Program planDiagnosis 1Goal and objectives. Since risk for cardiac diseases encompasses both modifiable and non-modifiable factors, our aim would be to monitor the weight a modifiable factor of the community members through the use of BMI to assess those who are obese and overweight. If overweight and obesity in the community is reduced, chronic illness like diabetes may also be reduced (Stanhope & Lancaster,2016) .Also because heart disease is the leading cause of death in Union county and state(NJDOH,2018c).Therefore, our goal is to reduce the number of adults and children in the community who are obese or overweight within 1 year. This goal closely resembles national goal set by the Office of Disease Prevention and Health Promotion (ODPHP,2018)In-order to achieve this goal, our clinicians within the community will conduct overweight and obesity screening for all the patients they encounter within 2 months. These screenings will enable the clinician to identify and also refer individual or families that are overweight and obese to the appropriate centers. The next approach for second objective is individuals that are obese , overweight and at-risk individuals will state lifestyle modification they have been implementing to improve their health for example physical activity , nutrition adjustment, alcohol consumption within 3 monthsStrategies. Our approach will be in many parts According to healthy people 2020 the promotion of health and reduction of chronic diseases risk can be achieved though consumption of healthful diet and maintenance of healthy body weight(ODPHP,2018,P.1). Many people do not have adequate knowledge of a heathy diet and how to maintain healthy weigh especially within the Hispanic and African American population who represent the largest population in the community. It is therefore imperative that education will be fundamental in the plan. United states Preventive Services Task force state that” all adults should be screened for obesity, and patient with BMI greater than or equal to 30 should be referred to multicomponent interventions.(USPSTF,2012). In moving along this direction, there will be a symposium at local community centers and Trinitas Regional Medical Center . The forum will address providers question pertaining to overweigh/obesity screening, referrals, treatment and renew providers’ commitment to screening for obesity during every patient encounter. Member will also provide screenings and referrals during a publicized health fair. Such intervention as screening programs is an example of secondary prevention(Stanhope& Lancaster, 2016)The next step is the community -based intervention . We would adopt the Active and Healthy families (AHF) program, originally developed for community in California By Falbe et al.(2017), for use in Elizabeth. The tertiary prevention program will be aimed at reducing overweight and obesity in in vulnerable individual and their family, utilizes a group format within a federally funded health care center to teach concerning lifestyle modification that can produce healthy weight loss. Offered in both Spanish and English, the AHF model is also highly considerate of cultural factors and incorporates a unique point person and a facilitator called a promotora.In addition to the AHF tertiary prevention program, we would partner with the Elizabeth Board of health to support and advocate community activities that promote healthy lifestyles such as dance class which might be fun ways to encourage some level of physical activity(Stanhope& Lancaster, 2016). Other activities included will be walking and cooking of healthy food. The walking activity will be done once in a month for 6 months while individuals will be encouraged to walk 20 -30minute for 5 days in a week. The cooking activity will be done once in a month. Starting from the 4th month to the 9th month.Primary prevention strategies will be implemented by involving school nurse and physical education teachers to develop programs and efforts to teach children on what food to eat and to avoid. Food that have high fat content, salt and refined sugars should not be eaten or limited. The school feeding system will also be revamped to provide healthy food with provision of healthier optionsPlan evaluation To evaluate the effectiveness of the AHF tertiary prevention program strategy, a pre/post-test of participants knowledge will be issued immediately prior, immediately upon the conclusion of the 12-week program and at 9 month follow up. Evidence of program success or failure will be provided by measurement of BMi during these interval and at 1-year post-completion. An anticipated 0.8kg/m2 average reduction in BMi will be achieved. In addition, open -ended questionnaire that would be issued in the participant preferred language will be utilized to ask participants in identifying at least 3 specific lifestyle modification they have implemented to promote their health as a result of the AHF program. These indicators would determine whether the intervention should continue, altered for improvement or discontinuedDiagnosis 2Program goal/objective is to reduce the incidence of undiagnosed diabetes in the community as a priority in union county. This is important because early intervention with life style changes can delay or prevent the development of diabetes type 2 .Therefore our goal is to monitor blood glucose level through blood testing for all members of the community who are not currently diabetic but are represent high risk group(obese /overweight, family history, African American and Hispanic ) .According to Selvin et.al. (2017).)Understanding the burden of undiagnosed diabetes is critical to the evaluation and monitoring of public health efforts related to diabetes screening and diagnosis In-order to meet this goal, our first objective will be that our local clinician will report conducting blood sugar screening at 100 percent of their patient encounter within 1 month. Our second objective is that the participants that have blood sugar level above the normal range or at -risk individual will state 3 life style modification they have implemented to promote their health(nutrition management, physical activity and exercise)Strategies and plan of actionProvision of community access to free testing by checking all the individuals and families that come to the community health centers and Trinitas medical Hospital. In order to increase the number of participants community awareness will be created to reach out to members of the community through vans at strategic spots within the city twice in a week (Wednesdays and Saturdays) for 4 weeks. Conﬁrmed undiagnosed diabetes was deﬁned as elevated levels of both fasting glucose (≥7.0 mmol/L [≥126 mg/dL]) and HbA1c (≥6.5%) measured in the same blood sample in a person without a previous diagnosis of diabetes(Selvin et.al.,2017).Since the community comprises of people that are more prone to diabetes as a result of genetic predisposition and life style. Therefore, if situation that can control prediabetes are dealt with, undiagnosed diabetes and diabetes will be at the very minimum. In-order to achieve this we would adapt the National Diabetes prevention program(DPP).This program was chosen because it has been promising result among participants since it started in 2012. (Ely, Gruss, , Luman, & Albright, 2017). The National Diabetes Prevention Program teaches participants strategies for incorporating physical activity into daily life and eating healthy. Participants that have blood sugar higher than the normal > 120 or hemoglobin A1C> than 6.5 will be encouraged to participate The program consists of 16 hourly sessions held at approximately weekly intervals during the ﬁrst 6months, followed by a minimum of six sessions held at approximately monthly intervals during months 7–12. Lifestyle coaches work with participants to identify emotions and situations that can sabotage their success, and the group process encourages participants to share strategies for dealing with challenging situations. Participants aim to lose 5 to 7 percent of their body weight by reducing fat and calories, and by being physically active for 150 minutes a week. Participants will get useful information about eating nutritious foods, eating the right portion sizes, reading food labels, and adding physical activity. The group will have time to interact during the 16-week core program .There will supportive group to cheer their successes and empathize with their setbacks if it occur participants would not have to make lifestyle changes alone. The second 6 months is intended to reinforce and build on content delivered in the ﬁrst half of the program. The 1-year duration and minimum of 22 sessions (i.e., intensity) are key to program success. The format of program delivery is customizable by stakeholders as long as key criteria are met, including the use of a CDC-approved curriculum that focuses on lifestyle change and the importance of at least moderate physical activity of 150 min or more each week, healthy eating, and weight loss of 5–7% over a 1-year period of time.Treatment and management plan of participants for those that were undiagnosed but discovered during the program will include Referral, education, follow up and incorporating them in the DPP program for life style modification as well.Providing Education in the school level will also be a priority for students. This will be actualized through seminars that will be held in conjunction with the school nurse and community partners for the middle and high school students on diet and physical activities which represent Primary preventionPlan evaluationAfter 6 months of the program and 6 months follow up, the effectiveness of the program will be evaluated to determine if our interventions were successful through systematically analysis of results before and after intervention took place. Hemoglobin A1C level and fasting blood glucose of the participant will be checked. BMI of the participants will also be checked since it is a risk factor for diabetes(Selvin et.al.,2017). Feedback through questionnaires will be analyzed to evaluate participants view and action concerning the program. These will determine whether the intervention should be continue, altered or discontinued. ReferenceEly, E. K., Gruss, S. M., Luman, E. T., & Albright, A. L. (2017). Response to Comment on Ely et al. A National Effort to Prevent Type 2 Diabetes: Participant-Level Evaluation of CDC’s National Diabetes Prevention Program. Diabetes Care 2017;40:1331–1341. Diabetes Care, 40(11). doi:10.2337/dci17-0036New Jersey Department Of health. (2018c). Query result for New Jersey mortality data:2000-2016(Data set). New Jersey State Health Assessment Data Webpage. Retrieved from http://www26.state.nj.us/doh-shad/query/result/MortStateICD10/Count.htmlOffice of Disease Prevention and Health Promotion. (2018). Nutrition and weight status. Healthypeople.gov Webpage. Retrieved from Https://www.healthypeople.gov/2020/topics-objectives/topics/nutrition-and-weight-statusSelvin E, Wang D, Lee AK, Bergenstal RM, Coresh J.(2017. Identifying Trends in Undiagnosed Diabetes in U.S. Adults by Using a Confirmatory Definition: A Cross-sectional Study. Ann Intern Med. 2017;167:769–776. doi: 10.7326/M17-1272Stanhope, M.,& Lancaster, J. (2016). 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