Faith Family Medical Center’s outcomes include: 50% (400/800) of patients with diabetes or at risk for diabetes will have an A1C of 7 or lower; 50% (1250/2500) of patients will have a blood pressure of 140/90 or lower; and 50% (125/250) of J2W patients will report at least one of the following outcomes: increase in nutritional knowledge, improved healthy meal planning, increase in physical activity.