To optimize diabetes self-management and glycemic control multiple factors driving health outcomes must be addressed and include socioeconomic factors (40%, e.g., income/food insecurity), health behaviors (30% diet quality, physical activity), access and quality of health care (20% diabetes self-management education (DSME)). This session will describe the Fresh Start program's comprehensive approach that integrates individually established evidence-based strategies to address to address each area that predicts health outcomes and successful improvements in diabetes self-management and glycemic control with an average decline of 1.87% HbA1c observed within 4 months for individuals who participated in all components of the program. The Fresh Start program includes 3 synergistic components, 1) the provision of 9 group classes to address knowledge, skills and self-efficacy around food, diabetes self-management and physical activity, 2) one on one health coaching conducted over the phone for individualized nutrition and physical activity behavioral goal targets, 3) a produce prescription with complimentary recipes to promote access to healthful food. The developed framework for needed community partnerships and best practices for implementation and evaluation will be expanded on for replication in other regions and settings and the potential to address other nutrition related cardiometabolic conditions will be outlined.