Implementation of the YMCA Diabetes Prevention Program throughout an Integrated Health System: A Translational Study

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1 Specil Report Implementtion of the YMCA Dibetes Prevention Progrm throughout n Integrted Helth System: A Trnsltionl Study Ron Adms, MD; Christopher J Hebert, MD, MS; Lind McVey; Roger Willims, MEd E-pub: 10/21/2016 Perm J 2016 Fll;20(4): ABSTRACT Context: HelthSpn Physicins (HSP), n integrted medicl system in Northest Ohio, prtnered with the Young Men s Christin Assocition (YMCA) of Greter Clevelnd to implement referrl system for the evidence-bsed Dibetes Prevention Progrm (DPP) throughout HSP. The YMCA of USA employs cost-effective, customized version of the originl DPP in which coches tke the plce of in-house clinicl stff. Efficcy of the YMCA DPP ws shown erlier in the DEPLOY Study. Objective: To improve outcomes of metrics used in the DEPLOY Study. Design: Observtionl study focusing on enggement, persistence, recruitment, nd dherence to the DPP. In August 2014, HSP miled n invittion to 2200 ptients identified s both Medicre eligible nd t risk of predibetes to ttend no-obligtion informtion sessions bout the DPP. After these sessions, YMCA stff clled interested prticipnts nd sked them to enroll in nd to commit to the progrm. Motivtion nd reinforcement were provided to ptients through YMCA-provided signs, brochures, nd posters; the HSP Web site; nd in-person converstions with primry cre physicins. Min Outcome Mesures: Averge weight loss t the end of 16 weeks in the progrm nd verge retention through Session 9. Results: Of the 2200 ptients contcted, 351 (16.0%) responded by ttending the informtion session, nd 228 enrolled in the YMCA DPP (11.3%) nd persisted through t lest Week 9. This result is n improvement over the 1.7% of eligible enrollees who responded to the DEPLOY Study s miling. Conclusions: A mrketing pproch to implementing the YMCA DPP in n integrted medicl system results in excellent outcomes. INTRODUCTION As reported by the Centers for Disese Control nd Prevention (CDC), more thn 86 million ptients hve predibetes, defined s impired glucose tolernce (2-hour plsm glucose level between 140 nd 199 mg/dl) or impired fsting glucose level between 100 nd 125 mg/dl. 1 People with predibetes re t incresed risk for development of Type 2 dibetes. 2 Obesity nd/or overweight conditions (body mss index [BMI] > 25 kg/m 2 ) re mjor contributing fctors to predibetes nd Type 2 dibetes. However, the progression from predibetes to Type 2 dibetes cn be significntly slowed nd/or reduced by ptients dhering to the protocol of n evidence-bsed Dibetes Prevention Progrm (DPP), developed in the mid-1990s with funding from the Ntionl Institute of Dibetes nd Digestive nd Kidney Diseses (NIDDK). In the first 3 yers of the rndomized, NIDDK-sponsored DPP Outcomes Study, the DPP lifestyle intervention group reduced the number of new cses of Type 2 dibetes by 58% compred with plcebo group. 3 In more thn 10 yers of rndomized trils, the dibetes incidence in high-risk dults ws reduced by 34% with intensive lifestyle intervention through the DPP. 4 The DPP s originlly constructed 5 ws hrd to implement nd sustin in busy helth cre settings, where cost ws lso mjor issue. 6 This problem hs clled for rel-world dpttion, s with the Young Men s Christin Assocition (YMCA) of the USA s customized 52-week version of the progrm (16 weekly sessions followed by 9 more sessions during the following 8 months), wherein specilly trined lifestyle coches provide mentoring nd support to the prticipnts in group settings. 7 Even with referrls from primry cre physicins (PCPs), enrollment nd progrm ttendnce/ dherence hs been chllenging in YMCA implementtion efforts. For instnce, in the well-known DEPLOY Study (Trnslting the Dibetes Prevention Progrm into the Community) involving the Indin School of Medicine nd the YMCA of Indinpolis there ws 1.7% client enrollment resulting from the initil miling to 7500 Indinpolis households (Figure 1). 6p357 Although the long-term effects of untreted predibetes re well-known, eduction nd informtion-only pproches to clients with predibetes nd to helth providers hve not resulted in dherence to the three pillrs of predibetes tretment: diet nd nutrition chnge, chnge in exercise hbits, nd lifestyle chnge. 8 Unchecked obesity is prime predictor of predibetes, leding to the onset of Type 2 dibetes. Despite this knowledge in ptients nd providers like, the YMCA hs experienced difficulty in ttrcting new clients to the preventive intervention of the YMCA DPP nd in securing client dherence to the progrm protocol. Here, we report unusully high outcomes in initil ttendnce, persistence, nd weight loss resulting from mrketing pproch to implementtion of the DPP. This ccomplishment ws mde possible through prtnership between the YMCA of Greter Clevelnd nd HelthSpn Physicins (HSP), division of Mercy Helth in Northest Ohio. Ron Adms, MD, is the former Associte Medicl Director for Qulity t HelthSpn nd the Lerning Director for Better Helth Prtnership nd is currently the Vice-Chir of Prcticing Trnsformtion for the Medicine Institute t the Clevelnd Clinic in OH. E-mil: dmsr8@ccf.org. Christopher J Hebert, MD, MS, is the Systems Director of Qulity t Mercy Helth in Cincinnti, OH. E-mil: cjhebert@helthspn.org. Lind McVey is the Executive Director of Helth Inititives for the YMCA of Greter Clevelnd in OH. E-mil: lmcvey@clevelndymc.org. Roger Willims, MEd, is freelnce Scientific Writer in Clevelnd, OH. E-mil: rlloydwillims2@yhoo.com. 82 The Permnente Journl/Perm J 2016 Fll;20(4):15-241

2 Implementtion of the YMCA Dibetes Prevention Progrm throughout n Integrted Helth System: A Trnsltionl Study ORIGINAL RESEARCH & CONTRIBUTIONS Africn Americn women chieved nd sustined roughly hlf the weight loss experienced by other ethnic groups. Figure 1. Implementtion of the YMCA s Dibetes Prevention Progrm in the DEPLOY Study. 1 1 Ackermnn RT, Finch EA, Brizendine E, Zhou H, Mrrero DG. Trnslting the Dibetes Prevention Progrm into the community. The DEPLOY pilot study. Am J Prev Med 2008 Oct;35(4): DOI: YMCA = Young Men s Christin Assocition; DPP = Dibetes Prevention Progrm. METHODS The initil thrust of the present prtnership nd trnsltionl study between the YMCA of Greter Clevelnd nd HSP, n integrted medicl system, hs been to motivte ttendnce t informtion sessions. The next gol ws to encourge enrollment in the YMCA s DPP nd dherence to the progrm protocol through t lest the first nine weeks of the progrm. Nine weeks ttendnce is the CDC-pproved stndrd for persistence in the progrm, leding presumbly to lsting behvior chnge. 9 Becuse of demogrphic fctors (loction, income, nd employment ptterns), the present study ws ble to ttrct primrily (95%) Africn Americn women with predibetes in the reserch cohort. The women were predomintely older thn ge 50 yers. Most were Medicre ptients. Obesity, s stted, is leding indictor of risk for the onset of Type 2 dibetes. As Hmmn et l 10 found in lrge field study of DPP prticipnts fter 3 yers of follow-up: Weight loss ws the dominnt predictor of reduced dibetes incidence... For every kilogrm of weight loss there ws 16% reduction in risk. Rce is nother mjor contributing vrible in efforts to mintin weight loss. Lrgely becuse of obesity or overweight conditions, some rcil nd ethnic groups hve much higher risk for development of Type 2 dibetes. In 2003 to 2004, pproximtely 30% of non-hispnic white dults were obese, s were 45% of non-hispnic blck dults nd 36.8% of Mexicn Americns. In tht sme period, blck women exhibited the highest rtes of overweight nd obesity, t 58% of the popultion ged 40 to 59 yers compred with bout 38% of non-hispnic white women of the sme ge. 11 Study fter study hs shown tht both chievement nd mintennce of weight loss hs been prticulrly problemtic for Africn Americn women, nd the DPP protocol hs been no exception. 12,13 In one controlled study using the DPP mong different groups, West et l 14 found tht Pilot Study (Phse 1) In October 2013, HSP of Northest Ohio nd the YMCA of Greter Clevelnd entered into collbortion in which HSP would refer its eligible clients with predibetes nd the YMCA would conduct its customized version of the progrm (up to 25 sessions during the course of yer using trined lifestyle coches). The first 9 weeks of the progrm focused on enggement, persistence, nd recruitment. In Phse 1 of this project, the pilot phse, the prtners relied primrily on the following tctics to ttrct clients. First, the PCP recommended tht his/her client investigte the YMCA DPP, becuse the client ws suspected of hving predibetes. Second, if interested, the ptient picked up n enggement brochure in the exmintion office which ws noted in the ptient s record giving description of the progrm s content, plus the time nd loction of the next informtionl session. Also provided ws YMCA telephone number to cll with questions. We then relied on the ptient s own motivtion (Stge 2 in the DiClemente nd Prochsk Stges of Chnge hierrchy, Contempltion of lifestyle chnge) s to whether the ptient would show up for the informtion session. 15 At this point, HSP engged in minimum of 2 telephone clls to repet the invittion to ttend the informtion session to those who hd picked up the informtionl brochure in either the outer office or the exmintion room. Initil efforts were focused on 2 HSP loctions, ech of which fetured predomintely Africn Americn popultion. From October 2013 to July 2014, there were pproximtely 100 referrls to the informtion sessions, which resulted in 33 enrollees in the yerlong progrm. The enrollees provided consent to the trcking mesures tht were to be used. After 5 months of Phse 1 prticiption in the YMCA DPP, the following outcomes were reported: 1) 17 ptients, or slightly more thn 50%, persisted in the progrm through Week 16, the finl weekly session; 2) of these 17 ptients, the verge weight loss ws pproximtely 4.7% of body weight, which conforms closely to the ntionl verge t this stge. The gol for the 16-week period ws 7% of body weight lost. Phse 2 Becuse of the perceived success of the pilot effort, the project entered into Phse 2 (August 2014 through November 2015), extended to the entirety of the HSP network of ptients in Northest Ohio. Thnks to grnt for Medicre-eligible older dults, Phse 2 of the project begn in August 2014 with n HSP miler to 2200 clients who hd been identified in the electronic helth record s both Medicre eligible nd t risk of dibetes. The miler invited them to informtion sessions to be held throughout the region. A follow-up miler ws sent to 1200 clients lrgely duplictive of these sme people. In ddition, HSP nd the YMCA decided to employ more of mrketing pproch, feturing mny touchpoints, or touches (methods or modes of contct between the orgniztion nd the consumer), nd direct contct from the Popultion Mngement The Permnente Journl/Perm J 2016 Fll;20(4):

3 Implementtion of the YMCA Dibetes Prevention Progrm throughout n Integrted Helth System: A Trnsltionl Study Deprtment stff. Vi referrl form t our Clevelnd loctions, we cptured the nmes of the clients who were referred to the YMCA DPP, which set into motion the following mechnism. Anyone who showed interest in the progrm nd ws perceived s eligible ws exposed to dditionl motivtors provided through signge, brochures, nd telephone follow-up for scheduled sessions, in which the nme of the PCP ws invoked. A smple phone script follows: Hi! I m clling on behlf of Dr, from HelthSpn. In recent visit, [s/]he noted tht you were very possibly predibetic nd were in dnger of developing Type 2 dibetes if this condition were not brought under control. Your doctor lso mentioned the YMCA s Dibetes Prevention Progrm, in which trined coches help you to bring bout necessry chnges in. The next no-obligtion informtion session on the YMCA s Dibetes Prevention Progrm is scheduled for t either 1 pm or 6 pm. Which session would be most convenient for you to ttend? [If needed] We hve other sessions. As described by Jy Conrd Levinson, 16 led uthor of the bestselling book, Guerill Mrketing for Non-Profits, the ide here is (once nme is cptured): Follow-up, Follow-up, Follow-up! At HSP, ll were involved: the PCP, the clinicl stff, nd (using the electronic helth records) the Popultion Mngement Deprtment. RESULTS The summry impct of Phse 2, in terms of enggement nd subsequent enrollment in the YMCA s DPP, ws much greter thn usully experienced with direct-mil cmpign nd resulted in greter turnout thn in previous YMCA joint projects. Outcomes were 1. Of the 2200 Medicre ptients identified s hving or likely to hve predibetes nd encourged to ttend YMCA informtion session in their community, 185 ttended vrious informtion sessions. 2. Of the ttendees, 168 evidenced interest in enrolling in the progrm. 3. After screening, 160 remined eligible nd provided informed consent, nd 152 formlly enrolled in the progrm. 4. Remrkbly, 137 of these persisted in the progrm through the 9th clss or longer. As mentioned previously, the 9th clss is the CDC-pproved stndrd for persistence in the progrm. With this success, we mplified our efforts, involving supportive follow-up telephone clls from our Popultion Mngement Deprtment. We sent second miler to 1200 persons from duplictive group of Medicre clients identified with the help of our electronic helth record s likely to hve predibetes. These results re displyed in Tble 1, with n overll enrollment of 248 persons nd persistence rte through Week 9 of 228 enrollees, or 11.3% of those perceived s eligible for the progrm. This represents fr greter persistence rte thn similr efforts heretofore reported in the DPP literture. 17,18 Finlly, in terms of weight loss, progrm outcomes exceeded ntionl verges for the YMCA DPP, which re verge weight loss t the end of the weekly sessions (week 16) of 4.6% nd verge retention (persistence) through Session 9 of 83.6%. As cn be seen in Tble 2, our corresponding figures were n verge weight loss of 5.37% nd persistence rte through Week 9 of 91%. There were only 20 dropouts in the progrm fter Phse 1 nd even fewer (N = 5) fter the conclusion of Phse 2. This lower dropout rte in Phse 2 ws counterintuitive becuse of the initilly high prticiption rte. This phenomenon will be the subject of further nlysis in forthcoming publictions. Tenttively, we hve identified the slient fctors in the success of the progrm s 1) PCP referrl, 2) intervention from Popultion Mngement with personlized telephone clls, nd 3) personlized follow-up from YMCA stff. The follow-up process, designed to mximize mrketing touches with the ptient, cn best be summrized s PCP provides the ptient referrl nd fills out referrl form Popultion Mngement employee mkes telephone cll to remind the ptient of the upcoming informtion session nd encourges ttendnce Ptient ttends the informtion session nd provides relese of informtion to obtin BMI nd blood test results Relese documents re sent to Popultion Mngement to verify the BMI nd qulifying blood test Informtion is sent to the YMCA YMCA mkes up to three clls to ptients who met the enrollment criteri to invite them to enroll in the progrm; those who did not meet the criteri re not invited to enroll. Tble 1. HelthSpn Physicins nd the YMCA s Dibetes Prevention Progrm enrollment dt (October 13, 2013 to September 4, 2015) Prticipnt ctegory Ptients perceived s eligible nd sent letter Group 1 (October 13, 2013) Group 2 (April 15, 2014) Totl Attended n informtion session Registered initil interest Remined eligible fter screening Enrolled nd ttended the first clss Attended the ninth clss b Dropped out before the ninth clss Of this totl, 1220 ptients received n dditionl duplicte miling in Mrch 2015 for clsses commencing April 15, b The ninth clss is tken s the client s mesure of efficcy/chnged behvior, ccording to the Centers for Disese Control nd Prevention. YMCA = Young Men s Christin Assocition. Tble 2. Weight loss outcome mesures in 228 prticipnts who completed the progrm (Phse 2) Mesure Percentge Persistence (ttended ninth clss) 91.0 Percentge of body weight loss Men 5.37 Medin 5.57 Progrm completion ws defined s completing minimum of 9 clsses, with some groups still in progress t the time of this writing. 84 The Permnente Journl/Perm J 2016 Fll;20(4):15-241

4 Implementtion of the YMCA Dibetes Prevention Progrm throughout n Integrted Helth System: A Trnsltionl Study ORIGINAL RESEARCH & CONTRIBUTIONS DISCUSSION Cost-Effectiveness In conceiving cost-effectiveness metrics for the YMCA s DPP, there re t lest 3 perspectives to be considered: 1) the cost of doing nothing the cost to the ptient nd the medicl provider/insurer incurred in treting dibetes itself, 2) the cost of the next best (medicinl) lterntive, nd 3) the dded yers of life expectncy. With respect to the cost of doing nothing, the Americn Dibetes Assocition provides these sttistics: People with dibetes hve helth cre expenditures tht re 2.3 times higher ($13,741 vs $5853) thn expenditures tht would be expected for this sme popultion in the bsence of dibetes [suggesting tht] dibetes is responsible for $7888 in excess expenditures per yer for the person with dibetes. 19 This ltter figure is exclusive of indirect costs (unemployment, bsenteeism, etc), which re considerble. There is significnt difference in cost of the YMCA s DPP vs the cost of some recently pproved weight loss drug tretments, which lso result in n verge 5% sustined weight loss over time (which is the Food nd Drug Administrtion stndrd s of October 10, 2015). 20 As of this writing, the Food nd Drug Administrtion hs pproved 5 weight loss drugs, rnging in cost from orlistt t $173/month to injectble lirglutide (Victoz) t $658/month. 21 The ltter is pproved for weight loss only in ptients with Type 2 dibetes, but higher-dose lirglutide mrketed s Sxend ws pproved for weight mngement in December 2014 for use in obese dults (BMI of 30 kg/m 2 or greter) or in overweight dults (BMI of 27 kg/m 2 or greter) who hve t lest 1 weight-relted condition such s hypertension, Type 2 dibetes, or dyslipidemi. 22 Alterntively, the full cost of the YMCA of the USA s DPP is $429/yer ($36 per month), which crries with it proven 5% verge weight loss nd is therefore less costly, with fewer risks, thn ny of the bove-mentioned drugs. Although there re vrious formultions of dded life expectncy, the clcultion is pretty much in the eyes of the beholder. At minimum, 29% of ll dults with predibetes progress to dignosis of Type 2 dibetes t the rte of 5% to 15% per yer. 3,19 According to some experts, Type 2 dibetes reduces life expectncy by 6 to 10 yers. 23 Previously cited studies hve shown tht the DPP, prticulrly with older dult popultions, hs been ble to reduce the incidence of new cses of dibetes by 71%. Phse 3 Becuse of the perceived efficcy of this project in the Northest Ohio region, the HSP-YMCA prtnership in the YMCA s DPP hs been extended sttewide, throughout the Mercy\HelthSpn Integrted Medicl system nd wherever YMCAs re locted (pproximtely 11 regionl YMCAs nd upwrd of 200,000 potentil predibetic referrls). On the bsis of the Greter Clevelnd experience nd the lernings tht resulted therefrom, we expect even greter rtes of enrollment nd enggement thn those reported bove. In terms of sclbility to other integrted helth systems, Mtt Longjohn, MD, of the YMCA offered the following observtion (personl communiction, July 14, 2015) : The rpid trnsformtion of our helth cre system towrds ccountbility nd vlue indictes tht the collbortion between HSP nd the YMCA in Ohio will be n ttrctive model for clinicins, helth cre systems nd policy mkers to explore nd replicte. Limittions A key limittion of this current study is tht it ws n observtionl study nd not rndomized clinicl tril. The nlytic results were not intended to reflect n experimentl design. In future nd ongoing work s the progrm expnds, we will hve the opportunity to conduct more rigorous stepped-wedge or cluster rndomized tril, incorporting controls nd tking into ccount criticl fctors unobserved in the current nlysis (eg, selection, dropout, nd intent-to-tret nlysis). CONCLUSIONS The erlier DEPLOY study demonstrted tht the YMCA possesses both promising vehicle for the dissemintion of the DPP lifestyle intervention nd one tht is cost-effective. The present study indictes wht is possible in n integrted helth cre system with concentrted systemwide effort in reching nd engging those t risk of developing dibetes. Both HSP nd the YMCA embrced principles of mrketing in which mximum number of touches nd follow-up with potentil clients ws the key ingredient. Now tht the client hs been engged, it remins to be seen how long on verge ptients will persist in the lifestyle chnge tht hs been found to be effective. In our next effort together, HSP nd the YMCA re engging in pilot study focusing on mintennce of lifestyle chnge in the YMCA DPP prticipnts. We hve designed project, termed SISTERS, 24 which mkes use of vtrs in home setting to encourge exercise nd thus weight loss mintennce. We propose to enhnce our current cpitlintense, fcility-bsed cre delivery system with n in-home digitl helth-enbled obesity-cre delivery system, working in concert with the YMCA DPP. v Ntionl Helth Officer, YMCA of the USA, Chicgo, IL. Disclosure Sttement The uthor(s) hve no conflicts of interest to disclose. Acknowledgments The uthors would like to cknowledge Adm Perzynski, PhD; Mtt Longjohn, MD; nd John Boltri, MD, FAAFP for their ssistnce in the preprtion of this mnuscript. Kthleen Louden, ELS, of Louden Helth Communictions provided editoril ssistnce. How to Cite this Article Adms R, Hebert C, McVey L, Willims R. Implementtion of the YMCA Dibetes Prevention Progrm throughout n integrted helth system: A trnsltionl study. Perm J 2016 Fll;20(4): DOI: org/ /tpp/ References 1. Ntionl Center for Chronic Disese Prevention nd Helth Promotion; Division of Dibetes Trnsltion. Ntionl Dibetes Sttistics Report, Estimtes of Dibetes nd its Burden in the United Sttes [Internet]. 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5 Implementtion of the YMCA Dibetes Prevention Progrm throughout n Integrted Helth System: A Trnsltionl Study 2. Gerstein HC, Sntguid P, Rin P, et l. Annul incidence nd reltive risk of dibetes in people with vrious ctegories of dysglycemi: systemtic overview nd met-nlysis of prospective studies. Dibetes Res Clin Prct 2007 Dec;78(3): DOI: 3. Knowler WC, Brrett-Connor E, Fowler SE, et l; Dibetes Prevention Progrm Reserch Group. Reduction in the incidence of type 2 dibetes with lifestyle intervention or metformin. New Engl J Med 2002 Feb 7;346(6): DOI: 4. Dibetes Prevention Progrm Reserch Group; Knowler WC, Fowler SE, Hmmn RF, et l. 10-yer follow-up of dibetes incidence nd weight loss in the Dibetes Prevention Progrm Outcomes Study. Lncet 2009 Nov 14;34(9702): DOI: 5. The Dibetes Prevention Progrm. Design nd methods for clinicl tril in the prevention of type 2 dibetes. Dibetes Cre 1999 Apr;22(4): DOI: 6. Ackermnn RT, Finch EA, Brizendine E, Zhou H, Mrrero DG. Trnslting the Dibetes Prevention Progrm into the community. The DEPLOY Pilot Study. Am J Prev Med 2008 Oct;35(4): DOI: mepre YMCA s Dibetes Prevention Progrm [Internet]. Chicgo, IL: YMCA of the USA; 2016 [cited 2016 Apr 30]. Avilble from: 8. Tussing-Humphreys LM, Fitzgibbon ML, Kong A, Odoms-Young A. Weight loss mintennce in Africn Americn women: systemtic review of the behviorl lifestyle intervention literture. J Obes 2013;2013: DOI: org/ /2013/ Centers for Disese Control nd Prevention Dibetes Recognition Progrm: stndrds nd operting procedures [Internet]. Atlnt, GA: Centers for Disese Control nd Prevention; 2015 Jn 1 [cited 2016 Apr 12]. Avilble from: dibetes/prevention/pdf/dprp-stndrds.pdf. 10. Hmmn RF, Wing RR, Edelstein SL, et l. Effect of weight loss with lifestyle intervention on risk of dibetes. Dibetes Cre 2006 Sep;29(9): DOI: dx.doi.org/ /dc Ogden CL, Crroll MD, Curtin LR, McDowell MA, Tbk CJ, Flegl KM. Prevlence of overweight nd obesity in the United Sttes: JAMA 2006 Apr 5;295(13): DOI: Kumnyik SK. Obesity tretment in minorities. In: Wdden TA, Stunkrd AJ, editors. Hndbook of obesity tretment. New York, NY: The Guilford Press; p Krnj N, Stevens VJ, Hollis JF, Kumnyik SK. Steps to soulful living (steps): weight loss progrm for Africn-Americn women. Ethn Dis 2002 Summer;12(3): West DS, Eline Prewitt T, Bursc Z, Felix HC. Weight loss of blck, white, nd Hispnic men nd women in the Dibetes Prevention Progrm. Obesity (Silver Spring) 2008 Jun;16(6): DOI: DiClemente CC, Prochsk JO, Firhurst SK, Velicer WF, Velsquez MM, Rossi JS. The process of smoking cesstion: n nlysis of precontempltion, contempltion, nd preprtion stges of chnge. J Consult Clin Psychol 1991 Apr;59(2): DOI: Levinson JC, Adkins F, Forbes C. Guerrill mrketing for nonprofits. Irvine, CA: Entrepreneur Medi, Inc; Chou CH, Burnet DL, Meltzer DO, Hung ES. The effectiveness of dibetes prevention progrms in community settings [Internet]. New York, NY: New York Stte Helth Foundtion; 2015 Mr [cited 2015 Sep 8]. Avilble from: nyshelthfoundtion.org/uplods/resources/report-dibetes-prevention-in-communitysettings.pdf. 18. Fitzgibbon ML,Tussing-Humphries LM, Porter JS, Mrtin IK, Odems-Young A, Shrp LK. Weight loss nd Africn-Americn women: systemtic review of the behviorl weight loss intervention literture. Obes Rev 2012 Mr 13(3): Americn Dibetes Assocition. Economic Costs of Dibetes in the US in Dibetes Cre 2013 Apr; 36(4): US Deprtment of Helth nd Humn Services; Food nd Drug Administrtion; Center for Drug Evlution nd Reserch (CDER). Guidnce for industry: developing products for weight mngement. Drft guidnce [Internet]. Rockville, MD: Food nd Drug Administrtion; 2007 Feb [cited 2016 Sep 16]. Avilble from: downlods/drugs/.../guidnces/ucm pdf. 21. GoodRx Web site [Internet]. Snt Monic, CA: GoodRx, Inc; c2016 [cited 2015 Nov 3]. Avilble from: FDA pproves weight-mngement drug Sxend [Internet]. Silver Spring, MD: US Food nd Drug Administrtion; 2014 Dec 23 [cited 2016 Apr 8]. Avilble from: Mddox N. Profiles of n ging society: Dibetes. Wshington, DC: Gerontologicl Society of Americ; Perzynski A, McVey L, Murphy P, Willims RL. Non-immersive virtul relity gming to promote weight loss mngement mongst Africn-Americn women in the Dibetes Prevention Progrm: the SISTERS project. Poster presenttion t the 33rd Annul Scientific Meeting of the Obesity Society; 2015 Nov 2-7; Los Angeles, CA. Crbon in Ft Every crbon in ft is derived from sugr tht mn te or tht the cow te. Oil or ft is nothing more thn congeled cndy. Rchmiel Levine, MD, , physicin nd resercher in how insulin increses the body s use of blood sugrs 86 The Permnente Journl/Perm J 2016 Fll;20(4):15-241