August 2007, Vol. 97, No. 8 SAMJ
Fruit and vegetables contain many nutrients such as vitamins,
minerals and fibre which may, individually or in combination,
be protective against cardiovascular diseases (CVDs) and
certain cancers.1 The World Health Organization (WHO)2
recognises that there is convincing evidence of decreased
risk of coronary heart disease, stroke, high blood pressure
and obesity associated with an increased fruit and vegetable
intake. Although definitive quantification of the protective
effects against other conditions is still lacking, there is probable
evidence of decreased risk for cancer of the oral cavity,
oesophagus, stomach, colon and rectum, as well as probable
evidence of decreased risk of type 2 diabetes mellitus with
an increased intake of fruits and vegetables. Eating plenty of
fruit and vegetables also reduces the occurrence of fractures,
cataracts, age-related macular degeneration3 and birth defects,
and plays a role in response to infections.
There are several mechanisms by which these protective
effects are mediated. In the case of cancers, anti-oxidants,
various micronutrients and other substances block and
suppress the action of carcinogens and prevent oxidative DNA
damage. In the case of atherosclerosis, deficiencies of folic
acid and vitamins B12 and B6 increase levels of homocysteine
and generate free radicals, resulting in oxidative damage
to endothelial cells, which in turn leads to aggregation of
monocytes and platelets and vasoconstriction.4,5 Another
potential mechanism by which fruit and vegetables affect
cardiovascular risk is an indirect link via the high potassium
concentration of some fruit and vegetables, that serves to
modulate blood pressure.6
Many fruit and vegetables are high in dietary fibre, which
expedites the movement of waste products through the
intestinal tract and also lowers blood cholesterol levels.7
Vitamin A helps protect against infectious diseases. It helps
maintain the lymphocyte pool and thus is involved in the
T-cell-mediated response to infection.8 Plants also produce
unique compounds called ‘phytochemicals’ to protect
themselves against viruses, bacteria and fungi. The exact
mechanisms by which these promote human health are
unclear.7 The interactive and synergistic effects of nutrients in
food cannot be discounted.8
Ideally, to protect against CVDs and certain cancers, the
WHO recommends an intake of 400 g/day – the equivalent of
5 portions of fruit and vegetables per day of 80 g each.2 This
Estimating the burden of disease attributable to low fruit
and vegetable intake in South Africa in 2000
Michelle Schneider, Rosana Norman, Nelia Steyn, Debbie Bradshaw and the South African Comparative Risk Assessment
Burden of Disease Research Unit, South African Medical Research Council,
Tygerberg, Cape Town
Michelle Schneider, MSc
Rosana Norman, PhD
Debbie Bradshaw, DPhil (Oxon)
Chronic Diseases of Lifestyle Research Unit, South African Medical Research
Council, Tygerberg, Cape Town
Nelia Steyn, PhD
Objectives. To estimate the burden of disease attributed to low
fruit and vegetable intake by sex and age group in South Africa
for the year 2000.
Design. The analysis follows the World Health Organization
comparative risk assessment (CRA) methodology. Population-
attributable fractions were calculated from South African
prevalence data from dietary surveys and applied to the
revised South African burden of disease estimates for 2000.
A theoretical maximum distribution of 600 g per day for fruit
and vegetable intake was chosen. Monte Carlo simulation-
modelling techniques were used for uncertainty analysis.
Setting. South Africa.
Subjects. Adults ≥ 15 years.
Outcome measures. Mortality and disability-adjusted life years
(DALYs), from ischaemic heart disease, ischaemic stroke, lung
cancer, gastric cancer, colorectal cancer and oesophageal cancer.
Results. Low fruit and vegetable intake accounted for 3.2%
of total deaths and 1.1% of the 16.2 million attributable
DALYs. For both males and females the largest proportion
of total years of healthy life lost attributed to low fruit and
vegetable intake was for ischaemic heart disease (60.6% and
52.2%, respectively). Ischaemic stroke accounted for 17.8% of
attributable DALYs for males and 32.7% for females. For the
related cancers, the leading attributable DALYs for men and
women were oesophageal cancer (9.8% and 7.0%, respectively)
and lung cancer (7.8% and 4.7%, respectively).
Conclusions. A high intake of fruit and vegetables can make a
significant contribution to decreasing mortality from certain
diseases. The challenge lies in creating the environment that
facilitates changes in dietary habits such as the increased intake
of fruit and vegetables.
S Afr Med J 2007; 97: 717-723.
Corresponding author: M Schneider (email@example.com)
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August 2007, Vol. 97, No. 8 SAMJ
recommendation has been based on a dose-response effect
which indicates an increased risk of disease at less than
200 g/day, yet little benefit above 400 g/day.9 The intake of
fruit and vegetables in South Africa is estimated to be similar
to that in the UK, with an average per capita intake of about
200 g/day.10 Although greater than that of India (120 - 140 g/
day), the South African intake is considerably less than that of
China (369 g/day) and Spain (600 g/day).10
Data from South African food balance sheets show that
annual per capita fruit intake increased from 67.6 kg in 1962 to
80.2 kg by 2001, while vegetable intake remained more or less
the same at 120 g/day.11 Overall, this amounted to an increase
in combined fruit and vegetable intake per capita per day from
185 g in 1962 to 220 g by 2001. Despite these increases, which
are mainly due to improved access, fruit and vegetable intake
in South Africa is extremely low.
It has been estimated that globally 2.7 million (4.9%) deaths
and 26.7 million (1.8%) disability-adjusted life years (DALYs)
per year in 2000 were attributable to low fruit and vegetable
intake.6 In the global study,6 low dietary intake of fruit and
vegetables is estimated to cause about 31% of ischaemic
heart disease, 19% of ischaemic stroke, 20% of oesophageal
cancer and 19% of gastric cancer worldwide. Attributable
fractions were lower for lung and colorectal cancers (12% and
2% respectively). The aim of this study was to estimate the
overall burden of disease attributed to low fruit and vegetable
intake, by sex and specific age groups in South Africa for 2000.
This will serve to provide country-level data and facilitate
Following the WHO comparative risk assessment (CRA)
methodology,6,12,13 the disease burden attributable to low fruit
and vegetable intake was estimated by comparing the levels
of fruit and vegetable intake observed in South Africa with a
counterfactual distribution conferring the lowest possible risk.
Fruit and vegetable intake was treated as a continuous variable,
defined as the mean per capita dietary intake of fruit and
vegetables measured in grams per day (g/day). The estimates
excluded potatoes in order to be consistent with international
recommendations.14 Sweet potatoes are used interchangeably
with potatoes in South Africa, and were also excluded. Pulses
or dry legumes such as lentils and beans were not included.
However, green legumes such as fresh peas or green beans
Fruit and vegetable consumption is unusual in that
there is an inverse risk factor-disease relationship. As fruit
and vegetable intake is protective, a theoretical maximum
distribution of intake, based on an upper consumption level
that is protective, was used to calculate the population-
attributable fractions (PAFs). It is not clear whether there
is a threshold effect for fruit and vegetable consumption,
although many studies6 have presented a linear dose-response
relationship. In the global CRA project6 the counterfactual was
chosen to be a constant level using a minimum risk approach.
The highest mean daily intake of fruit and vegetables is found
in Greece, and estimated to be about 700 - 800 g per person
per day. This finding notwithstanding, the global study6 found
that dietary survey data for adults in any country rarely went
above an intake of 500 g/day and never above 550 g/day,
even in countries such as Italy and Israel which are known for
their high fruit and vegetable intake. As in the global CRA, the
theoretical minimum risk distribution was therefore set at
600 g/day in adults with a standard deviation (SD) of 50 g/day
in an ideal scenario. Set intervals of fruit and vegetables of
80 g/day (equivalent to 1 serving) were used for the
distributional transition, constituting a plausible and feasible
change for individuals towards the selected counterfactual
(theoretical maximum risk) level.6
With the exception of the National Food Consumption
Survey on children,15 there are no nationally representative
dietary surveys in South Africa. However, a recent meta-
analysis that pooled data from the available dietary surveys
was re-analysed to determine the mean and SD of fruit
and vegetable intake measured in g/day for adults older
than 15 years by age groups.16,17 Despite the actual intake
data following a skewed distribution, fruit and vegetable
consumption was assumed to follow a truncated normal
distribution. Sensitivity analyses incorporating a skewness
value observed in US populations have shown the truncated
normal distribution to result in slightly conservative estimates
of exposure to low intakes (T Vos, School of Population Health,
University of Queensland, Brisbane – personal communication,
2006). Data were not available for the elderly; surveys only
included adults up to the age of 65 years. We assumed that
individuals aged 70 - 79 and 80+ years consumed the same
amount of fruit and vegetables as those in the closest age group
(60 - 69 years).
The choice of outcomes included in the analysis was
determined by reviews of the literature and strong evidence of
a risk factor-disease relationship suggesting a protective effect
of fruit and vegetable consumption in preventing ischaemic
heart disease, ischaemic stroke, lung, gastric, colorectal and
oesophageal cancers.6 Risk factor-disease relationships for each
selected outcome were determined on the basis of a systematic
literature review combined with meta-analysis.6 There is
also limited evidence for other protective health outcomes,
including type 2 diabetes, chronic obstructive pulmonary
disease, cataracts, cancers of the mouth and pharynx, and
cancers that may have a hormonal aetiology, including ovarian,
endometrial, thyroid and prostate cancers. These, however,
were not included in the global CRA project6 due to insufficient
evidence at this stage.
The relative risk (RR) estimates associated with an 80 g/d
increase in fruit and vegetable intake, adjusted for potential
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August 2007, Vol. 97, No. 8 SAMJ
confounders (including smoking, body mass index and
physical activity) are shown in Table I. The same RR applied
for individuals aged 15 - 69 years; however, for many diseases
the RR decreases with increasing age due to the increasing
background mortality from other causes. The RRs were
adjusted to take account of age attenuation. The excess risk
was reduced by a quarter for ages 70 - 79 years and by a half
for the age group 80+ years. It was assumed that there was no
protective effect below the age of 15 years. It was also assumed
that there was no difference in RR across sub-populations.6
Customised MS Excel spreadsheets based on templates used
in the Clinical Trials Research Unit at the University of Auckland
(S Vander Hoorn – personal communication, 2006) as well as
in Australian studies (T Vos – personal communication, 2006)
were used to calculate the PAFs using a discrete version of the
general potential impact fraction (see below), taking into account
continuous risk factor-disease exposures compared with a
theoretical maximum distribution (conferring the lowest possible
risk) on a categorical scale). The PAF was calculated as:
where n = the number of exposure categories; Pi = the
proportion of the South African population in exposure
category i; RRi = the relative risk for exposure category i; and
P’i = the proportion of population in exposure category i in the
The PAFs were then applied to revised South African burden
of disease estimates for 2000:19 number of deaths, years of
life lost (YLL) to premature mortality, years of life lived with
disability (YLD) and DALYs for the relevant disease and injury
categories to calculate attributable burden.
Decreased fruit and vegetable consumption is associated
with increased risk of ischaemic stroke, with insufficient
evidence for an association with haemorrhagic stroke. The
South African burden of disease endpoint, however, is ‘total
stroke’, rather than stroke subtypes. Total stroke deaths and
DALYs were therefore adjusted by the age-specific proportions
of ischaemic fatal and non-fatal strokes for the AFR-E region
using the method of Lawes and colleagues.20 (AFR-E refers to a
WHO mortality stratum sub-region; African regions with high
child and adult mortality rates, including South Africa.) These
proportions correspond to the limited data available on relative
burden of the sub-types in South Africa.21
Monte Carlo simulation-modelling techniques were used to
present uncertainty ranges around point estimates that reflect
all the main sources of uncertainty in the calculations. The @
RISK software version 4.5 for Excel22 was used, which allows
multiple recalculations of a spreadsheet, each time choosing
a value from distributions defined for input variables. The
probability distributions around the input variables were
based on standard errors of the prevalence specifying a normal
distribution. For the RR input variables we specified a normal
distribution with the natural logarithm of the RR estimates as
the entered means of the distribution and the standard errors
derived from the published 95% confidence intervals (CIs).6
For each of the output variables (namely attributable burden
as a percentage of total burden in South Africa, 2000), 95%
uncertainty intervals were calculated bounded by the 2.5th and
97.5th percentiles of the 2000 iteration values generated.
Mean intakes of fruit and vegetables by age and sex are shown
in Table II. The mean intake for males in the 30 - 44-year
age group was noticeably lower. The population-weighted
mean per capita intake of fruit and vegetables over all ages
Table I. Selected health outcomes and relative risks (95% confidence intervals) associated with increased fruit and vegetable
intake* by age group
Age groups (years)
Ischaemic heart disease
Source: Adapted from Lock et al., 2004.6
*Unit of change in risk is change per 80 g/d increase in fruit and vegetable intake.
15 - 69
(0.82 - 0.99)
(0.89 - 0.99)
(0.93 - 0.99)
(0.86 - 1.03)
(0.97 - 1.02)
(0.88 - 1.01)
70 - 79
(0.85 - 1.01)
(0.91 - 1.00)
(0.91 - 1.02)
(0.87 - 1.04)
(0.97 - 1.02)
(0.89 - 1.02)
(0.87 - 1.03)
(0.92 - 1.02)
(0.92 - 1.03)
(0.89 - 1.06)
(0.97 - 1.02)
(0.91 - 1.04)
i=1Pi RRi –
1 ) 1
( R R
1 ) 1
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August 2007, Vol. 97, No. 8 SAMJ
was 235 g/d for males and 226 g/d for females, just under 3
servings per day. Based on these mean levels, it was estimated
that about 80% of adults 15 years and older eat less than the
recommended 5 fruits and vegetables (400 g/d) each day.
Hence about 11.1 million males and 12.5 million females over
15 years of age were affected by low fruit and vegetable intake
in South Africa in 2000.
The PAFs for the related health outcomes varied by age
and sex (Table III). In 2000 a similar number of deaths were
attributable to low fruit and vegetable intake in males (8 673
deaths) and females (8 037 deaths). Uncertainty analysis showed
that in total between 10 232 and 21 467 deaths were attributable
to low fruit and vegetable intake. The burden attributable to
low fruit and vegetable intake accounted for 176 918 DALYs
(95% uncertainty interval 123 964 - 215 119). Since many of the
deaths occurred in middle and old age, the proportion of total
DALYs (1.1%) was lower than for total deaths (3.2%).
For both males and females the largest proportion of total
YLL attributed to low fruit and vegetable intake was for
ischaemic heart disease, accounting for 60.6% and 52.2%
respectively (Fig. 1). Ischaemic stroke accounted for 17.8%
of attributable DALYs for males and 32.7% for females. The
leading selected cancers were oesophageal cancer accounting
for 9.8% and 7.0% of attributable DALYs in males and females,
respectively, and lung cancer accounting for 7.8% and 4.7%
of all DALYs attributable to low fruit and vegetable intake in
males and females, respectively.
When examining the results of this study, various additional
uncertainties need to be acknowledged. These include the use
of the collective term ‘fruit and vegetables’, which comprises
a very heterogeneous group; the various components and
combinations of these may have different effects. Furthermore,
there are many uncertainties with regard to the mechanisms
of the protective effects of fruit and vegetable intake on health.
There is also marked heterogeneity in the best available
evidence on the effects of fruit and vegetable consumption on
risk of ischaemic heart disease.6
Table II. Mean and standard deviation (SD) of dietary intake of fruit and vegetables (g/day) (excluding potatoes)
Age group (years)
15 - 29 30 - 44 45 - 59 60 - 69* 70 - 79* 80+*
Source: Steyn et al., 2003.17
*Data only provided for 60+-year-olds.
Fig. 1. Burden attributable to low fruit and vegetable intake in males and females, South Africa, 2000.
schaemic heart disease
Attibutable DALYs = 79 436
Attibutable DALYs = 97 482
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August 2007, Vol. 97, No. 8 SAMJ
Available dietary data16 for South
Africa suggest that the average intake
of fruit and vegetables of just under
3 servings a day is considerably less
than the recommended 5 servings a
day. The present study shows that a
low fruit and vegetable intake makes
a significant contribution to the
number of deaths and DALYs from
ischaemic heart disease and ischaemic
stroke, accounting for 35% and 22%
respectively, as well as oesphageal
and gastric cancer (both 24%). Apart
from human loss and suffering, the
deaths and DALYs attributable to the
low intake of fruit and vegetables
have great cost implications for the
health services. This is particularly
regrettable since a large proportion
of these costs are believed to be
Low fruit and vegetable intake
ranked 11th on the list of 17 selected
risk factors in the current CRA study
for South Africa in 2000, accounting
for 1.1% of the 16.2 million DALYs.
In terms of the proportion of deaths
or DALYs, both were lower in South
Africa than globally, at 3.2% versus
4.9% of deaths and 1.1% versus 1.8%
of DALYs.6 It is interesting to note that
the South African PAFs were between
1% and 5% higher than the global
study for all selected health outcomes.
The lower attributable proportion is
a consequence of competing causes
and age structure. In both studies,
the estimate of the attributable
burden must be considered to be a
conservative quantification of the
role of fruit and vegetables. Limited
data on associations has restricted the
analysis to 5 health outcomes with
strong evidence. Contribution to other
conditions, including infections, was
not assessed in this study.
This study has several other
limitations. The lack of nationally
representative dietary data for adults
has made it necessary to make
use of a pooled estimate of small
studies17 that have been weighted
to represent the population profile
of the country. These studies were
undertaken between 1983 and 2000,
spanning a period during which there
was a slight increase in the intake.
Furthermore, there are indications that
eating patterns vary within the country.
For example, fruit and vegetable intake
is higher in urban areas compared
with rural areas (168 g/d versus 137
g/d), most probably because of greater
access to and availability of fruit and
vegetables in the urban areas.16 Two
studies23,24 have found very low intake
of fruit and vegetables among black
South Africans living in rural areas of
Limpopo, with an average 132 - 134 g/d
per capita. A study among black African
urban residents of Cape Town25 found
similarly low levels of consumption,
viz. 139 g/d or less than 2 portions per
day. One of the few studies undertaken
among white adults26 showed a far
higher fruit and vegetable intake of
In addition to dietary differences,
there are also substantial differences
in disease and mortality patterns
in CVDs and cancers for SA sub-
populations. For example, age-
standardised ischaemic heart disease
mortality per 100 000 population
in 2000 was 129 for South African
persons.19 The figures for whites,
black Africans, coloureds and
Indians were 247, 75, 184 and 414
per 100 000, respectively. Stroke age-
standardised mortality rate was 154
for black Africans, 80 for whites, 151
for coloureds and 127 for Asians.
The corresponding rate for the South
African population was 125 per 100
000.19 The causes of these conditions
are multi-factorial so it would be ideal
to assess the contribution of low fruit
and vegetable intake by population
group. Unfortunately, nationally
representative data on fruit and
vegetable intake by population group
are not yet available in South Africa.
Regardless of any shortcomings of
this study, overall the results support
the finding that a high intake of fruit
and vegetables can make a significant
Table III. Population-attributable fractions (PAFs) and burden attributable to low fruit and vegetable intake, South Africa, 2000
Ischaemic heart disease
10 068 100 515
3 841 43 382
996 11 352
502 5 843
1 238 15 059
16 709 176 918
95% uncertainty range
5 602 - 10 986
65 737 - 119 592
4 452 - 10 631
56 077 - 96 243
10 232 - 21 467 123 964 - 215 119
% of total burden
95% uncertainty range
2.0 - 4.0%
0.8 - 1.4%
1.8 - 4.3%
0.7 - 1.2%
2.0 - 4.1% 0.8 - 1.3%
PAF = population-attributable fraction; DALYs = disability-adjusted life years.
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August 2007, Vol. 97, No. 8 SAMJ
contribution to decreasing mortality from certain diseases. The
more difficult part, however, is persuading people to change
their behaviour, to eat more fruit and vegetables and to eat a
greater variety thereof. A multi-sectoral approach that includes
public sector and private enterprise initiatives is needed.
Interventions aimed at changing diet include: educating
individuals, undertaking community interventions, modifying
the food supply, changing the environment, and introducing
economic policies.1 Environmental and policy strategies should
address both supply and demand of fruit and vegetables.
In terms of supply, fruit and vegetable production can
provide employment and income to unskilled people thus
helping to alleviate poverty. It is well suited to small-scale
production units, such as those for individual households,
and community and school vegetable gardens.27 However,
sustainability of these types of projects is dependent on
partnerships between government, non-governmental
organisations and industry.27
South African studies8 show that the primary constraints to
eating fruit and vegetables are affordability, availability and
taste preferences. Fresh fruit and vegetables are not necessarily
the most economical, in terms of either preparation time or
cost. They are also not necessarily the easiest choice, especially
for the poor. Take, for example, the storage of fresh fruit and
vegetables, which last longer if refrigerated. The 2001 Census28
found that only 40% of households have refrigerators, with
lower proportions in rural areas and among the poor. As non-
communicable diseases are emerging at an accelerated rate
in poor countries and among poorer subpopulations in richer
countries, the priority should be interventions aimed at the
In addition, cognisance of the nutrition transition
is important when considering interventions.27 Most
middle-income countries are in the ‘westernised, mass
consumption’27 stage in the nutrition transition. The emphasis
for recommendations in these countries is to encourage the
replacement of unhealthy food with fruit and vegetables, rather
than adding fruit and vegetables to the diet.27 This may involve
going up against the politically powerful, well-funded food
Numerous interventions to promote fruit and vegetable
consumption in children and/or their parents have been tested
over the past 2 decades. Some of the most successful of these
have been delivered in the school setting; including Squire’s
Quest,29 TEENS,30 Gimme-531 and CATCH.32 The majority of
these interventions have included changes in school meals or
tuck shops/cafeterias, a curriculum taught by trained teachers,
and some parental involvement. They have all shown that fruit
and vegetable consumption can be significantly improved by
To date, no South African interventions have specifically
been aimed at improving fruit and vegetable consumption,
despite the fact that the National Department of Health’s
Nutrition Directorate promotes the dietary guideline of ‘Eat
plenty of vegetables and fruits’. Recently, however, the Medical
Research Council has launched an intervention similar to those
mentioned above in the Western Cape; this will be evaluated
to assess whether such a programme can be implemented in a
developing country like South Africa with the same degree of
success as those largely restricted to the USA and UK.
Conclusion and recommendations
On average, South Africans eat well below the recommended
5 servings of fruit and vegetables per day. In the context of the
current burden of disease attributable to low intake and the
health transition that is underway, this needs to be addressed
on a population level.
Environmental changes are more effective in changing
behaviour and increasing the demand for fruit and vegetables
than changing individual knowledge and attitudes.27
Nevertheless, it is also important to raise awareness of the
value of eating fresh fruit and vegetables among individuals.
The National Department of Health has recently implemented
a new strategy for nutrition education which is predicated
on the food-based dietary guidelines as part of the Integrated
Nutrition Programme.33 The 11 guidelines are being widely
promulgated as part of nutrition intervention programmes
aimed at developing healthy lifestyles. One of the guidelines is:
‘Eat plenty of vegetables and fruits every day’. Implementation
of the programme needs to include a specific focus on
interventions to achieve this, and the impact of such efforts
needs to be monitored.
The other members of the Burden of Disease Research Unit of
the South African Medical Research Council: Pam Groenewald,
Beatrice Nojilana, Nadine Nannan, Jané Joubert, Desireé Pieterse,
Karin Barnard and Elize de Kock are thanked for their valuable
contribution to the South African Comparative Risk Assessment
Project. Ms Leverne Gething is gratefully acknowledged for
editing the manuscript. Our sincere gratitude is expressed for
valuable contributions from the following persons: Karen Lock
from the London School of Hygiene and Tropical Medicine, part
of the Global Risk Factor Assessment team, who kindly provided
a draft of the global review chapter and reviewed the manuscript;
Associate Professor Theo Vos of Queensland University who
gave expert advice, specifically for the spreadsheet development
which made use of the Thai, Australian and WHO Risk Factor
study to guide us, and provided training and support for the
determination of the uncertainty estimates; Dr Hannelie Nel from
Stellenbosch University who provided statistical support; Dr Lesley
Bourne, Health and Development Research Group and Dr Petro
Wolmarans, Nutrition Intervention Research, both of the MRC,
who provided South African dietary survey data.
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August 2007, Vol. 97, No. 8 SAMJ
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