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STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 1
Management of Type 2 Diabetes in American Indian Adolescents Ages 1319
Carissa Bergman RN, BSN, CHPN
N895
San Francisco State University
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 2
Carissa Bergman
San Francisco State University 2014
Abstract
American Indians are two to six times more likely to have diabetes compared to the overall United
States population. Over the last 20 years, within the American Indian community, the predominance of
type 2 diabetes has sharply risen in the adolescent age bracket. The purpose of this field study is to
evaluate the most current evidencebased research and use the acquired data to create a standardized
protocol to assist Nurse Practitioners in the management of American Indian adolescents, ages 1319,
with type 2 diabetes.
I hereby certify that the Abstract is a correct representation of the content in this field study.
Dr Andrea Renwanz Boyle, PhD, ANPBC Date Chair: Field Study
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Certificate of Approval
I certify that I have reviewed Management of Type 2 Diabetes in American Indian Adolescents ages
1319 by Carissa Bergman RN, BSN, CHPN and that it meets the appropriate criteria for the field
study requirements for the degree of:
Master’s of Science in Nursing, emphasis in Family Nurse Practitioner from San Francisco State
University.
Andrea Boyle PhD, ANPBC
Connie H.Carr MSN, FNPBC
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Introduction
Type 2 diabetes mellitus (T2DM) is becoming a worldwide health concern among children and
adolescents. This disease, formally known as adultonset diabetes, is being diagnosed with increasing
regularity in the young. According to a recent study, the projected burden of childhood diabetes in this
country will nearly quadruple by 2050, an increase of nearly 49% (Imperatore, 2012). This diabetic
crisis is already costing the United States $174 billion annually and is anticipated to rise (NDEP,
2011).The financial burden is even reflected amongst the diabetic youth with the expenditure for
diabetes being 6.2 times higher than with a healthy child (Imperatore, 2012).
Ethnic minorities are disproportionately impacted by type 2 diabetes and found in especially high
numbers within the juvenile American Indian population. One study, evaluating disease incidence among
different ethnic adolescents, found type 2 diabetes among nonhispanic whites to be 6% as compared to
American Indian youth with a prevalence of over 76% (1.74 cases per 1000 youths), rating higher than
any other racial group (Liese, 2006). Not only do American Indian children/adolescents have a higher
percentage rate of type 2 diabetes, but the increase in incidence of disease is considered alarming.
According to the American Diabetes Association, type 2 diabetes amongst American Indian youth ages
1519 has increased 68% from 19942004 (ADA, 2013). Unlike other ethnicities where type 1
diabetes is dominant, American Indians (AI) are 95% more likely to have type 2 diabetes than type 1
diabetes (ADA, 2013).
At the present time very little integrated research on diabetes in American Indian adolescents
have been executed. It is imperative for Nurse Practitioners (NPs), practicing within the confines of the
American Indian community, to have proficiency and mastery of culturally specific diabetes in order to
provide medical care and education to this population. To better assist the Indian community, this
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project will review relevant research to create a medical protocol for the care of American Indian
adolescents, ages 1319, with type 2 diabetes mellitus (T2DM). With the use of valid research, the
topic will be reviewed and cover the latest evidencedbased recommendations for: evaluation,
treatment, follow up, and educational needs for American Indian Adolescents, while observing special
care in the cultural differences within this population.
Significance and Definition of Type 2 Diabetes in American Indians
The prevalence of type 2 diabetes among American Indians is four times higher than the general
population in the United States and is considered the fourth leading cause of death within this culture
(O’Connell, 2010). Although type 2 diabetes is more prevalent in adulthood, there has been a significant
increase amidst children and adolescents. For those in this population under the age of 20, it is estimated
that 3,700 children/adolescents will be diagnosed with type 2 diabetes annually (Imperatore, 2012).
Type 2 diabetes is a metabolic, chronic condition, triggered by insulin resistance or decreased
insulin production. This in turn decreases an ability to metabolize sugar resulting in hyperglycemia
(ADA,2013). High levels of glucose in the bloodstream over long periods of time can cause damage to
both the micro and macrovascular systems resulting in other chronic illnesses which can cause potentially
life threatening complications.
The American Diabetic Association (ADA) recommends individuals diagnosed with type 2
diabetes be closely monitored and treated according to appropriate guidelines. It is possible to manage
diabetes in adolescents through proper monitoring, treatment, and education on interventions such as
blood glucose monitoring, medication, and/or appropriate lifestyle choices.
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Purpose of Standardized Protocol in Diabetic Adolescent
The purpose of this document is to evaluate current evidencedbased research in order to
create a protocol that focuses on the treatment and disease prevention of type 2 diabetes in
asymptomatic adolescent American Indians ages 1319. This protocol has been developed to assist the
Nurse Practitioners (NP) in the treatment of type 2 diabetes in adolescents which includes the use of lab
monitoring, lifestyle modification therapy, (through diet and exercise regimens) and medication therapy.
It provides criteria for determining which adolescent requires further evaluation for diabetes when a
patient presents asymptomatically. The protocol recommends a detailed history be taken along with a
thorough physical examination focusing on the clinical presentation of diabetes and any potential vascular
complications. Laboratory tests should be done to establish initial diagnosis, using fasting blood sugar
(FBG) and the oral glucose tolerance test (OGTT), as well as hemoglobin A1c (HgbA1c) every three
months to monitor and titrate current treatment. Other tests should also be complete to evaluate for
complications of disease, these include lipid profile and renal levels.
The Nurse Practitioner should also design a culturally friendly, familypeer driven treatment plan
for AI adolescents addressing medication, diet, and exercise regimens. Education for this population is
imperative and should include blood glucose monitoring, nutrition, physical activity, emotional support,
stress management, and other supportive therapy.
By developing this youth centered protocol, nurse practitioners will understand how to direct
and manage care of adolescents ages 1319 with type 2 diabetes. This protocol utilizes the latest in
evidencebased literature providing a comprehensive guideline for nurse practitioners to follow when
addressing management of AI youths with type 2 diabetes.
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Literature Review
To locate recent evidencebased studies from 20092014, the bibliographic database of
CINAHL (Cumulative Index to Nursing and Health Literature), PubMed, American Diabetic
Association (ADA) Diabetes Pro were chosen as well as the utilization of Google Scholar as the search
engine. A combination of search terms: ‘American Indian’, ‘youth’, ‘type 2 diabetes’, ‘treatment’,
‘education’, ‘1319 years of age’, and ‘adolescent’ were used to collect relevant data. The studies
include a variety of randomized controlled trials, prospective cohort studies, case control studies,
descriptive studies, as well as one seminal study from 2002. A compilation of multiple peer reviewed
publications were integrated to formulate the best method of care for the treatment and prevention of
diabetes type 2 in American Indians (AI) adolescents. After analyzing the content of the research, it was
determined that the best strategy to organize this literature review was a topical approach. Seventy
journals were explored however, only twenty three journals were used to create this protocol.
The relevance and appropriateness of the research content was reviewed and determined
whether it used primary or secondary information, compared/contrasted data, and/or searched for the
strengths and weaknesses within each of these studies. The intention was to point out major themes in
the literature and acknowledge the gaps that may exist in order to create a protocol to use in any
medical practice.
Prevalence of Type 2 Diabetes amongst American Indians
Previous research suggests a strong correlation between type 2 diabetes and American Indians.
In a 2012 prospective cohort study, Imperatore, et al. observed the future projection of diabetic
increase incidence among the under 20 year old population. The purpose of this study was to project
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what the future of diabetes in children would be in 2050 if current health trends progressed incrementally
as they are today. In order to create a relevant study, the researchers used a large sample size of
154,000 diabetic children from both the U.S. census and the SEARCH study data pool. The study was
strengthened by utilizing modern models (ie poisson regression and dynamic transmission model) to
most accurately estimate the advancement of type 2 diabetes in children and adolescents through the
year 2050. The analysis was also bolstered by the consistently used inclusion criteria of age, sex and
racial ethnicity to collect data. While the study had its strengths, it was also limited by not factoring in the
research of current and future diabetic interventions across the country that have shown a decrease in
the presence of type 2 diabetes. The study concluded that a four fold increase in type 2 diabetes
amongst the youth of the US is expected by 2050.
Another study supporting the disparity of diabetes amongst American Indians is the 2010 study
by O’Connell, et al. This study concentrated its research on the potential morbidity of type 2 diabetes
amongst two specific populations the American Indians and the general United States population. The
study drew its data from a combination of both Indian Health Service (IHS) database (n=30,121) as
well as from the MarketScan Research Database (MSRD) (n= 1,500,002). The independent variables
of age, sex, and comorbidities were uniformly collected from both databases.The researchers used
ICD9 codes to accurately identify comorbidities which further strengthen the variables. The Diagnostic
Cost Group (DCG) model was utilized to incorporate an overall relative risk score for each individual
based on comorbidities the higher the risk score the higher the morbidity. The study was strong with its
large sample size and its ability to capitalize on an established model like DCG. One weakness of this
study is the lack of data collected from individuals with no insurance, medical, or medicare
recipientsdata that may better represent the American Indian population. Another limitation is the
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study’s focus solely on adults ages 1864. Even though the study does not target adolescents, the data
may shed some light on future complications of improperly managed diabetes amongst 1319 year olds.
The data noted a mortality burden among American Indians with diabetes that exceeded insured US
adults by 50%, a statistically significant (P<0.05) finding. The data also suggested AI with type 2
diabetes were found to have higher rates of end stage renal disease, lower limb amputation, and heart
disease compared with the rest of the US.. Overall, this study was able to create a cause and effect
relationship between diabetes and a higher morbidity amongst the American Indian population.
Hemoglobin A1c directed treatment in American Indian Youth
Although the current American Diabetic Association (ADA) guidelines suggest use of the lab
value Hemoglobin A1C (HbA1c) for monitoring disease progression in youths (at or below 7%) with
type 2 diabetes, it is unclear in the studies whether HbA1c should be used to establish a diagnosis and a
treatment plan in this population as well.
A cohort study by Nowicka, et. al. (2011) attempts to address this concern by evaluating the
“sensitivity and specificity” of HbA1c and its potential use as a diagnostic tool with or in lieu of the
current gold standard oral glucose tolerance test (OGTT) for children/adolescents. The sample of 1,156
obese adolescents was recruited from the Yale pediatric clinic between 20052010. One strength of the
study was that the dependent variables of oral glucose tolerance test (OGTT) and HbA1c were
consistently evaluated throughout the study. Another strength is the subjects had strict inclusion criteria
(>95% BMI for age, sex and no diabetes) and exclusion criteria (known diagnosis of type 2 diabetes,
previous testing, and/or on medication to lower diabetes). Although the study did evaluate various
cultures (Caucasian 36%, African American 35%, Hispanic 29%), a major limitation was the lack of
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American Indian culture in the data set. In conclusion, HbA1c data was meaningful as a clinical tool
however, as a diagnostic measurement the level highly underestimates the actual lab values for
prediabetes, making HbA1c a poor choice to diagnose children/adolescents.
The Petitti, et. al. 2009, study was focused on what HbA1c lab value levels mean when
monitoring in youths (ages 20 and younger) with diabetes. The research itself was a crosssectional
analysis from a six centered US study with a sample size of 3947 children with type 1 and 552 with type
2 diabetes. The research demonstrated that certain ethnicities, in particular the American Indian youth,
had worse glycemic control than non hispanic whites. The results also suggested a higher percentage of
youth fall above the recommended HbA1c target value, which if not controlled, could cause a lifetime of
poor health (ie. macro/micro vascular conditions, cardiac disease, or premature death). The strengths of
the study were the sample size, diversity, and coverage of both Type 1 and T2DM. Another strength
was the authors’ ability to acknowledge the limitations of the study and the need for further research.
One limitation was the researchers did not distinguish between type 1 and 2 diabetes in the data
interpretation. Another weakness was the use of a single variable, HbA1c, without consideration of
length of patients diabetes, current treatment regimen, underlying disease process, or
“sociodemographic factors”( ie. living environment, parental involvement, education level as possible
other causes for poor control).
Although neither study was able to establish HbA1c was useful in the diagnosis of diabetes, the
literature suggested that use of Hemoglobin A1c is an appropriate tool in the continued monitoring of
children/adolescent with an established diagnosis of type 2 diabetes. In conclusion, the use of the ADA
recommendation HbA1c level (at or below 7.0%) should continue to dictate treatment but should not
be used to diagnose a child/adolescent with diabetes.
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Use of Medications in Asymptomatic American Indian Diabetic Adolescents
Due to safety and efficacy issues, the FDA has yet to conduct trials on the use of medications
on diabetic youths. Since limited research on medication use have been completed, most practitioners
remain guarded in practice and chose to prescribe only Metformin, the one medication considered safe
for administration in children/adolescents.
The Jones, et. al. clinical trial from 2002 is the most well referenced research as pertaining to
youth, diabetes type 2, and medication administration. This seminal work was referenced to in several,
well established organizations research including the American Academy of Pediatrics, ISPAD 2009,
American Diabetes Association, as well as cited over 300 times on Google Scholar. The purpose of this
research was to establish the safety and efficiency of using Metformin in children with type 2 diabetes.
This research, although small, was strong due to its use of randomized double blind control trial. The
study used children ranging in age from 1016 and was completed at 44 various sites in 5 countries
using stringent, uniform protocols. Each subject had very strict inclusion/exclusion criteria in order to
participate including a fasting plasma glucose (FPG) level of > or = 7.0, HbA1c of > or = 7.0 %,
stimulating Cpeptide of > or = 0.5 nmol/l, and a BMI > 50th percentile for age which strengthen the
study. The 82 individuals who met the criteria were randomly assigned to either Metformin (titrating to
1000 mg BID) or the placebo group. The study does have its limitations including the sample size being
small (N=82) and the length of study being short (16 weeks). However, overall the results showed to
have statistical significance (P < 0.001) in meeting the target FPG and HbA1c level in the Metformin
group at 85% (with no adverse reactions) compared with the children that received the placebo (22%).
In 2012, the TODAY study (20042009), by Zeitler, et al., investigated three separate
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treatment options: Metformin (1000 mg BID) alone, Metformin (1000 mg BID) combined with
Rosiglitazone (4 mg BID), or Metformin along with lifestyle modification program. The study, funded by
the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), consisted of 699
participants ranging in age from 1017 years of age and assigned randomly via computer generated
selection into one of the three groups. Criteria of eligibility consisted of a diagnosis of type 2 diabetes
within last 2 years, a body mass index (BMI) > or = 85% for sex and age, a negative diabetic related
autoantibody test, a fast Cpeptide level of 0.6 ng per ml, and availability of caregiver willing to support
the child through study. Once assigned to a group, children participated in the study from July
2004February 2009 and continued with a minimum of 2 years follow up after the study. The study
used HbA1c as the variable, testing every 2 months the first year and then four times a year thereafter.
The study was strong in its equal representation of races (blacks32.5%, hispanics 39.7%, white 20%),
length of study (average of 3.86 years of participation), and its randomization. A limitation to this study
was adherence to the medication regimen dropped from 84% at 8 months to 57% at month 60 with no
major differences across comparison groups. Although these results appear to have a significant
downfall, the adherence did not seem to impact the rate of glycemic control between participants who
did and did not have treatment failure.
Serious adverse effects noted in 19.2% of participants (18.1% Metformin group, 14.6%
Metformin + Rosiglitazone, and 24.8% in Metformin with lifestyle group) however, 87% of the
reactions were not considered related to the study and were due predominantly to hypoglycemic events.
On the one hand, the results found clinically significant improvement in glycemic control with Metformin
and Rosiglitazone group (with a P value of of 0.006) on the other hand, one major consideration is this
cohort had an increase in weight gain (similar to another study conducted on Rosiglitazone.)
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Monotherapy with Metformin captured glycemic control in only half the children, while Metformin with
lifestyle change showed no clinical significant differences. Not to decrease the importance of lifestyle
changes in this population, the researchers did find this group to have a decrease in the percentage of
overweight children..
At the time this study was conducted, Rosiglitazone was restricted due to potential
complications of heart attacks. However since November 2013, the ban has since been lifted and
medication is back on the US market. Besides cardiac complications, there is also another potential
complication with the decrease of bone density in the use of rosiglitazone which is a major concern in
the long term use in children. Due to the potential serious complications, in October of 2013, the FDA
denied the drug manufacturers petition to include Rosiglitazone as an optional treatment for children.
Although Rosiglitazone/Metformin showed significant glycemic control compared to the other
two groups, potential weight gain, decrease in bone density, and cardiac complications are of major
concern. In conclusion, the use of Rosiglitazone for diabetic therapy is too risky for use in children and
adolescents, metformin is the only safe option for therapy.
The use of physical activity and dietary changes to decrease incidence of diabetes in
American Indian children and adolescents
Diet and exercise modifications have been the most effective therapy over the years for type 2
diabetes management in all age groups. Research has proven that through exercise and proper dietary
intake, weight loss occurs, and therefore, decreases the likelihood of type 2 diabetes. This is especially
important amongst children/adolescents with type 2 diabetes who are already deemed overweight and
obese.
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In 2009, Fretts et al. initially focused their study on cardiovascular disease and its risk factors
on American Indians but chose to expand their research further when statistical significance between
diabetes and exercise was found. The focus of the study then shifted from cardiac risk factors to
physical activity and incidence of diabetes amongst American Indians. This longitudinal study
(19891999) followed 1,651 subjects and encompassed 13 various American Indian tribes across four
states. The authors addressed physical activity limitations and the increase risk of diabetes by excluding
participants with other comorbidities. A baseline physical examination, smoking history, family history of
DM2, BMI, BP, and blood levels (HbA1C, oral glucose tolerance test, fasting glucose) were acquired.
A physical activity questionnaire was given during the study which measured the amount of hours per
week, type of leisure activities, and the perceived intensity of the exercise (moderatesevere). Some of
the strengths for this study include the use of a large sample size of 1,651, its longitudinal nature (10
yrs), and the use of Cox model (sensitive instrument) to observe the association between diabetic
incidences and physical activity. Although the study was strong, there were also weaknesses which
included the use of self reporting of physical activity to define intensity, as well as the lack of numerical
value to perceived activity using “moderate to high ”. Another limitation is that the research only
evaluated thirteen tribes in four states and focused solely on adults. Overall, the data was found to be
statistically significant (at 95% confidence interval) between those with no activity and the incidence of
diabetes. At the completion of the study, it was determined that those American Indians that were
physically inactive were at higher risk of diabetes than the general population.
As for dietary considerations, a metaanalysis by Malik, et.al. from 2010 evaluated eleven
prospective cohort studies on the topic of sugar sweetened beverages (sodas, fruit, energy, vitamin
water drinks) and the connection to metabolic syndrome and type 2 diabetes. The purpose of this study
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was to connect amount of daily sugar sweetened beverages intake to rate of type 2 diabetes. The meta
analysis data included a large sample size of 310,819 participants and the use of independent
metaregressions to adjust for total energy which both strengthen the study. Another strength was the
study’s evaluation for potential bias (using Begg and Eggers test) and use of longitudinal studies ranging
from 420 yrs in length. There are weaknesses that exist within this meta analysis including a few studies
that did not define their serving size (even though it is assumed to be 12 ounces) which may over or
underestimate the sugar sweetened beverage intake levels, and therefore, skew the results. Overall, the
meta analysis study was clinically significant in the data for connecting sugar sweetened beverages and
diabetes had a (95% CI) p value of 0.003. The results concluded individuals consuming 12 servings of
sugar sweetened beverages daily have a 26% greater risk of developing type 2 diabetes compared to
those who consume <1 serving a month.
Another meta analysis in 2011 by Waters, et.al. aimed to determine the most efficient
interventions for weight loss in obese children. The majority of the thirty seven studies were in the school
setting (for less than 12 months) and evaluated close to 28,000 children. The researchers chose studies
with the same objective measurement tools in order to create legitimacy; these inclusion criteria included:
BMI, percentage of body fat, and waist circumference. Although many of the studies used these
measurement tools, others did not, taking away some validity to the data. Another limitation is the
majority of studies were not randomized, which the authors believed could have possibly led to bias.
Most of the studies evaluated were able to state their own limitations (ie missing data or not having
100% participation all the time). Overall, the research did determine several interventions to be efficient
in multiple studies including integration of diet and exercise programs into school led curriculum. Other
successful interventions included more exercise during the school week, better quality food available to
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students, encouragement by teachers to promote health improvements, involvement of parents to carry
over school based education into the home, and the ability for children to decrease screen time.
In conclusion, diet and exercise still play an important role in the management of type 2
diabetes. Integration of specific scientifically proven interventions can be instrumental in decreasing
obesity, therefore, limiting diabetes in children/adolescents.
Specific Diet and Exercise Considerations for the American Indian Youth
Just as important as diet and exercise regiments are important in the general diabetic population,
so are culturally specific considerations of American Indians and diabetes. Many studies suggest in
order to maintain a set diet and exercise regimen one must have the means to do so. Many American
Indian youth are plagued by limited resources and culturally specific diet options (ie far grocery stores).
Although the following studies are restricted, it is still important to incorporate ethnic considerations in
the overall protocol for the patients practical adherence.
The article by Gittelsohn, et. al. 2011 investigated three separate peer reviewed case studies,
completed within various American Indian tribes, that focused on the implementation of lifestyle changes
(ie diet, exercise, access to healthy foods) as a means to combat chronic illnesses. The three case
studies consisted of the Pathways trial, the Apache Healthy Stores programs, and the Zhiwaapenewin
Akino’maagewin trial. All three studies were peer reviewed and sponsored by well established
organizations: the National Heart, Lung, and Blood Institute, the US Dept of Agriculture, and the
American Diabetes Association. The focus for all studies were to implement environmental changes for
children as a means to combating chronic disease epidemic in different geographical settings. All were
longitudinal studies (28 years in length) and took place at various American Indian reservations around
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the country. Many limitations were present including the small sample size and the presumptive result
from the qualitative studies. The interventions included eating more meals in the home versus fast food,
incorporating spirituality into plan, and use of community and intergenerational support to push health
based programs.The results of the study interventions were considered only moderately successful due
to limited access to grocery stores within the region (with no means for transportation to supermarkets
or farmers markets) and lacking adequate support in the home setting. Overall, the interventions
appeared to have more of a success rate when functioning with community lead interventions versus
individual programs. The use of school based programs appeared to have the largest influence on
American Indian children/ adolescents more than interventions in the home setting.
Another study addressing cultural considerations is Bachar’s 2009 research which evaluated the
efficiency of the CDC sponsored REACH program (Racial and Ethnic Approaches to Community
Health 2010) within the Eastern Cherokee Indians community. The interventions incorporated three
separate subsections of the community: elementary school education, work instituted interventions for
adults, and church driven health promotion for the community. The funding allowed multiples levels of
interventions including reaching out into the community with the use of television advertising and
broadcasting a documentary series on diabetes. The research was limited by the majority of the 800
participants being children, as well as there being no inclusion/exclusion criteria identifiable within the
study.The research used a nonlinear, multilevel community based approach which appears to be key in
executing and sustaining lifestyle changes for diabetics in the American Indian community. The subjective
data, although not generalizable, is helpful in determining potentially useful culturally based interventions.
The results did appear to be clinically significant with a high level of participation (>94% amongst
community members) and high number of participants achieving set individual goals which suggests a
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greater understanding of healthy lifestyle choices of diet and exercise.
In conclusion, American Indian adolescents are at a higher risk of developing type 2 diabetes
than the general population. For adolescents with type 2 diabetes, it is imperative to provide a safe and
adequate treatment plan in order to prevent further progression and complications from the disease.
According to the most recent evidence based research, the use of HbA1c should be used to
titrate the recommended therapies of medications (Metformin), diet alterations, and increase in exercise.
Current guidelines suggest family and community involvement in diet and exercises plans play an
important role in improving the health of children and adolescents. Through these twelve peer reviewed
research studies on diabetes, a standardized protocol has been created to assist Nurse Practitioners in
the care of adolescent American Indians.
Description of Standardized Protocol
For Nurse Practitioners to perform medical duties and treat patients accordingly, a standardized
protocol is required by the California Board of Nursing’s Nurse Practice Act (BRN, 2014). The
development of the standardized protocol for the treatment American Indian adolescents with
asymptomatic type 2 diabetes was executed collaboratively and approved by the Interdisciplinary
Practice Committee (IDPC) whose members consist of nurse practitioners (NP), registered nurses
(RN), physicians (MD), and administrators all conforming to all 11 steps of the standardized procedure
as specified in Title 16, Section 1474 (BRN, 2014). The type 2 diabetes treatment protocol is to be
stored in a manual, including the signed approval sheets, and should be reviewed annually to ensure
protocol is updated based on changes made by the IDPC.
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Criteria for Screening
Initially the practitioner should decipher whether an adolescent meets certain criteria that may
predispose him/her to type 2 diabetes. Evaluation of commonly seen criteria is crucial in determining
whether or not an asymptomatic American Indian adolescent needs to be screened for type 2 diabetes.
The most significant indicator of type 2 diabetes in an adolescent is being overweight or obese. Over the
last 30 years, obesity has tripled among youth ages 619 years old and has proven to be more
prominent amongst minorities compared to non hispanic whites (Liu, 2010). An overweight individual is
defined as having a weight between the 85th95th percentile for age and sex and an individual that is
above the 95th percentile is considered obese (ADA,2013). The strong correlations between obesity
and type 2 diabetes should not be overlooked. A recent cohort study echoed this when it concluded
children/adolescents between the ages of 319 years old previously diagnosed with type 2 diabetes,
10.4% were overweight and 79.4% were obesity (Lui, 2010). These statistics display the importance
weight plays in the consideration of a diabetes diagnosis in the youth.
According to the ADA consensus statement, the criteria for when to consider testing in an
asymptomatic adolescent includes being overweight/obese and two of the following risk factors: a
mother having gestational diabetes, a familial link (first or second degree relative with diabetes),
being of a certain ethnic background, and/or any symptoms of insulin resistance. In the case of
adolescents with type 2 diabetes in the US, greater than 75% of this population have at least one first or
second degree relative with diabetes (Rosenbloom, 2009). Ethnic considerations are also of concern
especially in high risk groups: American Indians, African Americans, Latinos, Asian Americans, Pacific
Islanders, all of which are more predisposed to having diabetes. Comparing prevalence rates within
these ethnicities, a recent study determined the American Indian population to have the highest diagnosis
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rate at 76% followed by Asian Americans at 40%, African Americans at 33%, 22% for Latinos, and
only 6% for nonHispanic whites. (Liese, 2006). Insulin Resistance Syndrome, also known as metabolic
syndrome, is the final criteria to consider during a diabetic screening . Insulin resistance consists of signs
and symptoms that include one or all of the following: acanthosis nigricans, hypertension, dyslipidemia,
polycystic ovarian syndrome, and obesity (Copeland, 2013).
History
Nurse practitioners should take a comprehensive history, which includes family and social
history, when evaluating for diabetes amongst juveniles. According to ADA guidelines, the age of
assessment for diabetes should begin at age 10 or at onset of puberty (if occurs younger than 10) and
every three years after initial assessment (ADA, 2013). In a large demographic study, presentation of
type 2 diabetes mellitus peaks around the age of 14 (Imperatore, 2012). It is also important to
recognize that female American Indian adolescents have a higher likelihood of having diabetes
compared to males (Rosenbloom, 2009).
As previously mentioned, consideration of a family history is an important factor in the
recognition of diabetes. A connection between an adolescent whose mother had gestational diabetes
and/or a first degree relative with diabetes significantly increases the likelihood he/she will have the
disease as well. In addition to family history, a psychosocial assessment with special attention on
emotional state, eating disorders, and substance abuse should be complete. “Emotional and behavioral
disorders, particularly depression, have been associated with diabetes” (Gahagan, 2013). Assessment
of psychological needs should be assessed, and if needs are identified, a prompt referral to psychologist
or psychiatrist may be warranted.
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Comorbidities
It is important when making a diagnosis of type 2 diabetes that potential comorbidities also be
considered, evaluated, and treated to ensure the adolescents longevity. The health complications
associated with type 2 diabetes include hypertension, hyperlipidemia, sleep apnea, orthopedic
complications (fractures), hepatic steatosis, depression, heart disease, and/or stroke. Microvascular
complications such as renal disease, peripheral neuropathy, and retinopathy, all of which if left untreated
could potentially lead to kidney failure, amputations, and/or blindness (ADA,2013). Studies have shown
American Indians are genetically predisposed to having a higher rate of complications from diabetes,
more than any other single ethnic group. Higher rates of ESRD, lower limb amputation, and heart
disease have been documented among American Indians with type 2 diabetes (O’Connell, 2010).
Statistics have shown American Indians are more likely to have renal failure and ten times more likely to
have amputation than other adults (O’Connell, 2010). Mental disorders (depression and anxiety) are
also twice as prevalent in the American Indian versus the general US population (O’Connell, 2010)
The mortality burden among American Indians with type 2 diabetes exceeds the insured United
States population by an overwhelming 50% (O’Connell, 2010). Although the statistics are all regarding
adult American Indians, as a healthcare provider caring for an adolescent, it is important to predict
potential complications if the diabetes is not well managed at a young age. Heart disease and strokes are
24 times higher in those with diabetes and two out of three people with type 2 diabetes will die of one
of those illnesses (O’Connell, 2010). Early management of diabetes in the youth can “profoundly
affecting their productivity, quality of life, and life expectancy” (Imperatore,2012). It is imperative to
incorporate comorbidity monitoring and prevention into the management of the diabetic youth.
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 22
Physical Examination
During the initial history and physical examination, the nurse practitioner should assess for the
presence of common primary and secondary symptoms that may be found in a patient with type 2
diabetes.
Although many documented cases of diabetes in adolescents present asymptomatically, it is
advantageous to be aware of classic symptoms of diabetes that may be present during the initial visit.
Typical symptoms for both type 1 and 2 diabetes include polyuria, polydipsia, blurred vision, recurrent
infections, or more critical symptoms when the patient presents with diabetic ketoacidosis (DKA) or
hyperglycemic hyperosmolar nonketotic (HHNK) symptoms (ADA, 2013). Depending on the extent of
symptoms, immediate medical care in an acute setting may be warranted. The severity of presentation
will determine course of action and may affect the choice in initial treatment. Symptoms like early onset
puberty, acanthosis nigricans, frequent infections (candida) may also be present in the juvenile with type
2 diabetes (Gahagan, 2013). For purposes of this protocol, the focus will only be on the presenting
adolescent whom have minimal or no symptomatology of type 2 diabetes.
During the physical exam for the diabetic adolescent, it is important for the nurse practitioner to
assess for any common micro or macrovascular complications that can ensue from diabetes.
Hypertension could occur with some adolescents and should be evaluated for every 3 months. If
hypertension is present and he/she is unable decrease blood pressure to <130/80 with lifestyle
modification, the use of ACE inhibitors or ARBs may be necessary (IHS,2012) Other common
problems that need to be evaluated are skin abnormalities, peripheral vascular circulation, kidney
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 23
complications, vision changes, and gum problems (IHS, 2012).
The skin should be assessed annually for secondary symptoms that may be present in a diabetic
patient include acanthosis nigricans, hirsutism, tinea, and acne (Gahagan, 2013). Visual foot inspection
and pedal pulses should also be done every 3 months with a more in depth analysis annually of nail
inspection and a thorough neurologic examination to test sensation using a monofilament tool (See
Appendix C for detailed foot screening) (ADA, 2013).
Focused annual assessments for diabetic adolescents require not only physical examinations but
also annual lab evaluation and specialized referrals. Nephropathy is a large concern amongst long
standing unmanaged diabetics. Annual screening of microalbuminuria with a random spot urine should
be done to check the albumin/creatinine ratio to rule out kidney damage. (ADA, 2013). Referral to a
nephrologist would be important if nephropathy is present.
A fundoscopic eye exam should also be complete along with a dilated eye exam by an
ophthalmologist or optometrist at diagnosis, and then annually thereafter, to manage or rule out
retinopathy (IHS, 2012). Due to potential high glucose levels, another consideration is gum
complications which is also a common problem amongst diabetics, annual dental exams are
recommended (ADA, 2013).
Nurse practitioners need to have heightened awareness to both potential and actual
complications of type 2 diabetes amongst American Indian youth during initial physical examination as
well as during each consecutive visit.
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 24
Diagnosis
According to all the major diabetic organizations: American Diabetic Association, International
Society of Pediatric/ Adolescent Diabetes, and American Academy of Pediatrics a diagnosis must meet
one of the following criteria: A fasting plasma glucose (FPG) is > or = 125 mg/dl (7.0 mmol/l), an oral
glucose tolerance test (OGTT) with a 2 hr postprandial plasma glucose > or = 200 mg/dl (11.1
mmol/L), or symptoms of diabetes AND a random plasma glucose > or = 200 mg/dl (11.1 mmol/L)
(ADA,2013).
Hemoglobin A1c (HgbA1c) is another powerful tool in the assessment of long term
management of glycemic levels and can be a good predictor of diabetic related complications. Although
HgbA1c is not a proficient diagnostic tool in the young, it is still an efficient way to monitor how
adolescents maintain their diabetic regimens. HgbA1c should be checked every three to four months
until a goal of < or = 7.0% is achieved (ADA, 2013). Along with HgbA1c, fasting blood glucose (FBG)
of < or = 126 mg/dl can also be used to adjust current therapy (Pettit,2009).
The American Diabetic Association also recommends other tests to monitor and prevent
diabetes related complications, including lipid and kidney lab evaluations. A fasting lipid profile with a
goal of less than 100 mg/dl is imperative to prevent dyslipidemia that could increase cardiovascular
disease risk factors in the adolescent. Microalbuminuria should also be checked using urine
albumin/creatinine ratio (UACR) through a random urine sample (normal <30 mg/g, micro 30300
mg/g, macro >300 mg/g) to rule out kidney complications. These test should be performed at diagnosis
and then annually thereafter (See Appendix B for Comprehensive Care Chart).
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 25
Treatment
Treatment may vary depending on the adolescent however, all diabetic regimens include lifestyle
modifications in the treatment plan. Diet and exercise improvements should be the first line treatment of
adolescents with type 2 diabetes (ADA, 2013).
Change in caloric intake and choice of food/beverage intake can significantly improve diabetes.
According to American Association of Pediatrics (AAP) because those younger than 20 are still
growing, restriction of calories should be no less than 1200 kcal (Copeland, 2013). Other dietary
changes should include an increase in the number of fruits and vegetables daily and a decrease in the
amount of high fatty food consumption (ADA, 2013). Over the last ten years, sugar sweetened
beverages have been on the rise in schools and home settings. A recent study suggests by decreasing
intake of sugar sweetened beverages there can be a marked difference in weight, therefore, creating a
reduction in diabetes prevalence (Malik, 2010). Although not always possible, promotion through
community programs that encourage good eating habits has proven to have a very positive response
especially in the American Indian community (Bachar, 2009).
Besides diet, evidence suggests that an increase in physical activity both in the home and school
setting decreases weight and prevalence of type 2 diabetes. According to AAP, moderate to vigorous
exercise for 60 minutes a day is recommended for adequate response for a diabetic adolescent
(Copeland, 2013). Studies suggest that the more exercise is introduced during school hours, the bigger
the positive impact is on the amount of exercise completed (Waters, 2011). Peer based activities
appear to enhance better adherence and encourage better weight loss results (Copeland, 2013).
A very important component of treatment that is often overlooked is the involvement of family.
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 26
Parent encouragement and participation in exercise has proven to be much more successful than relying
on a child to have self motivation (Gittelsohn, 2011). Beyond the home setting, promotion of exercise
through community involved programs that advocate for exercise have been shown to be immensely
successful (Bachar, 2009). Besides encouragement of exercise it is also important, especially in the
electronic age today, to discourage overuse of screen time which includes television, phone, internet,
video games, etc. Decrease in screen time encourages more involvement in other more productive
activities (Waters, 2011).
Although diet and exercise are the ideal way to manage type 2 diabetes, sometimes adolescents
are not able to achieve FBG and HbA1c goals through lifestyle modification and should be placed on
medication to prevent long term health complications from type 2 diabetes.There is a heightened need
for further research supporting medication options in the child/adolescent populations. At this time, due
to safety and efficacy concerns, clinical trials on the issue are limited and warrant further evaluation in the
future. At this time, Metformin is the only medication to be safe and effective in the treatment of
adolescents with type 2 diabetes (Zeitler, 2012). Metformin should be started at 500 mg by mouth
every day, titrating up every 12 weeks (as necessary) for a max dose of 2000 mg daily (in divided
doses: 1000 mg twice a day).
Whatever treatment choice is made, education on what diabetes is and how it impacts him/her
needs to be incorporated into all treatment plans. Education needs to include blood glucose monitoring ,
nutrition, physical activity, emotional support, stress management, support needs, and family support.
Family appears to have a substantial role within the American Indian culture and disease
prevention. A provider should observe the resources within the home such as availability of healthy food
choices, parent literacy level, cultural beliefs about diabetes, and family understanding about the disease
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 27
when considering the overall treatment plan (Gahagan, 2013). Inclusion of both diabetic adolescent
along with an involved family member will help drive successful management of diabetes.
In most cases, type 2 diabetes will be a life long ailment with life limiting consequences if not
managed properly. It is important to prepare adolescents as they transition into adulthood to
appropriately manage their own diabetes. Many adolescents have difficulty bridging into solo diabetic
management and tend to stop managing their own disease when they live independently of their support
system. If educational independence is not part of the overall treatment plan, many adolescents may be
lost to the health care system when they finally reach adulthood.
Follow up
Primary care providers should foresee actual and potential problems that may arise in a disease
process. When a diagnosis of a diabetes in an adolescent is made, it creates an important responsibility
for the nurse practitioner involved to appropriately manage care. The nurse practitioner should
collaborate with an MD and make referrals as deemed necessary. It is ideal with lifelong illnesses such
as diabetes to work in partnership with disciplines as needed including but not limited to collaborating
MDs, including diabetes educator, dietitian, social worker, psychologist/psychiatrist, endocrinologist,
nephrologist, optometrist/opthamologist, and/or dentist. Each plan should be individualized and
depending on the resources available. It is crucial to work with the patient, their family, and all
disciplines involved to develop a care plan that speaks to individual adolescents needs.
Conclusion
The ultimate goal of treatment for the type 2 diabetic adolescent is to maintain homeostasis of
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 28
glucose levels and prevent life limiting complications. Through the use of commonly used assessment and
monitoring techniques, preventing progression of diabetic illness is plausible. It is imperative for the
Nurse Practitioner to follow steadfast assessment and diagnostic techniques to appropriately and
sufficiently monitor and treat type 2 diabetes in the American Indian adolescent. Use of this protocol will
ultimately contribute to the overall health of the young diabetic and help direct the Nurse Practitioner to
the best possible care for this population.
Appendix A
Protocol for Management of Type 2 Diabetes in American Indian Adolescents Ages 1319
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 29
I. Develop and Review
A. The development of the standardized protocol for the treatment American Indian
adolescents with asymptomatic type 2 diabetes was executed collaboratively and approved
by the Interdisciplinary Practice Committee (IDPC) whose members consist of nurse
practitioners (NP), registered nurses (RN), physicians (MD), and administrators conforming
to all 11 steps of the standardized procedure as specified in Title 16, Section 1474 (California
BRN, 2014).
B.The type 2 diabetes treatment protocol is to be stored in a manual and include the date and approval
sheets signed by the individuals protected by the standardized procedure.
C. The standardized procedure need to be reviewed annually and updated based on changes made by
IDPC
D. Any alterations to the diabetes protocol must be approved IDPC and include an approval sheet
II. Scope and Setting of Practice
A. Nurse Practitioners may implement the following duties within their speciality areas and consistent
with their credential and experiences: assessment, management, treatment of episodic illness, chronic
illness (ie diabetes), common health promotions, and general evaluation including but not limited to labs,
scans, recommended diets as well as possible referral to a diabetic clinic if indicated (California BRN,
2014)
B. Standardized procedures, such as medication regimens, are to be performed in local clinics by the
nurse practitioners where physicians are available for consult in person or by phone (California BRN,
2014).
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 30
C Physician consultation should be obtainable in individual protocols and under the following cases:
1. Emergent condition requiring immediate medical interventions (after initial stabilization)
2. Acute decompensation of patient
3. Situation not resolved by intervention
4. History, physical examination, or labs not consistent with clinical depiction
5. Upon request of patient, RN, or supervising MD (California BRN, 2014).
III. Qualifications and Evaluations
A. Each nurse practitioner performing standardized procedures must possess a current RN license in the
state of practice, graduate from an accredited university nurse practitioner program, and hold a
certification for the California BRN
B. Evaluation of the Advance Practice Nurses’ competency will be evaluated as follows:
1. Initial: Evaluation by the nursing manager at 3, 6, and 12 months intervals by the
use of feedback from colleagues, MD’s, and chart reviews
2. Routine: Annually after initial evaluation continuing feedback and chart reviews
3. Followup: Areas where increased proficiency is required, nurse managers will
continue to evaluate until acceptable competency level is obtained.
IV. Protocol
A. History: A detailed history including evaluation of ethnicity, family history, and health history should be done to consider if further testing is needed. Psychosocial assessment should also part the history.
1. Frequency: a. Initial: Assessment for type 2 diabetes in children/adolescents should begin at the age of 10 or at the onset of puberty (if earlier) and every three years after initial assessment if no diabetes present.
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 31
2. Risk Factors: Further testing should be considered if the adolescent is obese (>95th percentile for age and sex) and has two or more of the following risk factors:
Race/Ethnicity: American Indians, African Americans, Latinos, Asian Americans, Pacific
Islanders are considered high risk for early onset type 2 diabetes. Family history of first or second degree relative with type 2 diabetes Maternal history of gestational diabetes Low birth weight Signs/symptoms of insulin resistance Common conditions associated with insulin resistance including hypertension,
acanthosis nigricans, dyslipidemia, or polycystic ovarian syndrome
3. Psychosocial Assessment: a. Depression (unmanaged depression, suicidal ideations) b. Assess for substance abuse (alcohol, tobacco, drugs) c. Eating disorders (binge eating, bulimia)
B. Physical Examination: Documentation of initial physical examination should note the presences of
diabetes and monitor closely for any changes that may indicate further progression of disease
1. Blood pressure/pulse: to monitor for potential cardiac complications
2. Height/Weight/BMI: should be taken and calculated every visit
3. Any macro or microvascular changes: with eye exam such as of retinopathy, test extremity
sensation for diabetic neuropathy, observe for signs and symptoms of organ damage (especially
kidneys) are considered manifestations of diabetic complications and should be referred to
appropriate specialists
C. Laboratory:
1. Diagnosis: 2 hr OGTT with a plasma glucose of > or = to 200 mg/dl or a FBG > or =
126
2. Monitoring: Every 3 months recheck to achieve a goal FBG of < or = 126 mg/dl and
HbA1c of < or = 7.0%. Adjust current therapy regimen if goal not achieved
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 32
D. Treatment
1. Lifestyle modifications: Diet and exercise improvements should be the first line treatment
of adolescents with type 2 diabetes
a. Diet: Change in caloric intake and choice of food/beverage intake can significantly
improve diabetes.
i. Restriction of calories to no less than 1200 kcal
ii. Increase of fruits and vegetables daily, decreasing high fatty food
consumption
iii. Decreasing intake of sugar sweetened beverages
iv. Promote community programs that encourage good eating habits
b. Exercise: Evidence suggests the increase in physical activity both in the home
and school setting decreases weight and prevalence of type 2 diabetes
i. Moderate to vigorous exercise for 60 minutes a day
ii. More exercise during school hours
iii. Decrease in screen time
iv. Parent encouragement and participation in exercise
v. Promote community programs advocate exercise
2. Medication: Adolescents that are not able to achieve FBG and HbA1c goals
through lifestyle modification should be placed on medication to prevent long term
health complications from type 2 diabetes
a. Metformin is the only medication to be safe and effective treatment in
adolescents.
i. Metformin 500 mg po q day, titrating up q 12 weeks (as necessary) for a
max dose of 2000 mg daily (in divided doses: 1000 mg BID)
E. Follow up: Once a diagnosis of type 2 diabetes has been made, the frequency of history/ physical
exam is every 3 months until metabolic control has been made then may decrease to every 612
months.
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 33
F. Referrals: Depending on the complication of type 2 diabetes, potential referral include:
1. Collaboration with MD: In complex cases of adolescent type 2 diabetes
2. Endocrinologist: Inability to manage diabetes with standard guidelines
3. Diabetic Educator: Education for adolescents on management of diabetes
4. Ophthalmologist: Annually and with any visual changes
5. Psychiatrist: Possible depression (commonly seen in the adolescent diabetics)
V. Policy (Scope and setting of the practice)
A. Functions: To provide guidance in the treatment of asymptomatic type 2 diabetes
in American Indian adolescents
B. Circumstances for when protocol comes into practice
1. Setting: Outpatient clinic
2. Supervision required: Collaboration with consulting MD
3. Patient condition/diagnosis: Adolescents with asymptomatic type 2 diabetes
VI. Development and Approval of the Standardized Protocol
This protocol was derived from the collaborative work of nurse practitioner with physician or designee
and approved by the clinics governing body: Chief of Nursing Officer, Chief of Medicine, and Medical
Group Administrator.
VII. This Diabetic Protocol with be reviewed and potentially revised annually
Review Date: Revise Date:
Review Date: Revise Date:
Review Date: Revise Date:
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 34
VIII. Signatures of Approval for Diabetic Protocol:
Chief of Nursing Officer: full name & date
(signature)
Chief of Medicine: full name & date
(signature)
Medical Group Administrator: full name & date
(signature)
Nurse Practitioners authorized to perform Diabetic Protocol:
Nurse Practitioner: Full name & date
(signature)
Nurse Practitioner: Full name & date
(signature)
Nurse Practitioner: Full name & date
(signature)
Appendix B
Comprehensive/Global Care of youth with Type 2 Diabetes
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 35
(ADA, 2011)
Appendix C
Foot screening for youth with diabetes
STANDARDIZED PROTOCOL: TREATMENT OF DIABETES IN ADOLESCENTS 36
(Gahagan, 2013)
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