Good afternoon. I'm Kathy mad, and it is my delight to be the dean of the College of Health Sciences. And I'm so excited to see all of our students and our guest here today for this wonderful seminar. So one of the things that I enjoyed as a student greatly when I was a student here at UD and also at other universities, was the opportunity to hear great speakers come and talk about various topics that are in research. But then how that research then translates into practice and how it really helps us to understand disease prevention and health promotion. So today, you have that opportunity and I think you are in for a delightful seminar. But one of the things that is always challenging is to figure out how do we make this possible. So you'll notice that today's seminar is called the Fulton seminar. And that is because these seminar today and this whole tradition of doing this seminar in nutrition is the, funded by some donors, Ted and Kathy Fulton and I will just ask you to stand. They are one, please give them a hand. They are also both UD grads, so they're wonderful blue hands. Ted graduated from the business college and Kathy graduated from behavioral health and nutrition. And they back in, I believe it was 2012, made a wonderful, wonderful donation and which created an endowment that really helps to fund this seminar series. And it started out very small, I think at the very first one was in 2013, and I think we were in a small room over in the student center. And it has grown. I think this year. It's over 300 people that have signed up to be here in a seminar. And again, I think the opportunity for you as students and faculty and guests and visitors is really this opportunity to take and think about the things that you're learning. But then lectures like this are very inspiring and take that to the next level. So with that, I want to turn the podium over to the Chair of the Department of Behavioral Health and Nutrition, Gillian triple C. Good afternoon. It's my pleasure to introduce Dr. Nicole Keith. Dr. Keith as a professor in the Department of Kinesiology and the Associate Dean of Faculty Affairs in the School of Health and Human Sciences at Indiana University, Purdue University Indianapolis. She served on faculty there since 2002, and it's also a research scientist at the Indiana University Center for Aging Research in the School of Medicine. Dr. Keith is dedicated to research and programming that increases physical activity, improves fitness, and positively affects health outcomes while also addressing health equity. Her research is funded by grants from the National Institute of arthritis and musculoskeletal diseases, as well as grants from the National Heart, Lung and Blood Institute. Dr. Keith is active in the American College of Sports Medicine, serving as Vice President of membership communication, education and policy 2014-2016, and serving as ACSM president 2020-2021. As if this was not enough, Dr. Keith continues to serve on ACSM. Exercise is Medicine and American fitness index advisory boards as well as several other ACSM national committees. Dr. Keith earned her Bachelor of Science degree in physical education from Howard University, a master's degree in exercise science from the University of Rhode Island. Her PhD and exercise physiology from the University of Connecticut, and a master's degree in clinical research from Indiana. So please join me in welcoming Dr. Keith to the University of Delaware. Thank you, everybody for coming and I want to especially thank Dr. Matt for inviting me. Julian has been wonderful. She's been quite a hostess to me for the last 24 ish hours. My joke is that I used to come to this campus all the time when my husband was the head football coach at the University of Rhode Island, we never beat the blue hands. I have a little bit of anxiety when I look over at your football stadium. It's great to be here and thank you for having me that the title of my talk, as you can see, it's been up, so make sure you read it as research and lessons learned. And racial disparities and weight-loss. But I wanted to start about a little bit about why I did that. Some people are like Dr. Keith. When did you decide you wanted to get your PhD? And that's my mom. And that's Little Nicky Johnson. That's me. And my mom got my Pete got her PhD. And I said, I want a PhD. That would be so cool. And so for my whole life, that was the goal. So I got my PhD at the University of Connecticut. Um, this is my little daughter, Imani. She's the middle girl. I have four kids now. I'm three girls and a boy. The famous husky state statue you all know of. And that's my daughter can ARE. And that's my daughter can ARE. When she got her master's degree. Education is really important to our families. Shelf finished law school in December. So really I just want to say that because it's important to use students that your role models like you don't know who you're influencing. You don't know how you're going to change lives. And I just say, hey, mom, look at this, Look what you did. So I just wanted you to know. That's what got me started. My presentation. I'm going to start out talking about my intervention, training through a program that's called Sister talk. And that was my postdoc. And then I went out on my own and I started this program and I thought I was so cool and I knew what I was doing as a junior faculty member. And that was called Soul empowerment. Then I will talk about my career development and a program that was called type charge light and then later on called healthy me. And so when you see those slides, you're going to think, I thought this was take charge light. Now it says healthy me because I switched back and forth. It's the same program just funded differently. And so the second funders wanted to change the name of the program, which is fine. I'll take that as long as you give me funding. We're still trying to figure this out. So there's a grant that we're just finishing up that's called assessing people, places, and micro environments. But because we really love acronyms, It's called acme. And you'll see why. I'm started out. This was my postdoc and I worked with Kim Gans and Patty Reza Khan, who are both nutrition scientists and excellent mentors and very forward thinking in so I want you to keep in mind that this was 1994, okay? And it's really important as I described this study, that this was happening in 1994. So they designed this research for black women using the social action theory. It was delivered through a cable television show. Everybody who enrolled and got randomized to the cable, to the television arm of the intervention. We got them cable. We didn't have Netflix, we didn't have YouTube, we have cable TV. So that's what they did. The content and crew included nutrition, physical activity, stress reduction, and self-management. And we wanted to learn about how black women view their weight. And I'm going to say we, I was a postdoc and it was them. But I felt like so much part of the team and it was also really important because they made me feel like I was important, even though I was a postdoc, I was part of the team and we talked all the time. We had a process evaluation, so we didn't wait. It wasn't a randomized controlled trial. That's like traditionally you collect all the data and then you wait until you find out what happens at the end of data collection we were evaluating throughout and it keeps saying it was them, but I feel like it was part of what I was doing too because I was part of the team. But we were evaluating the the intervention throughout. And so we looked at community networking. We looked at mixed methods data collection. So we were doing qualitative data, interviewing people, doing focus groups, learning about what they wanted. And then we were also doing quantitative data collection. We did social marketing. There is no social media back then, I claim I'm saying these women were so forward thinking that they knew they needed to develop a community who wanted to do this. We didn't have in style or Twitter or whatever you're using. Tiktok. We just talked to people so that they knew it had to happen. Then they use cultural anthropology. Our subsequent television seasons. So it was a four-year intervention. So first-year qualitative interviewing, learning how to develop the show. And then we had three years of television. And so every season built a pump on what we learned from the previous season. And we wanted to know how practical it was to ask people to watch a weight-loss program on television. We wanted to know how appealing it was and we wanted to make sure it was culturally sensitive. And so we learned about how we need it to deliver our messaging. And for these women, they wanted to hear about, no matter what my size is, whatever my they didn't say this. I'm saying it their body mass index was they could be healthy regardless of weight. They preferred people like them and people are more comfortable and homogeneous groups. They said they wanted the, the talent on the show to be black and they poke, the program format was developed, it was pre-recorded, and there was nutrition content. We asked about fat and calories portion sizes, increasing fruits and vegetables, low-fat shopping and cooking, and how to remain healthy even if you're eating out. So those were some of the topics that were covered on the show for physical activity. Um, the, the trainer talked about increasing lifestyle and leisure activity, increasing movement throughout the day. So again, it's 1994. And the American College of Sports Medicine is telling us we need 30 min of physical activity. And these brilliant scientists are saying just move before just move was a thing. And they were talking about decreasing sedentary behavior. Like when's the first time you heard about sedentary behavior. But they were talking about it in 1994. So really forward thinking. And then there was a 10-minute physical activity break built into the show, which is also really forward thinking. And that really didn't start happening as an evidence-based practice until the 2000s. This was the first group to do it. Then the last 20 min for those who were randomized to the television show. And I'll show you in the next slide what I'm talking about. There was a live social worker on the show and the people who were randomized to that group could call in and ask questions. So questions about positive reinforcement, how do I keep working on this and also how do I solve problems? So the study design was a two-by-two factorial design. There were these groups that were either interactive versus passive programming or phone support versus no foreign support. So they were actually four groups randomized to these four conditions. The community outreach educators, which I'll talk about at the end of this, worked with the participants and we recruited them from the community. So we train them. They were just people who were respected in the community. I didn't say this was in Boston. We recruited women in Boston who were respected by their community and they supported them. It's a 12 week cable show, lasted for four months. Then they were booster videos. We measured people at three months, eight months, and 12 months. And then there were surveyed, say very measures that you can see and physical measures that you can see. We monitor their TV TV viewing, which I'll tell you about in a minute. There were community outreach educator support logs. So when they called them, they logged whether or not they were watching TV. And then we use analysis of variance to look at the differences between overtime. So I told Julian I was gonna get rid of these these tables because they take up a lot of room. But there's something really important about these type, this, this table and the tables I'm going to show you. So I really want you to focus on this because it's really important. We were we were recruiting black women in Boston. And when we started to recruit them, we weren't getting anybody. We're on the right community. We could see they were black women everywhere. We had black women recruiting and nobody was signing up for this study. So we gotta focus group. And we were like, What's the problem? And they said We are all of your materials say that this is a study for African-American women and we're not African-American, were black. And I was like, Oh, and so if you look at this African, African American or black American, Indian Cape Verde in Caribbean, Hispanic, mixed race and other. So really if you're trying to recruit people, understand how they self-identify, it's really important. We didn't understand that, that was part of our process evaluation. And then I also want to point out that most of the people who we recruited were pretty well-educated. And so I don't think we did a great job of people who are at highest risk for health disparities. Because of their education and the same with their income. Most of these people were not living in poverty. So again, when you are trying to recruit individuals, think about what are the messages that you need to use to make them trust you and to feel comfortable with you. Because if you're looking for low income, low education, you have to recruit differently. And we learned that this is the other interesting part in we noticed that people who are class one obese, class two obese and class three obese. We're all willing to sign up for the study. And at the end of my presentation, near the end of my presentation, this is important, so just try to remember it. Most of the folks had hypertension and diabetes or some they were on medication for that and they had some physical limitation. We wanted to know about the TV viewing. And so we wanted to find out about like how often they view television. So we looked at most of the people watched 4-10 shows. And we also sent them written materials via snail mail. That's all we had at the time. And most of the people read something like nobody read nothing. And so those written materials worked. So the lessons we learned from Sister talk during my postdoc is that formative evaluation is important. We would have failed miserably had we not been evaluating throughout the project. Cpr is community-based participatory research. And that's also really important talking to people like what do you need? What are you willing to do? So that as you're designing your research, you understand like, what will you do? Not just what can you do. We have a user-centered design and so we really got to know our participants and made sure that we were designing our project around the people who were using it, and that we had to have different communication strategies. I told you we were using the wrong words and we learned from the community. You're not talking to us. This is not about me. They designed a logo. They designed the title. And they said Please stop saying you're recruiting African-American women because that does not describe how I self-identify. So it's really important that social interactions are really important. And so to make sure we're always talking to our participants and our staff about what's going on. And then the role of the community outreach educator was very interesting to me. So they were really great at the formative evaluation. Like what do we do in wrong? Go talk to the community, let us know I'm there from the community. We know that whoever they talked to will tell them the truth. They were excellent and recruiting. But when it came to the intervention, it fell off and it hurt the quality of our data. They liked working with the research team. They did not like working with the research participants. And I don't know why. Like I can't say this is why it was I can guess but I would be speculating, so I'm not going to say it, but they did not do their jobs when it came to like keeping the logs and making sure they were talking to the research participants. They liked being part of the staff, but they did not like interacting with the participants. And these are just people from the community. So it's really important and we didn't do it. But it's really important from beginning to end too, if you're enlisting people from the community and work on your study to let them know from beginning to end, this is gonna be your role. And we just kinda told them as we went along because it was a formative evaluation. And then I want to tell you that data-rich studies are lucrative and dissemination. So if you want to read about Sister talk, there's a paper about forming Sister talk. Then there's a paper about assessing change in dietary fat versus strtok. And then there's a paper about dietary behaviors for the participants and sister TOC. And then there's this paper about perceived racial discrimination and obesity among the participants in Sister talk. And then there's this paper That's the final results of Sister talk. But that's not the final paper. The final paper actually came out in 2020. And it's just her talk is still going like they got 100 again and so they're doing round to assist your talk. So it was lucrative. I'm not on any of these papers. I was a postdoc. If you pull up these papers, I'm I'm I'm mentioned in the acknowledgment. I worked my butt off. I don't care that I wasn't an author. I learned so much from this team that really made the rest of my career. So I moved because my husband, as I mentioned at the beginning, was the head coach of the University of Rhode Island where coaches go to die. He had to resign or get fired and he was looking for a job. And I was like, Hey, I have a PhD, I bet I could get a job. And so we both started looking for jobs. And I ended up at Southern Indiana University and he came with me, um, and this is Sister Jane. She's a nun who was the pastor of this Catholic church called St. John's, that was near downtown Evans bill. And St. John's was a really small Black Catholic Church. You can't really see it, but there's a school over there. The school had closed years before. Sister Jane was really interested in not only helping her community get healthier, but also like what can we do with this building to keep it open because it was expensive. And so I partnered with her. I was at Southern Indiana and I said, I need to find some place where I can do community-based participatory research. So she wanted to call this program's sole empowerment. And that's really important if you have a community partner and they've got something in their head and they want to do something, you have to do what they wanted to do within what's appropriate in evidence-based practice. And so I crackup, she wrote a grant. I wrote a grant, were catholic. She's a nun. And it was funded and we both got the grants funded by the well-born Baptist foundation. So I was like yay Baptist people. Um, we got money so that we could hire a community outreach organizer, similar to what I learned in cell empowerment. We had a health fitness instructor who is a supervisor, and that's Katie. She was my undergraduate student, but I trained her to supervise all of the other undergraduate students to make sure that the program was consistent among members. We had health fitness instructors including Katie, the supervisor. We bought exercise equipment and we got money so that we can pay rent to help keep the church open. It was an exercise and nutrition education program, and it was it was focused on increasing physical activity on the population to improve health outcomes. We had 351 participants. I have like their baseline characteristics right here. And I talked about that it was a student-led program. We encourage them to the participants to exercise three days a week. We were open five days a week so they could exercise more if they wanted to. And we focused on cardiovascular fitness, muscular strength and endurance and flexibility. And we attempted to make it culturally tailored. These were mostly black women because it was a Black Catholic Church. Something else really interesting is that the women did not want to exercise with the men. And I need you to take that into consideration. Never thought of it until that moment. That when we're asking people to exercise, we're asking them to put their bodies and positions. And some women are not comfortable putting their body in certain positions with men who are strangers or with men who are not their husbands. So they were, we have days where men and women could come, but most of our days it was women only. That wasn't a preference. We measured the heck out of them. So measurements we took. What we learned is that there were no differences. And so I'll stick to the significant differences that their diastolic resting heart rate or blood pressure decreased, and that their biceps increased, their waste decreased, and their thigh circumference increased. They didn't lose weight. This was not a weight-loss program. We were told by those women, just like the woman in Boston. Please don't focus on my way. I just want to get healthier. And that was fine. It was a six-month structured exercise program. But without dietary changes, we didn't have changes in measures that would need to check. You wouldn't need to improve your diet to make those changes. And again, lessons learned. I learned so much from doing this work. I learned about how to develop community partnerships by myself. I didn't have anyone to help me. I learned more about how rewarding community-based participatory research can be. But that it's very difficult. I had no at University of Southern Indiana, it was a teaching institution. I had no research colleagues. I was teaching eight classes a year. And it was hard and I was like, this is unsustainable. And I also had three little girls at home and my husband was in Indianapolis. He couldn't get a job in Evans bill. So he went to Indianapolis, so he was 4 h north and it was unsustainable. I couldn't do it. It wasn't good for my mental health and, you know, it wasn't good for my girls to not have their dad. So I had to leave. I needed to find a job closer to my husband and I had a choice. I interviewed for two positions when at Indiana State, it's about 45 min west of Indianapolis. But I also had an interview that IUPUI, which is where I landed. Obviously, we have our beautiful School of Health and Human Sciences, but there's also a School of Medicine and the Center for Aging Research. And so there was an opportunity for me to really have research mentors. And so I met my two research mentors. They've been, they still call them my research mentors. I don't really need a research mentor right now, but I run things by them all the time. Like what do you think? Would you read my grant proposal? This is Dr. Christopher Callahan and I smile, these have been my friends. This is my 21st year at IUPUI. So this has been my friends for a really long time. And Chris is known internationally for his work and cognitive impairment, cognitive decline, dementia, and Alzheimer's disease. And he actually testified in front of Congress with Maria Shriver. And I'm like you're the coolest person I know. So he is a physician by training. And then this is debt Dan Clark who is like this, this amazing, brilliant researcher. He's an IU faculty member. But he grows blueberries and Oregon and has a farm and doesn't even live in Indiana, and has been a full-time faculty member there for 30 years because he just finds himself. He's a, he's a prolific grant writer. And so I said, okay, so we started this program called take charge light. Dan and I did. And that kind of consumed the rest of my career. And it was ushered hospital in Wizard hospital is like on the on the northern end of the IUPUI campus. It's a public safety net hospital, which means that it serves patients who are uninsured and underinsured. It's downtown, so it's easy to get to. We have average public transportation that people can get to wizard or could there were 12 federally qualified health centers, same thing, uninsured and underinsured around the city of Indianapolis. So even if they couldn't get to the hospital, there was a clinic close to where they lived. And wishes serves. 1 million patients a year in 35% are uninsured and 32% are on Medicaid. And these numbers really change because it's kind of a transient population. So it's, it's kinda hard to look at demographics and understand who's a patient when, um, but take charge light was a weight management program and we did the same thing. We did the qualitative interviewing and I'll talk about that in a minute. But we didn't just form the program. We were asked to form the program by the hospital funded by the Fairbanks Foundation. People who participated and take charge light where 18 years or older. We thought we removed every barrier so it was developed a full full full support of the hospital administrators, of the providers, whether they were physicians, nurse practitioners or nurses or medical assistance. We talked to everybody. We talked to the staff and we talk to the patients. Like what do you want in a program? It was on the site of the federally qualified health centers so they could get to it. It was delivered in English and Spanish. We do have a pretty large and growing Hispanic population who are Spanish-speaking only. So we wanted to make sure it was accessible to everyone and it was free for the for the providers, so they didn't have to remember take charge light exists. We had an automatic screen and an electronic referral. So this is how it looked. The patient came to the federally qualified health center if they were 188 years of age or older, if they had a BMI more than 30, there was a physician reminder on order entry. So when the physician was doing all other orders, something would pop up as a reminder to say this patient is eligible for tick charge light and they would just have to press a button and they would get referred, um, and then the patient would receive information about the program at checkout. And then a coach would call them. If they didn't call to say, hey, I want an appointment with a coach. And then they would if they didn't call the coach will call them and then they would have half the new visit with the coach. And then we had ongoing contacts with the coach and then referral to whatever they wanted to do. And then our exercise science majors at IUPUI have a program, a different program that's not in my presentation where people can go into the communities they're in the high schools. In the fitness centers, the weight rooms in the exercise facilities in the high schools. So they could go and exercise for free at the high school if that's what they wanted to do, we use the five A's of behavior change. So then assess, assist, arrange, and agree. The initial assessments we asked about weight history, related lifestyle behavior, what they knew about weight loss. I always tell my students, people who are trying to lose weight. This isn't their first rodeo. Ask them, what have you done in the past to lose weight? What works for you? Like nobody knows more about them than them. And so we really wanted to know what they understood. What were their self-monitoring habits if they had any motivated, were they because they were referred by a physician and they didn't show up on their own. How confident were they that they could lose weight? And then we talked about goal-setting, had them develop a behavior plan. And we might refer them to a nutrition or to a dietitian if they needed it. And if they were willing to do it. Initially, it was a quality improvement program. Like I said, it was funded by the Fairbanks Foundation and it was to help patients lose weight and improve health behaviors. The design was inclusive. The funding was very adequate. And all we thought the patient and provider a barriers were eliminated. So we did some research which you should, if you're going to do a program, you should evaluate it. So we first evaluated like, what are you the providers? Think about this program and we did a 21 item survey. And we asked them, how important is it to you to treat obesity? And what are your perceptions of your obese patients? And how confident are you in take charge. Then we asked the patients, are we measured the patients. So we looked at their BMI, their sociodemographic characteristics. They're indicators of chronic illness, their substance abuse in their pregnancy, history before the women. And we have electronic medical records in our health care system. So we can just pull these data for women who participated and take charge light. So it wasn't self-report. It was what their physicians measured. The average age was 50, 73% of our participants were women, 28, 28% were Hispanic or African-American or black, and 21% where Hispanic. We thought it was really interesting that as the BMI category went up, the participation rate went down. And we wanted to understand like what's going on there. And then 34% had diabetes. So we published the design and reach of primary care weight loss management programs and we published about screening and referral, and it was an innovative design. And so, um, these papers were pretty easy to publish. I will say for those of you who are ever thinking about being a faculty member and you want to do this kind of work, you better get a side gig. You better have some other kind of research to do because this stuff takes for ever. And so I got to my third year review and crests who you met earlier said you better start doing something else. You're not going to get tenure. And he was like, I know you love this, we can keep doing it. But I started doing cross-sectional studies that I could get funded and publish quickly so that I could stay at IUPUI. So the world was changing as I was working on this stuff. And Wishart hospital became Eskenazi health. The Eskenazi is great benefactors like the photon's and they really cared about patients and patients who couldn't afford health care. So the, the hospital without named after them. And they built this beautiful hospital. And it's gorgeous, gorgeous outside. It's gorgeous inside. There's art throughout the hospital. When you walk in, there's a baby grand piano and people who have the talent, it's just like doctors and patients are sitting there playing this piano and sometimes they bring in an orchestra or they bring in other music. There's art everywhere. They have a sky farm on the site, on the seventh floor where they grow vegetables and herbs and then they have a restaurant on the first floor. And they use what they grow in the sky farm to prefer to prepare meals in the restaurant. And if you buy healthy meals that are cheaper than unhealthy meals, and there's no tipping allowed because patients and physicians are both eating the air and they don't want people to feel obligated who can't even afford to eat out, to tip the waitress. So there's no tipping and it's just a really beautiful place you can't tell. But like rate, that's not working because there's nothing to point to. But right below those rocks. There's this fountain. And in the summertime, like kids run through it. It's like a water playground and it's just like the coolest hospital. I love it. And that's where healthy me is now centered along with still the FQHCs. The other thing that changed is that my research institute was built in, it is just across the street from Ashkenazi. So really easy for us to get to engage with patients and so on. And still nothing to point to the side of the building that says Regenstrief Institute, IU School of Medicine, faces Eskenazi. That sculpture. Did I do that? That sculpture faces Riley's Hospital for Children. And just on the other side of Eskenazi is the VA. We have seven hospitals on campus. So whatever your pet patient population preference is, there somebody to work with there? So it's very cool. The building sits largely empty since the pandemic, but we're gonna get back together again. And it's just the most amazing research facility that i've, I've seen in awhile. I got tenure. Yay. And then I got to go back to work on take charge light. And so these are two people from T chart charged lightening. Like I said, I do qualitative research and so this is Anthony Powell and he says I was overweight and having pain including back pain. My Dr. referred me to the healthy BMI program to lose weight. It's convenience, right when my neighborhood doesn't cost me anything, they give me the proper way to exercise. They've been very helpful. Answer we publish, publish, what do people think about this program? And then I wanted to know like, what are weight-loss attitudes and social forces between black and white women. And so I wanted to explore the differences between these two groups. So we got 27 healthy may participants who either attended and stopped attending or who never attended. And recent research assistants to their house to do an in-home semi-structured interview. We also used scripts because we had focus groups just to talk about like what's good about the program, What's bad about the program? What should we be asking these women? And we use the theory of planned behavior to learn about weight-loss and attitudes, social forces, perceived behavioral control. And what we found is that black women reported eating for positive reasons. And white women reported having more social support for weight loss, but feeling more, I'm eating was more associated with negative feelings. And so I've got these quotes. This is from a black woman and it says Tuesday is the meeting. And then after the meeting and all, they're going up to the Country Buffet to have their lunch, go in and get their money's worth. What do you think the meeting was? It was a healthy May meeting. I know. You're like, Great. We're gonna get together and we're gonna go to healthy me and then we're going to eat. That's fine. So this is a quote from the white woman and it said, I mean, it's just like as far as losing weight, It's kinda like a cold. You know, you just like to get a shot and not have a cold the rest of your life, get a shot and not be fat for the rest of your life. So we were learning on black women and white women are very diverse in their view of weight. And so this is a table that I made for that, for the, for that paper. And it lists like the weight-loss attitudes, if I can. Nope. The weight-loss attitudes, social forces perceived behavioral control and reported behavioral intentions. And how the black women and white women differed. But then how they were the same in both groups and it's in the paper. So feel free to look it up because of time. I can't spend a ton of time on this table, but we thought it was really interesting. We started another study with a larger group of women. And the study was to identify contextual and emotional factors to explore weight-loss disparities. Bce between obese black and white women. And we wanted to understand the feasibility of like following them throughout the day is really what we were doing. And we had 16 obese black women and white women who were of low SES, socioeconomic status. And we had RAs, who were race and gender matched to the participants because we really wanted them to talk and feel comfortable talking. And the RAs did physical measures. They did in home observation of obesogenic cues. And so what I have to tell you is I did get IRB approval, but the people didn't know when the RAs were coming to their house that they were writing down, do I see food? Do I see candy? Do I see a scale? Do ICE pots and pans? Like are there cues that are making these women eat more? And so they had an inventory. And they did the surveys in the house. And then they did ecological momentary assessments. That's what EMA is for, um, and they were used every other day to capture emotion of these women. And we sent them text messages. We didn't, it was like a bot, but they got sent texts messages six to eight times every day throughout the day. Then the next day we had the RAs call them to say. You said at 08:00 you were sleeping. You said at 11:00 you haven't eaten, you sad at 01:00, you are with your sister and you were having lunch just to confirm what they said in their text messages were what was really happening. And then from that, we had fixed variables like the number of televisions the RAs saw, and time varying variables, like how many social interactions they had. I'm gonna skip this table because it's busy and it doesn't matter. This is what really matters. And the DRM and what we learned is the EMA and DRM completion was good. People would answer these questions. So we had 73% completion. That's really high. We're texting these women all day and 73% of the time they responded to us. We asked about where they were. And most of the time they said they were at home, at work or at the home of a social contact. And I just wanted to show you the other activities because most of the time they said they were working or watching TV, napping, eating, or relaxing. But there were other activities that we asked them about and they were negligible. They weren't doing these things. We ask them about how they were feeling. Everybody was happy. They were tired, sometimes a warm and friendly, but those were the other emotions we ask them about. And so we feel like it's like this useless, useless thing to ask people how you feel. Because everybody says, I feel like people say, How are you, I'm fine. That's not true. But that's what I'm going to say because that's the polite answer. And so that's what they were doing in this study. And then we ask them about food exposure and in social interactions. And our conclusion was that identifying individual contexts may lead to valuable insights about obesogenic behavior and new interventions to improve weight-loss. So the lessons learned from that study was, we think human behavior is automatic and there was a theory, it's called the theory of automaticity. And we were talking about it earlier today. So if you like bread and you walk by a bakery and you smell the bread, you might not be hungry. You weren't thinking about bread. But now I want some bread. And my joke was I texted my family when I landed in Philly yesterday. And I like our landed in Philly and I really feel like having a cheesecake cheesesteak with fresh fresh prints and they were like, What are you talking about? Because my kids are like What are you talking about? But my husband thought it was funny. Anyway. We know that obesity cues are pervasive in the homes of obese women. The inventory showed us that there's food everywhere. That's what our inventory is sad. And we should develop a weight loss intervention that manages queues. And that the field of automaticity shows that humans primarily manage their behaviors through habit. So we had to help these women create habits to manage their obesity. Healthy and sustainable. It's currently implemented in the main hospital, that big, beautiful building. I showed you at eight clinics throughout the city. And, um, It's over 18 years old. I know that because my son is 19 years old and that's when we started the year before or the year I was pregnant with him. So it's successful. But black women continue to lose 50% less weight than white women when all other variables are controlled. And we don't know why, and we're trying to figure that out. Um, so what we learned is that two pounds of weight loss is associated with a 10% reduction in the three-year risk of hypertension. Two pounds of weight loss is associated with a 16% reduction. The three-year risk of type two diabetes. So this means 50% less weight loss means a substantial loss of opportunity for obesity-related mortality. This is terrifying to me. I talked to people and healthy me and they weigh 300 pounds. And they say, my Dr. says I need to lose 150 pounds. That's a whole person exerts a whole person. I'm sure there are people in this room who weigh less than 150 pounds and you're supposed to lose 150 pounds when how, like what kind of advice and look to pounds. If you lose two pounds, you'll be healthier. So can we try for five pounds and not 150 pounds? So when you're coaching your patients and you're saying, oh, you have to lose weight. Let's make it reasonable. 150 pounds of weight loss. Good for the people who can do it. Great. That's hard and five pounds will make them healthier and live longer. So I need to leave that message with you. I'm in the Healthy People 2010 and then we didn't get better. So when the Healthy People 2020 final reviews, there's no progress on racial disparities and weight-loss. And there's a call for new and innovative research efforts. So I'm not gonna go over this too much. You don't need to know are specific games, it's not that important. We're trying to find ways to make women lose weight through an app. And so I presented at me to you in my introduction, addressing place and people microenvironments and weight-loss disparities. And I do have to tell you this because you're gonna be like, What are you talking about? So I do have to tell you, we created an app and we made two groups. Well, a group of black women, a group of white women, half of both groups were randomized to an app that we developed. And half of the group was random. I just was randomized to healthy me, but they didn't get the app. Everybody could continue to use heart-healthy me, but half of the women got the app. And we hypothesized that the people who got the app would lose 2 kg more than the people who didn't get the app. We made these messages. And so this is what people saw on their screen. This is Jimmy Carter. She's one of the health coaches. And we just asked everybody knew that Shoemaker, we asked everybody to who decided to participate in the app development. I'm too right. Like what would you tell patients in the moment? Because they're only open 730-430. So what do you want us to press to them at 08:00 at night when they want to eat unhealthily. And so like move 30 min a day, 10 min at a time for health. This is Jennifer Garner hand. She's actually my mom's Dr. and she's also my colleague. And so, um, I've talked her into doing it and she said Just keep trying, it's okay to start over. And then we asked participants like, who inspires you. And so we have a quote from Alice Walker. But they would say people like Joel Osteen or Oprah Winfrey or Michelle Obama. And so we have this whole library of over 500 messages that we were pushing to people all day long. And we also sent these beautiful pictures of healthy food to try and get them to eat more healthfully. And we worried a little bit, like are we making them eat more because we keep sending them pictures of food? Um, that could happen the case. This is what the app looks like and I just wanted to show you what it looked like on the screen. This is how the ecological momentary assessments were asked. We just did list, so they had to do is check a box and that's how they did it. And so our methods, they got a referral provider push into contact the patient to enroll in study. Practice-based research assistant invited the participants to do a screen or by phone than the IRAs scheduled and administered the informed consent? We did a for our four-week assessment, so it's like a running we wanted to make sure that we are going to participate. And so we just started sending them messages for four weeks just to make sure. And if they, if they responded to 50% or more of the messages than they were randomized. Then after the four weeks for the people who were randomized to usual care or RAs went back to their house, got their equipment, weighed them, and they got randomized. And then a blinded RA Completed their assessment. So we finished the study, yay. That's like a when we recruited 139 black women and 138 white women, the goal was 140 for each group. We were very pleased with our recruitment success. We have one manuscript published, we have to under review. We developed the app. We will continue to use the app to refine and do more research. We learned about the black and white differences and obesogenic cues and the study process. Whoops, went the wrong way. I will say that we have two papers under review. We're not happy. The white women gained weight. The black women didn't lose weight. So it didn't work. And that's part of the problem. And if you're going into research, you will fail. We did this for four years and we were sure this was the answer and it did not work. And so I'm back to the drawing board. And so, um, you know, we have two papers on her review. It's important even if you failed to disseminate your work so that other people don't make the same mistakes that you make. They need to know this was done before and it didn't work. And that's okay. So develop thick skin if you want to go into research and be ready to fail. But we're going to go back to the drawing board and we're going to try again. This is, I think my second-to-last slide. And so my lessons learned in 20 years pursuing research is that weight loss interventions are still very complicated. I'm the person who drove me from Philly to here. Last night was like you've been working on this for 20 years. And I said, yeah, so first like I got in a car and he turned on this Freud podcast and it was about Freud. It wasn't Freud. And he asked, Do carefully listen to this and I'm like, No, I'm a researcher, I listen to stuff. I don't want to hear all the time, It's cool. And he was like, You're a researcher and he turned it off and he's like, tell me about your work. And so I started telling him. And then he asked the question like 20 min in, you've been working on this for 20 years. Are you the only one? Like why can't you figure this out? And I'm like, no, there are tens of thousands of people working on this. It's hard. And that's what I'm saying. It's really complicated. But it can result in others successes beyond weight-loss. So these women were exercising, they felt like they were getting attention from us. Their mental health got better, so less anxiety, less depression. They didn't lose weight. But they felt part of something bigger and they understood they needed to keep trying and we weren't making them feel bad about you didn't lose weight. We understand it's hard. As I said, we think it's likely a less purposeful behavior. Like we don't think people can just say, I'm going to lose weight and it will happen, um, it's harder than that. The disparity has widened. So we're not doing a good job in the last 20 years. It's worse, it's not better. And we have to identify solutions. It's important. Technology may be important to 20 years ago, when I started telling you we use cable TV, we might need to use more technology to just bombard people with messages about the importance of losing weight. We need to understand what makes people gain weight. And we have to intervene outside of a clinic visit. The clinic is open for this many hours. Participants have trouble losing weight this many hours. So we have to find out ways. How can we help them when we're not with them? And there has to be social support, there has to be education, there has to be motivation. And so we have to figure out how do we do that. My last comment is that I loved this patient population, but I wouldn't have made it without that side gig that I was talking about. If you're going into faculty, a faculty position, you better already have everything established. Or are you better find something that's quicker? Because this takes a long time. I am so appreciative to these folks in this picture, in everyone likes them who were willing to share their data with me. They were giving me access to something that was the most important thing and that was them. But I also want you to understand obesity is steeped in generations. People live their whole life behaving a certain way, eating a certain way. I started by showing you a picture of my mom. I'm emulating their parents and their parents behavior. And asking them to change that when they're 15, 2030, 50. That's really hard to keep in mind that this isn't just them. It's them, it's their families, their parents, it's their generation, it's their culture. And so when you're thinking about disparities and health and especially obesity, you have to keep that in mind. I want to thank my team. My one team is my research team, all of these folks. And my other team is my family. And that's my husband Floyd, and my daughter Imani and my daughter can Yara and my daughter's Mickey, I and my son, Thailand and our dog cocoa. And I could not have done this with them. They have been so patient with me. I work really weird hours and they get it. They let me come and talk to you. And they encouraged me to travel. Even if I'm going to the school. They kicked our butts every year we played them. They were still my husband was like, yeah, go it's fine as long as it's not the football team, I'm cool. So sorry if their football players in here, I won't tell him. But thank you for listening and I welcomed we have time for questions. Okay. And I welcome any questions you have. The sister talked program. Well, two things. First of all, he talked about how took a Health at Every Size approach. I just finished reading the note Bacon's book, and I was wondering where there's just your talk was before or after the publication of the book by Dr. Linda Bacon. What year was it? I believe it was 1997 was the year that book was published was before because they started planning the program in 1992, and I joined them in 1994. I was also wondering in a meta-analysis done, I believe it was 2018 on approximately like 30 weight-loss studies, it showed that 50% of weight loss by patients was gained back within two years. And when you talked about your sister Talk program, I pointed out that you checked at 06:12 and 18 months and you check after the two-year mark, there was no way loss. Okay. So there wasn't a reason because they didn't lose weight, but the goal wasn't for them to lose weight. And so my approach lately, and I'm back then was that black women don't want to talk about weight. They're okay with their weight. And you can exercise and be healthy regardless of weight. You can eat healthy foods and it will make you healthier even if you don't lose weight. Again. So our focus has really been on try not to gain anymore weight. But be sure you're exercising and eating foods that are healthy for your body. I don't know what that is. I am not a dietitian, so I can talk to you about that. But the deal is we want to focus on success and failure. And you saw from the study that I presented, black women don't want to lose weight. And I tell her story, I think is funny and not funny. When we were doing these qualitative interviews and in-home visits and I was training my research assistant. And one of the things that we ask is, is there anybody here, like Is there anybody else in the house? And the lady said, yeah, my husband is in the kitchen and I said, Are you comfortable. I said Can you hear us? And she was like, Yes. And I said, Are you comfortable talking to us about the weight-loss program? And if he can hear us and she said yes, and then I hear from the kitchen, don't ask my baby to lose any weight. I'd like or just the way she is. And I was like, Yes, sir. That's not why we're here. It's just that's what I talk about, that obesity is steeped in generations and it's a positive thing for black women. They're not feeling bad about themselves if they're overweight or obese for the most part, it can't generalize, but that's what we learned in our research. Great questions. You got another one. Thank you very much for your very informative talk. Can you share your email address? So if we have a comment or question, we can write to you, please. Sure. Or is it not on my original? That's not like me wasn't on my first line. That's what I thought. Sorry. I don't know how to do this better. Stuck too fast. Thank you, guys. It's not there. So is it okay if I just tell you because it's pretty easy. It's NkT i-th at IUPUI dot edu. If you're on Twitter. Nicole Keith, PhD. I think I'm next. Thank you for your talk. Dr. Keith sets an amazing legacy of work there. So I'm really curious to hear your thoughts. So when you talk about that, it's not just about weight loss. That, and that's reminds me of Stephen Blair's work. That you can be heavy, you can be obese but you can still be fit. Steve says fat and fit? Yes. It's like the word fat. But that's what he said. Yes, he does say that. Um, so with that in mind, what are some of the other outcomes you're looking at? So are you looking at sleep? Are you looking at mood? Are you looking at depression symptoms, anxiety? What are some of the other benefits that you're seeing perhaps so not sleep. We don't have anybody with that expertise on our team or in our institute. They do look at depression and anxiety, um, and we look at fitness. So I'm an exercise scientists, of course, I'm looking at fitness. So we look at muscle strength and endurance, flexibility, cardiovascular fitness, other health outcomes like blood pressure and diabetes outcomes and chronic disease, cancer. So we do have access to their medical records. So we really want to know, even if they don't lose weight, do their disease outcomes improve? Do their fitness outcomes improve? Does their mental health and proof? So watch that space. Hi. I just wanted to ask, when you were the education component of the program, what did that focus on? Like, did it just focus on how to try and hide it, exercise. Problem manner, or how much exercise. Did that also include the value of Sophie and grade? How does that sort of benefit them? Print the value of eating, are exercising on a regular basis? Yeah, that's part of the education program. Definitely. I am just tips on how to change if your behaviors are unhealthy. How to how to strategize for healthier behaviors? Because at first I was like for which study, but that was in every study. Yeah, that's what we did. Did you face any resistance? Of course. I put up that quote. They go to the Healthy me, Amy meeting. They meet with the coach, they meet with the group and then they go to the country buffet. Definitely resistance. And it talked about the husband who didn't want his wife to lose any weight. Women who say, my kids won't cut it with me because I'm not soft and cushy like I used to be, so I want to gain my weight back. Of course, there was all kinds of resistance. And I was talking to a group earlier today that there are a population of women who think this is going to happen anyway. Everybody, after they have everybody in my family has a baby and then they catch diabetes. You don't catch diabetes. I don't say that. I'm listening. But there's this belief that no matter what happens, this is going to happen to me because this happens to everybody in my family. And that's the point of steeped in generations, like there's this expectation. So I go back to my mom and me and my daughter. We all expect to get degrees because that's what everybody in my family does. What if it was my mom, myself, my daughter, were all obese. That's what everybody does and my family. And that's the way humans behave. How to work within that context in order to change behavior is a challenge. We haven't figured that out. That was my next question. Hi. I just wanted to ask with the prior knowledge that you have with the 20 years of research you've done. Do you have any new research that you're going to try out with new methods because you have so much knowledge already from the 20 years that you've been doing this. So what are your next steps and like possibly any new research methods and stuff like that. So the silver lining of COVID, one of the challenges is that all of our programs happened at the same time. So you had to show up at 11:00 in the morning or four o'clock in the afternoon or seven o'clock in the evening in order to get the intervention. Now we can record on Zoom and people can watch it whenever they want. So that's one thing. We also want to create social networks. And so there is a scientist, I'm out of Harvard, christy, OK, as we have shown, that you behave. The way your social network behaves. And so if everybody who hang out with exercises, you're probably going to exercise. If everybody you hang out with smokes, you're probably going to smoke. And so we want to create these social networks to see if that might be a solution. We don't know. Our challenge right now is figuring out if your family, everybody in your family eats a certain way and you're the person who prepares meals. Does that mean everybody has to change the way they eat and are you willing to do that? Or let's say you don't get along with your brother. He teach you in a really negative way and has your whole life. And he's in your network, and he's in your network to try to sabotage you. Like we don't know how that's had a nuance that and so that's what we're trying to figure out right now. But we think people will do better in groups then they do individually. And the one thing we didn't do, even though healthy me had groups, we didn't enroll people who are going into groups together and have them interact with one another. So that's the next thing we're going to try. Hi, I have a black mom who has been wanting to lose weight for a long time. But I think there's something sopping her from wanting to go to the gym more like I have offered to pay for a membership drive her, but I do feel like there's this lack of motivation there. So I wanted to ask, how did you motivated people that may have shown some resistance with starting to exercise and eat better. Yeah, So we never told anybody they had to go to the gym. You know, people are asked like, what's the best exercise for people to do? My answer is the exercise they will do. That's the best exercise. And so maybe the gym isn't for your mom. Maybe walking is for your mom. Maybe an indoor cycle at her house is for your mom. I was laughing because on the Today Show this morning I saw this collapsible bike and I sent the like, I took the QR code and I was like, I want this for Christmas because I have a bad back. And so when my back is really hurting, I don't want to do anything that requires me to stand. So this was like $97 and I sent it to my husband and I was like, here's my Christmas present. It's what you will do. I don't like going to most fitness centers. I do belong to a fitness studio. They only let 16 people in the building at a time. Nobody is judging me. I'm not judging anybody. That's how I'm comfortable. I don't like to go to the fitness center on campus. I love my students, but they're all there. And I'm tired of, I'm not giving you a quiz questions right now. Please don't ask me about class right now. So you have to find something that she enjoys. And I sometimes ask women, especially like What did you do when you were young? What did you do for fun? Do that? Like Did you like to dance? Did you like to climb trees? Did you like to take your daughter to the playground, swing on the swings with her. Those are all large muscle group exercises. So go into the gym might not be the answer. Asked her, what do you want to do and then have her do that and be really encouraging whatever she does. Like mom just walk around the block and or I don't know if she has a block to walk around, walk for 15 min. And I got here yesterday and I had been sitting on planes all day. I was like, I'm going to walk for 30 min and that's good enough. Like you don't have to and I didn't break a sweat. Gillian picked me up. I was still wearing the same clothes. I didn't even change. I didn't even change my shoes. I just went for a walk. I walked 15 min somewhere, lost and remembered and walked back. And so it doesn't have to be so hard as changing your clothes and changing your shoes and joining a gym. It's just like what's easy that you will do. It's a great question. Okay. I was going to ask a question as well. Thank you so much for coming. Put your mic closer to you. Okay. I was going to ask concerning you did 20 years of research and everything you put towards it. Did you ever get frustrated that even though you did everything, you did all this work, people were losing weight and like weren't just getting it forever frustrated you like, you know, I knew when I was getting into and I joined this, um, research experience and there were wins. I made close connections to women. I know I changed their lives. We change their lives. I know that there were good things that happen. Of course I get frustrated. I get frustrated with my colleagues who were telling patients lose 150 pounds when they only need to lose five. And keep that vibe off. Of course, there's frustration, but there's also a tremendous reward. I wouldn't have done this for 20 years. And I think about like when you ask the question, you know, my kids all played sports. So did my husband. I'm rambling only non-athlete in their family. So you can't win if you don't play. And so it's like if you're on a losing team, do you quit the sport because you didn't win? No. You say, well get them next season will get better. We'll go back and think about, we'll get the right players. If you're really loving the sport, you're not going to quit. And I really love this work. I love these people and they deserve better. Um, and so I'm gonna keep trying. Yeah, I don't see ever quitting because there's an answer and we're going to figure it out or maybe you will. Thank you so much for your talk in coming to UD. Obviously this behavioral change and exercise leading to weight loss or any other outcome is gonna be really multi-factorial. But when it comes to exercise interventions, the dose, like other research has shown seems to be pretty important. So how have you look to control that or look to see what the dosage is. Do you feel like that's maybe kinda confounding results? Maybe you're not seeing things just because it's either not controlled or do you feel like controlling that in the future? While we do see things. So we do see improvements in health outcomes. We just don't see weight-loss. And the dose is important. You're, you're absolutely right. But now there's this research on the reduction of sedentary behavior. And so it's not just that you have to meet the American College of Sports Medicine guidelines of 30 min of moderate to vigorous exercise most days of the week. That's the guidelines. But if all you can do is walk for 10 min, a ten-minute walk for someone who has not walked in ten years is a long walk. And it's improving their cardiovascular health. And if they can get to 15, that's wonderful. But if they can't and they can do 10 min three times, they still got them 30 min and for that day, so the dose is important. They're not gonna lose weight like that. And I make it really clear. And I'm like, I'm not here to talk to you about losing weight. I'm sure to talk to you about increasing your physical activity. But just really important that you know the joke among people who study physical activity as you can out work a bad diet. And you can, and, and so, but even though you don't change your diet. And my colleague, Dan Clark that I introduce you to is now not asking people to stop eating the foods they like even if they're unhealthy. He's just he's asking him to start eating healthy foods that will help their brain and help their heart, but not taking away the other foods and the hope that they'll get full and eat less of the bad stuff. But yeah, the dose is important. It really is. But if I say go exercise for 30 min, many, many, many people, most people in America, about 70% Kent. And so that message has to be different. Questions, not building up on that, but in terms of the goal. So like weight being that measure, that outcome. Is that measure should it be the end-all be-all, or were there other measures that also reflected positive change for like the women in these studies? Is there another variable or something else that could be the goal if we're seeing that weight is not sure. So my training was on weight. So that's how it started. That might not be how it ends right now, that's what's funded. So the goal can be something else and you'll see if you look up any of my papers. I talk about fitness. I have my colleague married a group who talks about diabetes outcomes and mental health outcomes. But the goal is wait, I think that that's what's sexy and that's what people want to do. And if I say, Hey, I'm going to give you bigger biceps, is there gonna be like No, thank you. I say, Hey, you're gonna be in a better mood every day. They'll say my mood is fine even if it isn't. And so, but if I say, Hey, your weight is affecting your health, Let's try to help you not gain any more weight. And their Dr. has been tying them for ten years, you have to lose weight. And all they've done his gain weight. It's just a sexier goal. But we have other goals. And we're doing those measures. But that's not what attracts people to participate in research. Equal to. Let's take one more question. I think there was a question over there. So in physical activity research, especially research that uses wearable devices and activity trackers, participants are predominately white. So what can we do moving forward to ensure that we have adequate representation of Black and Hispanic populations. You can ensure that. But what we can do is deliver messages that are meaningful. And so we talked about this earlier today, but I will say it again and I'll give him a story because you already heard what my recommendations are. But I have a colleague who is a physician. She studied, she's a nephrologist who studies chronic kidney disease. And they're doing, they have what's called the musculoskeletal fit lab and they're doing data collection for all comers. And I'm about 90% of the all commoners are white and a really highly funded researcher. But she started going into recruit herself and I asked her, Can I go with you, can I just hear what you're saying? And she was saying the standard, this is why you should do it. This is what we're trying to learn. This is how you're going to help the community of researchers and physicians. And I went with her the first time I didn't say anything and the second time I'm like that as the wrong message. And so I asked her can I just talk to the group? And I told them if you don't study, I mean, if you don't participate in the study, I need you to understand. There are all of the recommendations that are made. All of the clinical practices that are done are gonna be done on white people. That's all the people are studying. I'm not suggesting that our physiology is different than the physiology of white people. But we have higher levels of stress. We faced racial discrimination. We grew up differently in America than many white people. But all of the research is based upon white people. All of the clinical guidelines are based upon white people. And so if only white people participate in research, all of our recommendations are gonna be only on white people. And so we need people of color to participate in research. And Dr. Marla is like, the best. People came. They heard you and they showed up and they brought their family members. And so I think that when it's an immediate threat to them, and I told you earlier, I don't like the scary language, but I liked the truth. And so you have to tell the truth. And so those of you who weren't in our earlier conversation, also, the truth is, well, I can't take care of myself because I have to take care of my family. Well, you can't take care of your family. If you can't recognize them because you have Alzheimer's, you can't take care of your family. If you have diabetes and have to have a lower limb amputation, you can't take care of your family if you're dead, you have to change your behavior for your family or you won't be around. And so those are messages that really resonate with people of color that aren't going to just sign up. I don't know. You gotta know your population. I know black people in Indianapolis, which is who they were trying to recruit. So I knew that that message would really resonate with them. Like all when you go to the Dr. your Dr. is going to get recommendations on all the white people who participate in, in his research because no black people are participating. So again, those are, those are the recommendations that can give you. But I can't promise I don't know people in Delaware. And I in you have to know your community and be in your community and that's the other thing. They trust us, like we have been with them for decades and we aren't going away. They know that. I think on that note we're going to wrap up the question-and-answer, but there's refreshments outside and when you can stop by and talk to Dr. Keith and let's give her one more round of applause. Thanks.
2022 Foltyn Seminar_Nicole Keith_10-12-22
From Regina Porter October 13, 2022
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