENTS WORK WITHIN THE CONDITIONS OF PEOPLE'S DAILY LIVES AND WE NEED RESEARCH TO DISCOVER NOT JUST WHAT MICRO INTERVENTIONS BUT CRITICALLY WHAT UPSTREAM MACRO LEVEL POLICY AND APPROACHES ARE FOR ACHIEVING GOOD HEALTH FOR ALL. AMAZI AMAZI AMAZING SCIENTIFIC ADVANCES HAVE BEEN MADE IN UNDERSTANDING DISEASE. THE POSSIBILITY JUST AS BOUNDLESS DID WE REACH UP TO DISCOVER INTERVENTIONS THAT ADVANCE POPULATION HEALTH AND HEALTH EQUITY? AT NINR WE ARE CONSIDERING OUR ROLE IN THIS RESEARCH FUTURE. NURSES HAVE A LONG HISTORY OF USING OUR HOLISTIC PERSPECTIVE TO COME UP WITH INNOVATIVE SOLUTIONS TO CHALLENGES ACROSS THE HEALTH CARE SPECTRUM AND DEVELOPING EVIDENCE-BASED STRATEGY TO IMPROVE HEALTH OUTCOMES. NURSING SCIENCE IS WELL POSITIONED TO ADDRESS MANY CHALLENGES I DESCRIBED TODAY. AT NINR WE BEGAN PLANNING A BOLD NEW AGENDA FOR NURSING SCIENCE WHICH WILL CULMINATE IN A NEW STRATEGIC PLAN TO BE RELEASED IN EARLY 2022. OVER NEXT SEVERAL MONTHS, WE'RE GOING TO BE SOLICITING INPUT FROM MANY GROUPS AND THE SCIENTIFIC COMMUNITY AND INTEREST GROUPS AND THE PUBLIC ABOUT FUTURE DIRECTIONS FOR NINR SUPPORTED SCIENCE AND THERE'S A WEBSITE TO FIND DETAILS OR WE WILL PROVIDE DETAILS ON THE OPPORTUNITIES BUT WE ALSO HAVE AN E-MAIL BOX WHERE YOU'RE WELCOME TO SEND THOUGHTS AT ANY TIME AND THAT INFORMATION'S ON THE SLIDE. WE WORKED WITH ALL OF OUR COLLEAGUES AT NIH AND BEYOND TO ADVANCE RESEARCH SO THAT ALL HEALTH IS CREATED EQUAL. I'LL END BY ACKNOWLEDGING THE FUNDERS OF THE RESEARCH I SHARED TODAY. ALL MY RESEARCH IS DONE AS PART OF INTERDISCIPLINARY RESEARCH TEAMS AND WOULD LIKE TO ACKNOWLEDGE THE FANTASTIC COLLEAGUE, STUDENTS AND STAFF I'VE HOOD THE PRIVILEGE TO WORK WITH OVER THE YEARS SOME ON THE SLIDE. THANK YOU AGAIN, DR. LENGEVIN FOR THE INVITATION. >> ARE THERE ANY QUESTIONS YOU WOULD LIKE TO POSE TO DR. ZENK TO BEGIN OUR Q&A SESSION? WE HAVE SEVERAL QUESTIONS FROM MEMBERS OF OUR AUDIENCE AND SO WE WELCOME -- I'D LIKE TO SEE WHAT QUESTION YOU MAY HAVE TO BEGIN OUR Q&A SESSION. >> FIRST, THANK YOU FOR THE INSPIRING TALK. WE CAN SEE YOU NOW. THANK YOU FOR ADDRESSING THE ENVIRONMENT AND THE SAME TREATMENT MAY BE MORE OR LESS EFFECTIVE IN THE ENVIRONMENT NOT ALWAYS INVOLVED IN CLINICAL TRIALS AND CALLS FOR A PUSH ON METHODOLOGY. I'M WONDERING IF YOU HAVE THOUGHTS ON RESEARCH DESIGNS THAT NEED VURJ DEVELOPMENT AND IMPROVING THE DESIGN COULD HELP BRING THE RESEARCH FORWARD? >> THANK YOU FOR THE QUESTION. I THINK WE NEED TO MOVE TO MORE MULTI LEVEL INTERVENTIONS. IT MAY NOT BE ENOUGH TO JUST WORK WITH FOLKS TO EAT BETTER OR ENGAGE IN PHYSICAL ACTIVITY. WE MAY NEED IN TANDEM NEED TO IMPROVE THEIR ENVIRONMENT. MOVING TO MORE MULTI LEVEL INTERVENTIONS IS A PROMISING APPROACH AND I THINK THE RESEARCH COULD MAKE BETTER USE OF NATURAL EXPERIMENTS BECAUSE THOSE TYPES OF STUDIES ARE HARD TO DO IN A RANDOMIZED TRIAL BUT TO TAKE ADVANTAGE OF THOSE AND BUILD EVIDENCE ON WHAT POLICIES AND ENVIRONMENTAL CHANGES MAY BE MOST PROMISING. >> THANK YOU. >> WE HAVE MANY QUESTIONS AND THEY RANGE FROM VERY SPECIFIC TO VERY GENERAL. I THOUGHT I MIGHT START WITH ONE FROM TORONTO. WE HAVE A VIEWER WHO HAS JOINED AND IS ASKING AND LOOKING AT THE STATISTICS YOU PRESENTED AND SAYING WHAT CAN I, AS JUST A REGULAR PERSON. HOW CAN I MAKE A DIFFERENCE AND WHAT CAN I DO ABOUT THE SPIFT STATISTICS YOU PRESENTED TODAY AND THANK YOU FOR A WONDERFUL PRESENTATION. WHAT CAN THE AVERAGE PERSON DO, MAYBE TO CONTRIBUTE IN A POSITIVE WAY? >> THAT'S A GREAT QUESTION. >> AT A SIMPLE LEVEL RESEARCH IS IMPORTANT AND BUILDING THE EVIDENCE BASE IS IMPORTANT. FOR FOLKS TO SUPPORT RESEARCH IN U.S. AND CANADA AND AROUND THE WORLD IS IMPORTANT. PARTICIPATE IN RESEARCH WHEN YOU HAVE THE OPPORTUNITY. AND THEN WHEN WE BUILD THE EVIDENCE THAT IMPROVEMENTS IN ENVIRONMENT OR POLICY WILL MAKE A DIFFERENCE, THE GENERAL PUBLIC CAN FEEL FREE TO REACH OUT AND WORK IN PARTNERSHIP WITH OTHERS TO BRING ABOUT CHANGES THAT ARE EVIDENCE BASED TO IMPROVE THE PUBLIC'S HEALTH AND REDUCE HEALTH DISPARITIES. >> SOMEBODY IS SAYING YOU TALKED ABOUT THE MULTI-COMPONENT INTERVENTION AND SOME ASKED WHAT MACRO INTERVENTIONS ARE EFFECTIVE IN IMPROVING COMMUNITY ENVIRONMENTS? WE HAD ANOTHER QUESTIONER WHO SUMMARIZED IN ONE CASE WHERE YOU SAID SO ARE YOU SAYING SOME STEPS WE TAKE ACTUALLY THAT DIDN'T HAVE THE INTENDED AFFECT BUT HAD UNINTENDED AFFECTS. THIS PERSON IS ASKING WHAT ARE THE MACRO INTERVENTION CAN BE EFFECTIVE IN IMPROVING COMMUNITY ENVIRONMENTS. >> I THINK I DIDN'T SHARE -- >> THERE'S SO MANY QUESTIONS BEGGING TO BE ANSWERED IN THIS AREA. THE PARK EXAMPLE IS ONE WHERE THE PLAYGROUNDS WERE RENOVATED BUT NOT THE BROADER PARK OR COMMUNITY CONDITIONS OR DIDN'T WORK WITH FOLKS TO TAKE ADVANTAGE OF THE PLAYGROUND. WE LEARNED LESSONS INVOLVING THE COMMUNITY BETTER AND MAKING SURE THE COMMUNITY IS HEARD AND MORE RESPONSIVE TO WHAT THEY SAY THEY NEED. >> THAT ALSO CONNECT TO ANOTHER QUESTION YOU WERE ASKED IT GETS TO MORE FOOD DESERTS. DO YOU THINK MORE REGULATION WOULD BE USEFUL FOR ADDRESSING THE FOOD DESERT SITUATION? AS AN INTERVENTION HOW DOES IT PLAY IN WORKING WITH COMMUNITY? >> THAT'S A FABULOUS QUESTION AS WELL. THERE'S THE NEED OF ADDRESSING HEALTHY FOODS WHILE NOT ADDRESSING OTHER PARTS OF THE ENVIRONMENT MAY NOT WORK AS IT COULD. THERE'S A LOT OF POSSIBILITIES IN TERMS OF SUBSIDIES FOR HEALTHY FOODS AND COULD CONSIDER OTHER STRATEGIES AS WELL AND WE SHOULD. THAT'S WHERE I THINK THE RESEARCH TO BUILD THE EVIDENCE BASED WITH CROSS-SECTIONAL DESIGNS AND BUILDING TO LONGITUDINAL TO HELP IDENTIFY THE MOST PROMISING STRATEGIES CAST LARGE NET IN TERMS OF WHAT'S POSSIBLE. WHY >> WE HAD PEOPLE WORKING IN THE FIELD AND A CASE MANAGER SAID WHAT RESOURCES SHOULD I INVESTIGATE TO HELP IMPROVE HEALTHY NUTRITION. WE HAD ANOTHER PERSON ASKING ABOUT ALSO CAN YOU COMMENT ON THE CRITIQUE OF THE SUGAR-SWEETENED BEVERAGE TAX. LET'S START WITH THE CASE MANAGER OUT IN THE FIELD. WHAT RESOURCES SHOULD THEY BE INVESTIGATING FOR NUTRITION. >> TO HELP THEIR CLIENTS IMPROVE NUTRITION? WELL, I THINK THAT'S WHERE WORKING INDIVIDUALLY AND WITH FAMILIES IS IMPORTANT. MAKE SURE THEY'RE EMPOWERED TO CHANGE THEIR EATING IF THAT'S NEEDED. THERE'S NOW EVIDENCE THAT BY ITSELF IS NOT SUFFICIENT. WE HAVE TO UNDERSTAND THE ENVIRONMENTS WHERE PEOPLE LIVE AND SPEND TIME TO TAILOR OUR APPROACHES BASED ON WHAT WE NODE ABOUT THEIR ENVIRONMENT AND THE SITUATIONS THAT THEIR FACING. AND -- THEY'RE FACING. AND WORK IN PARTNERSHIP FOR STRATEGIES TO MOBILIZE FOLKS TO WHAT THEY CAN DO. >> WE HAD A QUESTION THAT CAME IN SAYING THANKS FOR YOUR WONDERFUL PRESENTATION. AND CAN YOU TALK A LITTLE BIT ABOUT NINR'S FUTURE COMMITMENT TO COMMUNITY ENGAGEMENT RESEARCH. >> THANK YOU. I THINK WORK IN PARTNERSHIP WITH COMMUNITIES IS BORIMPORTANT. IT'S SOMETHING I HAVE GROWN TO APPRECIATE OVER MY CAREER AND I CAN EASILY SEE THAT BEING A PRIORITY AT NINR. >> WE HAD A QUESTION SOMEONE WAS ASKING HAVE YOU AND YOUR COLLEAGUES EXPLORED THE LINKS BETWEEN POTENTIALLY FOOD DESERTS AND GUT MICROBIOTA ASSOCIATION AND YOU MENTIONED THE AVAILABILITY OF FRUITS AND VEGETABLES BEING ASSOCIATED WITH OBESITY. I THINK THEY'RE ASKING SINCE WE UNDERSTAND FRUITS AND VEGGIES HAVE FIBER RICH AND CAN CAUSE CHANGES IN THE GUT MICROBIOTA HAVE YOU MADE THAT CONNECTION IN YOUR RESEARCH? >> NO, I HAVEN'T BUT IT'S A GREAT RESEARCH QUESTION AND A NICE EXAMPLE OF A MULTILEVEL APPROACH AND LOOKING AT HOW THE ENVIRONMENT IS EMBODIED. IT'S A GREAT EXAMPLE OF HOW OUR BIOLOGY AND SOCIETY AND FACTORS ACROSS LEVELS IMPACT OUR HEALTH. >> VERY TRUE. SOMEBODY ASKED A SPECIFIC QUESTION ABOUT SOME OF THE INTERVENTIONS AND HAVE YOU EXPLORED CULTURAL INDICATORS ON DIFFERENT HEALTH OUTCOMES RANGING ACROSS SOCIO ECONOMIC BACKGROUNDS. SO REALLY ASKING HOW DOES CULTURE MATTER WHEN IT COMES TO HEALTH OUTCOMES? >> MY RESEARCH HAS REALLY FOCUSSED ON THE ENVIRONMENT AND FOOD ENVIRONMENT AND FIELD ENVIRONMENT. I'VE DONE LESS IN TERMS OF CULTURE BUT I KNOW THERE ARE PEOPLE WORK IN THAT SPACE AND AGREE IT'S AN IMPORTANT AREA AS WELL. >> THIS PERSON IS ASKING ABOUT LOOKING AT USH SCRAN COMMUNITIES. CAN -- URBAN COMMUNITIES. CAN YOU SHARE INSIGHT ON IMPACT ON RURAL COMMUNITIES AND WHAT YOU KNOW ABOUT THAT RESEARCH. >> THERE'S CERTAINLY [NO AUDIO] IN SOME WAYS CHALLENGES ARE SIMILAR AND THERE ARE FOLKS I'M GLAD TO SAY ACTIVE AND WORKING IN HEALTH ENVIRONMENTS -- RURAL ENVIRONMENTS AND COMMUNITY AND UNDERSTAND WHAT'S EFFECTIVE TO IMPROVE PEOPLE'S HEALTH. >> FINALLY, WE HAD ONE PERSON I THINK WE CAN MAYBE TAKE ONE OR TWO MORE QUESTIONS IF YOU CAN INDULGE US WITH ANOTHER QUESTION I HAVE 20 OR SO STILL LINED UP AND WE WOULD LOVE TO TAKE THEM ALL TO I SAY TO THE VIEWERS THANK YOU FOR THE WONDERFUL QUESTIONS BUT WE JUST WON'T GET TO ALL OF THEM TODAY. WE HAVE A QUESTION TO WHAT EXTENT IS RACE CORRELATED TO THE DESCRIBED ADVERSE HEALTH AFFECTS IN COMMUNITIES WHEN YOU CONTROL FOR SOCIO ECONOMIC STATUS? CAN YOU COMMENT A LITTLE BIT ON THAT. >> I THINK IT DEPENDS ON THE OUTCOME YOU'RE LOOKING AT. THE EXAMPLES I GAVE IN TERMS OF THE DISPARITIES THAT WE SEE IN THE ENVIRONMENT THEY'RE NOT JUST DUE TO INCOME, THERE'S ADDED COMPONENT OF RACE. SO THERE IS EVIDENCE THAT EVEN CONTROLLING FOR SOCIO ECONOMIC STATUS WHICH IS AN IMPORTANT PART THERE ARE FOR SOME HEALTH OUTCOMES STILL RACIAL DISPARITIES. THE EXAMPLES OF THE DIFFERENCES IN THE ENVIRONMENT INDEPENDENT OF SOCIO ECONOMICS BY RACE ARE AN EXAMPLE OF WHY THAT MAY BE. >> I HAVE A QUESTION THAT'S COME IN FROM A RESEARCHER SAYING WHEN IT COMES TO APPLYING RESEARCH IN COMMUNITIES OF NEED, THERE SHOULD BE PRIORITIZED FOCUS, POLICY VERSUS PRIVATE FUNDING AND COMMUNITY PROGRAMS VERSUS SCHOOL-BASED INTERVENTIONS. DO YOU HAVE A THOUGHT ON WHICH ANGLE MIGHT BE THE BEST FIRST ANGLE TO TAKE? >> I DON'T HAVE A READY ANSWER TO THAT. I WOULD SAY AGAIN THAT'S WHERE WE NEED THE RESEARCH TO UNDERSTAND WHERE WE'LL GET THE BIGGEST IMPACT AND THAT CAN GUIDE DECISION MAKING IN TERMS OF WHERE BEST TO INTERVENE AND AGAIN THAT'S WHERE WE NEED TO BUILD THE EVIDENCE BASE. >> I SEE ONE FINAL QUESTION. ARE CHANGES IN ENVIRONMENT NEED TO BE PARTNERED WITH HEALTH CAMPAIGNS OR WHAT OTHER KINDS OF COMMUNITY ENGAGEMENTS CAN BENEFIT HEALTH ONCE THE STORES AND OTHER THINGS CHANGE. WHAT COMMENTS DO YOU HAVE ON THAT APPROACH. >> THERE ARE SO MANY OPPORTUNITIES TO FOT ONLY IMPROVE THE -- NOT ONLY IMPROVE THE PHYSICAL ENVIRONMENT BUT COMPLEMENT THAT WITH INDIVIDUAL STRATEGIES AND COMPLEMENTARY STRATEGIES TO ADDRESS, FOR EXAMPLE, THE SOCIAL ENVIRONMENT. SOCIAL MARKETING WHICH I THINK MIGHT HAVE BEEN PART OF WHAT THAT QUESTION IS I AGREE. IT COULD BE THE EFFECTIVENESS OF THESE APPROACHES ARE A COMBINATION OF THINGS HAPPENING TOGETHER AND THAT'S WHERE WE'LL BE MOST EFFECTIVE. >> WELL, I THINK WE'RE A COUPLE MINUTES AFTER 1:00 P.M. ANOTHER PERVASIVE QUESTION HAS BEEN CAN PEOPLE WATCH THIS LATER AND MY ANSWER IS YES, YOU CAN. THIS IS BEING RECORDED AND WILL BE ARCHIVED ON THE NIH VIDEOCAST SITE SO YOU CAN SHARE IT AND SHARE THE LINK LATER OR COME BACK AND WATCH IT AGAIN. THANK YOU FOR THE WONDERFUL TALK. I'LL TURN IT OVER BACK FOR FINAL OR CONCLUDING THOUGHTS ON THIS WONDERFUL LECTURE FROM DR. ZENK. >> I WANT TO THANK YOU, JEN, IN BRINGING UP THE WORD INTEGRATIVE SO MANY TIMES DURING YOUR TALK. IT IS AN INTEGRATION. INCLUDING THE ENVIRONMENT AS PART OF A MULTILEVEL, MULTICOMPONENT INTERACTIONS IT COULD BE A GO -- YOGA PROGRAM OR VACCINE CAMPAIGN. TAKING THE ENVIRONMENT INTO ACCOUNT YOU DEMONSTRATED NICELY IT'S VERY IMPORTANT TO NOT IGNORE IT. I WANT TO THANK YOU AND LOOK FORWARD TO HEARING WHAT NINR IS GOING TO DO. >> THANK YOU. THANKS AGAIN, NCCIH. >> THANK YOU FOR YOUR WONDERFUL LEADERSHIP. >> THANK YOU TO COLLEAGUES WHO HELPED MAKE THIS HAPPEN. WITH THAT I'LL DRAW EVERYTHING TO A CLOSE AND THANK OUR WONDERFUL VIEWERS AND FACEBOOK LIVE VIEWERS AND FOR YOUR GRACE FOR OUR TECHNOLOGY CHALLENGES AS WE GOT GOING BUT WE'RE THRILLED YOU WERE ABLE TO SHARE YOUR RESEARCH AND INSIGHTS WITH US TODAY. CONGRATULATIONS ON A WONDERFUL LECTURE. THANK YOU EVERYONE