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Sarcopenia, characterised by loss of skeletal muscle mass and strength with age, is a significant risk factor for loss of mobility and independence. The combination of low muscle mass and high fat mass in sarcopenic obesity is associated with particularly poor outcomes. Micronutrient deficiencies can occur alongside obesity despite total energy surplus, and older individuals may be at greater risk of deficiency. Research suggests vitamin C is important for musculoskeletal health, but the relationship with obesity is underexplored.
This study aimed to investigate associations of plasma vitamin C with obesity status and explore the relationship with the sarcopenic risk factor, low skeletal muscle mass.
EPIC-Norfolk cohort study data were analysed. Bioelectrical impedance analysis-estimated fat free mass (FFM; a proxy for skeletal muscle mass) was adjusted for BMI to give a scaled variable, FFMBMI. A ‘low muscle mass’ category was defined as individuals with the lowest 10% FFMBMI, representing those at high risk of sarcopenia. Plasma vitamin C (ascorbic acid) concentrations were categorised as inadequate (< 50micromol/L) or adequate (≥ 50micromol/L), and obesity status as non-obese (< 30kg/m2) or obese (≥ 30kg/m2).
Individuals were grouped according to vitamin C and obesity status: 1, non-obese and adequate vitamin C; 2, non-obese and inadequate vitamin C; 3, obese and adequate vitamin C; and 4, obese and inadequate vitamin C. Using logistic regression, the odds ratio (OR) of each vitamin/obesity status group was calculated in relation to membership of the ‘low muscle mass’ category. Analyses were sex-stratified and adjusted for age, smoking status, physical activity, social class, menopausal and HRT status in women, statin use, and corticosteroid use.
Data were analysed for 5903 men (mean 62.9 years, SD 9.0) and 7416 women (mean 61.5 years, SD 9.0). Prevalence of vitamin C inadequacy was higher in obese vs non-obese individuals (men 45.8% vs 33.0%; and women 26.0% vs 15.3%). The odds of ‘low muscle mass’ were higher in all vitamin/obesity status groups vs group 1, but the greatest odds were seen for group 4 (combined obesity and inadequate vitamin C) in men (OR 16.5, 95% CI: 12.6–21.6; p < 0.001) and women (OR 30.2, 95% CI: 23.0–39.8; p < 0.001).
In this cohort of older individuals higher prevalence of vitamin C inadequacy is associated with obese individuals. Of importance to musculoskeletal health and our understanding of sarcopenia is the observation that while vitamin C inadequacy and obesity are each independently important, their coexistence is a particularly strong predictor of sarcopenic risk.
Carotenoids are found in abundance in fruit and vegetables, and may be involved in the positive association of these foods with bone health. This study aimed to explore the associations of dietary carotenoid intakes and plasma concentrations with bone density status and osteoporotic fracture risk in a European population. Cross-sectional analyses (n 14 803) of bone density status, using calcaneal broadband ultrasound attenuation (BUA) and longitudinal analyses (n 25 439) of fracture cases were conducted on data from the prospective European Prospective Investigation into Cancer and Nutrition-Norfolk cohort of middle-aged and older men and women. Health and lifestyle questionnaires were completed, and dietary nutrient intakes were derived from 7-d food diaries. Multiple regression demonstrated significant positive trends in BUA for women across quintiles of dietary α-carotene intake (P=0·029), β-carotene intake (P=0·003), β-cryptoxanthin intake (P=0·031), combined lutein and zeaxanthin intake (P=0·010) and lycopene intake (P=0·005). No significant trends across plasma carotenoid concentration quintiles were apparent (n 4570). The Prentice-weighted Cox regression showed no trends in fracture risk across dietary carotenoid intake quintiles (mean follow-up time 12·5 years), except for a lower risk for wrist fracture in women with higher lutein and zeaxanthin intake (P=0·022); nevertheless, inter-quintile differences in fracture risk were found for both sexes. Analysis of plasma carotenoid data (mean follow-up time 11·9 years) showed lower hip fracture risk in men across higher plasma α-carotene (P=0·026) and β-carotene (P=0·027) quintiles. This study provides novel evidence that dietary carotenoid intake is relevant to bone health in men and women, demonstrating that associations with bone density status and fracture risk exist for dietary intake of specific carotenoids and their plasma concentrations.
The objective of the present study was to investigate associations between sugar intake and overweight using dietary biomarkers in the Norfolk cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC-Norfolk).
Prospective cohort study.
EPIC-Norfolk in the UK, recruitment between 1993 and 1997.
Men and women (n 1734) aged 39–77 years. Sucrose intake was assessed using 7 d diet diaries. Baseline spot urine samples were analysed for sucrose by GC-MS. Sucrose concentration adjusted by specific gravity was used as a biomarker for intake. Regression analyses were used to investigate associations between sucrose intake and risk of BMI>25·0 kg/m2 after three years of follow-up.
After three years of follow-up, mean BMI was 26·8 kg/m2. Self-reported sucrose intake was significantly positively associated with the biomarker. Associations between the biomarker and BMI were positive (β=0·25; 95 % CI 0·08, 0·43), while they were inverse when using self-reported dietary data (β=−1·40; 95 % CI −1·81, −0·99). The age- and sex-adjusted OR for BMI>25·0 kg/m2 in participants in the fifth v. first quintile was 1·54 (95 % CI 1·12, 2·12; Ptrend=0·003) when using biomarker and 0·56 (95 % CI 0·40, 0·77; Ptrend<0·001) with self-reported dietary data.
Our results suggest that sucrose measured by objective biomarker but not self-reported sucrose intake is positively associated with BMI. Future studies should consider the use of objective biomarkers of sucrose intake.
Dietary supplements are commonly consumed but may not be beneficial for everyone. It is known that supplement users have healthy behaviour characteristics but until now concordance between spouses living in the same household has not been investigated and concordance may be an important behavioural determinant.
Prospective cohort study, cross-sectional data analysis.
European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) in the UK, recruitment between 1993 and 1998.
Married (or living as married) participants sharing a household, who attended a health examination and completed a 7 d diet diary were included in the analysis (n 11 060). The age range was 39–79 years.
Nearly 75 % of the households in EPIC-Norfolk were concordant in their supplement use, with 46·7 % not using supplements and 27·0 % using supplements. Concordance increased with age; the percentage of concordant couples varied less by other sociodemographic characteristics. Participants who had a spouse who used a supplement were nearly nine times more likely to use a supplement (unadjusted). Depending on participants’ sex and type of supplement used, odds ratios for ‘supplement use by spouse’ in the prediction of participants’ supplement use varied between 6·2 and 11·7 adjusted for participants’ age, smoking status, BMI, social class, education level and physical activity.
‘Supplement use by spouse’ is an independent and the strongest predictor of participants’ supplement use. This phenomenon can be useful in the design of studies and health interventions; or when assessing risk of excessive intake from dietary supplements.
Consumption of a Mediterranean diet (MD) and genetic variation in the glucokinase regulatory protein (GCKR) gene have been reported to be associated with TAG and glucose metabolism. It is uncertain whether there is any interaction between these factors. Therefore, the aims of the present study were to test the association of adherence to a MD and rs780094 (G>A) SNP in the GCKR gene with the markers of cardiometabolic risk, and to investigate the interaction between genetic variation and MD adherence. We studied 20 986 individuals from the European Prospective Investigation into Cancer (EPIC)-Norfolk study. The relative Mediterranean Diet Score (rMED: range 0–18) was used to assess MD adherence. Linear regression was used to estimate the association between the rMED, genotype and cardiometabolic continuous traits, adjusting for potential confounders. In adjusted analyses, we observed independent associations of MD adherence and genotype with cardiometabolic risk, with the highest risk group (AA genotype; lowest rMED) having higher concentrations of TAG, total cholesterol and apoB (12·5, 2·3 and 3·1 %, respectively) v. those at the lowest risk (GG genotype; highest rMED). However, the associations of MD adherence with metabolic markers did not differ by genotype, with no significant gene–diet interactions for lipids or for glycated Hb. In conclusion, we found independent associations of the rMED and of the GCKR genotype with cardiometabolic profile, but found no evidence of interaction between them.
Dietary interventions with flavan-3-ols have shown beneficial effects on vascular function. The translation of these findings into the context of the health of the general public requires detailed information on habitual dietary intake. However, only limited data are currently available for European populations. Therefore, in the present study, we assessed the habitual intake of flavan-3-ol monomers, proanthocyanidins (PA) and theaflavins in the European Union (EU) and determined their main food sources using the EFSA (European Food Safety Authority) Comprehensive European Food Consumption Database. Data for adults aged 18–64 years were available from fourteen European countries, and intake was determined using the FLAVIOLA Flavanol Food Composition Database, developed for the present study and based on the latest US Department of Agriculture and Phenol-Explorer databases. The mean habitual intake of flavan-3-ol monomers, theaflavins and PA ranged from 181 mg/d (Czech Republic) to 793 mg/d (Ireland). The highest intakes of flavan-3-ol monomers and theaflavins were observed in Ireland (191/505 mg/d) and the lowest intakes in Spain (24/9 mg/d). In contrast, the daily intake of PA was highest in Spain (175 mg/d) and lowest in The Netherlands (96 mg/d). Main sources were tea (62 %), pome fruits (11 %), berries (3 %) and cocoa products (3 %). Tea was the major single contributor to monomer intake (75 %), followed by pome fruits (6 %). Pome fruits were also the main source of PA (28 %). The present study provides important data on the population-based intake of flavanols in the EU and demonstrates that dietary intake amounts for flavan-3-ol monomers, PA and theaflavins vary significantly across European countries. The average habitual intake of flavan-3-ols is considerably below the amounts used in most dietary intervention studies.
The aim of the present study was to describe the energy, nutrient and crude v. disaggregated food intake measured using 7 d diet diaries (7dDD) for the full baseline Norfolk cohort recruited for the European Prospective Investigation into Cancer (EPIC-Norfolk) study, with emphasis on methodological issues. The first data collection took place between 1993 and 1998 in Norfolk, East Anglia (UK). Of the 30 445 men and women, aged 40–79 years, registered with a general practitioner invited to participate in the study, 25 639 came for a health examination and were asked to complete a 7dDD. Data from diaries with data recorded for at least 1 d were obtained for 99 % members of the cohort; 10 354 (89·8 %) of the men and 12 779 (91·5 %) of the women completed the diet diaries for all 7 d. Mean energy intake (EI) was 9·44 (sd 2·22) MJ/d and 7·15 (sd 1·66) MJ/d, respectively. EI remained approximately stable across the days, but there was apparent under-reporting among the participants, especially among those with BMI >25 kg/m2. Micronutrient density was higher among women than among men. In conclusion, under-reporting is an issue, but not more so than that found in national surveys. How foods were grouped (crude or disaggregated) made a difference to the estimates obtained, and comparison of intakes showed wide limits of agreement. The choice of variables influences estimates obtained from the food group data; while this may not alter the ranking of individuals within studies, this issue may be relevant when comparing absolute food intakes between studies.
In the present study, we investigated the association between dietary intake of carbohydrates and the risk of type 2 diabetes. Incident cases of diabetes (n 749) were identified and compared with a randomly selected subcohort of 3496 participants aged 40–79 years. For dietary assessment, we used 7 d food diaries administered at baseline. We carried out modified Cox proportional hazards regression analyses and compared results obtained from the different methods of adjustment for total energy intake. Dietary intakes of total carbohydrates, starch, sucrose, lactose or maltose were not significantly related to diabetes risk after adjustment for confounders. However, in the residual method for energy adjustment, intakes of fructose and glucose were inversely related to diabetes risk. The multivariable-adjusted hazard ratios (HR) of diabetes comparing the extreme quintiles of intake were 0·79 (95 % CI 0·59, 1·07; P for trend = 0·03) for glucose and 0·62 (95 % CI 0·46, 0·83; P for trend = 0·01) for fructose. In the nutrient density method, only fructose was inversely related to diabetes risk (HR 0·65, 95 % CI 0·48, 0·88). The replacement of 5 % energy intake from SFA with an isoenergetic amount of fructose was associated with a 30 % lower diabetes risk (HR 0·69, 95 % CI 0·50, 0·96). Results of the standard and energy partition methods were similar to those of the residual method. These prospective findings suggest that the intakes of starch and sucrose are not associated, but that those of fructose and glucose are inversely associated with diabetes risk. Whether the inverse associations with fructose and glucose reflect the effect of substitution of these carbohydrate subtypes with other nutrients (i.e. SFA), their net higher intake or other nutrients associated with their intake remains to be established through further investigation.
Epidemiological studies suggest health-protective effects of flavan-3-ols and their derived compounds on chronic diseases. The present study aimed to estimate dietary flavan-3-ol, proanthocyanidin (PA) and theaflavin intakes, their food sources and potential determinants in the European Prospective Investigation into Cancer and Nutrition (EPIC) calibration cohort. Dietary data were collected using a standardised 24 h dietary recall software administered to 36 037 subjects aged 35–74 years. Dietary data were linked with a flavanoid food composition database compiled from the latest US Department of Agriculture and Phenol-Explorer databases and expanded to include recipes, estimations and retention factors. Total flavan-3-ol intake was the highest in UK Health-conscious men (453·6 mg/d) and women of UK General population (377·6 mg/d), while the intake was the lowest in Greece (men: 160·5 mg/d; women: 124·8 mg/d). Monomer intake was the highest in UK General population (men: 213·5 mg/d; women: 178·6 mg/d) and the lowest in Greece (men: 26·6 mg/d in men; women: 20·7 mg/d). Theaflavin intake was the highest in UK General population (men: 29·3 mg/d; women: 25·3 mg/d) and close to zero in Greece and Spain. PA intake was the highest in Asturias (men: 455·2 mg/d) and San Sebastian (women: 253 mg/d), while being the lowest in Greece (men: 134·6 mg/d; women: 101·0 mg/d). Except for the UK, non-citrus fruits (apples/pears) were the highest contributors to the total flavan-3-ol intake. Tea was the main contributor of total flavan-3-ols in the UK. Flavan-3-ol, PA and theaflavin intakes were significantly different among all assessed groups. This study showed heterogeneity in flavan-3-ol, PA and theaflavin intake throughout the EPIC countries.
Phyto-oestrogens have been associated with a decreased risk for osteoporosis, but results from intervention and observational studies in Western countries have been inconsistent. In the present study, we investigated the association between habitual phyto-oestrogen intake and broadband ultrasound attenuation (BUA) of the calcanaeum as a marker of bone density. We collected 7 d records of diet, medical history and demographic and anthropometric data from participants (aged 45–75 years) in the European Prospective Investigation into Cancer-Norfolk study. Phyto-oestrogen (biochanin A, daidzein, formononetin; genistein, glycitein; matairesinol; secoisolariciresinol; enterolactone; equol) intake was determined using a newly developed food composition database. Bone density was assessed using BUA of the calcanaeum. Associations between bone density and phyto-oestrogen intake were investigated in 2580 postmenopausal women who were not on hormone replacement therapy and 4973 men. Median intake of total phyto-oestrogens was 876 (interquartile range 412) μg/d in postmenopausal women and 1212 (interquartile range 604) μg/d in men. The non-soya isoflavones formononetin and biochanin A were marginally significant or significantly associated with BUA in postmenopausal women (β = 1·2; P < 0·1) and men (β = 1·2; P < 0·05), respectively; enterolignans and equol were positively associated with bone density in postmenopausal women, but this association became non-significant when dietary Ca was added to the model. In the lowest quintile of Ca intake, soya isoflavones were positively associated with bone density in postmenopausal women (β = 1·4; P < 0·1). The present results therefore suggest that non-soya isoflavones are associated with bone density independent of Ca, whereas the association with soya or soya isoflavones is affected by dietary Ca.
To examine the risk of CHD in relation to alcohol intake from three different instruments.
In the European Prospective Investigation into Cancer in Norfolk study, weekly alcohol intake was estimated from a single question in a mail-in health and lifestyle questionnaire (HLQ), a semi-quantitative FFQ, and a 7 d diet diary (7DD). Information on smoking status, physical activity, disease history, social class and medication use was reported in the HLQ. Height, weight, blood pressure and blood lipids were measured at a health check-up. The average length of follow-up was 11 years. The association between alcohol intake and incident fatal and non-fatal CHD in a nested case–control sample was calculated using logistic regression.
A total of 2151 cases of incident fatal and non-fatal CHD and 5354 controls.
The Spearman correlation values between the 7DD, FFQ and HLQ alcohol estimates ranged from r = 0·70 to 0·82 (P < 0·0001 for all r values). Alcohol intake from all instruments was inversely associated with the risk of CHD in age- and multivariate-adjusted models. The relationships between the risk of CHD and alcohol intake from the 7DD, HLQ or FFQ were not significantly different from each other (P >0·10). A marginal difference between men and women was detected for the risk of CHD in relation to HLQ alcohol intake (P = 0·065).
In conclusion, while the instruments were not uniform in their assessment of alcohol intake levels, the 7DD, HLQ and FFQ yielded similar inverse associations between alcohol intake and risk of CHD.
The objective of the present study was to investigate the influence of the single nucleotide polymorphism (rs17238540) at the 3-hydroxy-3-methylglutaryl-coenzyme A reductase gene (HMGCR) on the relationship between serum lipids and dietary fat and fibre (NSP). FFQ and pyrosequencing were used to assess cross-sectional dietary intake and HMGCR genotype in a population study with data for serum lipids available. Genotype frequencies and allele distributions for 23 011 participants were: TT 95·65 %, TG 4·29 % and GG 0·06 %; T 97·8 % and G 2·2 %. In regression analyses, the TG+GG group showed a significant positive relationship between TAG and SFA intake (+0·11 (95 % CI 0·02, 0·20) mmol TAG/l; P = 0·017; per 3 % SFA energy increase) while the TT individuals showed no change in the TAG levels related to SFA intake ( − 0·0007 (95 % CI − 0·02, 0·02) mmol TAG/l; P = 0·99). TG+GG individuals showed an inverse relationship between TAG and fibre intake higher ( − 0·14 (95 % CI − 0·22, − 0·05) mmol TAG/l than the TT group ( − 0·04 (95 % CI − 0·06, − 0·02) mmol TAG/l). In both cases the respective coefficient regressions of TAG were different between the genotype groups (Z = 2·27, P = 0·023 for SFA intake; Z = 2·19, P = 0·029 for fibre intake). Individuals carrying the G allele may show a greater response in lower TAG levels with reduced SFA intake and increased fibre intake compared with those homozygous for the T allele. The effectiveness of different dietary interventions to control serum lipids may vary according to HMGCR genotype.
To describe methods and dietary habits of a large population cohort.
Prospective assessment of diet using diet diaries and food-frequency questionnaires, and biomarkers of diet in 24-h urine collections and blood samples.
Free living individuals aged 45 to 75 years living in Norfolk, UK.
Food and nutrient intake from a food-frequency questionnaire on 23 003 men and women, and from a 7-day diet diary from 2117 men and women. Nitrogen, sodium and potassium excretion was obtained from single 24-h urine samples from 300 individuals in the EPIC cohort. Plasma vitamin C was measured for 20 846 men and women.
The food-frequency questionnaire (FFQ) and the food diary were able to determine differences in foods and nutrients between the sexes and were reliable as judged by repeated administrations of each method. Plasma vitamin C was significantly higher in women than men. There were significant (P<0.001) differences in mean intake of all nutrients measured by the two different methods in women but less so in men. The questionnaire overestimated dairy products and vegetables in both men and women when compared with intakes derived from the diary, but underestimated cereal and meat intake in men. There were some consistent trends with age in food and nutrient intakes assessed by both methods, particularly in men. Correlation coefficients between dietary intake assessed from the diary and excretion of nitrogen and potassium in a single 24-h urine sample ranged from 0.36 to 0.47. Those comparing urine excretion and intake assessed from the FFQ were 0.09 to 0.26. The correlations between plasma vitamin C and dietary intake from the first FFQ, 24-h recall or diary were 0.28, 0.35 and 0.40.
EPIC Norfolk is one of the largest epidemiological studies of nutrition in the UK and the largest on which plasma vitamin C has been obtained. Methods for obtaining food and nutrient intake are described in detail. The results shown here for food and nutrient intakes can be compared with results from other population studies utilising different methods of assessing dietary intake. The utility of different methods used in different settings within the main EPIC cohort is described. The FFQ is to be used particularly in pooled analyses of risk from diet in relation to cancer incidence within the larger European EPIC study, where measurement error is more likely to be overcome by large dietary heterogeneity on an international basis. Findings in the UK, where dietary variation between individuals is smaller and hence the need to use a more accurate individual method greater, will be derived from the 7-day diary information on a nested case–control basis. 24-h recalls can be used in the event that diary information should not be forthcoming from some eventual cases. Combinations of results utilising all dietary methods and biomarkers may also be possible.
To examine the association between fish consumption and stroke risk.
Prospective population cohort study.
Norfolk, UK cohort of the European Prospective Investigation into Cancer (EPIC–Norfolk).
Subjects were 24 312 men and women aged 40–79 years who had no previous history of stroke at baseline.
Fish consumption was assessed using a food-frequency questionnaire at baseline in 1993–1997 and stroke incidence ascertained to 2004.
A total of 421 incident strokes were identified (mean follow-up=8.5 years, total person-years=209 238). There were no significant relationships between total fish, shellfish or fish roe consumption and risk of stroke in men and women after adjusting for age, systolic blood pressure, body mass index, smoking, cholesterol, diabetes, physical activity, alcohol consumption, fish oil supplement use and total energy intake using Cox regression analyses. Oily fish consumption was significantly lower in women who subsequently had a stroke (odds ratio (OR) for consumers vs. non-consumers=0.69, 95% confidence interval (CI) 0.51–0.94, P=0.02). The trend in men was similar but not significant (OR for consumers vs. non-consumers=0.88, 95% CI 0.65–1.19, P=0.41).
There was no consistent relationship between fish consumption and stroke in this British population. Inconsistencies in the observed health effects of fish consumption in different populations may reflect different patterns and type of fish consumed and preparation methods.
To investigate the association between fruit and vegetable consumption and self-reported physical and mental functional health measured by an anglicised short-form 36-item questionnaire (UK SF-36).
Population-based cross-sectional study.
General community in Norfolk, UK.
A total of 16 792 men and women aged 40–79 years recruited from general practice population registers as part of the European Prospective Investigation into Cancer (EPIC)–Norfolk study, who completed food-frequency questionnaires in 1993–1997 and Health and Life Experiences Questionnaires 18 months later, were enrolled in the study.
Mean SF-36 physical component summary scores increased significantly with increasing total fruit and vegetable consumption in both men and women (P < 0.0001 for trend). Men and women in the top quartile of consumption compared with the bottom quartile had a significantly higher likelihood of reporting good physical health (defined as a score ≥ 55); odds ratio (OR) 1.30, 95% confidence interval (CI) 1.11–1.53 for men and OR 1.28, 95% CI 1.11–1.48 for women, after controlling for age, body mass index, smoking, education, social class, prevalent illness and total energy intake. Exclusion of current smokers and people with prevalent illness did not alter the associations.
Higher fruit and vegetable consumption is associated with better self-reported physical functional health within a general population. Increasing daily intake by two portions of fruit and vegetables was associated with an 11% higher likelihood of good functional health. Since the current average consumption of fruit and vegetables in the UK is about three portions, the recommended ‘five a day’ strategy may have additional benefit for functional as well as other health outcomes in the population.
High plasma concentrations of ascorbic acid, a marker of fruit and vegetable intake, are associated with low risk of coronary artery disease. Whether this relationship is explained by a reduction in systemic inflammation is unclear. We investigated the relationship between ascorbic acid plasma concentration and coronary artery disease risk, and in addition whether this relationship depended on classical risk factors and C-reactive protein (CRP) concentration. We used a prospective nested case–control design. The study consisted of 979 cases and 1794 controls (1767 men and 1006 women). Increasing ascorbic acid quartiles were associated with lower age, BMI, systolic and diastolic blood pressure, and CRP concentration, but with higher HDL-cholesterol concentration. No associations existed between ascorbic acid concentration and total cholesterol concentration or LDL-cholesterol concentration. When data from men and women were pooled, the risk estimates decreased with increasing ascorbic acid quartiles such that people in the highest ascorbic acid quartile had an odds ratio for future coronary artery disease of 0·67 (95% CI 0·52, 0·87) compared with those in the lowest quartile (P for linearity=0·001). This relationship was independent of sex, age, diabetes, smoking, BMI, LDL-cholesterol, HDL-cholesterol, systolic blood pressure and CRP level. These data suggest that the risk reduction associated with higher ascorbic acid plasma concentrations, a marker of fruit and vegetable intake, is independent of classical risk factors and also independent of CRP concentration.
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