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Dietary Adherence, Glycemic Control, and Psychological Factors
Associated with Binge Eating Among Indigenous
and Non-Indigenous Chileans with Type 2 Diabetes
Sylvia Herbozo & Patricia M. Flynn & Serena D. Stevens &
Hector Betancourt
#
International Society of Behavioral Medicine 2015
Abstract
Background Despite the strong association between obesity
and binge eating, limited research has examined the implica-
tions of binge eating on dietary adherence and psychological
factors in ethnically diverse type 2 diabetes patients.
Purpose This study investigated the prevalence of binge eat-
ing and its association with dietary adherence, glycemic con-
trol, and psychological factors among indigenous and non-
indigenous type 2 diabetes patients in Chile.
Method Participants were 387 indigenous (Mapuche) and
non-indigenous (non-Mapuche) adults with type 2 diabetes.
Self-report measures of binge eating, dietary adherence, diet
self-efficacy, body image dissatisfaction, and psychological
well-being were administered. Participants’ weight, height,
and glycemic control (HbA
1c
)werealsoobtained.
Results Approximately 8 % of the type 2 diabetes patients
reported binge eating. The prevalence among Mapuche pa-
tients was 4.9 %, and among non-Mapuche patients, it was
9.9 %. Compared to non-binge eaters, binge eating diabetes
patients had greater body mass index values, consumed more
high-fat foods, were less likely to adhere to their eating plan,
and reported poorer body image and emotional well-being.
Conclusion Results of this study extend previous research by
examining the co-occurrence of binge eating and type 2 dia-
betes as well as the associated dietary behaviors, glycemic
control, and psychological factors among indigenous and
non-indigenous patients in Chile. These findings may increase
our understanding of the health challenges faced by indige-
nous populations from other countries and highlight the need
for additional research that may inform interventions address-
ing binge eating in diverse patients with type 2 diabetes.
Keyword Bingeeating
.
Type 2 diabetes
.
Dietary adherence
.
Glycemic control
Introduction
Binge eating disorder (BED), characterized by recurrent epi-
sodes of uncontrollable overeating in the absence of compen-
satory behaviors, is a significant clinical problem that occurs
more frequently among overweight and obese individuals [1,
2]. Research indicates that binge eating and BED are associ-
ated with various medical and psychiatric comorbidities. For
instance, results from a 5-year longitudinal study revealed that
individuals with BED had an increased risk of metabolic syn-
drome (hypertension, dyslipidemia, or type 2 diabetes), rela-
tive to a matched comparison group without BED [3]. Other
research has demonstrated that binge eating and BED are as-
sociated with increased body mass index (BMI) [4], higher
rates of diabetes and hypertension [5], lower self-efficacy for
healthy eating and exercise [6], poorer body image [7], and
increased likelihood of other mental disorders such as depres-
sion and anxiety [8, 9].
While there are significant psychological and medical con-
sequences of BED in the general population, the occurrence of
binge eating among diabetes patients is associated with addi-
tional complications that have implications for the
S. Herbozo
:
P. M. Flynn
:
S. D. Stevens
:
H. Betancourt
Loma Linda University, 11130 Anderson St., Loma
Linda, CA 92350, USA
H. Betancourt
Universidad de La Frontera, Francisco Salazar 1145,
4811230 Temuco, Araucanía, Chile
S. Herbozo (*)
Department of Psychology, Loma Linda University, 11130 Anderson
Street, Loma Linda, CA 92350, USA
e-mail: sherbozo@llu.edu
Int.J. Behav. Med.
DOI 10.1007/s12529-015-9478-y
management and progression of diabetes. Most studies in this
area, however, focus on patients with type 1 diabetes [10]. The
limited research examining binge eating among type 2 diabe-
tes patients reveals that compared to patients without binge
eating, those with binge eating are diagnosed with diabetes at
a younger age; are more likely to be women; have a higher
BMI; and report greater depressive symptoms, poorer quality
of life, and more weight-related impairment [11–13]. In addi-
tion, results from a study on disordered eating behaviors
among women with type 2 diabetes indicated poorer self-
efficacy for diet and exercise self-management in women with
binge eating as compared to those without binge eating [12].
Moreover, weight loss interventions appear to be less effective
for diabetes patients with binge eating. Results of a random-
ized control trial revealed that weight loss was the most poor
among diabetes patients that continued to binge eat over the
course of the study [14]. In regard to glycemic control, find-
ings are mixed with some studies indicating no association
with binge eating or BED [11, 12, 14, 15]whileonestudy
reported a significant positive association with BED among
ethnically diverse type 2 diabetes patients [16].
Population-based data from 14 countries indicates a BED
prevalence rate of 1.4 % [5] whereas the prevalence among
individuals with type 2 diabetes varies considerably ranging
from 1.4 to 25.6 % [17]. However, most studies on disordered
eating and diabetes do not include ethnic minority populations
[10] or diabetes patients from countries other than the United
States. This is noteworthy given that the prevalence of diabe-
tes has increased in many developing countries partly due to
changes in food consumption [18]. In Chile, over half of the
national population is considered overweight [19 ] and the
prevalence of diabetes (10.2 %) is one of the highest among
all countries in South America [20]. Moreover, rates of obesity
have increased significantly and the prevalence of type 2 dia-
betes has tripled over the last 15 years among Mapuches, the
largest indigenous population in Chile [21, 22]. Still, little is
known regarding the prevalence of binge eating among type 2
diabetes patients and the associated dietary behaviors and psy-
chological factors that may impact the management and pro-
gression of diabetes in countries like Chile. This is particularly
the case for indigenous populations that have experienced
significant cultural and lifestyle changes associated with eco-
nomic development and globalization.
The purpose of this study was to examine the prevalence of
binge eating and its association with dietary adherence, glyce-
mic control, and psychological factors among ethnically di-
verse type 2 diabetes patients in Chile. This study addresses
some of the limitations of research in this area, such as the
focus on type 1 diabetes patients and non-Latino White sam-
ples as well as the incomplete psychological characterization
of type 2 diabetes patients with binge eating [10]. A better
understanding of the dietary behaviors and psychological
needs of type 2 diabetes patients among diverse populations
with binge eating could allow for more effective intervention
approaches that may curb the numerous complications asso-
ciated with the co-occurrence of binge eating and diabetes.
Furthermore, the study of indigenous (Mapuche) and main-
stream non-indigenous (non-Mapuche) patients in Chile may
shed light on the co-occurrence of binge eating and diabetes in
Latin America and indigenous diabetes populations in other
countries.
Materials and Methods
Study Population and Procedures
A total of 400 (Mapuche; n=146, non-Mapuche; n=254) type
2 diabetes patients from urban and rural areas of La Araucanía
Region of Chile participated in the study. Thirteen participants
were excluded from statistical analyses due to missing data
resulting in a sample of 387. The mean age was 58 (SD=
5.82), 62 % were women, and average year of education
was 8.39 (SD=4.77). Of the total sample, 37 % (n=144) were
Mapuche and 63 % (n=243) were non-Mapuche. The mean
BMI was 31.71 (SD=5.82), and approximately 89 % of the
sample was overweight or obese (BMI ≥25).
Research approval was obtained from the public university
ethics committee for research and the regional office of the
Chilean Ministry of Health (SEREMI de Salud, Region de La
Araucanía). Participants were recruited through health care
personnel and flyers posted and distributed at public and pri-
vate health care centers. Individuals interested in participating
contacted the study research office at which time they were
provided with information on the study and were screened for
inclusion criteria (minimum age of 18 years, self-identified
ethnicity as either Mapuche or non-Mapuche, diagnosis of
type 2 diabetes for at least 1 year, non-insulin dependent).
Those interested in participating scheduled a time for data
collection at one of the data collection locations.
Two research assistants were present during data collec-
tion. The research assistants reviewed the informed consent
form with participants, obtained written consent, and then
distributed the questionnaire. Once the questionnaire was
completed, a trained research assistant measured the partici-
pant’s height and weight and administered the HbA
1c
test.
Participants were given their HbA
1c
results as well as the
equivalent to $10 USD for their participation. Participation
took approximately 1 hour including processing time for the
HbA
1c
test.
Demographic and Physical Health Information
Demographic variables included self-reported ethnicity, age,
gender, and education. Physical health measures included
weight, height, and HbA
1c
. BMI was calculated using
Int.J. Behav. Med.
measured height and weight. Participants were classified as
overweight based on a BMI of 25–29.99 and obese based on
aBMI≥30.
Binge Eating
Three diagnostic items from the Spanish version of the Ques-
tionnaire on Eating and Weight Patterns-Revised (QEWP-R;
[23]) were administered to assess binge eating. Participants
were asked, (1) BIn a 2-hour period, have you ever eaten what
most people would regard as an unusually large amount of
food?^,(2)BDuring the period in which you ate too much,
did you feel you could not stop eating or control what or how
much you were eating?^, and (3) BDuring the past 6 months,
how often, on average, did you have times when you ate this
way (that is, large amounts of food plus the feeling that your
eating was out of control)?^ The first two questions were
based on a dichotomous yes/no response, whereas the third
question was based on a five-point scale (less than 1 day a
week, 1 day per week, 2 or 3 days a week, 4 or 5 days a week,
nearly every day). Consistent with the frequency of binge
eating required for a diagnosis of BED based on the Diagnos-
tic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5;[24]), participants were categorized as binge eaters if
they responded Byes^ to the first two questions (overeating
and loss of control) and had engaged in one or more episodes
of binge eating per week. A binge eating frequency score was
calculated based on how often participants engaged in binge
eating per week, on average, and assigning a value of 0 to
participants who indicated no binge eating episodes. The
binge eating frequency score ranged from never (0) to nearly
every day (5).
Dietary Adherence
Three items fr om the Spanish version of the Summary of
Diabetes Self-Care Activity (SDSCA) scale [25]wereused
to assess dietary adherence. Participants were asked, BOn av-
erage, over the past month, how many days per week have you
followed your eating plan?^. Participants were also asked to
indicate how many of the last 7 days that they ate B5ormore
servings of fruit and vegetables^ and Bhigh-fat foods such as
red meat or full-fat dairy products.^ The SDSCA uses an
eight-point scale ranging from 0 to 7 days.
Dietary Self-Efficacy
Five items from the Spanish diabetes self-efficacy scale [26],
which was developed based on Bandura’s social cognitive
theory [27] and validated with a sample of type 2 diabetes
patients in Mexico, were used to measure diet self-efficacy.
The items assess how capable diabetes patients feel about
performing be haviors relevant to eating a healthy diet. A
sample item includes, B
How capable do you feel about
avoiding foods that are not part of your diet?^ Participants
responded to the items based on a four-point Likert scale from
not capable (1) to very capable (4). Internal consistency was
good for the total (α =0.88), Mapuche (α =0.88), and non-
Mapuche (α =0.88) samples. A diet self-efficacy score was
calculated by averaging the five items.
Body Image Dissatisfaction
Two items from the weight and shape concern subscales of the
Spanish version of the Eating Disorders Examination—Ques-
tionnaire (EDE-Q; [28]) were used to assess body image dis-
satisfaction. Participants were asked, (1) BDuring the past
28 days, how dissatisfied have you been with your weight?^
and (2) BDuring the past 28 days, how dissatisfied have you
been with your shape?^ The items were based on a seven-
point Likert scale ranging from not at all (0) to markedly
(6). The EDE-Q items demonstrated good internal consistency
for the total (α=0.85), Mapuche (α =0.81), and non-Mapuche
(α=0.87) samples. Scores from the weight and shape concern
items were totaled and averaged to provide an overall body
image dissatisfaction score.
Emotional Well-Being
The Spanish version of the Fiv e Well-Being Index of the
World Health Organization (WHO-5; [29]) was used to assess
emotional well-being. Participants were asked about positive
affect and level of energy based on a six-point Likert scale
ranging from at no time (0) to all of the time (5). This subscale
showed good internal consistency for the total (α=0.89), Ma-
puche (α=0.85), and non-Mapuche (α=0.90) samples. Con-
sistent with previous use of the WHO-5, item scores were
summed and transformed to a 0–100 scale with lower scores
representing poorer emotional well-being. A WHO-5 cutoff of
<50 is recommended as the threshold for further testing of
depression and suggests mild–severe depression [30].
Statistical Analyses
All statistical analyses were performed using SPSS software
version 22.0. A missing variable analysis was conducted to
identify individuals with missing data on one or more of the
key study variables. Individuals excluded from the study due
to missing data were compared to the retained sample on
demographic variables using t tests for continuous and chi-
square tests for categorical variables which indicated no sig-
nificant differences between the eliminated and retained cases.
The prevalence of binge eating was determined for the total
sample as well as based on ethnicity and gender. Differences
were evaluated using the chi-square test. The binge eating and
non-binge eating groups were then compared on dietary
Int.J. Behav. Med.
adherence, glycemic control, and psychological variables. Di-
chotomous study variables were examined using the chi-square
test, and continuous study variables were examined with a t test
using Holm’s Sequ ential Bonferroni procedure to correct for
multiple comparisons [31]. Cohen’s d and the Phi coefficient
were also calculated to examine effect sizes. Pearson’s r coef-
ficient was used to test the strength of association between
binge eating frequency and the dietary adherence, glycemic
control, and psychological variables for each ethnic group.
Results
Prevalence of Binge Eating
Approximately 8 % (n=31) of the total sample reported binge
eating, on average, at least once a week for 6 months. The
prevalence of binge eating for Mapuche patients was 4.9 %
(n=7), and for non-Mapuche patients, it was 9.9 % (n=24) [χ
2
(1, n=387)=3.09, p=0.079, phi=0.089].
Differences Between Binge Eaters and Non-Binge Eaters
on Dietary Adherence, Psychological Factors, and Glycemic
Control
Table 1 shows the descriptive statistics and mean differences
between the binge and non-binge eating groups after correcting
for multiple comparisons using Holm’s Sequential Bonferroni
procedure [31]. The binge eating group had greater BMI values
than the non-binge eating group. In terms of dietary adherence,
the binge eating group was more like ly to eat foods high in fat
and less likely to adhere to the prescribed eating plan compared
to the non-binge eating group. Furthermore, the binge eating
group reported poorer body image and lower emotional well-
being. Based on the WHO-5 index cutoff of <50, the binge
eating group was more likely to report depressive symptoms.
There were no differences in HbA
1c
levels; however, the binge
eating group reported a younger age at diabetes diagnosis com-
pared to the non-binge eating group.
Associations Between Frequency of Binge Eating and Dietary
Adherence, Psychological Factors, and Glycemic Control
Based on Ethnicity
Table 2 presents the correlations between binge eating fre-
quency and study variables based on ethnic ity. For the
Table 1 Comparison of dietary adherence, psychological factors, and glycemic control by binge eating status
Binge eaters (n=31) Non-binge eaters (n=356) Significance Effect size
n (%) n (%) p value Phi
Overweight 7 (22.6) 114 (32.0) 0.277 0.110
Obese 23 (74.2) 202 (56.7) 0.059 0.193
Depressed symptoms* 10 (32.3) 57 (16.0) 0.022 0.236
Dietary adherence M (SD) M (SD) p value Cohen’s d
High-fat foods* 3.48 (1.76) 2.05 (1.70) <0.001 0.839
>5 fruits and vegetables 4.61 (2.17) 4.70 (2.09) 0.823 0.040
Eating plan adherence* 3.48 (2.28) 4.56 (1.90) 0.003 0.557
Diet self-efficacy 2.36 (.73) 2.63 (.66) 0.031 0.407
Body image dissatisfaction* 5.61 (1.65) 3.71 (2.21) <0.001 0.874
Emotional well-being* 63.12 (28.27) 74.72 (23.60) 0.010 0.484
Body mass index* 34.78 (7.94) 31.44 (5.54) 0.002 0.580
HbA
1c
7.26 (1.80) 7.26 (2.02) 0.998 0.000
Age at diabetes diagnosis* 43.98 (12.27) 51.87 (12.70) 0.001 0.613
Depressive symptoms based on WHO-5 index cutoff of <50
*Significant at the p<0.05 level for chi-square tests and after Holm’s Sequential Bonferroni correction for t-tests
Table 2 Correlations between frequency of binge eating and study
variables by ethnicity
Ethnicity
Mapuche Non-Mapuche
High-fat foods 0.183* 0.225***
>5 fruits and vegetables −0.113 −0.013
Eating plan adherence −0.095 −0.232***
Diet self-efficacy −0.144 −0.137*
Body image dissatisfaction 0.154 0.306***
Emotional well-being −0.037 −0.144*
Body mass index 0.093 0.305***
HbA
1c
0.162 −0.010
Age at diabetes diagnosis −0.126 −0.185**
*p<0.05; **p<0.01; ***p<0.001
Int.J. Behav. Med.
Mapuche sample, binge eating frequency was positively asso-
ciated with consuming high-fat foods. Among the non-
Mapuche sample, binge eating frequency was positively asso-
ciated with consuming high-fat foods and negatively associ-
ated with eating plan adherence. Binge frequency was also
associated with lower diet self-efficacy, higher BMI, greater
body image dissatisfaction, lower emotional well-being, and
younger age at diabetes diagnosis.
Conclusion
The co-occurrence of binge eating and type 2 diabetes in Chile
was consistent with prevalence rates found in some studies
[14, 32, 33] and lower than those reported in other studies
[12]. On average, approximately 8 % of Mapuche and non-
Mapuche type 2 diabetes patients engaged in one or more
episodes of binge eating per week over the previous 6 months.
Findings from this study may increase our understanding of
the dietary adherence, glycemic control, and psychological
issues associated with binge eating among type 2 diabetes
patients in general, while highlighting important consider-
ations that may be unique to indigenous and mainstream La-
tino patients in a Latin American country.
Dietary adherence and weight control are important com-
ponents of diabetes management, which are influenced by
binge eating status according to the study findings. The higher
BMI among binge eaters may be the result of eating behaviors
and lower adherence to the diabetes diet in patients with this
co-morbid diagnosis. Interestingly, binge eaters and non-
binge eaters were equally likely to eat five or more servings
of fruits and vegetables. However, binge eaters consumed
more high-fat foods such as meats and dairy than non-binge
eaters which is consistent with behavioral patterns reported by
women who binge eat [34–36].
Results from this study could be useful for the development
of interventions aimed at improving dietary adherence and
controlling weight among type 2 diabetes patients engaging
in binge eating. For instance, addressing self-efficacy associ-
ated with avoiding high-fat foods and eating fruits and vege-
tables could be particularly effective given that binge eaters in
this study reported lower diet self-efficacy compared to non-
binge eaters. Enhancing perceptions of control may also be an
important factor to consider in intervention efforts based on
recent research indicating that dietary adherence and the con-
sumption of high-fat foods were associated with perceived
control over developing diabetes complications [37]. Addi-
tionally, cognitive b ehavioral guided self-help (CBTgsh)
may be an effective means for helping binge eaters establish
a regular pattern of eating. Recent research revealed that binge
eaters who received ten sessions of CBTgsh had better dietary
adherence and fewer binge episodes [38].
Findings also indicated important psychological aspects
concerning the co-occurrence of binge eating and type 2 dia-
betes. Results suggest that engaging in binge eating contrib-
utes to greater body image dissatisfaction and poorer emotion-
al well-being. These findings are consistent with a study of
youth with type 2 diabetes, which indicated that patients en-
gaging in binge eating had greater depressive symptoms and
impairment in quality of life than those without binge eating
[13]. In the current study, twice as many binge eaters (32 %)
than non-binge eaters (16 %) were identified as potentially
depressed. Depressive symptoms have been linked with inad-
equate diabetes management such as poor self-care, medica-
tion adherence [39], and glycemic control [40]. Such findings
have highlighted the need to consider developing more com-
prehensive interventions for diabetes that address depression
[41]. With regard to binge eating, future research could ex-
plore the potential indirect effect of binge eating on measures
of diabetes control, such as HbA
1c
, through depression and
other mediating psychological factors, which may further in-
form interventions specifically for type 2 diabetes patients
with binge eating.
This study revealed some interesting findings with regard
to ethnicity. For instance, although the difference was not
statistically significant, the prevalence of binge eating was
4.9 % for Mapuche and 9.9 % for non-Mapuche diabetes
patients. Several Latin American countries, including Chile,
have undergone rapid environmental and cultural changes due
to globalization, economic growth, and urbanization resulting
in a more westernized lifestyle [42]. Research suggests that
the Anglo American cultural ideal of thinness plays an impor-
tant role in the development of eating disorders [43]. In Chile,
the indigenous Mapuche population has historically resided in
traditional rural en vironments th at may be more protected
from the influence of westernization and the mass media. Un-
like the Mapuches, non-Mapuches may be more exposed to
and potentially internalize Anglo American portrayals of
physical attractiveness, which may contribute to the occur-
rence of binge eating in this population. However, recent eco-
nomic and social changes have resulted in the migration of
greater numbers of Mapuches to urban areas [44], and such
migration could potentially make this population more sus-
ceptible to disordered eating behaviors in the near future.
For Mapuche diabetes patients, as well as non-Mapuches,
results indicated that binge eating frequency was associated
with an increased consumption of high-fat foods such as meat
and dairy products. The traditional Mapuche diet is scarce in
meat and consists predominantly of vegetables [45], which is
quite inconsistent with the high-caloric/high-fat foods that are
typically consumed during binges. According to the B thrifty
genotype^ hypothesis, which has been used to explain the
higher prevalence of obesity and diabetes among American
Pima Indians, Australian Aborigines, and Pacific Islanders,
hunter-gatherer societies adapted mechanisms that allowed
Int.J. Behav. Med.
them to hoard calories to conserve energy and withstand times
of famine [46]. Such beneficial mechanisms may be disadvan-
tageous when high-calorie, high-fat diets are more frequently
consumed such as during binge episodes. This is in line with
recent research that revealed that adiposity and increased sed-
entary time influenced insulin resistance to a greater extent in
Mapuches as compared to non-Mapuches [47].
Findings from this study may also contribute to a better
understanding of the health challenges faced by indigenous
populations in other co untries such as Australia, Canada,
and the United States where they experience higher rates of
obesity, type 2 diabetes, and cardiovascular disease compared
to non-indigenous populations [48–50]. Research in these
countries suggests that disordered eating and body
dissatisfaction are as prevalent among indigenous as non-
indigenous populations [51, 52], which is contrary to findings
in Chile [53]. Considering the prevalence of binge eating in
these countries, the implications of co-morbid binge eating
and diabetes may be even more far reaching for indigenous
populations in such countries. Future research examining this
co-morbid diagnosis among indigenous populations in other
countries is warranted. Moreover, future research may also
benefit from exploring differences in health behaviors and
outcomes among indigenous-majority as compared to
indigenous-minority countries. Berry and Kalin (1995) argue
that the general orientation of society or a particular country
toward cultural pluralism can support or hinder cultural diver-
sity and the treatment of indigenous populations, particularly
depending on whether the indigenous population is a domi-
nant or non-dominant ethnic group [54]. As such, indigenous
patients from indigenous-minority countries may experience
more stress, discrimination, and hostility leading to worse
health behaviors and outcomes.
The strengths of this study include the use of DSM-5
criteria to identify binge eating, the use of indigenous and
non-indigenous type 2 diabetes patients, and the inclusion of
a biological measure of diabetes control (HbA
1c
). One limita-
tion of the study is the small sample of patients with binge
eating, which may have affected the ability to detect signifi-
cant relations with some of the study variables. Another lim-
itation is the use of diagnostic items from the QEWP-R, a self-
report questionnaire, rather than a diagnostic interview to as-
sess binge eating. However, the QEWP-R has been identified
as a useful tool for screening binge eating that can be easily
utilized given its brevity [55].
Despite these limitations, the present study provides pre-
liminary evidence concerning the prevalence of binge eating
among type 2 diabetes patients and its implications for dietary
adherence, glycemic control, and psychological well-being in
a Latin American country, including mainstream Latino and
indigenous populations. Research suggests that the prognosis
of patients with this co-morbid diagnosis is poor in the ab-
sence of specialized treatment [56]. Health care professionals
treating diabetes patients could be encouraged to screen their
patients for binge eating so they can make referrals for treat-
ments that specifically address issues associated with binge
eating. Such efforts could result in improved eating behaviors
and d isea se management for diabetes patients with binge
eating.
Acknowledgments This study was part of a larger research project
supported by funding from the Government of Chile, through its National
Council for Scientific and Technological Research (CONICYT),
FONDECYT project 1090660 to the last author. The authors thank the
FONDECYT project research team, particularly Tamara Hernandez
Otzen, Gloria Muñoz, and Ligia Orellana, whose contribution made the
data collection for this study possible.
Conflict of Interest Sylvia Herbozo, Patricia M. Flynn, Serena D. Ste-
vens, and Hector Betancourt declare that they have no conflict of interest.
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