The Bodyweight Challenge (Formidable Fighter Book 8)

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In addition to demonstrating durability of treatment effect, it is also critical that healthcare costs associated with community-based lifestyle intervention for preventing Type 2 diabetes are assessed. Evidence from a simulation model projecting the costs and benefits of a nationwide community-based lifestyle intervention suggest that such a program would represent an efficient use of healthcare resources [ 46 ]. Although cost savings would occur in both younger and older individuals, greater health and economic gains would be achieved if directed at those under the age of 65 years.

Reduction in the incidence of Type 2 diabetes on a population level requires collaboration among community-based organizations, insurance payers, healthcare and public health professionals, academia and others. The National DPP brings together the groups listed above and unifies delivery of proven lifestyle change programs in communities throughout the country. The National DPP consists of four components, as outlined below.

The CDC Diabetes Prevention Recognition Program DPRP [ ] assures program quality, consistency, provides a registry of recognized programs and implements standardized reporting on performance of recognized programs. This is a new payment model in which an insurer reimburses a community-based organization based on performance. With implementation of the DPRP, more organizations are involved in program delivery and reimbursement.

Participant engagement and healthcare provider referrals are important for program success. CDC and others, such as the Diabetes Prevention and Control Alliance, are testing various marketing strategies to enhance program participation. Implementing lifestyle change programs to prevent diabetes is not without challenges.

In order to achieve the desired health outcomes on a large scale, the areas discussed in the following sections are among those that need to be addressed. The preponderance of evidence for diabetes prevention is derived from initiatives focusing on those at increased risk i. Measuring risk, however, is more challenging when defined at the population level, and therefore validated instruments assessing risk gradients are required [ 48 , 49 ].

A two-step screening procedure starting with the FINDRISK questionnaire followed by a glucose test for those identified at increased risk might be the most cost-effective approach [ 49 , 50 ]. Policy development requires utilization of evidence-based, standardized lifestyle intervention recommendations that are customized to reflect cultural and individual circumstances.

Furthermore, diabetes prevention is strongly related to an increase in physical activity and a reduction in fat and increased fiber consumption. Standardized recommendations for diabetes prevention can therefore be related to physiologically based core goals and increased effectiveness of policy development.


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Alternatively, curricula can be evaluated to ensure that required content areas and program length are met. Implementation of diabetes prevention initiatives, although not requiring medical specialists per se , requires skilled personnel. There is a growing need for the development and implementation of training curricula for prevention personnel so that they may effectively instruct individuals at risk in sustained lifestyle change [ 54 ].

Curricula have been developed in Europe [ 55 ] and the USA [ ], although it will take time until a critical mass has been trained. The number of skilled personnel will depend on the organizational structure in which they will work. The public health sector can play an important role in continuous evaluation and monitoring to ensure successful implementation of diabetes prevention programs.

Furthermore, this is vital for quality assurance and benchmarking of standardized procedures.

Scientific outcome evaluation indicators and measurement recommendations e. Recent experience demonstrates that monitoring alone, as a function of quality management, is a driver for increasing the quality of intervention programs [ 57 ]. In addition to targeting high-risk individuals through lifestyle change programs in the community, general population level policy requires implementation of evidence and practice-based policies in modifying the environment and infrastructure to improve nutrition, decrease weight, increase physical activity and facilitate tobacco cessation.

In some places, complementary strategies targeting those at high risk and the general population is not occurring and in some cases, only one segment of a population is involved. Some countries assign responsibilities for diabetes prevention to agricultural ministries in which activities are often restricted to aspects of food production, and therefore do not establish a prevention initiative. As LMICs often lack the financial resources to manage diabetes, they therefore may only develop strategies for lifestyle education as well as physical activity in schools [ 48 ].

Effective policies for food procurement and production, as well as strategies promoting healthy lifestyles in children, have important potential to contribute to diabetes prevention and should continue to be examined. As previously described, screening procedures for diabetes and prediabetes are fraught with complexity and inaccuracy, often making diagnosis difficult except in the most obvious circumstances.

Thus, 79 million Americans aged 20 years or older are estimated to have prediabetes in [ ].


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Although the reasons for this are unknown, national policies, such as public and provider education programs, need to be developed, especially as dissemination of national guidelines are generally ineffective in changing clinical practice [ 59 ]. There exists an urgent need to translate evidence from prevention initiatives into policy and affordable, feasible programs [ 59 , 60 ] in order to detect individuals at risk with appropriate referral to lifestyle intervention programs. This is particularly essential because once individuals with prediabetes progress to diabetes, management of the latter remains inadequate.

Furthermore, effective prevention strategies should constitute a major approach particularly in view of the lengthy preclinical phase characterizing the transition from prediabetes to Type 2 diabetes that thereby provide an extended window for intervention [ 62 ]. Examining current public health policies with regard to diabetes prevention is vital, given the enormous economic and social burdens diabetes creates, as it most often affects individuals in the prime of their lives, reducing their productivity aside from driving direct healthcare expenditures.

It has been estimated that the proportion of cardiovascular disease attributable to diabetes has increased over the past 50 years, highlighting the need for increased efforts at prevention and aggressively addressing cardiovascular risk factors among those with diabetes [ 63 ]. Indirect costs, such as decreased income, premature retirement and unemployment, can be even more costly than the direct expenditures associated with the condition [ 64 ]. Calorie excess serves as a transmissible agent, propagated by inadequate food labeling and poorly regulated advertising vectors embedded within a reservoir of fast-food outlets providing cheap calories.

Sedentary lifestyles provide a predisposing toxic milieu in which limited physical activity works in concert with consumption of excess calories leading to weight gain, obesity and increased risk of diabetes [ 66 ].

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Analogous to an infectious pandemic, breaking the cycle of transmission in the case of diabetes must involve political will and decisive legislation and support by the medical community [ 66 ]. Whether diabetes is characterized as communicable or noncommunicable, both perspectives commonly point to the critical need for action. Thus, the increasing toll associated with NCDs led to a 2-day high-level meeting of the UN General Assembly in September , creating an awareness of the enormity of the global problem.

This meeting was constituted by unprecedented participation of global leadership from Heads of State, the WHO, nongovernmental organizations and member states. This was a very positive step for NCDs as well as global collaboration as the high-level meeting resulted in a political declaration calling for collaborative effort to reduce risk factors and strengthen national policies to prevent and control NCDs. While recognizing the NCD epidemic, the conference did not elucidate deadlines or targets or a system of accountability and neither was funding allocated for treatment or prevention.

However, targets are under discussion and will be released before the end of Although the UN Summit did not address all of the expectations, it provided diabetes and NCDs with a global platform [ 67 ]. The International Diabetes Federation has been instrumental in providing an overall framework representing the global diabetes community [ 67 ].

In addition to improving the health outcomes of individuals with diabetes and addressing discrimination of individuals with diabetes, prevention of Type 2 diabetes constitutes a key objective of the plan. Prevention and treatment are not considered to be alternative options as they are both equally important. The UN and its agencies are advised to work with national governments to reorient health systems to a preventative model addressing health in all polices, such as urban design and housing, workplace design, food production, healthy nutrition and physical activity.

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Concerted action at the international and national policy levels will, therefore, be required to advance science-driven health initiatives in these areas and translation into practice [ 68 , 69 ], while meticulously avoiding overzealous and well-meaning policy initiatives of hitherto unproven benefit. These recommendations are congruous with the three pivotal levers for change described by Yach et al. These should also include entire government systems beyond healthcare and involve global corporations and labor unions, as well as nongovernmental organizations.

Furthermore, chronic disease alliances need to be formulated including industry and academia [ 60 , 71 , ], such as the Oxford Health Alliance, the Global Alliance for Chronic Diseases and the Global Partnerships Forum. Political commitment and action are critically required at high global and national levels particularly as prevention of diabetes and its complications are dramatically underfunded and as major gaps exist between findings from clinical trials and their implementation in clinical and public health practice [ 71 ].

Research funding agencies tend to favor medical and surgical solutions over health promotion and health systems interventions and policies [ 71 ]. Furthermore, although research has shown that improving diets has greater potential to improve quality-adjusted life years, reduce morality and medical costs than medications, funding favors medications [ 72 , ]. The WHO has called for research into prevention and intervention implementation in addition to integrating prevention efforts in national programs and engaging government and corporate sectors [ 72 , 73 ].

The WHO priority areas for diabetes prevention, control and research include community-based primary prevention models focusing on nutrition, physical activity, urbanization and transportation [ 73 ]. Detecting prediabetes and undiagnosed diabetes may be the link and stimulus to reorient systems toward preventive care. Hence, if efforts are not made in primary prevention, the increasing rate of diabetes will obscure or negate achieved successes in secondary prevention [ 74 ]. Realistic policy interventions must be directed at making healthy choices easier rather than coercing individuals to make healthy choices [ 76 ].

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Taxation is one option to change health behavior [ 77 ] but may not be a popular approach [ 78 ]. The pricing and availability of healthy foods needs attention. Pricing is best addressed across all major food categories, and supported by the need for better agricultural and food policies to address diabetes [ 79 ]. Strong industry collaboration has made significant progress on several key areas, such as reformulating to reduce sugar, innovating smaller package sizes, labeling calories and sugar, restricting marketing to children, withdrawing full-calorie sodas from schools and investment in activity programs, such as the Healthy Weight Commitment Foundation and the International Food and Beverage Alliance [ 80 ].


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Focusing on improving health through modifying the environment for the entire population is more desirable than health education or promotion campaigns. Policies to align agricultural policy with nutrition and health goals will allow the agriculture and food industries, both with great influence on health, to contribute to the prevention and control of diabetes and other NCDs [ 80 , 81 ].

While confronting NCDs in general and diabetes in particular at the highest levels of national and international governmental agencies is absolutely necessary to promote shifts in healthcare delivery, this process will clearly take time. Since the crisis is well upon us, current strategies involving community resources described above are crucial and need further expansion.

Narayan et al. So, what additional options can be undertaken to identify and refer individuals at risk for progression to diabetes? Evidence-based approaches involving health promotion, obesity prevention and policies to improve the behaviors and environment on a population basis need to be reinforced with the identification and referral of the almost one-third of adults with prediabetes to effective lifestyle change programs [ 74 ].

Investment in research to better understand what kinds of policies at environmental levels work to reduce obesity and diabetes risk is needed. Currently, few interventions tested at the population or environmental levels are proven to be beneficial. Novel approaches to training are required to meet the global demands of caring for patients with chronic conditions [ 82 ].

The healthcare system needs to transition from a reactive to a proactive perspective with regard to prevention and approach this issue on a population basis beyond caring for the individual patient [ 82 ]. Healthcare workers will, therefore, need to develop a broad approach to patient care considering the entire continuum from community prevention to palliative care [ 82 ].