Nathalie Hilmi
email: hilmi@centrescientifique.mc

Ritu Basu

Matías Crisóstomo

Lara Lebleu

Joachim Claudet

Davide Seveso

The pressures and opportunities for coral reef preservation and restoration in the Maldives

Keywords: Coral reefs, climate change, mitigation, GDP, environmental plans and strategies

The ocean plays a fundamental role in the human well-being and development. Therefore, it is vital to preserve and restore the marine ecosystem services that are being damage through climate change and anthropic activities, even more in countries such as the Maldives that has been classified under a high degree of exposure and vulnerability. The purpose of this article is to provide an overview of the problems facing coral reefs in the Maldives through relevant scientific insights; outline the importance of reef conservation in this area, given their ecosystem services; and briefly discuss policies and mitigation plans for reef conservation in the Maldives against anthropic activities and climate change, including potential funding sources and how best to engage with local communities and other stakeholders in this effort. This will help to achieve several SDGs.

List of acronyms

In recent years, climate change and anthropic activities have been shown to affect many biological marine ecosystems and their services detrimentally [START_REF] Claudet | A roadmap for using the UN Decade of Ocean Science for Sustainable Development in support of science, policy, and action[END_REF]. The mitigation of climate and anthropic impacts has never been more imperative, especially for countries like the Maldives whose vulnerability to climate change impacts paired with a longstanding dependency to marine ecosystem services threaten their economies, well-being and livelihoods. Mitigation has been defined as an anthropic intervention to decrease the sources of greenhouse gases (GHGs) or improve their sinks [START_REF] Washington | Annex II: Glossary[END_REF]. Given the high biomass and biodiversity of corals that can be observed in the EEZ of the Maldives, this country is defined as a coral reef province [START_REF] Naseer | Inventory of the Maldives' coral reefs using morphometrics generated from Landsat ETM+ imagery[END_REF], which therefore requires reliable plans and policies to assist in safeguarding its marine resources with an understanding of the needs of future generations. Coral reefs in the Maldives have a particularly important role in the livelihood and welfare of its people as a key resource in the economy through tourism and activities. And yet, the Maldivian corals remain poorly known as underdeveloped systems of data collection and analyses fail to fully highlight the underlying value of existing resources and the challenges associated with safeguarding them (Mukherjee & Chakraborty, 2013;[START_REF] Schoenaker | Comparison of measurement systems for sustainable development at the national level[END_REF][START_REF] Radovanović | Sustainable economic-environmental planning in Southeast Europebeyond-GDP and climate change emphases Sustainable Development[END_REF]. This article therefore aims to showcase points of view from different experts and fields on the importance of preserving and restoring the coral reefs in The Maldives.

2 What is the current state of coral reefs in the Maldives?

Geographical Overview Of The Republic Of Maldives

The Republic of Maldives is an archipelagic state composed of 1192 coralline islands located in the Indian Ocean, south-west of India and Sri Lanka. The small island nation, with its capital in Malé, extends for 860 km in longitude, from the Ihavandippolu Atoll in the northern hemisphere (7°06'54"N), to the southernmost atolls, Fuvahmulah and Addu, lying just under the equator (0°42'24"S). The islands, grouped into 20 atoll-systems for administrative purposes [START_REF] Zubair | Not quite paradise: Inadequacies of environmental impact assessment in the Maldives[END_REF], sit on top of two parallel submerged ridges with an average altitude of 1.5 m and no point higher than 2.3 m above mean sea level [START_REF] Di Fiore | Geophysical approach to study the potential ocean wave-induced liquefaction: an example at Magoodhoo Island (Faafu Atoll, Maldives, Indian Ocean)[END_REF].

The islands are geographically fragmented over a total area of 115.300 km 2 (Maldives National Bureau of Statistics, 2020), but the land area only accounts for roughly 298 km 2 [START_REF] Kothari | Contestation over an island imaginary landscape: The management and maintenance of touristic nature[END_REF]. The majority of the islands have a land area between 0.5 to 1 km 2 [START_REF] Domroes | Conceptualising State-controlled resort island for an environmentfriendly development of tourism: The Maldivian experience[END_REF], with no island larger than 10 km 2 [START_REF] Stojanov | Local perceptions of climate change impacts and migration patterns in Malé, Maldives[END_REF].

Around 62% of the total resident population of the Maldives, estimated at around 530,953 individuals (World Bank, 2020a), is scattered throughout the country from central to peripheral islands. Numbers vary across atolls with a small population (between 1,000 and 4,500 inhabitants) to much fewer inhabited islands and atolls with over 15,000 inhabitants [START_REF] Malatesta | Environmental policy and climate change vulnerability in the Maldives: from the 'lexicon of risk' to social response to change[END_REF]. In contrast, the remaining 38% of the population lives in the capital island of Malé, in a surface area of less than 2 km 2 (Maldives National Bureau of Statistics, 2020). The urban centre of the island, one of the most densely populated in the world, has a population density over 39 000 inhabitants/km 2 and is expected to continue growing with increased urbanization [START_REF] Bisaro | Leveraging public adaptation finance through urban land reclamation: cases from Germany, the Netherlands and the Maldives[END_REF]. Indeed, the Greater Malé Region attracts communities from remote islands, owing to its wider access to both infrastructure and economic opportunities [START_REF]Second National Communication of Maldives to the United Nations Framework Convention on Climate Change: Ministry of Environment and Energy[END_REF]. To date, 187 islands are inhabited, 145 are resorts islands, structured following the so-called 'One island, one resort' model, and the remaining islands are dedicated to airports, plantations, industrial and agricultural activities, garbage storage and prisons, or remain uninhabited (dell'Agnese, 2019).

A Coral Reef Province

The Maldivian atoll ecosystems include a great variety of habitats, such as extensive shallow and deep lagoons, deep slopes, sandy beaches, and limited mangrove and seagrass areas. However, the Maldives are known across the globe to be an historical archetype of a coral reef province [START_REF] Naseer | Inventory of the Maldives' coral reefs using morphometrics generated from Landsat ETM+ imagery[END_REF]. Coral reefs in the Indian Ocean, where the Maldives are situated, make up about 11% of the global reef area [START_REF] Burke | Reefs at Risk Revisited[END_REF]. The Maldivian reefs cover an area of approximately 4,500 km 2 , comprised of 2,041 distinct coral reefs [START_REF] Naseer | Inventory of the Maldives' coral reefs using morphometrics generated from Landsat ETM+ imagery[END_REF], corresponding to nearly 5% of the world's reefs and representing the 7 th largest coral reef system in the world in terms of area covered [START_REF] Spalding | World atlas of coral reefs[END_REF].

Maldivian reefs are known for the diversity of life forms that they host, despite vast knowledge gaps on the biodiversity they sustain. The major actors in coral reef ecosystems are usually stony corals, which are colonial animals able to build a skeletal structure made of calcium carbonate. The Maldives hosts some 300 species of reef building corals [START_REF] Pichon | Taxonomic re-appraisal of zooxanthellate Scleractinian Corals in the Maldive Archipelago[END_REF] that support the incredible biodiversity of organisms living in Maldivian waters. The Maldives accounts for a total of 1,100 species of demersal and epipelagic fish, including sharks, 5 species of marine turtles and 20 species of whales and dolphins [START_REF] Frazier | Marine Turtles in the Maldive Archipelago, Ministry of Fisheries and Agriculture[END_REF][START_REF] Anderson | Observations of cetaceans in the Maldives[END_REF][START_REF] Ali | Review of the Status of Marine Turtles in the Maldives[END_REF]. The majority of species are invertebrates, including 400 species of mollusks, 120 species of copepods, 15 species of amphipods, over 145 species of crabs and 48 species of shrimps (Convention on Biological Diversity). This census of species is subject to change as these species are often cryptic, morphologically very simple and difficult to study from a taxonomical point of view [START_REF] Maggioni | Molecular evidence for cryptic species in Pteroclava krempfi (Hydrozoa, Cladocorynidae) living in association with alcyonaceans[END_REF](Maggioni et al. , 2017a[START_REF] Maggioni | Integrative systematics illuminates the relationships in two spongeassociated hydrozoan families (Capitata: Sphaerocorynidae and Zancleopsidae)[END_REF]Montano et al. 2015a,b;[START_REF] Seveso | Investigating the heat shock protein response involved in coral bleaching across scleractinian species in the central Red Sea[END_REF].

3 Why should coral reefs in the Maldives be protected?

A Unique Ecosystem Under Threat

The last decades have witnessed a continuous decline of coral reefs around the world. Only twenty-five states have jurisdiction in most of the world's warm-water coral reef ecosystems, however threats to these ecosystems trespass geographic barriers in several of these states and continue to increase. Exploitative uses of the ocean such as intense fisheries, coral and sand mining, and non-exploitative but damaging reef uses such as anchoring on reefs [START_REF] Shareef | Fourth National report to the convention on biological diversity Maldives[END_REF] have resulted in a loss of topographic complexity and species diversity, leaving behind an unconsolidated substrate, which is only subject to further erosion. Coastal zones have undergone changes through the addition of hard structures such as seawalls, breakwaters and jetties, which have become the standard in many inhabited islands, as a direct consequence of the advance of human settlements towards beaches. This expansion has led to increased land reclamation, the creation of artificial islands and of new touristic resorts, which in turn introduce new risks linked to plastic pollution and emerging contaminants [START_REF] Fallati | Land use and land cover (LULC) of the Republic of the Maldives: first national map and LULC change analysis using remote-sensing data[END_REF][START_REF] Saliu | Microplastic and charred microplastic in the Faafu Atoll, Maldives[END_REF][START_REF] Saliu | Detection of plastic particles in marine sponges by a combined infrared micro-spectroscopy and pyrolysis-gas chromatography-mass spectrometry approach[END_REF][START_REF] Duvat | Human-driven atoll island expansion in the Maldives[END_REF][START_REF] Pancrazi | Synergic effect of global thermal anomalies and local dredging activities on coral reefs of the Maldives[END_REF][START_REF] Rizzi | First record of emerging contaminants in sponges of an inhabited island in the Maldives[END_REF][START_REF] Montano | Spatial variability of phthalates contamination in the reef-building corals Porites lutea, Pocillopora verrucosa and Pavona varians[END_REF][START_REF] Galli | Coral reef biodiversity of the Maldives[END_REF]. Research indicates that coral reefs can effectively protect coastlines from tropical cyclones and other large wave impacts.1 "Restored reefs could reduce wave energy immediately, becoming more valuable through the years as they grow, keeping pace with rising sea levels. While reducing risk, coral reefs also support biodiversity, improve water quality, and support fisheries and tourism." 2 This is of relevance to the Maldives, as about over 80 per cent of the land area is less than one meter above mean sea level, so it is particularly at risk from future sea level rise.

In the Maldives specifically, multiple stressors are affecting coral reef communities, resulting in a rapid decrease in diversity, area coverage and ecological interactions in reef ecosystems.

The Maldivian reefs have been among the most affected areas in the world by climate change, thermal stressors, and related coral bleaching episodes with 60 percent to 100 percent coral mortality reported after the event of 1998 [START_REF] Zahir | Assessment of Maldivian coral reefs in 2009 after natural disaster[END_REF], followed by another bleaching event in 2010 [START_REF] Tkachenko | The northernmost coral frontier of the Maldives: The coral reefs of Ihavandippolu atoll under long-term environmental change[END_REF][START_REF] Tkachenko | Impact of repetitive thermal anomalies on survival and development of mass reef-building corals in the Maldives[END_REF]. The more recent event in 2015-2016 is to date considered the longest and most widespread global coral bleaching event (Hughes et al. 2018;[START_REF] Sully | A global analysis of coral bleaching over the past two decades[END_REF]. The Maldivian reefs were severely affected: sea surface temperatures peaked from late April to mid-May 2016 with recorded temperatures over 32°C. The overall percentage of bleached corals was recorded at around 75%, including corals sitting as far as 15m depth [START_REF] Ibrahim | Status of Coral Bleaching in the Maldives in 2016[END_REF][START_REF] Perry | Bleaching drives collapse in reef carbonate budgets and reef growth potential on southern Maldives reefs[END_REF]. Other stressors also include an increased recurrence of different epizootic disease caused by fungi, protozoa and bacteria (Montano et al. 2012[START_REF] Montano | Prevalence, host range, and spatial distribution of black band disease in the Maldivian Archipelago[END_REF](Montano et al. , 2014[START_REF] Montano | Widespread occurrence of coral diseases in the central Maldives[END_REF][START_REF] Seveso | Up-regulation of Hsp60 in response to skeleton eroding band disease but not by algal overgrowth in the scleractinian coral Acropora muricata[END_REF][START_REF] Seveso | Modulation of Hsp60 in response to coral brown band disease[END_REF], as well as by the anomalous outbreaks of corallivorous organisms that feed on corals, such as the crown-of-thorns seastar Acanthaster species and the cushion star Culcita species [START_REF] Saponari | The occurrence of an Acanthaster planci outbreak in Ari Atoll, Maldives[END_REF][START_REF] Saponari | Monitoring and assessing a 2-year outbreak of the corallivorous seastar Acanthaster planci in Ari Atoll, Republic of Maldives[END_REF][START_REF] Montalbetti | New insights into the ecology and corallivory of Culcita sp. (Echinodermata: Asteroidea) in the Republic of Maldives[END_REF][START_REF] Montalbetti | Reef complexity influences distribution and habitat choice of the corallivorous seastar Culcita schmideliana in the Maldives[END_REF].

An Endangered Pillar Of The Maldivian Economy

The marine environment has always been fundamental to societal welfare and development in the Maldives [START_REF] Collins | Advocacy for Marine Management: Contributions to a Policy Advocacy Initiative in the Maldives. Capstone Collection. Constitution of the Republic of Maldives[END_REF]. Coral reefs began to be used for building purposes in the 1970s to offer natural coastal protection and fisheries opportunities [START_REF] Lam | Dealing with the effects of ocean acidification on coral reefs in the Indian Ocean and Asia[END_REF]. This period saw the advent of tourism, which quickly became the economic sector with the highest growth rate, due in part to significant developments in island infrastructure that made tourism the country's main industry (World Trade Organization [WTO] 2019; [START_REF] Collins | Advocacy for Marine Management: Contributions to a Policy Advocacy Initiative in the Maldives. Capstone Collection. Constitution of the Republic of Maldives[END_REF]. Since 2015, the service sector has accounted for about 75% of the country's GDP (Maldives National Bureau of Statistics, 2020). Indeed, the Maldives' economy has grown fast since the 1970s, with a GDP which were among the lowest in the world and yet reached the level of uppermiddle-income countries in the 2010s (Encyclopaedia Britannica, 2020). However, tourism has been seriously affected by COVID-19, with the hotel occupancy rate falling from 73% in January 2020 (pre pandemic) to 69percent in February, 36% in March, 4% in April, 5.2% in May and 2.5% in June (Republic of Maldives. Tourism Yearbook, 2021). Consequently, in the first quarter of 2020, tourism revenues fell by 23.4%, and GDP contracted by 5.9% (World Bank, 2020b). While real GDP growth rebounded to 37% in 2021, it will likely remain below 2019 levels until 2023. It is projected that even if long and medium-term tourism stays strong, visitor arrivals will not return to pre-pandemic levels until 2023. Extra financial aid will be difficult to get due to the pandemic's global impact (World Bank, 2020b).

While coral reefs are a major factor in the Maldives' appeal as a tourist destination, coral mining has resulted in massive degradation of shallow reef-flat areas, with important negative impacts on coastal protection . This has called for the launch of monitoring programs [START_REF] Risk | Final report to international centre for ocean development[END_REF], carried out by the Ministry of Fisheries and Agriculture which is mandated with an aspect of environmental management expressly associated with marine resources and fisheries. The majority of the work related to marine resources, fisheries, monitoring, and research on reef health is carried out by the Marine Research Centre, which in turn is regulated by the Ministry of Fisheries [START_REF] Jaleel | The status of the coral reefs and the management approaches: The case of the Maldives[END_REF]. To promote sustainable tourism the Maldives is (1) diversifying the products from tourism offered by the Maldives; (2) increasing the benefits of tourism accruing to local communities; (3) increasing the number of Maldivians employed in the tourism sector, (4) strengthening regulatory frameworks governing the tourism industry and the monitoring capacity of relevant institutions; and ( 5) achieving sustainable growth in the guesthouse tourism sector (SAP, 2019).

4 Which funding is needed to preserve and restore coral reefs in the Maldives?

Funding From A Government Invested In Coral Reef Conservation

In 1978, the Maldives became a member of the World Bank, which has brought support for the implementation of 32 sustainable projects, requiring US$295 million. The partnership aimed to help the country achieve more sustainable and inclusive growth, and improve the use of natural, human, and financial capital (World Bank, 2020a Additionally, the Maldivian government through the establishment of a National Climate Change Trust Fund continues its efforts to attract climate finance through investments in projects, providing loans and innovating their financing mechanisms to increase lowemission and resilience development programs. The National Strategic Framework will be updated every five years to attract international climate finance, by prioritizing areas for donor support and establishing a system to track private and public climate finance flows. In order to finance investments in climate actions, the Maldivian government will also continue allocations from the Maldives Green Fund, among others, creating incentives for different stakeholders to invest in green development [START_REF]Second National Communication of Maldives to the United Nations Framework Convention on Climate Change: Ministry of Environment and Energy[END_REF].

The cost of coral reefs restoration is high; it can range anywhere from US$11,717/ha to US$2,879,773/ha [START_REF] Bayraktarov | The cost and feasibility of marine coastal restoration[END_REF][START_REF] Hein | Ecotourism and coral reef restoration[END_REF]. Coral reefs protection can be financed in several ways: governments that provide financial support through direct government expenditures, market regulation, pollution credits and taxes, subsidies and fiscal policies [START_REF] Iyer | Finance Tools for Coral Reef Conservation: A Guide[END_REF], can be paired with fees and taxation systems directed at users to generate resources for protected areas. Fees and taxation systems are methods to charge users of natural resources for the management costs of those resources [START_REF] Iyer | Finance Tools for Coral Reef Conservation: A Guide[END_REF]. The Maldives use a green tax, levied on tourists staying at resorts, hotels, or on vessels. The green tax is used in diverse projects like the Maldives Clean Environmental Project as well as for island sanitation, the establishment of sewage systems and the construction of regional laboratories for water research. This total green tax revenue between January and November 2020 amounted to around US$21 million (Figure 1). Alternatively, debt-for-nature swaps can create very targeted funding for conservation [START_REF] Iyer | Finance Tools for Coral Reef Conservation: A Guide[END_REF], defined by [START_REF] Quintela | on behalf of the Conservation Finance Alliance[END_REF] as "a multiple-party transaction in which the sovereign debt of a country is forgiven or partially forgiven by its debtors, in exchange for certain commitments to biodiversity conservation by the indebted country." The debt is usually owed in hard currency and the creditors tend to be mature economies. For biodiversity offsets and insurance schemes, technical capacity and expertise are needed, thus requiring more time and resources.

The Acknowledgement Of Socioeconomic Co-Benefits

One possible mechanism to support coral reef conservation that is popular among decision makers is based on payments for ecosystem services (PES). PES is defined as the payment that an ecosystem services owner (a landowner or community, for example) will receive to protect a specific ecosystem service, thereby supporting human well-being from both a socioeconomic and ecological perspective [START_REF] Costanza | Twenty years of ecosystem services: How far have we come and how far do we still need to go?[END_REF]. This means that the coastal protection and maintenance of natural habitats and biodiversity (including fish stock) that are naturally provided by coral reefs potentially hold financial benefits for local communities. However, this approach has to be implemented with great care because, as Braat & de Groot (2012) explains, some advocates argue that "it is analytically more appropriate to conceptualize payments for ecosystem services as incentives for collective action rather than as quasi-perfect market transactions to solve market failures." Alternative sources of funding for such ecosystem services include conservation trust funds that can provide targeted financial support for specific ecosystems (UN Environment, 2019). The Global Fund Coral Reef (GFCR) is a 10-year financial instrument specifically created to restore and protect coral reefs ecosystems.

It is supported by the Conservation Finance Alliance (CFA), which is an investment and development plan. The GFCR acts as an investment link to bring funds for improved resilience of coral reefs and livelihoods of local communities, by providing grants for projects that can have both positive environmental and socioeconomical impacts. The investments provided by the GFCR are managed by BNP Paribas and supported by blue economy expertise from Althelia Funds (Mirova/Natixis). There are currently around $125 million provided by donors, near $375 million in partner assets and between $2-3 billion unlocked from global private and public financial instruments (GFCR, 2021).

The relationship between educationsocial perceptionvaluation of ES must be carefully considered to develop a better approach for realistic valuation of nature. This approach is still a long way from being achieved coherently and productively but can be considered a valuable tool to mitigate climate change impacts and contribute to conservation. The participation of institutions will be vital to ensure biodiversity conservation and the sustainable use of ES in the long-term (TEEB Foundations, 2010). Furthermore, decision-makers must understand the complex interrelations between social, cultural, and economic factors and values. Policymakers and stakeholders can promote integrated coastal zone management with shared benefits and increased knowledge and research. New financial tools and mechanisms can help states gain access to additional resources to fill the capacity gap. The need to diversify and increase funding for coral reefs could fuel the implementation of a mechanism specifically for coral reef ecosystems conservation for the benefit of society alongside biodiversity.

5 Can adaptive governance of coral reefs be used in the Maldives?

Tools For A National Approach To Coral Reef Management And Conservation

The Maldivian Constitution states specifically in its Article 22 that "the State has a fundamental duty to protect and preserve the natural environment, biodiversity, resources and beauty of the country for the benefit of present and future generations". In addition, Article 67(h) states that "the Executive has the duty to prevent and protect the natural environment, biodiversity, resources and beauty of the country and to abstain from all forms of pollution and ecological degradation," (Constitution of the Republic of Maldives, 2008;[START_REF] Dhunya | Coastal Habitats of Maldives: Status, Trends, Threats, and potential conservation Strategies[END_REF]. The Maldives has considerable scope for adaptive capacity, being part of The Commonwealth Blue Charter, which defends coral reef restoration and protection as well as approaches to sustainable blue economies and coastal fisheries (The Commonwealth Blue Charter 2018).

Since the launch of a sea wall project around the capital Malé in September 1988, the government has implemented several projects aimed at adapting to environmental threats.

Frontier analysis based on the positive relationship between the adaptation index and income levels suggests that distance to the frontier is large for the Maldives, among several countries (IMF, 2021). The green and adaptive infrastructure gap in the country is threatening both climate mitigation (renewables and nature preservation) and adaptation (coastal protection, water and waste management and resilient infrastructure).

Marine protected areas are among the most useful tools to reduce human pressures on coral reefs and restore their natural functions [START_REF] Dryden | A rapid assessment of natural environments in the Maldives[END_REF]. The Maldives have proposed to transform a vast part of the country as a UNESCO Biosphere Reserve to protect diverse key ecosystems and the related ecosystem services which can support the sustainable development of the Maldivian economy [START_REF] Dryden | A rapid assessment of natural environments in the Maldives[END_REF] 3 . Yet, the marine area with currently implemented protection in 2022 covers less than 1% (614 km 2 ) of the country's 920,739 km 2 exclusive economic zone (EEZ) (Table 1).

Table 1. Marine Protection Status in Maldives

Source: Marine Protection Atlas (mpatlas.org/countries/MDV).

Note: EEZ = Exclusive Economic Zone.

Adapting To Climate Change

The Maldives is active in international climate fora and have shown early Assessment: A Climate Change Enabling Activity. The Maldives' strategy to reduce CO2, CH4 and N2O emissions was created under the influence of the 2006 IPCC Guidelines.

In 2006, the Maldives adopted the National Adaptation Program of Action (NAPA), which lays out a framework for action built around the complex relationship between sustainability and adaptation to climate change. 5 The first NAPA was then used in that same year to communicate the most urgent and immediate adaptation needs of the Maldives, as stipulated under UNFCCC Decision 28/CP and supporting the sustainable development goals (SDGs). Various national mitigation and adaptation strategic plans and policies have been enacted since then. 6Since the adoption of NAPA, the Maldives have implemented various non-structural interventions and institutional reforms in support of climate adaptation7 , which involved developing guidelines, operating frameworks and action plans to help guide current and/or future planning. These plans are quite granular in nature, invariably outlining sectoral action plans for each vulnerable sector. And yet, implementation is lacking as the Maldives have not enacted any regulations to directly address climate change nor do they have concrete financing plans. This implementation gap is particularly problematic for coral reef protection and restoration, despite a bleaching response program created and developed to guide different stakeholders in the assessment, detection and response to coral bleaching events in the Maldives. The plan would be implemented through an early warning system, an incident response plan and communications strategies, with the help of task forces, coast guards, the Environmental Protection Agency and the Marine Research Centre [START_REF] Marshall | Maldives Coral Bleaching Response Plan 2017[END_REF].

A Financial Challenge And Opportunity

Although investing in adaptation infrastructure can yield high returns, it is fiscally costly. Financing large adaptation investment will challenge fiscal space in many countries, which have deteriorated due to the COVID-19 pandemic (IMF, 2021). The Maldives featured among countries with high adaptation costs and limited fiscal space even before the COVID-19 (IMF, 2021). With worsening of the growth-debt trade-off post pandemic, financing adaptation costs would require further strengthening of policiesdomestic revenue mobilization, expenditure rationalization, a prioritization of adaptation investment-, and/or mobilization of grant and concessional financing (IMF 2022).

The increased likelihood of adverse climate-change-related shocks calls for building climatechange resilient infrastructure in the Maldives. Building resilient infrastructure will yield dividends and cost-savings under worsened climate conditions. Fulfilling these infrastructure needs requires a comprehensive analysis of investment plans with respect to their degree of climate resilience, their impact on future economic prospects, and their funding costs and sources. [START_REF] Santoro | Enhancing Resilience to Climate Change in the Maldives[END_REF], calibrating a theoretical model for the Maldives, show that there is a significant dividend associated with building resilient infrastructure8 . Under worsened climate conditions, the cumulative output gain from investing in more resilient technologies increases up to a factor of two. Firstly, building resilient infrastructure in the Maldives can halve the losses in terms in GDP (Table 2) at the trough triggered by a natural disaster. Investing in resilient infrastructure yields a dividend even before a disaster occurs, as its greater gross rate of return and durability imply that its net return is higher (the greater durability is captured by a smaller depreciation rate of resilient infrastructure relative to that of standard infrastructure). The additional tax pressure required for reconstruction in the case of standard infrastructure would be (politically) infeasible. The supplementary increase in tax revenues should be of the tune of 6-7 percentage points of GDP, in the aftermath of a shock. Secondly, financing public investment (in standard or adaptation infrastructure) with higher taxation would lead to a sacrifice in terms of GDP, and private consumption and investment in the ramp up of the investment effort9 . Grant financing can reduce this cost or eliminate it if it covers the investment plan in full. Melina & Santoro ( 2021) also highlight that it is more financially convenient for donors to help build resilience prior to the occurrence of a natural disaster rather than helping to finance the reconstruction afterwards.

The World Bank noted that many strategies are "needed to explore potential financing for scaling nature action, including policy, debt, and non-debt instruments. There isn't a single financial instrument that can provide all the financing needed to plug the gap in nature or climate financing. Rather, a broad range of financial structures and investment types should be considered, of course paying close attention to debt-limits, implications on concessional resources, macro-and fiscal realities," (World Bank, 2022).

Access to concessional climate finance remains a challenge, however. Authorities stated that there are very few projects that are under global climate funds because it is difficult to access these funds owing to the bureaucratic process and the need for scientific evidence to qualify as climate ready (F&D, 2021). Some of the main obstacles to timely access to global climate funds seem to be the lack of capacity to satisfy preconditions for climate finance, including provision of scientific evidence and involved paperwork. In this context, given that the Maldives has limited fiscal space, particularly post COVID-19, the authorities reiterated their request to the international community to step up cooperation efforts through financial assistance, capacity development, and facilitation of access to global climate finance and at concessional rates. (F&D 2021)

A Strategy Within A Global Vision

Nations around the world can share common objectives for the sustainable management of marine ecosystems. They include (i) engaging in mitigation solutions to increased GHG concentrations in the atmosphere, while supporting adaptation in developing states and particularly SIDS; (ii) regulating and monitoring fish stock to maintain stocks under the targeted levels (science-based limits) while measuring, protecting and controlling adjacent ecosystems; (iii) leading integrated planning processes to avoid and decrease land-based sources of ocean pollution, emphasizing on waste treatment effectiveness; (iv) monitoring and controlling pollution from non-living resources, including shipping; and (v) integrating marine spatial planning and coastal zone management in physical reconstruction of the coastline (UN Environment, 2019). Policymakers must use both local knowledge systems in the field and ocean task forces driven by scientific knowledge to construct policy. International leadership is needed to ratify and implement international treaties, agreements and conventions [START_REF] Stuchtey | Ocean solutions that benefit people, nature and the economy. High Level Panel for a Sustainable Ocean Economy[END_REF].

Coral reefs are classified as a priority and transboundary concern. However, the majority of coral reefs are under national jurisdiction and therefore challenging to characterize as global public goods even if they have the characteristics of common pool resources, despite being under threat from cumulative impacts of a range of human activities. It has been defined that shared concern, despite coral reefs not being a shared resource, can be the foundation for collective action, as outlined in the rationale of the Convention on Biological Diversity. In 2016, the United Nations Environment Assembly emphasized the need for protection of oceanic ecosystems through international cooperation, calling for an increase in governmental efforts to encourage financial and technical support from donors (UNEA, 2016; UN Environment, 2019). The idea of generating a supranational ocean agency was presented on the UNESCO program "Man and the Biosphere" [START_REF] Bridgewater | The Man and Biosphere Programme of UNESCO: Rambunctious Child of the Sixties, but Was the Promise Fulfilled?[END_REF]. This ocean agency can be generated by UN resolution or can be generated by founding groups that can stimulate other stakeholders to get involved [START_REF] Stuchtey | Ocean solutions that benefit people, nature and the economy. High Level Panel for a Sustainable Ocean Economy[END_REF],

There has never been a more urgent need for national strategies coherently put together within a global vision for a resilient ocean, from coral reef ecosystems to the global climate system. Initiatives like the UN decade of Ocean Science for Sustainable Development (2021-2030) and the UN Decade of Ecosystem Restoration (2021-2030) present an opportunity for such structured action, including by aggregating funding related to coral reef management on local, national and international scales. Addressing financial and anthropogenic capacity challenges is now critical. Limited capacity is a central barrier to international reef-related commitments in different countries, particularly in SIDS (Small Island Developing States), less developed countries, and some developing countries (UN Environment, 2019).

Conclusion

Climate change and anthropic activities have been shown to affect many biological marine ecosystems and their services adversely, including coral reefs. While the exact biological and chemical impacts of climate change and ocean acidification on coral reefs remain unclear in the Maldives, multiple stressors, including epizootic disease, are affecting coral reef communities, resulting in a rapid decrease in diversity, area coverage and ecological interactions in reef ecosystems. The Maldivian reefs have been among the most affected areas in the world by climate change, thermal stressors, and related coral bleaching episodes with 60% to 100% coral mortality reported. Investing in coral reef restoration, would help to rebuild resilience through preservation of biodiversity and secure ecosystem services supporting coastal protection, fisheries, food security, tourism, among others [START_REF] Lam | Dealing with the effects of ocean acidification on coral reefs in the Indian Ocean and Asia[END_REF]. Coordinated efforts from the government, organizations and all affected stakeholders are needed to improve conservation strategies towards facilitate the livelihoods and well-being of the Maldivian population. Therefore, a sustainable plan with shared benefits for all stakeholders paired with an updated set of regulations is needed in the different sectors impacted by coral reefs degradation. Long-term monitoring mechanisms for coral reef protection must rely on the active participation of local communities. The Maldivian government is currently implementing the SAP 2019-23, which provides a central policy framework aiming to monitor progress in different sectoral areas in order to enhance the livelihoods and well-being in the country. This framework includes metrics of well-being across diverse sectors, such as blue economy, caring state, family dignity, good governance, and decentralization, involving topics like clean energy, fisheries and marine resources, tourism, health, education, sports, gender equality, public service reforms, among others. However, the pace of its implementation remains slow due to a lack of facilitating regulations and limited access to concessional climate finance; this framework and its underlying programs in the SAP should therefore adapt and morph into early warning systems, incident response plans and communications strategies. Some of the main obstacles to timely access to global climate funds appears to be the lack of capacity to satisfy preconditions for climate finance, including provision of scientific evidence and involved paperwork. Many strategies are needed to explore financing tools to scale-up nature action, including policy, debt, and non-debt instruments (World Bank 2022) and debt-nature swaps could also be considered in the overall scheme. Alternative sources of funding for specific ecosystem services include conservation trust funds that can provide targeted financial support for specific ecosystems (UN Environment, 2019), such as the Global Fund Coral Reef (GFCR), which is a 10-year financial instrument specifically created to restore and protect coral reefs ecosystems.

The ocean is the cornerstone of the human development of small island developing states (SIDS), making coral reefs the 'rainforests of the sea', able to provide benefits to millions of people worldwide [START_REF] Mulhall | Saving the rainforests of the sea: an analysis of international efforts to conserve coral reefs[END_REF]ORG, 2007;[START_REF] Mongbay | Coral Reefs: The Tropical Rainforests of the Sea[END_REF]. The Maldives' economic development relies heavily on the islands' ecosystems and particularly the coral reefs, which are under continuous exposure from climate change threats. It is imperative that these challenges are met urgently and managed sustainably which local communities, whose inclusion can change the perception of protected areas as unproductive to a productive national asset. Coral reefs are classified as a priority and transboundary concern, therefore this sustainable management priority is one of global concern and not restricted to Maldivian waters only. There is an urgent need to put together national strategies coherently within a global vision for a resilient ocean, from coral reef ecosystems to the global climate system. Initiatives like the UN decade of Ocean Science for Sustainable Development (2021-2030) and the UN Decade of Ecosystem Restoration (2021-2030) present an opportunity for such structured action, particularly as they aggregate funding related to coral reef management on local, national and international scales as financial and anthropogenic capacity challenges remain a major hurdle to effective conservation. Indeed, limited capacity is a central barrier to international reef-related commitments in different countries, particularly in SIDS (Small Island Developing States), less developed countries, and some developing countries (UN commission, 2013). The association between physical elements and natural species is known as natural landscapes, which provide valuable ecosystem services to humanity (MEA, 2005;[START_REF] Díaz | Biodiversity loss threatens human well-being[END_REF]. The more common definition of ecosystem services found in the literature focuses on the ecological characteristics, functions, or processes of an ecosystem that directly or indirectly contribute to human well-being [START_REF] Costanza | The value of the world's ecosystem services and natural capital[END_REF]MEA,2005).

Coral reefs are among the most economically and ecologically valuable ecosystems on our planet, providing a vast number of ecosystem services such as food sources, raw materials, genetic diversity, substrate, erosion prevention, coastal protection, bioprospecting, tourism, and fisheries production, among others [START_REF] De Groot | Global estimates of the value of ecosystems and their services in monetary units[END_REF][START_REF] Bindoff | Changing ocean, marine ecosystems, and dependent communities[END_REF]. Coral reefs have been defined as the 'rain forests of the sea' providing benefits to millions of people worldwide [START_REF] Mulhall | Saving the rainforests of the sea: an analysis of international efforts to conserve coral reefs[END_REF]ORG, 2007;[START_REF] Mongbay | Coral Reefs: The Tropical Rainforests of the Sea[END_REF]. Worldwide coral reefs cover less than 0.1% of the ocean, and yet they support over 25% of marine biodiversity, as well as near 250 million people directly through tourism, fish production, and coastal protection. [START_REF] Dryden | A rapid assessment of natural environments in the Maldives[END_REF] separate the value of corals as "direct" and "indirect". Extractive activities like fisheries, mariculture, aquarium trade, pharmaceutical, and non-extractive activities like tourism, research, education, aesthetics, and culture are part of the direct values set. Biological services such as the support of seabirds, turtles, and marine mammals, the creation of connected ecosystems, and physical services like wave break and erosion of reef structures producing sand for beach maintenance and island formation are part of the indirect values set.

Coral reefs have intrinsic value, which if considered through the prism of human benefits, is defined as "aesthetic" or "cognitive". Aesthetics, an unconscious and immediate result of cognitive mechanisms, can control and regulate emotions, thereby having a direct impact on human cognitive development and cultural enrichment [START_REF] Blood | Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion[END_REF][START_REF] Kawabata | Neural correlates of beauty[END_REF][START_REF] Reber | Processing fluency and aesthetic pleasure: is beauty in the perceiver's processing experience?[END_REF]MEA, 2005). And yet, the majority of studies on ES have focused on economic benefits such as regulating and provisional services and their effect on biodiversity [START_REF] Hooper | Effects of Biodiversity on Ecosystem Functioning: a consensus of current knowledge[END_REF][START_REF] Cardinale | Biodiversity loss and its impact on humanity[END_REF], while the relationship between biodiversity and aesthetic value has scarcely been explored [START_REF] Tribot | Taxonomic and functional diversity increase the aesthetic value of coralligenous reefs[END_REF]. The few assessments of aesthetic values of marine ecosystems have highlighted that recreational areas are highly threatened by anthropic activities (UNEP, 2006), and should therefore be considered in conservation planning strategies [START_REF] Kalivoda | Consensus in landscape preference judgments: the effects of landscape visual aesthetic quality and respondents' characteristics[END_REF]. Aesthetic experiences can generate ecosystem conservation action through social motivation. Hence, the landscape can be a good medium to educate the general public on environmental issues [START_REF] Gobster | The shared landscape: what does aesthetics have to do with ecology?[END_REF][START_REF] Jorgensen | Beyond the view: Future directions in landscape aesthetics research[END_REF], and promote beauty and ecology through the relationship of "functional beauty" [START_REF] Parsons | Functional Beauty[END_REF], building both on aesthetic experiences and ecological understanding [START_REF] Tribot | Taxonomic and functional diversity increase the aesthetic value of coralligenous reefs[END_REF]. Erosion protection, flooding protection and protection from monsoons are direct ES from coral reefs, evaluated close to $22 billion per year in the Maldivian (REF). The South Asian Monsoon (SAM) generates changes in the atmospheric and ocean circulation of the tropical Indian Ocean, impacting rainfall on land and oceanic primary productivity [START_REF] García | Sea-surface temperature, productivity and hydrological changes in the Northern Indian Ocean (Maldives) during the interval ~575-175 ka (MIS 14 to 7)[END_REF].

The replacement cost of coral reefs for shoreline protection is evaluated around $2.75 million per km 2 [START_REF] Hedges | Climate Change and Coastal Defence[END_REF] contributing to the oceanic expansion and damage [START_REF] Firth | Ocean sprawl: challenges and opportunities for biodiversity management in a changing world[END_REF][START_REF] Bishop | Effects of ocean sprawl on ecological connectivity: impacts and solutions[END_REF].

Complex valuation methodologies

The valuation of coral reefs can play a vital role in their management, reflecting the benefits perceived [START_REF] Ahmed | An Overview of Problems and Issues of Coral Reef Management. Economic Valuation and Policy Priorities for Sustainable Management of Coral Reefs[END_REF]. They are crucial, not only as a source of livelihood to dependent coastal communities but also to national and international population, due to their contribution to food security, tourism, coastal protection, and indicators of climate change [START_REF] Fabres | Policy issues and Caribbean coral reefssurfing in the perfect storm[END_REF]. Valuing those services must therefore include marketable values (functions, products, and services) and non-marketable values (cultural importance, opportunities, and simple existence) [START_REF] Ahmed | An Overview of Problems and Issues of Coral Reef Management. Economic Valuation and Policy Priorities for Sustainable Management of Coral Reefs[END_REF]. The environmental and socioeconomic context will influence the choice of the most appropriate valuation method for a given service. Provisioning services are often valued through direct market pricing methods while regulating services are mainly valued using replacement cost and avoided cost. Habitat is also valued through direct market pricing, contingent value, and factor income while cultural services are mainly valued using travel cost and direct market pricing.

In addition, it should be emphasized that "values derived from different valuation methods may not be measuring the same economic construct, hence, values from different methods may not be directly comparable" [START_REF] De Groot | Global estimates of the value of ecosystems and their services in monetary units[END_REF]. Coral reef tourism provides approximately 43.17% of GDP and has a value of US$ 205,505/km 2 /year [START_REF] Spalding | Mapping the global value and distribution of coral reef tourism[END_REF], for the whole country this equates to a total of approximately US$ 1 billion/year.

Different methodologies are needed to define and value the services derived from an environment's functions however there are several limitations and complementarities in each method, from qualitative methods such as semi-structured interviews to quantitative methods like questionnaires [START_REF] Rasmussen | A combination of methods needed to assess the actual use of provisioning ecosystem services[END_REF]. Other examples include site-scale and landscapescale modelling, biophysical observations and economic studies [START_REF] Bagstad | A comparative assessment of decision support tools for ecosystem services quantification and valuation[END_REF]. In addition, some services are not always known by those who benefit from them, therefore the collective preferences are not the sum of individual preferences, and there is no "single model fits all" scenario. Many systems are nonlinear, the different scenario approach is not predictive and must be paired with informed and up-to-date policies and decision-making [START_REF] Hilmi | Analyse critique de la notion de services écosystémiques en milieu corallien[END_REF]. Some authors argue that the most appropriate methods rely on the value of the market trade and the net factor income [START_REF] Ngazy | Coral bleaching and the demand for coral reefs: A marine recreation case in Zanzibar[END_REF][START_REF] Ahmed | An Overview of Problems and Issues of Coral Reef Management. Economic Valuation and Policy Priorities for Sustainable Management of Coral Reefs[END_REF][START_REF] Cesar | Economic valuation and socioeconomics of coral reefs: Methodological issues and three case studies[END_REF], which estimate the relationship between economic activity and coral reefs. It is important to include the replacement cost as well [START_REF] Ahmed | An Overview of Problems and Issues of Coral Reef Management. Economic Valuation and Policy Priorities for Sustainable Management of Coral Reefs[END_REF] due to the vital role of reefs in protection against natural hazards. Non-market values are encompassed through methods such as Hedonic pricing, contingent valuation price, and travel costs [START_REF] Costanza | Twenty years of ecosystem services: How far have we come and how far do we still need to go?[END_REF][START_REF] Hilmi | Analyse critique de la notion de services écosystémiques en milieu corallien[END_REF]. This type of valuation has gained in relevance due to the integration of objectives of social justice, sustainability, and economic efficiency into public and private decisionmaking processes [START_REF] Farley | Ecosystem Services: The Economics Debate[END_REF][START_REF] Jacobs | A new valuation school: Integrating diverse values of nature in resource and land-use decisions[END_REF], thereby generating metrics such as GPI (Genuine Progress Indicator), which considers both social and environmental costs of ES management [START_REF] Kubiszewski | Beyond GDP: Measuring and achieving global genuine progress[END_REF]Reyes et al., 2013;[START_REF] Long | Economic Growth Quality, Environmental Sustainability, and Social Welfare in China -Provincial Assessment Based on Genuine Progress Indicator (GPI)[END_REF]. Interestingly, most current valuation methods assign a higher value to a scarce resource with a higher acquisition capacity than a vital resource which is more abundant (WWF Perú, 2014). Note, however, that "values from different valuation methods may not be measuring the same economic construct, hence, values from different methods may not be directly comparable" [START_REF] De Groot | Global estimates of the value of ecosystems and their services in monetary units[END_REF].

Ecosystem Services at risk

Despite the key impact of coral reefs on coastal human development, around 24% of the world's corals are under imminent risk of collapse, and another 26% are under a longer-term threat of collapse (The Commonwealth Blue Chart, 2018;[START_REF] Hein | Coral Reef Restoration as a strategy to improve ecosystem services -A guide to coral restoration methods[END_REF]. The recent report of the Intergovernmental Panel on Climate Change (IPCC) highlights that around 90% of corals could be damaged and lost by 2050, even in a scenario with an increase limited to 1.5°C [START_REF] Bindoff | Changing ocean, marine ecosystems, and dependent communities[END_REF]. There are many environmental stressors like overfishing, destructive fishing practices, pollution, and habitat destruction that are harming coral reefs in the Indian Ocean and Asia [START_REF] Burke | Reefs at Risk Revisited[END_REF][START_REF] Lam | Dealing with the effects of ocean acidification on coral reefs in the Indian Ocean and Asia[END_REF]. The degradation of ecosystems and their associated services is harming many of the world's poorest people and communities, becoming a key driving factor of poverty in vulnerable countries (TEEB Foundations, 2010). The interlinkages between ES will multiply adverse effects of the degradation of ecosystems: for example, coral bleaching will disperse species and decrease available biomass, while also reducing tourist arrival rate and driving the collapse of fisheries, thereby decreasing the food resources and protein intake of a whole community [START_REF] Hilmi | Ocean-Related Effects of Climate Change on Society[END_REF]. The recovery of the stock can take a long time, which will significantly decreasing the well-being of a population or community dependent on this marine resources (TEEB Foundations, 2010).

For example, the loss of coastal protection provided by coral reefs from sea level rise (SLR) will have projected impacts on coastal ecosystems from loss of functionality and biodiversity, to lateral and inland migration, and habitat contraction. This adds to compound risks associated with climate change as warmer regions will have a vaster impact on SLR heat uptake than cold regions [START_REF] Oppenheimer | Sea Level Rise and Implications for Low-Lying Islands, Coasts and Communities[END_REF], which may drive fishers to increase their effort to get resources in already overexploited areas. Consequently, an extensive number of destructive and illegal practices like dynamite fishing are perpetuated across Southeast Asian countries [START_REF] Mcclanahan | The effect of marine reserves and habitat on populations of east african coral reef fishes[END_REF][START_REF] Allen | Coral reef fish assessment in the 'coral triangle' of southeastern Asia[END_REF][START_REF] Cinner | Poverty and the use of destructive fishing gear near east African marine protected areas[END_REF][START_REF] Kimura | Status of Coral Reefs in East Asian Seas Region: 2014[END_REF], in turn directly harming destroying coral reef habitats and their associated species and thus, income sources [START_REF] Souter | Coral Reef Degradation in the Indian Ocean: Status report[END_REF][START_REF] Lam | Dealing with the effects of ocean acidification on coral reefs in the Indian Ocean and Asia[END_REF]. In addition, the increase in temperature due to climate change is generating massive bleaching events, affecting the growth, development, and survival of corals and fish communities through habitat degradation [START_REF] Paddack | Recent region-wide declines in Caribbean reef fish abundance[END_REF][START_REF] Anlauf | A corrosive concoction: the combined effects of ocean warming and acidification on the early growth of a stony coral are multiplicative[END_REF][START_REF] Pandolfi | Projecting coral reef futures under global warming and ocean acidification[END_REF][START_REF] Lam | Dealing with the effects of ocean acidification on coral reefs in the Indian Ocean and Asia[END_REF].

Ocean heat absorption has increased, and consequently sea surface temperature (SST), coral reefs bleaching, and ocean acidification. The SST in the Maldives can change between islands, but has generally increased across the islands over the last two decades beyond the resilience levels of local coral reefs [START_REF] Pearce | How the Maldives is Saving its Coral Reefs[END_REF]. This has caused two massive bleaching events in the area, first in 1997/1998 and then in 2016. During the first event in shallow areas around 80% of corals either completely or partially bleached [START_REF] Rajasuriya | Status of coral reefs in South Asia: Bangladesh, India, Maldives, Sri Lanka[END_REF][START_REF] Dryden | A rapid assessment of natural environments in the Maldives[END_REF]. [START_REF] Ibrahim | Status of Coral Bleaching in the Maldives in 2016[END_REF] explain that recent studies about the 2016 bleaching events show that 73% of corals on shallow (<13 m) reefs were negatively impacted.

  commitment to adaptation and mitigation plans for climate change. The number of scientific and technical assessments undertaken in the country since 1987 has reiterated the need for long-term adaptation to climate change(NAPA, 2006) 4 .The country was a prominent player in the negotiations that led to the United Nations Framework Convention on Climate Change (UNFCCC) and was the first to sign the Kyoto Protocol to the UNFCCC. The Maldives submitted the First National Communication (FNC) to the UNFCCC in 2001 following the implementation of the Maldives Greenhouse Gas (GHG) Inventory and Vulnerability 3 There is three biosphere reserve in the Maldives: Baa Atoll Biosphere Reserve designated in 2011, Addu Atoll Biosphere Reserve designated in 2020, Fuvahmulah Biosphere Reserve designated in 2020.4 The Government of Maldives. National Adaptation Programme of Action (NAPA).

  ). Moreover, since 1983, the IFC has invested over US$157 million in the Maldives (World Bank, 2020a). The The International Monetary Fund (IMF) is providing financing solutions, publishing research on economic implications of climate change and providing policy advice to help member countries capture

the opportunities of low-carbon, resilient growth. The Fund is also offering data analytics including through a Climate Change Indicators Dashboard, capacity development to help member countries address climate change challenges. Maldivian government continues to look for different ways to increase its private and public resources available for climate action. To this end, partnerships with the private sector, civil society, philanthropists, and local governments must secure climate finance-through annual budget increases and new budgetary contributions, local contributions, and Public Sector Investment Program allocations.

  Environment, 2019). Multilateral organizations like the International Monetary Fund together with other Multilateral Development Banks are well placed to provide financial solutions and capacity development and scale up nature action by leveraging private sector participation. A globally relevant sustainable management of marine ecosystems should rely on (i) engaging in mitigation solutions to increased GHG concentrations in the atmosphere, while supporting

	adaptation in developing states and particularly SIDS; (ii) regulating and monitoring fish stock
	to maintain stocks under the targeted levels (science-based limits) while measuring, protecting
	and controlling adjacent ecosystems; (iii) leading integrated planning processes to avoid and
	decrease land-based sources of ocean pollution, emphasizing on waste treatment effectiveness;
	(iv) monitoring and controlling pollution from non-living resources, including shipping; and
	(v) integrating marine spatial planning and coastal zone management in physical reconstruction
	of the coastlines.
	SUPPLEMENTARY MATERIAL: ES VALUATION METHODOLOGY THAT CAN
	BE APPLIED TO CORAL REEFS IN THE MALDIVES
	An ecosystem is a complex, dynamic, and adaptative open system of animals, plants,
	microorganisms, and the natural environment coexisting interdependently (European

Arc Center of Excellence Coral Reef Studies.

Coral reefs protect coasts from severe storms." April. 2 Stanford Report. 2014. Coral Reefs Provide Protection from Storms and Rising Sea Levels, Stanford Research Finds. The research was conducted by scientists from the University of Bologna, the Nature Conservancy, the U.S. Geological Survey, Stanford and the University of California, Santa Cruz.

NAPA was prepared with support from the Global Environment Facility (GEF) and the United Nations Development Programme (UNDP). Preparations for this programme began in October 2004 and while the process was halted because of the South Asian tsunami of December 2004, a follow-up started again in February 2006. On mitigation, the Update of Nationally Determined Contribution (NDC) of Maldives (2020) by the Ministry of Environment lays out plans to reduce 26 percent of emissions by 2030 and to strive to achieve net zero by 2030, if there is adequate international support and assistance. To achieve the emission reduction targets, the NDC sets forth ambitious plans to increase the share of renewable energy in the energy mix through various initiatives.

i) Climate Change Emergency (2021), ii) Nationally determined Contribution (NDC) 2020, iii) Strategic Action Plan (2019-2023 (2019), iv) Maldives Climate Change Policy Framework (MCCPF) (2015), v) Disaster Management Act (2007), and (vi) National Adaptation Program of Action (2006).

On mitigation, the Maldives recently adopted the Climate Emergency Act, adopted (29th April 2021). It provides a complete framework for Maldives' ambitious plan to achieve net-zero carbon emissions by 2030. The Act mandates to submit the subsequent year's national carbon budget to the Parliament for approval 3 months before the end of each year.

[START_REF] Santoro | Enhancing Resilience to Climate Change in the Maldives[END_REF]. "Enhancing Resilience to Climate Change in the Maldives, IMF Working Paper No. 2021/096

The Maldives Monetary Authority (MMA) has recently joined IFC's Sustainable Banking Network (SBN, January 2021). The primary objective was to formulate a National Sustainable Financing Framework with a clear roadmap to support broad based adoption of sustainable finance policies, including both improved environment and social risk management by financial institutions.


Heverton Alves Peres
email: haperes@usp.br

Heverton Alves Peres

Edson Zangiacomi Martinez

Leonardo Régis

Leira Pereira

Maria Cristina Foss De Freitas

Glucose Levels in Elderly Diabetics Taking Propranolol and Hydrochlorothiazide

Keywords: Propranolol, Hydrochlorothiazide, Diabetes, Glycemic control, Fasting blood glucose

To achieve glycemic control in patients with Diabetes, various medicines are prescribed; however, some may affect blood glucose concentration, requiring dose adjustment. Studies with small sample size, reported that propranolol and hydrochlorothiazide may change glycemic levels but this data are conflicting. The aim this study is evaluating if propranolol and hydrochlorothiazide change glycemic control in elderly hypertensive diabetics compared to diabetics without hypertension. We conducted a cross-section study and included hypertensive diabetics of both genders from 18 yrs to 90 yrs of age, using propranolol and hydrochlorothiazide (DHPH) taken orally either together or separate. The group of diabetics without hypertension was composed of patients of both genders from 18 yrs to 90 yrs of age. Clinical parameters being fasting blood glucose, postprandial glycaemia and glycated hemoglobin from the last six months was collected from medical records. The differences between groups were compared by the Student's t-test (continuous variables) and the X2-test (categorical variables). Logistic regression analyses were used to compare the influence of variables in glycemic control in both groups. The per capita income (<0.01), age (<0.01), complexity of pharmacotherapy (<0.01), number of medicines taken (<0.01) and comorbidities (<0.01) in the DHPH group was significant. Logistic regression analyses demonstrated that the comorbidities (<0.01), number of drugs taken (<0.01) and age (<0.01), influence fasting blood glucose in the DHPH group. Fasting blood glucose levels of elderly hypertensive diabetics taking propranolol and hydrochlorothiazide are influenced by age, number of medicines taken and number comorbidities.

Introduction

Currently 382 million people are affected by diabetes worldwide and 85% of patients have comorbidities that require them to take various medications [START_REF] Litwak | Prevalence of diabetes complications in people with type 2 diabetes mellitus and its association with baseline characteristics in the multinational A1chieve study[END_REF][START_REF]IDF Diabetes Atlas[END_REF][START_REF] Peres | Low scores in the auto-compliance method and fast medical care influence the poor adherence in diabetics attended in the basic health unit[END_REF]. Medications used in disease control are essential but they may affect blood glucose concentration, requiring insulin dose adjustment. An extensive list of medications that may adversely affect glycemic control in diabetics was evaluated by the European Medicines Agency and Internet-based information resources (e.g. Diabetes in Control and dLife) [4][5][6]. Propranolol and hydrochlorothiazide presented in the list are frequently used by hypertensive diabetics, but your effects in change of glucose levels are still conflicting [START_REF] Bakris | Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: A randomized controlled trial[END_REF][START_REF] Wai | Beta blocker use in subjects with type 2 diabetes mellitus and systolic heart failure does not worsen glycaemic control[END_REF][START_REF] Sarafidis | Antihypertensive treatment with beta-blockers and the spectrum of glycaemic control[END_REF].

Propranolol is antihypertensive drug used by elderly hypertensive diabetics with adverse effects in carbohydrate metabolism, producing distinct effects in blood glucose control [START_REF] Anyanwagu | Drug-induced diabetes mellitus: Evidence for statins and other drugs affecting glucose metabolism[END_REF]. It may reduce blood glucose concentration by blocking catecholamine stimulating glycogenolysis and gluconeogenesis [START_REF] Popp | Role of epinephrine-mediated betaadrenergic mechanisms in hypoglycemic glucose counterregulation and posthypoglycemic hyperglycemia in insulin-dependent diabetes mellitus[END_REF] or increase glucose concentration by inhibition of the release of insulin from pancreatic β-cells mediated by β 2 adrenoceptors [START_REF] Barron | Systematic review of genuine versus spurious side-effects of beta-blockers in heart failure using placebo control: Recommendations for patient information[END_REF]. Clinical trials suggest that hypertensive diabetics can take beta-blockers safely but the results are conflicting due to small sample size [START_REF] Jacob | Differential effect of chronic treatment with two beta-blocking agents on insulin sensitivity: the carvedilol-metoprolol study[END_REF][START_REF] Balamuthusamy | Comparative analysis of beta-blockers with other antihypertensive agents on cardiovascular outcomes in hypertensive Patients with diabetes mellitus: A systematic review and meta-analysis[END_REF].

Diuretics are used in low doses by elderly hypertensive diabetics in the prevention of major cardiovascular events [START_REF] Curb | Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group[END_REF][START_REF] Kostis | Long-term effect of diuretic-based therapy on fatal outcomes in subjects with isolated systolic hypertension with and without diabetes[END_REF]. However, the use of diuretics in elderly diabetics is dangerous because of the affect of release of insulin and when combined with propranolol may increase blood glucose concentration [START_REF] Dornhorst | Aggravation by propranolol of hyperglycaemic effect of hydrochlorothiazide in type II diabetics without alteration of insulin secretion[END_REF]. Besides producing hypoglycemia [START_REF] Sander | Thiazide diuretics and β-blockers in the treatment of Hypertension in diabetes mellitus[END_REF], thiazide diuretics are associated with adverse metabolic effects, glucose intolerance and hyperglycaemia as well as the incidence of diabetes [START_REF] Barzilay | Fasting glucose levels and incident diabetes mellitus in older nondiabetic adults randomized to receive 3 different classes of antihypertensive treatment[END_REF][START_REF] Shafi | Changes in serum potassium mediate thiazide-induced diabetes[END_REF].

Ethics

All individuals who fulfilled the inclusion criteria were invited to sign the Free and Informed Consent Terms and this study was approved by Ethics Committee, protocol number No.7724/2015.

Statistical analysis

Statistical analysis was performed using SAS version 9.3. Continuous variables were reported as means and standard deviations (sd) and the categorical variables were reported as frequencies and percentages. Approximate normality of distributions was assessed by normal probability plots.

Considering the relatively small number of independent variables and the absence of effect of collinearity, it was used a multiple logistic regression model simultaneously including all the variables and this procedure allows us to identify the variables that have any association with the outcome. It was therefore not necessary to use any type of method for selection of variables, such as the forward or backward. In addition, we observed that these methods of variable selection do not provide any gain in the results (the conclusions are the same as before). Significance was set as p<0.05.

health system units, five family health programs, as well as outpatient and specialty care units (Assistance Management Center, Adult and Infantile Mental Health Outpatient Clinic, Diabetic Care Home, Ophthalmology Center), DILC -Diagnostic Image and Laboratory Center and ready-to-care (Adult and Child Emergency, X-ray). The public health unit in the study had a mean monthly attendance of 350 people. The patients were recruited in this unit between August 2016 and December 2016 and the STROBE Statement was followed in this study.

Selection of patients

We included all patients that were attendance in the heath unit in the period of study, thus we did not calculate the sample size. The study sample included elderly hypertensive diabetics of both genders with between 18 yrs and 90 yrs of age in use of insulin NPH and oral hypoglycemic agents, using propranolol and hydrochlorothiazide (DHPH) taken orally together or separated. As control group, we recruit elderly diabetics without hypertension (DWH) was composed of both genders between 18 yrs and 90 yrs of age. Clinical parameters such as fasting blood glucose, postprandial glycaemia and glycated hemoglobin from the last six months were collected from medical records. An average of the last six months this parameters. We excluded patients of both groups without medical records of glycemic control levels because this variable is crucial for this study and patients in use of medicines that may change glycemic control as glucorticoids.

Data collection

Participant recruitment occurred as follows: Patients were selected before medical consultation, interviews were made in a room separate from the doctor's office and the average time of each interview was 20 min. A questionnaire consisting of open questions was applied to all patients by one of the authors of this study. A pilot study was made for validation and standardization of the questionnaire in twenty patients to correct difficulties in interpretation and these volunteers were excluded from the analysis. The variables collected through the questionnaire were age, gender, marital status, per capita income, schooling, comorbidities, diabetes diagnosis time, number of drugs taken, fasting blood glucose levels, postprandial glycaemia and glycated hemoglobin.

The complexity of pharmacotherapy and complications of diabetes can modify quality of life by altering blood glucose control. Thus, the instruments: Complexity of Pharmacotherapy Index (CPI) and Diabetes Complications Index (DCI) were applied to both groups. CPI is an instrument divided into three sections: A, B and C. CPI is obtained by the sum of scores of the three sections. High section scores are defined as greater complexity [START_REF] Melchiors | Translation and validation into Portuguese language of the medication regimen complexity index[END_REF].

DCI is an instrument composed of 17 questions to analyze the complications related to diabetes. Five questions evaluate coronary heart disease, three questions for stroke, two questions for peripheral vascular disease, two questions for neuropathy, three questions for diabetic foot complications and two questions for diabetic retinopathy [START_REF] Fincke | Assessment of long-term complications due to type 2 diabetes using patient self-report: The diabetes complications index[END_REF]. Each complication is determined for two or more questions, for example, coronary heart disease is present if the patient reported having myocardial infarction, symptoms of angina pectoris, or having been diagnosed by a doctor. The sums of any complications that are present are calculated, resulting in scores from 0 to 6. High section scores are defined as greater complications of Diabetes.

Results

In baseline, the final sample consisted of 154 patients. The DWH group consisted of 93 patients (45% male and 55% female) and the DHPH group consisted of 61 patients (26% male and 74% female). The DWH group had 41 (45%) white, 11 (11%) black and 41 mixed race people and the DHPH group had 26 (44%) white, 5 (8%) black and 30 (48%) mixed race people. Marital status in DWH had more people married (45 vs. 38) and single/divorced (48 vs. 23) compared to DHPH. The schooling level was significant in the DWH group 0.33 (95% CI: 0.14-0.78, <0.01) compared with the DHPH group (Table 1).

The time of diagnosis in diabetes in the DHPH group was higher (204 ± 91 vs. 195 ± 99) compared to DWH. Fasting blood glucose levels in the DHPH group was higher (167 ± 69.1 vs. 150.8 ± 73) compared to DWH however, postprandial glycaemia levels (219 ± 93 vs. 212 ± 99) and glycated hemoglobin (9 ± 2 vs. 8.8 ± 1.5) of the DWH group were slightly higher compared to the DHPH group. There were significant differences in age (63.9 ± 1.3 vs. 59.5 ± 1, <0.01), per capita income (629.8 ± 242.4 vs. 523.6 ± 240, <0.01), comorbidities (4.5 ± 1.9 vs. 3.5 ± 2.2, <0.01), number drugs taken (7.3 ± 1.9 vs. 4.2 ± 2.2, <0.01), CPI (21.8 ± 5.6 vs. 15.4 ± 5, <0.01) of DHPH compared to DWH. There were no significant differences between groups in Table 2, but the levels of fasting blood glucose and Hb1Ac of elderly hypertensive diabetics taking propranolol, propranolol+hydrochlorothiazide and hydrochlorothiazide alone, were high comparing in the DWH.

Logistic regression analysis demonstrated that the number of comorbidities (<0.01), number of drugs taken, (<0.01) and age (<0.01) can influence the levels of fasting blood glucose in the DHPH group (Table 3).

Discussion

In this study, we demonstrated that of propranolol and hydrochlorothiazide taken orally alone or concomitantly may alter fasting blood glucose concentration in elderly hypertensive diabetics compared with DWH. This is an original study and to our knowledge, no previous report has compared elderly hypertensive diabetics taking propranolol and hydrochlorothiazide orally alone or concomitantly with elderly diabetic patients without hypertension especially in the basic unit health.

As the main result, logistic regression analyses (Table 3) demonstrated that age, number of comorbidities and number of drugs taken, influence fasting blood glucose in the DHPH group. The study confirms the hypothesis that the use of propranolol and hydrochlorothiazide in elderly hypertensive diabetics added to the number of drugs taken and CPI, influence fasting blood glucose. In 2015, a systematic review showed that propranolol and hydrochlorothiazide increased fasting blood glucose and HbA1c in hypertensive diabetics [START_REF] Hirst | Quantifying the effects of diuretics and β-adrenoceptor blockers on glycaemic control in diabetes mellitus: A systematic review and meta-analysis[END_REF]. Poor glycemic control can cause long-term macrovascular and microvascular diabetes complications, thus the patients require use of various medications for the control of diabetes complications. Interestingly, our study demonstrated that there were significant differences (Table 1) in the CPI of the DHPH group compared with the DWH group. It is noteworthy that the biggest number of comorbidities, number of drugs taken and age contributed to higher CPI scores of the DHPH group compared with the DWH group. The comorbidities can progress to development of macrovascular and microvascular complications in diabetes, increasing the number of drugs taken; producing adverse effects that compromise the quality of life of diabetic patients. There were no significant differences of glycemic control in comparing the groups (Table 2). Although when separate levels of fasting blood glucose were analyzed, postprandial glucose and glycated hemoglobin according to the drugs taken (propranolol 80 mg/day, hydrochlorothiazide 50 mg/day or taken together), verified a small difference. Fasting blood levels of six patients taking only propranolol were increased when compared to DWH. When only the six elderly hypertensive diabetics taking propranolol and hydrochlorothiazide were analyzed, it is noteworthy that there were differences of glycemic levels compared to DWH, though they are not significant. Only a small clinical trial with 14 male hypertensive diabetics followed for 3 weeks, taking drugs in the dosages described above, showed that both drugs change fasting blood glucose concentration and glycated hemoglobin [START_REF] Dornhorst | Aggravation by propranolol of hyperglycaemic effect of hydrochlorothiazide in type II diabetics without alteration of insulin secretion[END_REF]. Comparing the fasting blood glucose levels of hypertensive diabetics taking only propranolol 80 mg/day with those taking only hydrochlorothiazide, a small difference was verified.

The clinical trials with non-selective beta-blockers found that propranolol increased levels of fasting blood glucose more than selective beta-blockers; however these data are conflicting [START_REF] Bakris | Metabolic effects of carvedilol vs metoprolol in patients with type 2 diabetes mellitus and hypertension: A randomized controlled trial[END_REF][START_REF] Wai | Beta blocker use in subjects with type 2 diabetes mellitus and systolic heart failure does not worsen glycaemic control[END_REF][START_REF] Sarafidis | Antihypertensive treatment with beta-blockers and the spectrum of glycaemic control[END_REF]. The opposing mechanism of action of non-selective beta-blockers that can alter insulin secretion and glucose utilization and increase glucose concentration in elderly hypertensive diabetics taking propranolol, predominate over those that could cause a reduction due to the effects of mediated via B2-adrenoceptors.

Hydrochlorothiazide has been associated with hyperglycemia in hypertensive diabetics [START_REF] Fathallah | Drug-induced hyperglycaemia and diabetes[END_REF][START_REF] Ferner | Drug-induced diabetes[END_REF]. In our study, fasting blood glucose levels of 49 patients taking only hydrochlorothiazide were increased when compared to DWH were demonstrated, but not significant. Interestingly, elderly hypertensive diabetics taking both medications had all clinical parameters increased when compared to the other groups (Table 2). This fact may be due to diuretics probably only affecting insulin secretion and when combined with beta-blockers can increase blood glucose concentration [START_REF] Dornhorst | Aggravation by propranolol of hyperglycaemic effect of hydrochlorothiazide in type II diabetics without alteration of insulin secretion[END_REF][START_REF] Fathallah | Drug-induced hyperglycaemia and diabetes[END_REF][START_REF] Ferner | Drug-induced diabetes[END_REF]. Beta-blockers and thiazide diuretics are widely used for people with diabetes for blood pressure control, nevertheless there are few studies showing adverse effects of propranolol and hydrochlorothiazide and the follow-up of these patients using these drugs is relatively short [START_REF] Dornhorst | Aggravation by propranolol of hyperglycaemic effect of hydrochlorothiazide in type II diabetics without alteration of insulin secretion[END_REF]. Several studies reported that some drugs can affect blood glucose control, but there is little information about which drugs should be avoided in people with diabetes. There is strong evidence targeting the use of other classes of antihypertensive when possible and closer monitoring of glycemic control for a short time after initiating one of these medications [START_REF] Hirst | Quantifying the effects of diuretics and β-adrenoceptor blockers on glycaemic control in diabetes mellitus: A systematic review and meta-analysis[END_REF]. A list of the drugs that affect glycemic control placed on the table of doctor would help both physicians and patients.

This study had some limitations. First, the group of hypertensive diabetic had only six patients taking propranolol orally and six patients taking both medications orally. Even with small sample size, we can demonstrate that propranolol and hydrochlorothiazide taken orally alone or concomitantly may alter the fasting blood glucose concentration in hypertensive diabetics compared with diabetics without hypertension. A larger sample in the DHPH group would argue significant differences. Moreover, all trials were small when compared with this study and none analyzed the influence of these drugs between hypertensive diabetics compared with diabetics without hypertension. The largest level of schooling was in the DWH group which influenced glycemic control compared with DHPH. Second, the associations are cross-sectional, limiting causal inference and cross sectional and longitudinal studies are both observational studies; cross sectional studies provide only a single "snapshot". Third, we no recruit patients without diabetes or others diseases (negative control) for comparing with the others groups. Finally, our study was conducted in a single service, so the generalization of data should be performed with caution.

Conclusions

The results obtained in this work showed that propranolol and hydrochlorothiazide taken orally alone or concomitantly may alter the fasting blood glucose concentration in elderly hypertensive diabetics compared with diabetics without hypertension. Fasting blood glucose levels of the DHPH group were influenced by age, number of comorbidities and number of drugs taken, according to logistic regression analysis. Poor glycemic control contributes to macrovascular and microvascular complications in diabetes, thus it is recommended to replace propranolol and hydrochlorothiazide in the elderly by other drugs that do not modify fasting blood glucose. Furthermore, closer monitoring of glycemic control time after initiating one of these medications is advisable. However, it is not possible to attribute all weightings of glycemic change levels in propranolol and hydrochlorothiazide because diabetes complications and poor adherence to medication may influence glycemic control. Controlled clinical trials with a larger sample, evaluating the adherence to medication, longer follow-up, must be performed in the future to evaluate the change in glycemic control caused for both medicines.

Table 1 :

 1 Demographic and basic characteristics of patients. Peres HA, Martinez EZ, Leira Pereira LR, Freitas Foss MC (2017) Age, the Number of Medicines Taken and Comorbidities are Associated with Changes of Fasting Blood Glucose Levels in Elderly Diabetics Taking Propranolol and Hydrochlorothiazide. J Bioanal Biomed 9: 240-243.

	Variables	DWH (n=93) DHPH (n=61) OR (CI)	P
	Sex
	Male	42 (45%)	21 (74%)	1.56 (0.80-3.5)	0.18
	Female	51 (55%)	40 (26%)
	Race
	White	41 (45%)	26 (44%)	0.70 (0.22-2.2)	0.57
	Black	11 (11%)	5 (8%)
	Brown	41 (44%)	30 (48%)	1.15 (0.58-2.2)	0.68
	Marital status
	Married	45 (48%)	38 (63%)	0.56 (0.29-1.0)	0.09
	Single/divorced	48 (52%)	23 (27%)
	Levels schooling
	(years)
	0-8	64 (69%)	53 (86%)	0.33 (0.14-0.78) <0.01*
	09-12	29 (31%)	8 (14%)
	Comorbidities
	Dyslipidemia	20 (22%)	28 (46%)
	Obesity	44 (47%)	36 (59%)
	Retinopathy	17 (18%)	21 (34%)
	Depression	8 (9%)	14 (23%)
	Thyroid disorders	11 (18%)	11 (12%)
	Time of diagnosis	195 ± 99	204 ± 91	174-215ª 180-	0.59
	(months)			226 b
	Age (years)	58 ± 15,7	63,9 ± 10,3	54-61 a 61-66 b	<0.01*
	Per capita income	523,6 ± 240 629,8 ± 242	473-573 a 568-	<0.01*
				691 b
	Fasting blood glucose	150,8 ± 73 167 ± 69	135-165 a 149-	0.15
	(mg/dl)			184 b
	Postprandial glucose	219 ± 93	212 ± 99	200-239 a 186-	0.62
	(mg/dl)			237 b
	HbA1 c (%)	9 ± 2	8,8 ± 1,5	8.5-9.4 a 8.4-9.1 b 0.54
	Number of	3,5 ± 2,2	4,5 ± 1,9	3-3.9 a 4,2-5 b	<0.01*
	comorbidities
	Complications diabetes	2,2 ± 1,4	2,4 ± 1,3	1.9-2.5 a 2-2,7 b	0.4
	index
	Number drugs taking	4,2 ± 2,2	7,3 ± 1,9	3.7-4.6 a 6.8-7.7 b <0.01*
	Complexity of	15,3 ± 5	21,8 ± 5,6	14-16 a 20-23 b	<0.01*
	pharmacotherapy

Citation: doi:10.4172/1948-593X.1000186 Volume 9(5): 240-243 (2017) -242 J Bioanal Biomed, an open access journal ISSN: 1948-593X

DWH a n=93 Hydro b .50 mg n=49 Prop b .80 mg n=6 Prop d .80+Hydro.50 n=6 p

	Fasting blood	150.7 ±	162.9 ±	169 ± 33.2	201 ± 58.4	0.32
	glucose	72.8	72.9
	Postprandial	219 ± 93.2 209.4 ± 100 197 ± 80	246 ± 116	0.75
	glucose
	HbA1 c	8.9 ± 2,1	8.7 ± 1.5	8.5 ± 1,2	9.8 ± 1,5	0.53

Table 2 :

 2 Influence of hydrochlorothiazide and propranolol in glycemic control.

	a) DWH: Diabetics without hypertension; b) Hydrochlorothiazide 50 mg/day; c)
	Prop.80: Propranolol 80 mg/day; d) Prop.80/day+Hydro.50/day; mean and sd,
	t-student test.

Table 3 :

 3 Results of logistic regression analysis of predictor's variables control glycemic.

	Predictors variables Estimate Standard error Chi-square	P
	Comorbidities	0.36	0.1	11.41	<0.01
	Gender	-0.17	0.19	0.76	0.38
	Age	0.03	0.01	4.66	<0.03
	Number medications	0.71	0.12	33.9	<0.01
	Fasting blood glucose	0	0.01	4.39	<0.03
	Postprandial glucose	0	0	0.94	0.32
	HbA1 c	0	0.13	0	0.94
	Diabetes complications	-0.26	0.16	2.54	0.11

Acknowledgments

We thank the care home for diabetics in Franca and the Ribeirão Preto Medical School, University of Sao Paulo. We thank John Carpenter, Ribeirão, Sao Paulo, SP, Brazil, for the English translation and revision.


Julien Reungoat
email: julien.reungoat@insa-toulouse.fr

Jean-Stéphane S Pic

Marie-Hélène H Manero

Hubert Debellefontaine

The use of ozone and high silica zeolites to enhance refractory compounds removal

matrix like natural water. They are highly resistant to chemical agents as acids, bases or oxidising agents such as ozone. Moreover, high silica zeolites have a high adsorption capacity for organics. Ozone is known to be a powerful oxidising agent able to react with various organic compounds. Its action -either direct or indirect -leads to the decomposition of organics into smaller molecules that are generally biodegradable. Previous studies have shown that organics adsorbed onto zeolites could be oxidised by ozonated water faster than in bulk water because of a micropore concentration effect (Fujita et al, 2004 and[START_REF] Sagehashi | [END_REF]. In the gas phase, Monneyron et al (2003) showed that high silica zeolites could catalyse ozone decomposition into radical species and that adsorption properties were not significantly modified after exposition to ozone. Hence it is expected that zeolites saturated with organics could undergo regeneration by ozone without degradation of their structures or decrease of their adsorption capacities. The present work showed that high silica zeolites could efficiently adsorb nitrobenzene from water although their capacity stayed beyond that of activated carbon, except at low concentrations. The adsorption capacity depended on the zeolite structure and the Si/Al ratio. Adsorption isotherms could be well described by Langmuir or Freundlich models. As regards the three phase coupled process, the adsorbent could be efficiently regenerated during an ozonation step consisting in bubbling ozone through a suspension of saturated zeolite in a nitrobenzene solution at equilibrium. The initial adsorption capacity was quickly recovered and, continuing the treatment, the adsorption capacity of the zeolite was even increased. This may be due to the cleaning of zeolites pores by ozone [START_REF] Pic | 17 th IOA World Congress[END_REF]. Yet traces of template molecules could probably remain from the zeolite synthesis process. Until now the catalytic effect of the zeolites has not been evidenced in the liquid phase. Therefore future work will focus on the conditions in which the oxidation kinetics can be enhanced in the presence of zeolites through a concentration effect, and to what extent.


est destinée au dépôt

An integrated process has been developed for the treatment of waste water containing refractory or toxic organic compounds. This process couples adsorption and catalytic oxidation in the same apparatus and on the same material: activated carbon. The porous solid plays successively the role of adsorbent under ambient conditions then that of catalyst under air at higher pressure and temperature. The first step of adsorption of phenols and derivatives is presented in this work, including both experimental results and calculation model. The experimental study is carried out in batch reactor to obtain the kinetics of adsorption and the adsorption isotherms. The theoretical approach is based on the ideal model called "Ideal Adsorption Solution Theory" to obtain theoretical adsorption isotherms. Two binary mixtures were chosen to investigate the behaviour of the adsorbent in competitive adsorption : a mixture of para-hydroxy benzoic acid and dimethyl phenol (PBHA/2,4DMP) and a mixture of para-hydroxy benzoic acid and phenol (PBHA/Phenol). For each binary mixture, different molar proportions were studied : equimolar (50%-50%) and unbalanced proportions (30%-70% and 70%-30%). Activated carbon was supplied by Merck. The solutions were analysed by HPLC. Experimental dynamic adsorption of pure compounds allowed to compare the adsorption kinetics of the two compounds of the binary mixtures. Kinetics of adsorption of each component out of a binary mixture were similar to those observed for each pure substance.

Experimental adsorption isotherms showed that, for the molecule having the best affinity with active carbon, adsorption in competitive mode is roughly as efficient as in non-competitive mode. For a given mixture, according to the proportion of each component, an inversion in the behaviour of the system was found. The preferential adsorption could be inverted if the proportion of the two compounds was reversed. This behaviour was better observed for lower values of the equilibrium concentrations than for high concentrations.

Partial isotherms for competitive mode predicted by IAST model were in good agreement with the experimental results for equimolar mixtures. For non equimolar mixtures the thermodynamic model was in good agreement with the partial isotherms provided that selectivity does not change. Indeed, in the case of inversion of selectivity the IAST model was not able to predict this change. In these cases, the IAST model presents some limits: the mixture is no longer ideal. In these cases the RAST model (Real Adsorption Solution Theory) would be more convenient to predict interactions between the compounds.

  Refractory compounds abatement by adsorption and oxidative catalytic regeneration on activated carbon -Experimental and modelling of competitive adsorption -ANDRIANTSIFERANA Caroline*, MANERO Marie-Hélène*, FARDET-LEMAIRE Edith**, DELMAS Henri*, WILHELM Anne-Marie* * Laboratoire de Génie Chimique, 5 rue Paulin Talabot, 31106 TOULOUSE Cedex 1 ** Laboratoire d'Ingénierie des Procédés de l'Environnement, 135 av. de RANGUEIL 31077 TOULOUSE Cedex 4