Magnitude and determinants of psychological morbidities among pregnant women: Results from a pregnancy cohort in rural Central India.

Background: Psychological morbidities are one of the emerging global health problems. It affects a considerable number of ante-natal women leading to consequences during the postnatal period as well. We conducted this research to study the magnitude and determinants of psychological morbidities during pregnancy. Methods: In this study, we included 650 pregnant women from an established cohort of 2500 pregnant women and assessed the psychological morbidities among them using the GMHAT/PC tool. Results: The overall prevalence of psychological morbidities during pregnancy was 14.6%, with anxiety and depression being the leading ones. Low education levels, lower socio-economic status, unintended pregnancy, complicated previous pregnancy, lack of family and social support, and domestic violence increased the odds of psychological morbidity. On Multivariate logistic regression, Low education levels increased the odds to more than twice [illiterate/primary schooling OR: 4.00, p = 0.026; secondary schooling OR: 2.64, p = 0.034; high school OR: 2.60, p = 0.033] unintended pregnancy [OR: 1.91, p = 0.043] and lack of family support [OR: 7.19, p < 0.001] increased the odds of psychological morbidity among pregnant women. Conclusion: Bringing these issues to the mainstream and addressing them by developing interventions to address them during the lifecycle of a female will help to prevent episodes of psychological stress and morbidity among pregnant females.

Effectiveness of Japanese encephalitis vaccination among children in central India.

Japanese encephalitis (JE) disease among children continues in central India despite vaccination implemented in the routine immunization program. Therefore, we planned to estimate the JE vaccination effectiveness among children by undertaking a 1:2 individually-matched population-based case-control study from August 2018 to October 2020. The laboratory-confirmed JE cases aged 1-15 years were enrolled along with neighborhood controls without fever and encephalitis matched on the residence area, age and sex. The JE vaccination history was enquired from parents and verified independently from the vaccination cards available at home and records at health facilities. We enrolled 35 JE cases and 70 matched controls. The vaccination effectiveness of 86.7% (95% confidence interval [CI]: 30.8-94.7) was estimated on the per-protocol analysis of 31 case-control sets. The screening method provided an effectiveness of 89.5% (CI: 78.9-94.7) on using the population vaccination coverage of 90% reported earlier in the same area. In conclusion, JE vaccination offered a moderate level of protection among children in JE medium-endemic central India, similar to reports from high-endemic areas in India. The operational aspects of vaccination program implementation need to be evaluated to assess the impact of vaccination on the disease burden of JE in medium-endemic regions of India.

Coverage of Japanese encephalitis routine vaccination among children in Central India.

BACKGROUND: We aimed to estimate the coverage of Japanese encephalitis (JE) vaccination in central India to help explain the continued occurrence of JE disease despite routine vaccination. METHODS: We implemented a 30-cluster survey for estimating the coverage of JE vaccination in the medium-endemic areas implemented with JE vaccination in central India. The parents were enquired about the uptake of the JE vaccine by their children aged 2 to 6 years, followed by verification of the immunization cards at home along with reasons for non-vaccination. Vaccination coverage was reported as a percentage with 95% confidence intervals. RESULTS: We estimated high coverage of live-attenuated SA 14-14-2 JE vaccination in Maharashtra (94.8%, 95% CI 92.7-96.3) and Telangana (92.8%, 90.0-94.9). The vaccination card retention was 90.3% in Maharashtra and 70.4% in Telangana state. There were no gender differences in coverage in both states. A similar level of JE vaccination coverage was observed during the year 2013 to 2021 in both states. In Maharashtra, the maximum age-wise coverage was 96.6% in the >60 months age category, whereas in Telangana it was in the <24 months age category (97.2%). The timeliness of JE vaccination was appropriate and similar in both states. We found very good agreement between JE and Measles-Rubella vaccinations administered simultaneously. The reasons for non-vaccination were the shortage of vaccines and the parental migration for work. CONCLUSIONS: The coverage of Japanese encephalitis vaccination was high in medium-endemic regions in central India. Vaccination effectiveness studies may help further explain the continued incidence of Japanese encephalitis. This article is protected by copyright. All rights reserved.

Scrub typhus in urban areas of Wardha district in central India.

Background & objectives: Scrub typhus caused by Orientia tsutsugamushi presents as acute undifferentiated fever and can be confused with other infectious causes of fever. We studied scrub typhus as part of a study on hospital-based surveillance of zoonotic and vector-borne zoonotic diseases at a tertiary care hospital located in the Wardha district, Maharashtra, India. We report here descriptive epidemiology and climatic factors affecting scrub typhus. Methods: Patients of any age and sex with fever of ≥5 days were enrolled for this study. Data on sociodemographic variables were collected by personal interviews. Blood samples were tested by IgM ELISA to diagnose scrub typhus. Confirmation of scrub typhus was done by indirect immunofluorescence assay for IgM (IgM IFA). The climatic determinants were determined using time-series Poisson regression analysis. Results: It was found that 15.9 per cent of the study participants were positive for scrub typhus by IgM ELISA and IgM IFA, both. Positivity was maximum (23.0%) in 41-60 yr of age and more females were affected than males (16.6 vs. 15.5%). Farmworkers were affected more (23.6%) than non-farm workers (12.9%). The disease positivity was found to be high in monsoon and post-monsoon seasons (22.9 and 19.4%) than in summer and winter. Interpretation & conclusions: There were three hot spots of scrub typhus in urban areas of Wardha district. Rainfall and relative humidity in the previous month were the significant determinants of the disease.

Optimal Drug Regimen and Combined Drug Therapy and Its Efficacy in the Treatment of COVID-19: A Within-Host Modeling Study.

The COVID-19 pandemic has resulted in more than 524 million cases and 6 million deaths worldwide. Various drug interventions targeting multiple stages of COVID-19 pathogenesis can significantly reduce infection-related mortality. The current within-host mathematical modeling study addresses the optimal drug regimen and efficacy of combination therapies in the treatment of COVID-19. The drugs/interventions considered include Arbidol, Remdesivir, Interferon (INF) and Lopinavir/Ritonavir. It is concluded that these drugs, when administered singly or in combination, reduce the number of infected cells and viral load. Four scenarios dealing with the administration of a single drug, two drugs, three drugs and all four are discussed. In all these scenarios, the optimal drug regimen is proposed based on two methods. In the first method, these medical interventions are modeled as control interventions and a corresponding objective function and optimal control problem are formulated. In this framework, the optimal drug regimen is derived. Later, using the comparative effectiveness method, the optimal drug regimen is derived based on the basic reproduction number and viral load. The average number of infected cells and viral load decreased the most when all four drugs were used together. On the other hand, the average number of susceptible cells decreased the most when Arbidol was administered alone. The basic reproduction number and viral load decreased the most when all four interventions were used together, confirming the previously obtained finding of the optimal control problem. The results of this study can help physicians make decisions about the treatment of the life-threatening COVID-19 infection.

Social isolation, social support, and psychological distress among the elderly during the COVID-19 pandemic: A cross-sectional study from central India.

Background: In the present COVID-19 pandemic, social distancing measures have been advised to protect elderly from infection which might have led to poor mental health state. Objective: A cross-sectional study was carried out to assess the magnitude of social isolation, social support, and psychological distress among the elderly during the COVID-19 pandemic in Central India. Methods: The estimated sample size was 1535. The sample was equally distributed among rural, semiurban, and urban strata of districts. Social isolation was measured using Lubben's Social Network Scale-Revised, and psychological distress was assessed using Kessler K10 Psychological Distress Scale. Other parameters such as a history of COVID-19 illness and COVID-19 vaccination were assessed. Results: The prevalence of social isolation was higher at 23.6% during the COVID-19 pandemic compared to before the pandemic period (15.0%). The majority perceived a high level of social support during the pandemic (55.3%) and 39.9% received moderate support. Overall, 18.4% of the respondents had psychological distress. Out of them, 56.2% had mild distress, 20.1% had moderate distress, and 23.7% had severe distress. Significant predictors of psychological distress were female gender, lower socioeconomic status, history of COVID-19 disease among the participants, social isolation, and lack of social support. Conclusion: Social isolation and lack of social support were significant predictors of psychological distress among the elderly during the pandemic.

Why tuberculosis patients under revised national tuberculosis control programme delay in health-care seeking? A mixed-methods research from Wardha District, Maharashtra.

BACKGROUND: Timely treatment of tuberculosis is imperative for its control. This can get delayed due to delay in care seeking, diagnosis or treatment initiation. OBJECTIVES: The study aims to find out the magnitude of delays in care seeking, diagnosis or treatment initiation, and understand the reasons behind these delays in Wardha district of Maharashtra, India. METHODS: A mixed methods study was conducted among 275 patients selected from those enrolled under Revised National Tuberculosis Control Programme in 2014. We collected information regarding the duration of delays and generated a free list of reasons for delays in care seeking and diagnosis. The free list items were then subjected to pile sorting. Two-dimensional scaling and hierarchical clustering analysis were performed to identify the various domains of reasons for delays. RESULTS: The median delay in initial care seeking and diagnosis was 10 days each, and that for treatment initiation was 2 days. The domains identified for delay in care seeking were negligence toward health, health conditions, facility-related issues, and household and social reasons. The domains identified for delay in diagnosis were system-related reasons; and patient-related reasons, each of them further having two subdomains. CONCLUSIONS: Interventions for reducing the knowledge gap and stigma, increasing the accessibility of services, active case finding; capacity building of providers, quality assured sputum microscopy, and communication skills will help reduce these delays.

Functioning and time utilisation by female multi-purpose health workers in South India: a time and motion study.

BACKGROUND: Auxillary nurse midwives (ANMs) are the most important frontline multi-purpose workers in rural India. This study was conducted to assess the spectrum of service delivery, time utilisation, work planning, and factors affecting functioning of ANMs in South India. METHODS: We conducted a time and motion study in three districts across two states in South India. The districts selected in such a manner that they had a considerable tribal population. We conducted multi-stage sampling to select ANMs. We directly observed 43 ANMs consecutively for six working days and in-depth interviewed all selected ANMs, their supervisors, medical officers, and district health officials. We conducted an FGD to substantiate the findings from observations and interviews. Observation findings were analysed under three broad domains: (i) programme activities, (ii) programme support activities, and (iii) other work. Time spent was calculated in median (interquartile range, IQR) minutes/ANM per week or day. Qualitative data were coded and analysed using grounded theory, and appropriate themes and sub-themes were identified. RESULTS: ANMs worked for median 7 h a day (7:10 h, non-tribal; 6:20 h, tribal). There is variation in the hours of work, the pattern of service provided and time utilisation across days of a week. ANMs spent 60% of their on-job time on programmatic activities (median 22:38 h; IQR, 20:48-27:01 h) in a week. Emphasis is more on home visits, universal immunisation, antenatal care, school health, and seasonal diseases. ANMs spent negligible time on non-communicable diseases, adolescent health, nutrition, etc. ANMs spent the remaining time in program support activities, such as meetings with seniors, community meetings, and other non-health related work. There are no renewed job description, work plans, and supervision guidelines, even with newly added programs and tasks. ANMs prioritised work as per the priorities set by the supervisors and leaders. Health administration often disrupts the regular functioning of ANMs for training, meetings and other ad hoc work. CONCLUSION: ANMs are overworked; they often multi-task and fail to deliver efficiently. The administration needs to re-assess the workload. The administration may reduce expected work, provide strong supervisory support, and make conscious efforts to pose fewer disruptions in regular working of ANMs.

Time motion study using mixed methods to assess service delivery by frontline health workers from South India: methods.

BACKGROUND: In India, amidst the increasing number of health programmes, there are concerns about the performance of frontline health workers (FLHW). We assessed the time utilisation and factors affecting the work of frontline health workers from South India. METHODS: This is a mixed methods study using time and motion (TAM) direct observations and qualitative enquiry among frontline/community health workers. These included 43 female and 6 male multipurpose health workers (namely, auxiliary nurse midwives (ANMs) and male-MPHWs), 12 nutrition and health workers (Anganwadi workers, AWWs) and 53 incentive-based community health workers (accredited social health activists, ASHAs). We conducted the study in two phases. In the formative phase, we conducted an in-depth inductive investigation to develop observation checklists and qualitative tools. The main study involved deductive approach for TAM observations. This enabled us to observe a larger sample to capture variations across non-tribal and tribal regions and different health cadres. For the main study, we developed GPRS-enabled android-based application to precisely record time, multi-tasking and field movement. We conducted non-participatory direct observations (home to home) for consecutively 6 days for each participant. We conducted in-depth interviews with all the participants and 33 of their supervisors and relevant officials. We conducted six focus group discussions (FGDs) with ASHAs and one FGD with ANMs to validate preliminary findings. We established a mechanism for quality assurance of data collection and analysis. We analysed the data separately for each cadre and stratified for non-tribal and tribal regions. RESULTS: On any working day, the ANMs spent median 7:04 h, male-MPHWs spent median 5:44 h and AWWs spent median 6:50 h on the job. The time spent on the job was less among the FLHWs from tribal areas as compared to those from non-tribal areas. ANMs and AWWs prioritised maternal and child health, while male-MPHWs were involved in seasonal diseases and school health. ASHAs visited homes to provide maternal health, basic curative care, and follow-up of tuberculosis patients. The results describe issues related with work planning, time management and several systemic, community-based and personnel factors affecting work of FLHWs. CONCLUSION: TAM study with mixed methods can help researchers as well as managers to periodically review work patterns, devise appropriate job responsibilities and improve the efficiency of health workers.

Determinants of adverse treatment outcomes among patients treated under Revised National Tuberculosis Control Program in Wardha, India: Case-control study.

BACKGROUND: Tuberculosis (TB) leads to a considerable loss of lung functions and Quality Adjusted Life Years. Several factors are associated with adverse treatment outcomes from TB which further increases this loss. We undertook the study to study the determinants of adverse treatment outcomes among tuberculosis patients treated under the Revised National Tuberculosis Control Program in a tuberculosis unit in India. METHODS: 88 cases and 187 controls from among patients registered in Wardha Tuberculosis Unit in the year 2014 were interviewed to study the determinants of adverse treatment outcomes of tuberculosis. All patients with adverse treatment outcomes were taken as cases. Controls were chosen from relapse free successfully treated patients using simple random sampling. RESULTS: On multivariate analysis indoor air pollution, pulmonary TB, discrimination due to TB and poor satisfaction with services significantly increased the odds of adverse treatment outcomes whereas the senior treatment supervisor visiting the patients during treatment was protective. CONCLUSION: Appropriate new interventions and strengthening of the existing mechanisms to reduce treatment interruptions along with proper implementation of the program will help in reducing the adverse treatment outcomes and improving program performance.

How "Elderly Staying Alone" Cope Up with their Age and Deteriorating Health: A Qualitative Exploration from Rural Wardha, Central India.

BACKGROUND: This study is done to explore the various changes and problems faced by the "elderly people staying alone" and how they cope up to maintain their life amidst the physical, familial, social, and financial crisis in their lives. MATERIALS AND METHODS: This qualitative study was carried out in the villages surrounding Bhidi Rural Health and Training Center, located in the Vidarbha region of Maharashtra. A triangulation of free listing and pile sorting exercise was used. Elderly >65 years of age of either sex, living alone in their own houses, for at least 2 years were included in the study. Twenty-four such individuals were selected purposively who could figure out the different words and concepts regarding the three domains of our study for the purpose of line listing, namely, change of life since staying alone, problems faced while staying alone, and how they cope up with the problem of living alone. The data were analyzed using Anthropac software. The study findings were presented to the participants, who later pointed out few recommendations to be made. RESULTS: The "elderly staying alone" face the problems of lack of family, social, and financial support in their day-to-day life. They cope with these problems by a number of ways. Although there are a number of government schemes to protect the elderly, none of these policies are dedicated to this special group of elderlies. CONCLUSION: There is no social structure that can take care of this vulnerable group of elderlies in rural India. It is high time for the government to step in to bring some societal and familial reforms that will safeguard the elderly staying alone from the ongoing familial, social, and financial hardship.

Socio-demographic determinants of out-of-pocket health expenditure in a rural area of Wardha district of Maharashtra, India.

Background & objectives: In India, health expenditure accounts for less than 5 per cent of the Gross Domestic Product and the level of out-of-pocket (OOP) spending is 69.5 per cent of total health expenditures. OOP expenditure exacerbates poverty and has a negative impact on equity and can increase the risk of vulnerable groups slipping into poverty. This study was conducted to estimate the OOP expenditure on health and catastrophic health expenditure and their socio-demographic determinants in a rural area of Maharashtra, India. Methods: This was a prospective observational study involving monthly follow up visits, done in 180 households of three villages under a primary health centre in Wardha district, India. Results: Of the 180 families, 18.9 per cent had catastrophic health expenditure over a period of one year. The median total out-of-pocket health expenditure was '1105.00 with median medical expenditure being '863.85 and median non-medical health expenditure being '100.00. A total of 151 (83.9%) had enough money, 27 (15%) borrowed money and two (1.1%) of them sold assets. The significant correlates for the ratio of out-of-pocket health expenditure to total annual income of the family were the occupation of head of family, caste category and type of village. The significant correlate for catastrophic health expenditure was type of village. Interpretation & conclusions: Around one-fifth of the households had catastrophic health expenditure. People with no healthcare facility located in their village had higher odds of having catastrophic health expenditure. Private providers were preferred for the treatment of acute illnesses and medical college hospitals for hospitalization.

Asymptomatic Presentation of Large Cardiac Hydatid.

Hydatid cyst is a tissue parasitic infection caused by tapeworm Echinococcus granulosus. Common location for hydatid cysts are the liver (65%) and the lungs (25%). Cardiac hydatid cyst is seen rarely, occurring in about 0.5-2% of all cases of hydatid disease. We present this case of 45 years female who presented with short duration of dry cough and atypical chest pain. Chest X ray showed cardiomegaly with round bulge at the right heart border and curvilinear calcification in left upper abdomen in the region of spleen. Transthoracic echocardiography (TTE) depicted cystic lesion in Right Ventricle free wall causing compression of right atrial and ventricular cavity. Cardiac CT confirmed this cyst as hydatid cyst. Patient underwent successful excision of right ventricular hydatid cyst.

Heart Failure and the Iron Deficiency.

Iron deficiency anemia is a significant problem worldwide and more so in developing countries, like India. The prevention and treatment of iron deficiency is a major public health goal in India It is now well recognized that iron deficiency has detrimental effects in patients with coronary artery disease, heart failure, and pulmonary hypertension, and possibly in patients undergoing cardiac surgery. Around one-third of all patients with HF, and around one-half of patients with pulmonary hypertension, are affected by iron deficiency.1.

Catheter Assisted Management of Massive Pulmonary Embolism.

Pulmonary thromboembolism is common and missed by clinicians. We report a case of massive pulmonary embolism which was life threatening treated by the catheter assisted technique. Anticoagulation is the mainstay of therapy for most patients, with thrombolytic therapy reserved for some patients.1 Recent studies have suggested a role for systemic or catheter-directed thrombolytic therapy in selected patients.2 We present a case of a patient who presented with an PE, was successfully treated with catheter-directed thrombolysis.

Asymptomatic Presentation of Large Cardiac Ball.

A 45 years female presented with short duration of dry cough and atypical chest pain. Chest X ray showed cardiomegaly with a bulge at the right heart border and curvilinear calcification in left upper abdomen. Transthoracic echocardiography (TTE) revealed a cystic lesion in the right ventricle free wall causing compression of right atrial and ventricular cavity. Cardiac CT confirmed this cyst as hydatid cyst. Patient underwent successful excision of right ventricular hydatid cyst.

Prevalence and determinants of self-reported chronic bronchitis among women in rural Central India.

BACKGROUND: Chronic respiratory conditions are increasingly becoming a cause of health concern with India attributing 11% of its mortality due to non-communicable diseases to chronic respiratory conditions. Chronic bronchitis and asthma take a large toll in terms of morbidity. Lesser number of studies have mentioned their counts of these conditions affecting women in rural area and therefore the present study was conducted with the objectives of determining the prevalence and correlates of chronic obstructive pulmonary diseases (COPD) in an area of a primary health centre in rural central India. METHODS: A cross-sectional study was conducted in 24 villages of the study area. Women aged 40 years or more were interviewed using the IUATLD questionnaire. Chronic bronchitis was measured by using the standard criteria for chronic bronchitis, that is, "Presence of cough with expectoration for more than 3 months in a year for the past two or more years". RESULTS: Prevalence of chronic bronchitis among women was found to be 2.7%. Factors like older age, presence of a cattle shed within house premises, storage of fertilizers inside house, history of allergy, past history of pulmonary tuberculosis emerged as significant correlates of chronic bronchitis. CONCLUSIONS: The present study provides an insight into the prevalence of chronic bronchitis among rural women exposed to several epidemiological determinants and an opportunity to address the modifiable risk factors.

Role of social, cultural and economic capitals in perceived quality of life among old age people in kerala, India.

OBJECTIVE: To find out the relationship of collective social, economic, and cultural properties of a population on the perceived quality of life (QOL) among old age people. MATERIALS AND METHODS: In a community-based cross-sectional study, we analyzed information on a representative sample of 900 old age (aged > 60 years) from 28 villages in Kollam district of Kerala. WHO-Quality of Life - BREF questionnaire was used. Ethical clearance from Institutional Ethics Committee was obtained. The mean scores for perceived QOL for domains such as physical health, psychological health, social relations, and control of environments were calculated. The three scales (social capital, cultural capital, and economic capital) were standardized using z-score transformation to make them comparable. Using multiple linear regression, we calculated the independent effect of economic capital, social capital, and cultural capital on perceived QOL among old people adjusted for age, sex, and the presence of chronic disease. RESULTS: For overall QOL, only cultural capital contributed significantly. An increase of one unit z-score cultural capital led to three units increase in overall QOL score (ß = 3.362; 95% CI: 2.645-4.078). Social capital and cultural capital contributed significantly to the physical health domain of QOL. With one z-score increase in social capital and cultural capital, QOL score of physical health domain increased by 0.2 units (ß = 0. 227; 95% CI: 0.020-0.434), and 0.5 (ß = 0. 596; 95% CI: 0.384-0.808) units, respectively. Psychological health domain and environmental domain were affected by all three capitals significantly. But, the social relations domain was significantly affected only by cultural capital (ß = 0. 576; 95% CI: 0.373-0.779). CONCLUSION: Hence, the policies for old people should envision retaining our cultural and social norms along with the economic interventions for a better palliative care.

Epidemiology of injuries in rural Wardha, central India.

Injury is a major public health problem in India. As very few studies are available from rural areas, hence the present study was carried out to study the epidemiology of injuries in the rural areas of Maharashtra. A cross-sectional study was carried out in Primary Health Centres (PHC) of a district in Maharashtra. 4790 subjects were studied using a two stage sampling technique. During last one year, 19.0% (95% CI: 17.7%-19.9%) had at least one injury. Majority of injuries (94.0%) were unintentional while assault and suicide related injuries were 37 (4.1%) and 10 (1.1%) respectively. Age, sex, education, occupation and socio-economic status were significantly associated with injuries.

Effect of a two-only-meals-a-day and exercise lifestyle on HbA1c and anti-diabetic medication in a follow-up study of subjects with type 2 diabetes attending a free clinic in a north Maharashtra city.

Background: Type 2 Diabetes (T2D) is a global challenge with rising prevalence, inadequate compliance, and poor outcomes. Aims: Assess the effect of a 2-only-daily-meals with exercise lifestyle (2-OMEX) on (a) HbA1c, (b) anti-diabetic medication count (ADMC), (c) Kcal intakes, body weight, fasting insulin, and subjective well-being. Materials and Methods: This is a single-arm follow-up study conducted in a free 2-OMEX clinic in 2019-2020. Information for two meals and exercise compliance was obtained during the clinic visit. HbA1c was tested by HPLC and fasting insulin by the CLIA/CMIA method in private laboratories. Results: Eligible subjects (f = 49, m = 116) completing two or more visits and 60 days of follow-up had a mean age of 55.92 (10.43) years, a T2D duration of 8.20 (6.28) years, and a median observation period of 140 days. Statistically significant changes included HbA1c decline from 7.69 (1.70) to 7.00 (1.20) gm% (equivalent by the LogNormal method to 1.088 gm%), average weight loss at 5%(m), and 2%(f). ADMC declined from 2.32 to 2.14, the difference being significant with the WSR test (z = 2.0087, P = 0.0223). Subjects attaining anti-diabetic medication-free and normoglycemic status (HbA1c < 6.5 gm%) were 20 (12%). The number attaining HbA1c ≤ 7 gm%) significantly rose from 73 (44%) to 101 (61%) with an ADMC of 1.9 (chi-square = 9.531, df1, P = 0.0020203). Participants reported 'feeling energetic' (79%), feeling lighter (50%), and better sleep (35%). Average energy intakes dropped by 120 Kcal to 1580/day. Fasting insulin remained unchanged, from 12.61 (11.06) to 12.34 (11.78) mlU/L. The dropout rate was 35%. Conclusions: The 2-OMEX lifestyle showed a sizeable, favorable, and significant change in HbA1c, body weight, ADMC use in five months, and subjective benefits. Studies are necessary for remission impact and pathways.