Boom! Science in action. (P.S. I have sooooo totally done this. And the group crouch. I don’t know why. )
Ever felt that there’s got to be more to gaining and losing weight than just calories in/calories out? Well, it turns out the American Medical Association agrees with you. In a surprising and controversial decision – they actually went against the recommendation of their own board set up to study this issue for the past year – the AMA announced last Tuesday that they are now officially classifying obesity as a “disease” in its own right rather than just a contributing factor to other diseases like diabetes and heart disease. The semantics are important as this implies that there’s a medical dysfunction involved in weight gain and is not just a product of “eating too much and exercising too little.”
When I first read about the decision, my initial reaction – like so many of my glitchy first impressions – was a not-well-thought-out but very assured “Well about time!” But then Shape asked me to cover it and I realized I probably needed to think about it a little deeper. My original stance stems mainly from the fact that the more science discovers about the physics of weight gain in humans (and mice and monkeys), the more factors we discover are involved – things like pollution, viruses (oh yes), altitude (check out this super interesting map!), your mother’s diet while pregnant, processed foods designed to be addictive, and even estrogenic compounds in the plastic liners of your “healthy” organic beans affect people’s ability to put on weight or take it off. Then there’s the stuff we already knew about like genetics. And of course, there’s also the recent findings that thinner is not always better, health wise and that it turns out it is possible to be “overweight” and quite healthy. So when there’s so much going on – and how much more don’t we know? – then it seems insultingly reductionist to tell people “Well if you just tried harder you could lose all that weight!”
And yet what are the implications of labeling over 1/3 of the American population “ill” – as opposed to having a “condition” or “disorder” as obesity was previously defined? Will people begin to think of themselves as victims and stop trying to make healthy lifestyle changes? Does this mean that people can no longer be obese and considered healthy despite the growing body of research showing that some obese people are just as healthy or healthier than their skinny counterparts?
And how do you even define what constitutes obesity as a disease anyhow, especially when the main diagnostic criterion – the BMI or body mass index – is widely considered flawed by most medical professionals, including the AMA themselves?
When I posted about the decision (which, by the way, is not legally binding in any way – it’s just the AMA’s single, but very influential, opinion) on Facebook, I was surprised to find most of my friends were very much against calling obesity a disease.
Anna responded by pointing out that “but you can overcome those obstacles [and lose weight] if you put the work in…” And she’s right. In spite of everything, some people do manage to successfully lose weight and keep it off.
Beck added,
“I’m afraid that will lead to more demonizing of fat people in general, and it misses (again) the point that one can be fat/obese AND be healthy.”
Lizzie pointed out the ambiguity, saying, ” Nonsense. Very slippery slope…”
Lesley disagreed with the AMA on corporate grounds rather than personal ones:
“Most weight gain is a product of the wrong habits including so called ‘health foods’ – this change absolves processed ‘food’ manufacturers etc of any responsibility. I do agree with the addictive nature of these products & I believe manufacturers need to be held accountable rather than reaping their massive profits.”
Annabel pointed out the financial benefits of the decision:
“AMA defined obesity as a disease against the wishes of the scientific advisory board. why? because creating a disease is profitable. this will only further stigmatize fat people and continue to perpetuate the fallacious, though well-conditioned, belief that fat=unhealthy”
While these worries are valid says Dr. Patrice Harris, M.D. and a board member of the AMA, she adds that the distinction is important because “Recognizing obesity as a disease will help change the way the medical community tackles this complex issue that affects approximately one in three Americans. The AMA is committed to improving health outcomes and is working to reduce the incidence of cardiovascular disease and type 2 diabetes, which are often linked to obesity.”
Reading through the AMA literature and early commentary by experts, I gleaned some potential positives of the decision:
– Reduced stigma. By classifying obesity as a disease, it takes away some of the stigma from the individual. Despite much evidence to the contrary, obese people are often (unfairly) considered lazy, unmotivated or deluded. This could help both doctors and patients work together to treat it seriously rather than simply shame and blame.
– Greater access to medical benefits. Currently many treatments for obesity are not covered by most health insurers, a problem that will likely be remedied by this declaration. This opens the door for more people to be covered for things like bariatric surgery and weight loss pills but perhaps also for things like gym memberships and nutritionists.
– Research and drug funding. While the AMA’s decision has no legal authority, the “official” stamp opens it up to increased money and resources dedicated to finding a cure.
My friends saw some other benefits as well:
Melissa thought it sounded good because it might increase access to gym memberships and personal training if they were deemed “medically necessary by health insurers.
Grant pointed out this might change doctors’ attitudes towards obesity and perhaps change the way they interact with obese patients:
” Looks like it might improve the coverage for medical nutrition therapy with a registered dietitian. If I remember the research right, doctors are not very likely to ask how physically active you are on intake forms or other assessments. Hopefully this will help improve it. It has been a little while since I reviewed this http://exerciseismedicine.org/“
Sonia made an excellent point, writing,
“Also could lead to protection against employment discrimination, which isn’t there now.”
Janet, a teacher, backed up her positive reaction with actual science lesson:
“if an agent causes a disease, you can transplant the disease agent from a sick individual to a healthy individual, and cause the disease. Lab researchers can induce obesity in mice by transplanting feces from obese mice to healthy mice, suggesting that obesity is caused by whatever is in the feces.”
But I have to admit that it was Jeremy’s comment about how all eating disorders are just different sides of the same coin (or dice? I need a throwable object with more than two sides!) that made me really think the most:
“There are reasons why some people tend towards obesity just as there are reasons why other people tend toward malnourishment. Why should bulimia or anorexia be classified as diseases but obesity should not? Why are skinny people allowed to assign a name to their disorder in order to justify their lack of self control but fat people can’t do the same thing? The same types of insecurities drive some people toward malnourishment and others toward obesity. Obesity is the end result of some other underlying problem, just as malnourishment is the end result of things like bulimia and anorexia. I apologize if this sounds unkind but reading all of these comments many of which I’m sure are coming from “gym addicts”, I’m seeing a lot of hypocrisy. Bulimia and anorexia and every other eating disorder are the result of bad habits. Making yourself puke is a bad habit. Not eating enough nourishing foods is a bad habit. Eating too much junk food is also a bad habit. So, what is it that makes all of you skinny people feel justified in putting a name to your disorder but denying that same thing to the overweight? I think more thought should be put into analyzing the different causes of obesity and classifying each of those causes as diseases/disorders rather than lumping it all together into the term “obesity”, but this is no less justified than the other end of the weight scale.”
In the end, I think I still do agree with the AMA’s decision, albeit much less assuredly. Mostly I hope that this will lead to more understanding and less stigmatizing of not only obese people but of all of us who have struggled so much with our weight because something major needs to change in the way we talk about all of this. But maybe that’s too much to hope for from one tiny word change?
What’s your opinion on the AMA’s decision? Should obesity be defined as a “disease”? Were you as surprised as I was at how many random things contribute to what we weigh??
I am glad Jeremy spoke up because I was having the same reaction reading through the Facebook comments! I agree that the decision is difficult to form a strong opinion on because a lot of the issues are grey, rather than black and white; but I think way more diseases are like that than we laypeople realise. This sort of controversy is a common one in science, but with most things the public don’t pay nearly as much attention. A lot of diseases receive a label even when they are a cluster of disorders or conditions, and these labels are important, even when they are imperfect. Labels can raise the profile of the disease, attract more money for research on the myriad of causes, allow a community of researchers to identify with each other, etc. I agree with a lot of the criticisms of the ruling that have been brought up, but in the end I think we need to be honest with ourselves about the way science works. OCD is not a single disorder. MS is not a single disease. Autism is not a single thing. Irritable bowel syndrome is a cluster of symptoms. For such clusters we often have very little understanding of the underlying pathology. Of course this new designation could increase the stigma for obese people, but it could also help them in many ways. I didn’t like having the label of having an eating disorder, but if it hadn’t had one – and if there weren’t a community of researchers and practitioners committed to addressing it, and an establishment willing to legitimise it as a condition – I might not have come out the other side. The common thread in the comments against this decision is a belief that obese people have an agency that they aren’t exercising, but I think that’s a gross oversimplification. And it’s far more damaging than giving obesity a new label.
Someone pointed out in one of the facebook discussions that I’d read that classifying obesity as a disease could actually reduce access to insurance since otherwise healthy people will be classified as having a preexisting condition and hence the premiums will go sky high.
I also don’t agree with Jeremy’s point about EDs and obesity stemming from lack of self control. Well it might be valid for bulimia, but isn’t anorexia in essence too much self control (that eventually gets out of control)? Also, watching many overweight/obese people I find that many of them have absolutely no self control issues. There is just too much misinformation on what constitutes good nutrition, and many markets offer almost exclusively processed foods with a tonne of additives that basically kill nutrients dead and are addictive on top of that. People just don’t know what to do anymore and even if they do know, they have a hard time getting access to the right foods.
The pre-existing condition issue will no longer be relevant soon for folks in the US. As of 2014, insurers will not be allowed to charge higher premiums due to pre-existing conditions under the Affordable Care Act.
I have no medical training, but I’d been under the impression that obesity was a symptom of disease somewhere in your body. I don’t mean in the contributes to diabetes way, but that just weighing past a certain point is not itself a disease but a sign of illness (whether its thyroid or metabolism or an eating disorder). Sort of like the fact that being underweight is not itself a disease but a sign if an existing illness, whether eating disorder or thyroid (or intestinal parasite…). There may be disease or disorders that cause obesity that we haven’t discovered yet, and its noble to want to look at obesity itself instead of how it affects other things like diabetes, but how does this affect treatment of underlying conditions that are causing obesity?
Bullimia is NOT self control. There’s way to much information about EDs to have misunderstood that. (Touchy-much? Yes, yes I am! I’m anorexic and bullimic – just not active in either.)
Thank you.
OK, a naive take here, but it seems like a lot of conditions we regard as “diseases” can be caused or compounded by personal choices, and also cured or improved by personal choices. Yet we still think of alcoholism or lung cancer caused by smoking, or AIDS contracted by unsafe sex, or depression exacerbated by lifestyle choices, as diseases.
I’m thinking that by whatever combination of genetics, environment, or personal lifestyle choices gets someone to the point where they are obese, they are still suffering from a condition that affects the way the whole body functions. Which makes weight loss a lot more complicated, both physiologically and behaviorally. The kind of help available for any other disease should be available to the obese, many of whom got there without doing anything all that different from what some of us leaner folks do.
Just my take, and I’m so not an expert!
This is about selling drugs, and treatments for a “disease” that has been invented. “Obesity” is defined by a ratio (BMI) that is highly problematic, not a measure or health and that benefits the weight loss industry more than anyone else as far as I can see. If obesity is a disease, it’s one that we cannot treat successfully in 95% of people. What scares the crap out of me is that regardless of what my health actually is, this classification will only encourage doctors to suggest more out there, more risky and likely useless interventions for something that is simply a part of me and has little to do with my health, lifestyle choices or anything other than how others see me.
I agree with this completely. It seems that new “diseases” are being invented every year, often alongside a new drug to treat them, such as drugs for shyness or teenage rebellion. As far as obesity goes, I am sure it is difficult to lose weight, but most people can make a big difference to their health, if not their weight, by lifestyle changes.
And how will it be determined who is suffering from this “disease”? BMI doesn’t really tell us very much. Someone can be “overweight” or even “obese” and yet still be fit and active, eat healthy food, and have perfectly normal labs. Someone can be thin and sedentary, living off junk food, with elevated blood pressure, blood sugar and cholesterol. And let’s not forget that Jim Fixx, marathoner and fit and healthy to behold, died of a heart attack. (I recently watched a fun documentary on Netflix, American the Beautiful 2: The Thin Commandments, that brought up a lot of these issues.)
Anyway, I am probably extra cynical because until very recently I worked for a doctor who routinely prescribed phentermine (a stimulant diet pill) or tried to sell costly weight loss shakes and supplements to people (mostly women) who were a mere 10-30 pounds over their ideal weight, or the weight they thought they should be…in other words, not overweight at all, really.
And then there’s weight loss surgery, which is a whole other can of worms I don’t think I want to open now, except to say that I don’t think being mutilated for big bucks is a good thing, unless it’s really a life or death situation. Whether or not it’s a disease, obesity is already a cash cow, and I’m afraid that reclassifying it will just make that worse, without making many people much thinner.
Um, yeah. It wasn’t insecurity or a lack of self-control that gave me an eating disorder. It was environmental triggers playing on a genetic brain condition. Accusing someone with anorexia of giving into “bad habits” is like saying someone with cancer is giving into the bad habit of letting their cells divide too much. Ugh.
But I do think that obesity is way too general a term. Sometimes it is as easy as a diet change and increased exercise. Then there are the people who can do everything right and still struggle with their weight. I don’t know if I think these people have the same disease.
“Reduced stigma” : I really like this point. It will help the obese move forward more readily and with much more help.
I have to respectfully disagree. There are other diseases, that have been identified for years that still carry gobs and gobs of stigma. As someone with a degree in psychology, who has worked in mental health and has experienced mental health problems in a very intimate way, I speak obviously of what seems like every psychiatric disorder. Those still carry a huge amount of stigma and bring upon the people with them shame and embarrassment. I’ve been there. And while I’m coping much more effectively now, I consider depression and anxiety chronic conditions that I will always have. Yet very few people in my real life know because I’m scared to be looked down upon as a flawed or broken person.
Good point, Shady. I feel the same way about mental health problems. And it’s good to hear that you are coping better with your problems.
For me it was always a big relief when I opened up to a person whom I trust, and shared my feelings and concerns.
Maybe I’m cynical, but to me this just seems like a way to green stamp the production and development of diet drugs and antiobesity treatments. I take issue with this because I struggled with it for a long time and I had to take personal responsibility for my actions and lifestyle before a change occurred. This takes the responsibility away from the manufacturers of crappy foods and although it might help some people get help, which is good, for the most part it just seems like a way of removing personal responsibility from the whole issue of health. Yes, some issues with weight gain are medical and mental ones and yes some physical issues can interfere, but largely it’s poor diet and lack of exercise. You can be overweight and be healthy. It is those who are overweight with poor health that are the problem and I don’t see what this will do other than offer overweight people more gimmick pills and treatments instead of focusing on support and healthy ways to be healthier. By putting the focus on weight we are removing the proper emphasis of health over weight. Health should be the focus. Always.
I’m cynical too. This is from the New York Times article about the AMA’s decision:
“Two new obesity drugs — Qsymia from Vivus, and Belviq from Arena Pharmaceuticals and Eisai — have entered the market in the last year.
Qsymia has not sold well for a variety of reasons, including poor reimbursement and distribution restrictions imposed because of concerns that the drug can cause birth defects. Those restrictions are now being relaxed. Belviq went on sale only about a week ago, so it is too early to tell how it is doing. “
Wow, how’s that for timing?! Just as the AMA says obesity is a disease, not one but two drugs to fight this disease are available? Things that make you go hmmm….
No doubt I’m ignoring larger issues, but if it would make my insurer pay for gym membership (and, all the better, a personal trainer), well, I’m for that.
I don’t see the AMA’s decision as inherently good or bad, as I think a lot will depend on how medical professionals and insurers respond to this. I do think its clear that obesity is a major problem than needs increased attention. Some obese people are healthy but many are not, and it’s clear that as a society we are going in the wrong direction. We desperately need a way to reverse this trend that can truly be successful for people. If this is viewed as a complex condition that requires resolution of underlying medical and psychological issues, people may be more successful at losing weight. If it’s marketed as yet another ‘take our pill and everything will be roses and rainbows!’ condition, then we will have missed a big opportunity to make a difference for millions of people.
I don’t like the idea that it’s considered a disease because of the social stigma and the attitude that people might just go “well, I have a disease, guess I’m just out of luck”.
I agree that there’s the difference between people who gained a bunch of weight because they enjoy beer and hot dogs and ice cream and smoke cigarettes and just don’t really care about their weight (who could fully get down to a healthy weight if they just decided to eat better), and there are people who try really hard and are actually fairly fit and/or are doing all the right things, and still having problems.
I am happy that classifying it as a disease might help people get some help. When I was morbidly obese (and also fairly broke), my doctor told me I should lose weight. I asked if there was anything he could do to help. He said “nothing covered by insurance, but I can sell you this 600$ plan”, so that went right out. Perhaps if I could have worked with a nutritionist or worked with a personal trainer covered by a co-pay, I could have made changes sooner than if it was all up to me and my “willpower”.
Just some thoughts from someone who is about ~5 lbs shy of being obese, but is about to do her 2nd half ironman triathlon Sunday. 🙂
This is an interesting topic. Definitely has me thinking.
I’m going to step away from the eating disorders=self control issues because it’s wrong and is making me see red, and simply comment that “obesity” is far more analagous to “underweight” than it is “anorexia”.
Sometimes underweight stems from a health problem. (Anorexia, thyroid issues, cancer…) Sometimes an individual’s normal happens to sit at the far end of the weight distribution bellcurve. One needs treating; the other doesn’t. So too with obesity.
I love the meme, that cracked me up! I think its automatic for us all to lean together so we can fit in the frame!
“There are reasons why some people tend towards obesity just as there are reasons why other people tend toward malnourishment. Why should bulimia or anorexia be classified as diseases but obesity should not?”
I believe that obesity is not a disease any more than thinness is. Very thin people, however, often have a disease that causes or is caused by their thinness (anorexia/ anorexia as a coping mechanism, a thyroid/ digestive problem, or ie bone problems caused by malnutrition.) Likewise, very fat people are not automatically sick, but often have a disease that causes or is caused by their fat (compulsive eating/ compulsive eating as a coping mechanism, a thyroid problem, or ie heart problems caused by malnutrition/ clogged arteries). I think that this distinction is crucial to get to the root of some peoples’ problems without disrespecting people, trying to treat nonexistent problems or the wrong problems, or even creating problems.
This will be an interesting discussion in the future.
Perhaps it is time to stop “treating” diseases and try preventative medicine, why won’t many insurance companies pay for preventative plans? Lifestyle plans? just my 2 cents… Of course, I am not talking about grievous illnesses or things there is little to no prevention for like cancers, auto-immune disorders or other genetic disorders Parkinsons, Alzheimers, etc. but things that are preventable.
All that to say to me, it’s just a label, the problem, for those that have health issues associated with it, is still the same unfortunately…
First, thanks for the heads up, Charlotte, as I hadn’t heard about this decision. Second, I agree with you about the many underlying causes of obesity; it’s certainly much more complex than the “calories in, calories out,” “we just need enough willpower” statements. However, I worry that classifying it is a medical condition goes to the other extreme. My fear is that it will not be thought of as a MENTAL disorder that needs significant work and change (like Anorexia and Bulimia), but as a MEDICAL disorder that we cannot and society must accept (or change solely through medical intervention). I’m all for admitting the complexity of the problem and throwing a lot more resources at solving it…I’m just afraid this will cause some people to think they can’t/don’t need to solve it at all. Does that make sense? Am I crazy here, or do others think this could be an issue with the new classification?
My initial thought: What will this do fir and the $ aspect of the whole thing. Thus is a can of worms as far as I am concerned!
How many MORE Rx will we see for this DISEASE?
Will we get benefits for health? What will happen as the diagnosis ends up in patient charts?
Who defines obese for the individual? What if my bones are heavy?
What if……
I think it iis a very complicated question with multiple reasons to side both ways.. I am still reading & thinking about it but love reading what others have to say.
I’m afraid to put the title of disease on things like obesity of which there are personal choices at stake, to at least some degree. I’m afraid it will create more of a culture of victimhood and people offering pills and other such solutions.
Once we start believing our condition is out of our control we become victims and lose all of our power.
I’m all for finding diseases such as eating disorders and various issues which can be a big factor in obesity, but as soon as someone tells me that my struggles aren’t my fault, I know I’m about to cross a very dangerous line when it comes to personal power over my own life.
Sure it’s reductionist. Distilling multiple, possibly incomprehensible (to most people, who just want to say, “it’s a question of willpower”) into a ‘disease’ concept does two good things, imo.
1) researchers are finding that once-obese bodies are not the same, metabolically, as never-obese bodies. it’s probable they’ll find evidence for a need for lifelong management (which all of us can plainly see, anyway). inasmuch as insurers (in the US) and the power-brokers of health in other countries can be persuaded by ‘disease’ reasoning, it could be a good thing.
2) if obesity is defined as a disease, and strong correlates can be shown (and, they can), that *could* be the thin edge of a wedge that legal people can use to start assigning liability, which might support greater government regulation of food manufacturers. And maybe even, contribute to local governance/urban planning that supports fitness.
(It took a while to establish the case against smoking, but most people now support bans, and tobacco companies endure *some* kind of censure, have to make payouts, etc. Today, it doesn’t feel crazy to say that it’s conceivable that smoking will be altogether illegal in a few generations.)
I feel less great about excitement in the pharma industry (I’m cagey about drugs that haven’t been out for 50 years), but maybe some useful drug with not too many side effects will emerge, and help some.
Sugar, or more importantly fructose stops fullness hormones working properly. It’s also addictive. (do the test – imagine you are asked to give up cabbage and carrots, my guess is it wouldn’t be too difficult, then imagine giving up sugar in all its forms and just see how you feel)
Just stop eating sugar and reduce all those grain carbs. Going to the gym won’t help.
A few things first –
1. It is definitely possible, and actually quite common, for someone to be obese AND malnourished. The opposite of obese is not malnourished, it is ’emaciated’.
2. Eating disorders are NOT problems with ‘willpower’ or ‘self control’. They are biologically based brain disorders. They also affect plenty of people who are at a perfectly healthy weight – in fact EDNOS kills the most of any ED.
Personally I don’t think calling obesity a disease is a good idea. It’s not IMO, it’s a symptom of something not right going on. Just as someone being emaciated has something not right going on with their body, their mind, or both to cause their emaciation and the cause needs to be found and treated. Obesity is a descriptor, not an eating disorder, as emaciation describes someone’s weight and is not an eating disorder either. I would be really glad if this funneled more funds to treat people’s health problems, but if it’s just going to bankroll the weight loss industry then I can see the population getting a heck of a lot MORE obese into the future.
Obesity itself needs better determining factors other than BMI and body measurements. If we could better say who is infact obese and who is not, then it would help clear some of the grey area around this issue. I think it is a good step in recognizing all the complex issues that go into weight gain. It will also help with coverage for treatments. Mississippi, where I used to live, helped me cover monthly counseling, diet guidance, and offered a gym membership as part of a program they did for state workers and their families. It helped a lot. I didn’t feel stigmatized when they classified me obese in order to qualify for all that. I already knew how big I was. I saw that in the mirror every day.
I also wanted to add that when they recently listed Binge Eating Disorder as an actual eating disorder recognized by psychological boards in America I was ecstatic. I knew that something had been wrong with me. My doctor and diet counselor both suggested I had the disorder, but it wasn’t fully recognized at the time. I was already free from binge eating for a year and half when the APA listed it, but seeing it listed made me want to cry. Finally I had a name to put to what had plugged me for over eight years.
My father is currently ill and we can’t find a diagnosis. Just having the name for something that fit his symptoms would make us feel so much better even if it was just a name for the clusters of things going wrong. It would be a starting point. This is just my personal opinion based on my own personal experiences. Just wanted to share.
As with many, I think obesity as disease is a bad idea
.
* Not all who are obese are unhealthy
* Not all who are not obese are healthy
I can imagine with how insurance works that there will be a “protocol of treatment” for obesity. Insurance will cover your treatments in a certain order – if one doesn’t work, then they may reimburse you for the next.
For example, if you’re obese, maybe your doctor will classify you as such. Then, insurance might require that you start treatments in a certain order. Maybe that starts with some new kind of drug, or more diagnostic tests that will be covered to see if there’s an underlying issue causing the obesity.
On the good side, maybe, just maybe, there might be an allowance for therapy for those with disordered eating that is causing obesity. Maybe for those who truly lead an unhealthy lifestyle, there will be reimbursements or reduced-cost exercise and nutrition classes.
However, if you’re obese and otherwise healthy, are you then “diseased?” Do your insurance premiums go up? The blanket term “obesity” is almost meaningless from a health standpoint. I hope insurance companies and doctors look at far more factors than BMI when determining a plan for health.
There needs to be an extremely narrow definition of obesity as a disease–and it CANNOT be determined by how much a person weighs.
For example, the terms “anorexic” and “bulimic” have exacting definitions that go beyond “pretty skinny” and “vomits after eating”. The word “obesity” *means* fat right now. If the AMA is determined to classify a new disease, they need to give it another name with a narrow, clinical definition.
The psychology behind over-eating and a lack of satiety should, absolutely, be defined as a disorder–the word obesity is the wrong choice.
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I find it hard to believe that it can be classed as a disease. To me this gives more people the opportunity to say “poor me, I can’t do anything about my weight I’m ill. Pass me another cream cake to make me feel better”
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