National Health Expenditure Projections, 2023-32: Payer Trends Diverge As Pandemic-Related Policies Fade.

Health care spending growth is expected to outpace that of the gross domestic product (GDP) during the coming decade, resulting in a health share of GDP that reaches 19.7 percent by 2032 (up from 17.3 percent in 2022). National health expenditures are projected to have grown 7.5 percent in 2023, when the COVID-19 public health emergency ended. This reflects broad increases in the use of health care, which is associated with an estimated 93.1 percent of the population being insured that year. In 2024, Medicaid enrollment is projected to decline significantly as states continue their eligibility redeterminations. Simultaneously, private health insurance enrollment is projected to increase because of the extension of enhanced subsidies for direct-purchase health insurance under the Inflation Reduction Act (IRA) of 2022, as well as a temporary special enrollment period for qualified people losing Medicaid coverage (after eligibility redeterminations). Over the course of 2024-26, the IRA expands Medicare's drug benefit generosity and implements drug price negotiations for beneficiaries; concurrently, the extended enhanced subsidies for direct-purchase health insurance expire in 2026. During 2027-32, personal health care price inflation and growth in the use of health care services and goods contribute to projected health spending that grows at a faster rate than the rest of the economy.

Early Cold Stored Platelet Transfusion Following Severe Injury: A Randomized Clinical Trial.

OBJECTIVE: To determine the feasibility, efficacy, and safety of early cold stored platelet transfusion compared with standard care resuscitation in patients with hemorrhagic shock. BACKGROUND: Data demonstrating the safety and efficacy of early cold stored platelet transfusion are lacking following severe injury. METHODS: A phase 2, multicenter, randomized, open label, clinical trial was performed at 5 US trauma centers. Injured patients at risk of large volume blood transfusion and the need for hemorrhage control procedures were enrolled and randomized. The intervention was the early transfusion of a single apheresis cold stored platelet unit, stored for up to 14 days versus standard care resuscitation. The primary outcome was feasibility and the principal clinical outcome for efficacy and safety was 24-hour mortality. RESULTS: Mortality at 24 hours was 5.9% in patients who were randomized to early cold stored platelet transfusion compared with 10.2% in the standard care arm (difference, -4.3%; 95% CI, -12.8% to 3.5%; P =0.26). No significant differences were found for any of the prespecified ancillary outcomes. Rates of arterial and/or venous thromboembolism and adverse events did not differ across treatment groups. CONCLUSIONS AND RELEVANCE: In severely injured patients, early cold stored platelet transfusion is feasible, safe and did not result in a significant lower rate of 24-hour mortality. Early cold stored platelet transfusion did not result in a higher incidence of arterial and/or venous thrombotic complications or adverse events. The storage age of the cold stored platelet product was not associated with significant outcome differences. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04667468.

Recommendations for laboratory workflow that better support centralised amalgamation of genomic variant data: findings from CanVIG-UK national molecular laboratory survey.

BACKGROUND: National and international amalgamation of genomic data offers opportunity for research and audit, including analyses enabling improved classification of variants of uncertain significance. Review of individual-level data from National Health Service (NHS) testing of cancer susceptibility genes (2002-2023) submitted to the National Disease Registration Service revealed heterogeneity across participating laboratories regarding (1) the structure, quality and completeness of submitted data, and (2) the ease with which that data could be assembled locally for submission. METHODS: In May 2023, we undertook a closed online survey of 51 clinical scientists who provided consensus responses representing all 17 of 17 NHS molecular genetic laboratories in England and Wales which undertake NHS diagnostic analyses of cancer susceptibility genes. The survey included 18 questions relating to 'next-generation sequencing workflow' (11), 'variant classification' (3) and 'phenotypical context' (4). RESULTS: Widely differing processes were reported for transfer of variant data into their local LIMS (Laboratory Information Management System), for the formatting in which the variants are stored in the LIMS and which classes of variants are retained in the local LIMS. Differing local provisions and workflow for variant classifications were also reported, including the resources provided and the mechanisms by which classifications are stored. CONCLUSION: The survey responses illustrate heterogeneous laboratory workflow for preparation of genomic variant data from local LIMS for centralised submission. Workflow is often labour-intensive and inefficient, involving multiple manual steps which introduce opportunities for error. These survey findings and adoption of the concomitant recommendations may support improvement in laboratory dataflows, better facilitating submission of data for central amalgamation.

National Health Expenditure Projections, 2022-31: Growth To Stabilize Once The COVID-19 Public Health Emergency Ends.

National health expenditures are projected to grow 5.4 percent, on average, over the course of 2022-31 and to account for roughly 20 percent of the economy by the end of that period. The insured share of the population is anticipated to exceed 92 percent through 2023, in part as a result of record-high Medicaid enrollment, and then decline toward 90 percent as coverage requirements related to the COVID-19 public health emergency expire. The prescription drug provisions of the Inflation Reduction Act of 2022 are anticipated to lower out-of-pocket spending for Medicare Part D enrollees beginning in 2024 and to result in savings to Medicare beginning in 2031.

Call to action: equity, diversity, and inclusion in emergency medicine resident physician selection.

OBJECTIVES: This call to action seeks to improve emergency care in Canada for equity-deserving communities, enabled by equitable representation among emergency physicians nationally. Specifically, this work describes current resident selection processes and makes recommendations to enhance the equity, diversity, and inclusion (EDI) of resident physician selection in Canadian emergency medicine (EM) residency programs. METHODS: A diverse panel of EM residency program directors, attending and resident physicians, medical students, and community representatives met monthly from September 2021 to May 2022 via videoconference to coordinate a scoping literature review, two surveys, and structured interviews. This work informed the development of recommendations for incorporating EDI into Canadian EM resident physician selection. At the 2022 Canadian Association of Emergency Physicians (CAEP) Academic Symposium, these recommendations were presented to symposium attendees composed of national EM community leaders, members, and learners. Attendees were divided into small working groups to discuss the recommendations and address three conversation-facilitating questions. RESULTS: Symposium feedback informed a final set of eight recommendations to promote EDI practices during the resident selection process that address recruitment, retention, mitigating inequities and biases, and education. Each recommendation is accompanied by specific, actionable sub-items to guide programs toward a more equitable selection process. The small working groups also described perceived barriers to the implementation of these recommendations and outlined strategies for success that are incorporated into the recommendations. CONCLUSION: We call on Canadian EM training programs to implement these eight recommendations to strengthen EDI practices in EM resident physician selection and, in doing so, help to improve the care that patients from equity-deserving groups receive in Canada's emergency departments (EDs).

ABSTRAIT: OBJECTIFS: Cet appel à l'action vise à améliorer les soins d'urgence au Canada pour les collectivités méritant l'équité, grâce à une représentation équitable parmi les médecins d'urgence à l'échelle nationale. Plus précisément, ce travail décrit les processus actuels de sélection des médecins résidents et formule des recommandations pour améliorer l'équité, la diversité et l'inclusion (EDI) de la sélection des médecins résidents dans les programmes de résidence en médecine d'urgence (SE) du Canada. MéTHODES: Un groupe diversifié de directeurs du programme de résidence en GU, de médecins résidents, d'étudiants en médecine et de représentants communautaires se sont réunis mensuellement de septembre 2021 à mai 2022 par vidéoconférence pour coordonner une analyse documentaire, deux sondages et des entrevues structurées. Ces travaux ont orienté l'élaboration de recommandations pour l'intégration de l'IDE dans la sélection des médecins résidents en SE au Canada. À l'occasion du Symposium universitaire 2022 de l'Association canadienne des médecins d'urgence (ACMU), ces recommandations ont été présentées aux participants au symposium composé de dirigeants, de membres et d'apprenants de la communauté nationale de la GU. Les participants ont été divisés en petits groupes de travail pour discuter des recommandations et aborder trois questions facilitant la conversation. RéSULTATS: Les commentaires recueillis lors du symposium ont servi à formuler une dernière série de huit recommandations visant à promouvoir les pratiques de l'IDE au cours du processus de sélection des résidents qui traitent du recrutement, du maintien en poste, de l'atténuation des inégalités et des préjugés, et de l'éducation. Chaque recommandation est accompagnée de sous-éléments précis et réalisables pour orienter les programmes vers un processus de sélection plus équitable. Les petits groupes de travail ont également décrit les obstacles perçus à la mise en œuvre de ces recommandations et décrit les stratégies de réussite qui sont intégrées aux recommandations. CONCLUSION: Nous demandons aux programmes canadiens de formation en GU de mettre en œuvre ces huit recommandations afin de renforcer les pratiques d'IDE dans la sélection des médecins résidents en GU et, ce faisant, d'aider à améliorer les soins que les patients des groupes méritant l'équité reçoivent dans les services d'urgence du Canada.

Implementation of an Assault Prevention Quality Improvement Initiative in an Urban Emergency Department.

BACKGROUND: Emergency department (ED) health care workers experience high rates of workplace violence (WPV). LOCAL PROBLEM: Patient-to-staff physical assaults at an urban, academic adult ED ranged between 1 and 5 per month, with a rate of 0.265 per 1000 patient visits. METHODS: A quality improvement initiative, guided by the Social Ecological Model framework that contextualized WPV in the ED setting, informed the development of a Risk for Violence Screening Tool (RVST) to screen adult patients presenting to the ED. INTERVENTIONS: Plan-Do-Study-Act cycles were utilized to implement a violence prevention bundle that incorporated the RVST, an alert system, and focused assault reduction strategies. RESULTS: Patient-to-staff physical assaults decreased to a rate of 0.146 per 1000 patient visits. CONCLUSIONS: Risk for violence screening, an alert system, and assault prevention strategies provide opportunities for nurse leaders to promote ED workplace safety.

A systematic review of U.S. nursing faculty's knowledge, awareness, inclusion, and perceived importance of sexual and gender minority-related content in nursing curricula.

BACKGROUND: In the US, sexual and gender minority (SGM) individuals continue to experience health inequities, and nursing curricula content and nursing faculty with SGM health expertise in the US remain limited. Addressing health disparities begins with the preparation of future nurses-US nursing faculty must be supported to meet these growing needs. PURPOSE: To describe, appraise, and synthesize research from 2000-2020 on US nursing faculty knowledge, awareness, inclusion, and perceived importance of SGM health content. METHODS: Following PRISMA 2020 guidelines, we registered a systematic review and appraisal protocol in PROSPERO, and then executed the protocol and synthesized the literature. DISCUSSION: We found an empirical evidence base surrounding US nursing faculty and SGM health much more limited than expected. Only four cross-sectional, descriptive empirical articles fit the a priori inclusion criteria. The studies were of moderate quality at best and often relied on unvalidated or older measures. In general, the studies focused on examining characteristics of nursing programs, faculty comfort with content, faculty perceptions of content importance, and hours dedicated to content. CONCLUSION: Since the close of the review, new commentaries and editorials expanding the call for change in the US were published-the time for commentary has passed. It remains unclear whether US nursing faculty are adequately prepared to educate future nurses about SGM health issues-and an unprepared healthcare workforce is yet another barrier to SGM health equity. The evidence base supporting US nursing faculty development desperately needs more studies using rigorous methodologies.

Nursing pre-licensure and graduate education for LGBTQ health: A systematic review.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer plus (LGBTQ) people experience discrimination and health disparities compared to heterosexual cisgender people. Clinicians report discomfort and insufficient preparation for providing care to LGBTQ people and nursing has been slow to integrate LGBTQ health into curricula. PURPOSE: Conduct a systematic review to examine and critically appraise peer-reviewed literature on nursing student knowledge, skills, and attitudes (KSAs) regarding LGBTQ health and the development/evaluation of LGBTQ health content in nursing curricula. METHODS: A systematic review was conducted (N = 1275 articles from PubMed, LGBT Health, CINAHL, ERIC, and Health Source-Nursing/Academic Edition). FINDINGS: Twenty articles met inclusion criteria. Twelve studies described curricular interventions; however, there were few validated tools to evaluate content coverage or KSAs. Four themes emerged specific to LGBTQ health content inclusion. DISCUSSION: While an emerging science of LGBTQ nursing education has been identified, more work is needed to build and evaluate a comprehensive curricular approach for full programmatic integration of LGBTQ health. CONCLUSION: As nursing programs build LGBTQ content into nursing curricula, care must be taken to integrate this content fully with the depth of curricular content in population health, social determinants of health, social justice, intersectionality, cultural competence, and political advocacy. TWEETABLE ABSTRACT: Greater integration of LGBTQ health content into nursing education should be a priority for nursing education.

Scoping review: Diagnostic reasoning as a component of clinical reasoning in the U.S. primary care nurse practitioner education.

AIMS: Diagnostic Reasoning (DR) is an essential competency requiring mastery for safe, independent Nurse Practitioner (NP) practice, but little is known about DR content included in NP education programs. The aims of this study were to identify whether and how the concept of DR is addressed in NP education. DESIGN: We conducted a scoping review on DR-related content and teaching innovations in U.S. primary care NP education programs, with implications for NP education programs worldwide. Concepts and principles with global applicability include: conducting focused and hypothesis-directed histories and exams, generating the problem statement, formulating the differential diagnosis, appropriate and relevant diagnostic testing, determining the working diagnosis and developing evidence-based, patient-centred management plans. DATA SOURCES: N = 1115 articles retrieved from Medline, Embase, PsycINFO, and CINAHL for the period 2005-2021. Forty-one scholarly articles met inclusion/exclusion criteria. REVIEW METHODS: Data were extracted, synthesized and grouped by theoretical frameworks, content included, educational interventions and assessment measures. RESULTS: Most articles provided descriptions of approaches for teaching NP clinical or diagnostic reasoning. Ten papers directly referenced the current science and theory of DR. CONCLUSION: The US NP education literature addressing DR is limited and demonstrates a lack of shared conceptualizations of DR. Whilst numerous components of DR are identifiable in the literature, a robust teaching/learning scholarship for DR has not yet been established in the US NP education literature. IMPACT: Whilst primary care NP education programs are beginning to incorporate DR education into their curricula, little research has been conducted to demonstrate the effectiveness of educational outcomes. Increased integration of DR content into NP education is needed, including increased educational research on teaching DR competencies. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution was included in this review, as the public is generally not familiar with DR or its teaching approaches.

Abnormal urinary loss of vitamin C in diabetes: prevalence and clinical characteristics of a vitamin C renal leak.

BACKGROUND: Diabetes is associated with low plasma vitamin C concentrations. OBJECTIVES: We investigated the contribution of dysregulated vitamin C renal physiology, its prevalence, and associated clinical characteristics. METHODS: An essential prerequisite was determination of normal vitamin C renal threshold, the plasma concentration at which vitamin C first appears in urine. Using data from 17 healthy participants who underwent vitamin C depletion-repletion studies with a vitamin C dose range of 15-1250 mg daily, renal threshold was estimated using physiology-based pharmacokinetics modeling. Applying renal threshold 95% CIs, we estimated the minimal elimination threshold, the plasma concentration below which no vitamin C was expected in urine of healthy people. Renal leak was defined as abnormal presence of vitamin C in urine with plasma concentrations below the minimal elimination threshold. Criteria were tested in a cross-sectional cohort study of individuals with diabetes (82) and nondiabetic controls (80) using matched plasma and urine samples. RESULTS: Vitamin C renal thresholds in healthy men and women were [mean (SD)] 48.5 (5.2) µM and 58.3 (7.5) µM, respectively. Compared with nondiabetic controls, participants with diabetes had significantly higher prevalence of vitamin C renal leak (9% compared with 33%; OR: 5.07; 95% CI: 1.97, 14.83; P < 0.001) and 30% lower mean plasma vitamin C concentrations (53.1 µM compared with 40.9 µM, P < 0.001). Fasting plasma glucose, glycosylated hemoglobin A1c, BMI, micro/macrovascular complications, and protein/creatinine ratio were predictive of vitamin C renal leak. CONCLUSIONS: Increased prevalence of vitamin C renal leak in diabetes is associated with reduced plasma vitamin C concentrations. Glycemic control, microvascular complications, obesity, and proteinuria are predictive of renal leak.

How can the nursing profession help reduce sexual and gender minority related health disparities: Recommendations from the National Nursing LGBTQ Health Summit.

BACKGROUND: Lesbian, gay, bisexual, transgender and queer (LGBTQ) people, also commonly referred to as sexual and gender minorities (SGMs), live in every part of the United States and encompass all races and/or ethnicities, religions, and social classes. Major reports from various sources document higher rates of health issues (e.g., substance abuse, depression, suicidality, cardiovascular disease) among SGMs than heterosexuals. Chronic stress related to marginalization and discrimination is a key contributor to these disparities. The nursing profession has paid relatively little attention to SGM health issues. PURPOSE AND METHODS: To address these gaps, the first National Nursing LGBTQ Health Summit brought together nursing deans, leaders of national nursing organizations, and other participants from across the United States. FINDINGS: Participants agreed that increasing SGM-specific content in nursing curricula, practice guidelines, faculty development, and research is necessary to improve the health of SGM people. DISCUSSION: The Summit ended with a call to action for the nursing profession to prioritize SGM health through innovations in education, research, and practice.

National Health Expenditure Projections, 2021-30: Growth To Moderate As COVID-19 Impacts Wane.

Although considerable uncertainty remains, the COVID-19 pandemic and public health emergency are expected to continue to influence the near-term outlook for national health spending and enrollment. National health spending growth is expected to have decelerated from 9.7 percent in 2020 to 4.2 percent in 2021 as federal supplemental funding was expected to decline substantially relative to 2020. Through 2024 health care use is expected to normalize after the declines observed in 2020, health insurance enrollments are assumed to evolve toward their prepandemic distributions, and the remaining federal supplemental funding is expected to wane. Economic growth is expected to outpace health spending growth for much of this period, leading the projected health share of gross domestic product (GDP) to decline from 19.7 percent in 2020 to just over 18 percent over the course of 2022-24. For 2025-30, factors that typically drive changes in health spending and enrollment, such as economic, demographic, and health-specific factors, are again expected to primarily influence trends in the health sector. By 2030 the health spending share of GDP is projected to reach 19.6 percent.

Education about sexual and gender minorities within Canadian emergency medicine residency programs.

OBJECTIVES: The CAEP 2021 2SLGBTQIA +i panel sought whether a gap exists within Canadian emergency medicine training pertaining to sexual and gender minority communities. This panel aimed to generate practical recommendations on improving emergency medicine education about sexual and gender minorities, thereby improving access to equitable healthcare. METHODS: From August 2020 to June 2021, a panel of emergency medicine practitioners, residents, students, and community representatives met monthly via videoconference. A literature review was undertaken, and three mixed methods surveys were distributed to the CAEP member list, CAEP Resident Section, College of Family Physicians of Canada (CFPC)iii Emergency Medicine Members Interest Group, and to emergency medicine residency program directors and their residents. Informed by the review and surveys, recommendations were drafted and refined by panel members before presentation at the 2021 CAEP Academic Symposium. A plenary was presented to symposium attendees composed of national emergency medicine community members, which reported the survey results and literature review. All attendees were divided into small groups to develop an action plan for each recommendation. CONCLUSIONS: The panel outlines eight recommendations for closing the curricular gap. It identifies three perceived or real barriers to the inclusion of sexual and gender minority content in emergency medicine residency curricula. It acknowledges three enabling recommendations that are beyond the scope of individual emergency medicine programs or emergency departments (EDs), that if enacted would enable the implementation of the recommendations. Each recommendation is accompanied by two action items as a guide to implementation. Each of the three barriers is accompanied by two action items that offer specific solutions to overcome these obstacles. Each enabling recommendation suggests an action that would shift emergency medicine towards sociocultural competence nationally. These recommendations set the primary steps towards closing the educational gap.

RéSUMé: OBJECTIFS: Le panel ACMU 2021 2SLGBTQIA+ i a cherché à savoir s'il existe une lacune dans la formation en médecine d'urgence au Canada en ce qui concerne les communautés de minorités sexuelles et de genre. Ce panel visait à générer des recommandations pratiques sur l'amélioration de l'éducation en médecine d'urgence sur les minorités sexuelles et de genre, améliorant ainsi l'accès à des soins de santé équitables. MéTHODES: D'août 2020 à juin 2021, un groupe de praticiens en médecine d'urgence, de résidents, d'étudiants et de représentants communautaires se sont réunis chaque mois par vidéoconférence. Une revue de la littérature a été entreprise et trois enquêtes à méthodes mixtes ont été distribuées à la liste des membres de l'ACMU, à la Section des résidents de l'ACMU, au Groupe d'intérêt des membres en médecine d'urgence du Collège des médecins de famille du Canada (CMFC) iii, ainsi qu'aux directeurs des programmes de résidence en médecine d'urgence et à leurs résidents. À la lumière de l'examen et des sondages, les recommandations ont été rédigées et peaufinées par les membres du comité avant d'être présentées au Symposium universitaire de l'ACMU de 2021. Une séance plénière a été présentée aux participants du symposium, composés de membres de la communauté nationale de la médecine d'urgence, qui ont fait état des résultats du sondage et de la revue de la littérature. Tous les participants ont été répartis en petits groupes afin d'élaborer un plan d'action pour chaque recommandation. CONCLUSIONS: Le groupe d'experts formule huit recommandations pour combler le fossé entre les programmes d'enseignement. Il identifie trois obstacles perçus ou réels à l'inclusion du contenu sur les minorités sexuelles et de genre dans les programmes de résidence en médecine d'urgence. Il reconnaît trois recommandations habilitantes qui dépassent la portée des programmes de médecine d'urgence individuels ou des services d'urgence (SU) et qui, si elles étaient adoptées, permettraient la mise en œuvre des recommandations. Chaque recommandation est accompagnée de deux mesures de suivi comme guide de mise en œuvre. Chacun des trois obstacles est accompagné de deux éléments d'action qui offrent des solutions spécifiques pour surmonter ces obstacles. Chaque recommandation habilitante suggère une action qui ferait évoluer la médecine d'urgence vers une compétence socioculturelle au niveau national. Ces recommandations établissent les principales étapes pour combler l'écart en matière d'éducation.

Natural history of NF1 c.2970_2972del p.(Met992del): confirmation of a low risk of complications in a longitudinal study.

Individuals with the three base pair deletion NM_000267.3(NF1):c.2970_2972del p.(Met992del) have been recognised to present with a milder neurofibromatosis type 1 (NF1) phenotype characterised by café-au-lait macules (CALs) and intertriginous freckling, as well as a lack of cutaneous, subcutaneous and plexiform neurofibromas and other NF1-associated complications. Examining large cohorts of patients over time with this specific genotype is important to confirm the presentation and associated risks of this variant across the lifespan. Forty-one individuals with the in-frame NF1 deletion p.Met992del were identified from 31 families. Clinicians completed a standardised clinical questionnaire for each patient and the resulting data were collated and compared to published cohorts. Thirteen patients have been previously reported, and updated clinical information has been obtained for these individuals. Both CALs and intertriginous freckling were present in the majority of individuals (26/41, 63%) and the only confirmed features in 11 (27%). 34/41 (83%) of the cohort met NIH diagnostic criteria. There was a notable absence of all NF1-associated tumour types (neurofibroma and glioma). Neurofibroma were observed in only one individual-a subcutaneous lesion (confirmed histologically). Nineteen individuals were described as having a learning disability (46%). This study confirms that individuals with p.Met992del display a mild tumoural phenotype compared to those with 'classical', clinically diagnosed NF1, and this appears to be the case longitudinally through time as well as at presentation. Learning difficulties, however, appear to affect a significant proportion of NF1 subjects with this phenotype. Knowledge of this genotype-phenotype association is fundamental to accurate prognostication for families and caregivers.

Examination of the Effectiveness of the Healthy Empowered Active Lifestyles (HEAL) Program on Advanced Glycation End Products.

This pilot study investigated the effectiveness of the healthy empowered active lifestyles (HEAL) program to reduce circulatory levels of advanced glycation end products (AGEs) and assess its relationship to BMI, % body fat, fasting glucose, and A1C. The HEAL program was delivered at a local wellness center using a team-based approach and focused on physical activity and dietary education. A sample of twenty primarily European American (19 white, 1 black) participants (i.e., 10 males, 10 females) aged 26 to 71 (m = 48.75 ± 10.26) completed 12 weeks of the HEAL intervention. Pre to post changes in AGEs, BMI, % body fat, fasting glucose, and A1C were examined as primary outcomes. The findings showed participants had the following average reductions: AGEs 36.04 ± 18.48 ug/mL, BMI 2.0 ± 1.2 kg/m2, % body fat 3.18 ± 1.57%, fasting glucose 5.9 ± 17.21 mg/dL, and A1C 0.68 ± 1.11%. All twenty participants successfully completed the entire twelve weeks of the HEAL intervention. The results of this study show that the HEAL intervention provides beneficial reductions of AGEs, BMI, % body fat, fasting glucose, and A1C. In addition, the high adherence shows promise, and demonstrates the potential for HEAL as a behavioral intervention to improve pre-diabetic and other inflammatory related comorbidities. Further replication of results via additional randomized controlled trials is needed.