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10 Game-Changing Rules for Obesity Management




One of the talks I gave at the National Obesity Summit last week was on obesity management in primary care. In this talk, I focussed on 10 simple principles of weight management, that I believe even the most busy primary care practitioner can easily adopt and will prove ‘game changing’ in terms of obesity management (note to HAES readers – these same rules apply both to helping people sustain their weight as well as helping those people, who need to, reduce their weight).

The video above is a summary of the ‘dos and don’ts’ as recorded by Paul Boivert (laval).

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Once again – all comments are appreciated.

AMS
Edmonton, Alberta

p.s. for more videos and interviews from the Obesity Summit visit the Chaire sur l’obésité channel on YouTube

25 Comments

  1. Arya – These rules are an excellent and an easy to understand tool for physicians. While not directly related to obesity treatment, I would also mention ‘do not assume that all health problems are related to excess weight’ given what we heard from Dr. Puhl at CON’s weight bias conference.

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  2. Very nice, succint summary of common sense, that, sadly is not universal in the medical profession. People who violate your rule #1, and so many do, are showing their contempt for their fat patients. It is sad. I understand medical schools are not countering it, either.

    I would like to highlight one thing you said that runs counter to HAES, but YOU ARE RIGHT ON THIS and HAES is wrong. Under subpoint four you said you encourage your patients to not allow themselves to get hungry. Many in the mindful eating movement recommend eating when modestly hungry (a 3 or 4 on a scale of 1 to 10) and until satisfied (5 – 7 on that same scale). Most of us are incapable of this kind of precision and/or our schedules and social lives preclude executing it. Moreover, allowing hunger to happen is uncomfortable, and not only encourages a one-time over-reaction (binge or mini-binge), but I think it triggers endocrine reverberations that can last for days, though I don’t have the proof for this. I know that for me, one weight-reduced person (n=1), this is true. An episode of legit hunger triggers days of annoying “eat now” impulses.

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  3. 11. The first thing that you should ask your patients about is their maximum weight. If they’re below it, then don’t tell them that they need to lose weight. They’re already maintaining a weight loss.
    12. Don’t assume that your fat patients don’t already know all of the factual information referred to in the earlier points, and aren’t already eating well and getting regular exercise. ASK them. 13. Many people who are classified as “overweight” or “obese” would like to receive size-neutral medical care. Again, ask. If that’s what your patients want, then don’t mention their weight unless it’s clearly relevant.

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  4. I like it. I think its a fabulous first step to improving care at the ground level. Two suggestions: is there anywhere to fit in a recommendation for the pschycological support needed for many obese people? Also would a 10 steps poster for principles of care for obese children be possible? I think some of the steps would be different and obviously meed to involve parents as well. Children need to feel doctors are on their side and understand them.

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  5. Why go to step 3 after step 10? I would suggest going all the way back to step 1! The patient is feeling terrible and needs even more reinforcment at step 10! Great job on the 10 steps though.

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  6. I have another idea: in brackets after step one offer physicians a positive action option e.g. “instead offer your patients compassion, committment and understanding” That gives doctors a “do” after the “dont”.

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  7. @M: You are absolutely right – check out my previous post on indications for obesity treatment, which makes this point – http://www.drsharma.ca/indications-for-obesity-treatment.html

    @DeeLeigh: Correct on all counts: I just did not want this to be the 20 things you can do – remember, we started with the problem that docs don’t have time to do this – so giving them 20 things to do is not helpful – but I agree all of your additional points are well taken.

    @Rachel: If you recall yesterday’s post – the first M is Mental health – so yes, pyschological and behavioural intervention should be part of most weight management plans. I also agree that the rules for kids would be different. In fact, I believe that if the parents themselves had a weight issue and followed these rules, the kids would probably take care of themselves.

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  8. @Rachel: “offer your patients compassion, committment and understanding”

    Love it! Great suggestion.

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  9. Your blog is great! I’ve read it many times. I was a person who didn’t really believe that certain foods were as many calories as the label said. My mind just couldn’t twist around the fact that a “mini”-sized candy bar could be 120 calories while a 1/2 cantaloupe was less. It’s just really hard to imagine that to be correct.

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  10. @DeeLeigh: Correct on all counts: I just did not want this to be the 20 things you can do – remember, we started with the problem that docs don’t have time to do this – so giving them 20 things to do is not helpful – but I agree all of your additional points are well taken.

    If they follow my points as the first three, then they are likely to save a lot of time with not having to cover the later points.

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  11. should have included this with my previous post:

    Listening to your patients should be your first priority, not a set of optional points that can be set aside to make a perfect list of ten things to lecture on.

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  12. The other thing that I believe would be helpful would be a setting of goals that are not just weight loss related. If a patient starts, and maintains an exercise program… well, that is pretty darn good, even if weight loss doesn’t follow. Encouraging doctors to notice positive healthy steps, even if there is no (immediate?) weight loss, I think is important, and can also help the patient realise that these things are good for them, and that weight loss, if it is a goal, is one among many.

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  13. Dr. Sharma – that you are proposing these rules really saddened me; the research is very clear that many of your tenets, while popularly believed, are not only ineffective at supporting sustained weight loss, but damaging. I encourage you to re-read an article you cited in your work previously (http://www.nutritionj.com/content/10/1/9) as it provides the evidence challenging many of your claims. Also, your sidebar to those of us who support Health at Every Size (HAES) clearly shows that you don’t understand the premise of HAES. HAES does NOT have weight maintenance as its goal – it’s approach is weight neutrality – and it is valuable for people across the entire size spectrum, fat and thin alike. It is clear from the research that weight cannot be controlled to the degree you suggest is possible – and your suggestion to try is more likely to result in damaging weight cycling and stigmatization than sustained weight loss. (The failure is YOURS, resulting from promoting your unscientific weight loss ideology, not in the individuals who try to implement it and end up getting the blame.) HAES, on the other hand, supports people in adopting healthy habits and being open-minded to weight outcome. Why are you so resistant to this? If you want people to adopt good health habits, why not suggest they go after it directly – why use weight as a mediator? As the article I cited shows, improved health is better achieved – and sustained – through improved health habits than weight loss.

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  14. @Linda: “the research is very clear that many of your tenets, while popularly believed, are not only ineffective at supporting sustained weight loss, but damaging.”

    Sorry, but this where you apparently choose to misunderstand the entire field of obesity management that I promote. The research is actually very very clear on all of the principles I propose: removing anti-fat bias, chronicity of obesity, importance of self-monitoring, improving health and not weight, avoiding liquid calories, etc., etc., etc., etc.

    You only have to do my job for 6 months to see the tremendous positive impact on health and life that successful obesity management with ongoing intervention has on the many people who cannot breathe, move, put on their shoes, clean themselves, or work in their profession without weight LOSS – sorry, but for 1000s of Canadians, eating more fruit and walking round the block while working on their self-esteem is not going to cut it.

    At the same time, I fully agree (and not a day passes without me telling this to my patients), to have my patients stop focussing on their weight and rather focus on positive thoughts and behaviours; to not pursue weight loss as a primary goal or to see numbers as a definition of success.

    I am happy to live with this ambivalence – as a practicing physician I have done that all my life – it is about finding solution to each patient’s individual needs and problems that meets their very unique circumstances – denying that is just that – denial.

    While I am happy to see HAES as an important consideration I am not dogmatic about it and don’t see this as a religious ‘belief’ system. Unfortunately, most HAES enthusiasts I speak to, appear to suffer from a bad case of dichotomous thinking – either you’re in or you’re out – either it is a great success or a complete and utter failure – every thing is either black or white – either we throw out the scale or we do bariatric surgery on EVERYONE!

    HAES is primarily about health but when a given patient’s health is at a point where their lives break down and they do have a realistic opportunity to change their size to achieve better health (and 1000s do), then it’s my job to help them get there, without making this only or even mostly about weight.

    The notion that I should be telling my 24 year-old 450 lb patient to just try and be as healthy as she can at her size and for me to sit back and watch her progressively gain 40 lbs a year while each day is a mental and physical struggle, is not acceptable practice. If HAES promotes ignoring weight and accepting this situation – then HAES is simply wrong (not to say inhuman and cruel – like most dogmatic philosophies). But my understanding of HAES (at least till now) has been that people at any size can strive to maximise their health – but for some, this is neither possible nor enough.

    Yes, it is nice to see my patient with diabetes stop smoking, increase their physical activity, eat more fruit and vegetables and work on their mood and self-esteem, but in the end some may still need medications to lower their blood glucose levels to avoid going blind or losing their feet. Proposing that they should simply ignore their HbA1c levels and just focus on living as healthy as possible is malpractice.

    Similarly, I would probably also not completely buy into a ‘philosophy’ that proposes Health At Every Blood Pressure (HAEBP) or Health At Every Apnea (HAEA), etc.

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  15. Hi Dr. Sharma,

    I am really pleased with these guidelines (!). We are inundated with complex and opaque information regarding “obesity” and “healthy body weights”. Unfortunatley, we often confuse the obesity issue with the physical attraction issue- they are not the same!

    It’s not our job, or even any of our business, to pass judgement about other people’s eating habits. This kind of sanctimony smacks of the Victorian or even Medieval eras, and I’m really happy with this clear and feasible set of tips.

    Touche with Health At Every Apnea…

    Cheers,

    MYL

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  16. Thanks for sharing videos from the Summit. Really was sorry I couldn’t attend. Please post the date of the next summit when it’s set. Can’t say enough about how much I appreciate your blog and Yoni’s blog. Think the two styles are very complementary.

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  17. @ AMS – Your exchange with Linda Bacon is disturbing. You have mischaracterized her writing and the whole idea of HAES, and I think it is because you really don’t understand it. YOU are the one with the binary thinking, and your argument breaks down to “either my patient is trying to lose weight, or she is gaining weight.” You did not name a single practice that HAES would disagree with – except for losing weight. And no, ignoring weight is not the same as “accepting the situation.” If your 450 lb. patient wants a better situation, she will learn about nutrition from a balanced (not weight loss) perspective, she will find ways to increase her activity levels as much as possible, stop smoking, and yes, take appropriate medications to treat whatever medical conditions she has (nobody believe in Hypertension At Any Size or any other disorder for which there is a known, validated, safe and effective treatment). That’s not accepting the situation, that’s making an action plan and working it. But where in there does she weight have anything to do with it? She will either lose weight, stay the same, or perhaps gain weight, but that doesn’t tell you anything about her healthful behaviors. If she has a lot of room for improvement on these healthy behaviors, then yes there’s a good chance she will lose weight. Great (from your perspective) but incidental news.
    Oh, but perhaps you think weighing a patient is a substitute for *believing what she tells you*. THIS is what sticks in the craw of HAES practitioners, the attitude that if the patient doesn’t lose weight, she must be lying about something that she claims to be doing or not doing. When all is said and done, the only real purpose of weight is to give doctors a safe, non-self-incriminating way of saying “YOU’RE LYING.” This is what drives fat people, and HAES proponents of all sizes, nearly crazy.
    And if this is not what you are doing, then work with your patients on healthy behaviors, encourage them when they struggle, treat actual medical conditions as well as possible, form a trusting relationship and then BELIEVE them when they say tell you what they are doing. And if their stamina or their blood pressure or glucose levels never improve, then talk with them about that in a respectful way. Now THAT is true caring.
    But meanwhile, please try to understand HAES better before you stereotype it too.

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  18. Decades of outcomes data for medically supervised weight-loss methods of all sorts clearly show that the vast majority of people (85% to 98%) who lose weight will regain in a brief time. Even people who sacrifice healthy, internal organs end up regaining lost weight…and gaining life-threatening complications, too!

    I cannot trust any medical care provider who insists on pursuing a goal (weight loss) that has such a consistent and obvious failure rate. I can’t imagine why your patients place their trust in you. It must be the lack of a proper, positive alternative. I’m optimistic: science can’t remain so egregiously unscientific forever. At some point soon, I hope there will be no shortage of healthcare providers who opt for the effective/ethical double bonus of a Health At Every Size approach. It’s both good for health and good for social justice.

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  19. Dear Dr. Sharma,

    You are correct. HAES (SM) is about the ways that people of all sizes can maximize their health. But I think you, like many others may have a few misconceptions about the active nature of a HAES(SM) approach to health. HAES(SM) does not mean to give up or to let everything go. It is an active process by which people work positively with their bodies and within their lifestyles to achieve a level of health which is reasonable and above all, sustainable for them. It means managing health within a framework of a life well lived as opposed to weight centric, thin at any cost methods. It means managing nutrition and fitness within a global health framework that would include managing stress, sleeping well, maintaining social connectedness and much, much more. This is not passive, and it is not easy. It requires a lifetime of careful work in learning which foods nourish you and which leave you feeling unwell; in learning what forms of exercise strengthen you and energize you and which forms leave you depleted and hurting; and in learning to make positive, gradual changes based on self-care rather than self-hatred.

    You presented this example:
    “The notion that I should be telling my 24 year-old 450 lb patient to just try and be as healthy as she can at her size and for me to sit back and watch her progressively gain 40 lbs a year while each day is a mental and physical struggle, is not acceptable practice.”

    Nowhere in the HAES(SM) approach does it suggest that this is a valid course of action for a physician. People’s weight changes throughout their life for many reasons, and that is natural. But a weight change of 40 lbs. in one year would certainly be cause for investigation by a physician. But the key word here is investigation. There is so much that we still don’t know about weight. There has not been an extensive study to see why some people are larger than others, or why some people gain weight and others can’t keep it on. Do we know if the endocrine system is different in people who are “obese?” Do we know why some people develop disordered eating and others faced with similar triggers do not? Do we know why one person’s metabolism can be so different from another and for some there is no adjusting it through nutrition or physical activity? Do we know why when someone has bariatric surgery it appears their diabetes is cured immediately and we know they have not yet started their altered intake long enough to have had this impact on insulin uptake? No. We don’t.

    Thus far, it seems the only research that is funded is the alarmist, “obesity epidemic” research that presupposes that fat people are lying about their lifestyles and supports the “weight loss by any means” approach. What I think many proponents of the HAES(SM) Paradigm would like to see happen is an investigation into and dialog about an alternative approach to health. This approach would listen to fat people and assume that they are being truthful about their symptoms and lifestyle. This approach would help people of all sizes integrate fitness and nutrition in a way that first, does no harm. This approach would help people actively and knowledgeably advocate for their own health no matter what their size or shape. We at The Association for Size Diversity and Health believe that this approach would make health and healthcare better for all people.

    Thank you,
    Deb Lemire
    ASDAH, President

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  20. drlbinks has hit the nail on the head. Look at this post, where Dr. Sharma writes

    “Obesity, as we all know, is a chronic progressive condition. Left untreated, patients generally continue to gain weight – those, who do not already have weight-related health issues, will eventually get them.”

    “As we all know?” What a bunch of b.s. Interesting, Red No. 3 recently wrote a post on this type of rhetoric.

    I speak, by the way, as someone whose BMI is in the ‘obese’ range and who has been approximately the same size since reaching my adult height. I’ve been a conscious non-dieter since I was a teenager. Having a weight/height ratio in an arbitrarily defined range isn’t a progressive disease. Dieting is what makes fat people gain weight. Oh, and how long does it take to develop those inevitable weight related health issues, Dr. Sharma? Because I’m in my early forties, have been obese since childhood, and it still hasn’t happened.

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  21. I support HAES, but have really changed my mind on the issue. There are many manifestations of metabolic syndrome, and you can be thin and still be pre-diabetic. Many doctors don’t recognize this, even though the treatment for the thin pre-diabetic might be the same as it would be for a person who has gained 100 lbs over a period of time. But still, both fatness and pre-diabetes are symptoms of insulin resistance and metabolic syndrome, which are diseases that for the most part did not exist until the 20th century.

    There are now some doctors (like Arya Sharma) who are able to help patients improve their diet very successfully, so that the patient is much happier and ironically, much less hungry, even though some fat loss results from the new way of eating. There are certainly lots of people and organizations that promote and profit from fat hatred. It’s unfortunate that HAES proponents are attacking Dr. Sharma, who is one of the least prejudiced and most well-informed doctors when it comes to obesity treatment.

    While the failure rate for dieting and weight loss may be abysmal over all, for those fortunate enough to have really well-informed and compassionate doctors, I bet that many more people succeed in reaching their goals. It can actually be easier that you would think, and does not necessarily involve starving, deprivation or self-hatred.

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  22. I suspect that the number of people who are able to maintain weight loss/reverse metabolic syndrome among Dr Sharma’s patients is much higher than the 10-15% cited above. I follow a similar program through Dr. Yoni Freedhoff’s clinic, and I must say, based on the approach they both use, I think the days of unsuccessful weight loss programs are now over. I don’t believe you need to be lean in order to be healthy, but fatness is often a symptom of metabolic syndrome, as are high blood pressure, fatty liver disease and high blood sugar. Like as not, until about 100 years ago, it was rare for people to be extremely fat, and it is probably not an indication of good health in most cases. We living a a crazy food environment, where we allow corporations to get rich pushing junk food on us, even though it makes us sick. In this environment, taking the approach of just listening to your body might not be effective – our bodies did not evolve to contend with this food environment, so how can you know that the signals you are getting are taking you in the right direction?

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  23. I was really shocked at the attacks at Dr. Sharma, as I never saw him promoting weight loss, but rather behaviours that promote health (and a potential modest weight loss of 5-10%- which we know can bring +ve health results) with patients who are at the end of the rope. I’ve recently started following both him and Dr. Freedhoff, and read Health At Every Size to help me make up my own opinions about obesity, health, myths straddling both, as well as, the cultural norms around weight & how one defines self in our society. As much as I want to be open and support Health At Every Size, comments made about dietians and the unsupportive nature of comments around healthy eating recommendations make me uneasy (in the book). I like the comment made by Dr. Sharma about seeing things as black & white – because this is what is being argued here above. Why are we so adamant to establish that one is right over the other, when there is so much we don’t know yet about the multi-factorial influencers of overweight & obesity? Also, can we truly argue that HAES is the best course of action to take, for individuals who’s lives are severely affected by their weight? Where radical changes are needed or else the outcomes may be severe? I’m beginning to view HAES as an approach that is most fitting in the preventive arm, and a great philosophy to convey at the public health level. I do think that the de-emphasis of focus on weight should also be promoted via MDs. However, let’s not be blind to the fact that weight is a health indicator – the problem in our society lies with the fact that it is seen as THE ONLY one – and that is the biggest problem. I feel that the work Dr. Sharma is doing, is necessary, just like we need surgeons to go in and remove tumors (we don’t need them at the primary level of health promotion). I guess the discourse is good in that it promotes thinking and helps us assess whether the work we do Does No Harm. I’m curious to see where we will end up in the next 20 years – as this is not going to be solved tomorrow;)

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  24. It is quite aggravating to see some commenters willfully misrepresent what Dr. Sharma is trying to do, in order to justify their own lifestyle choices and the consequences of those choices, and feel better about themselves. Dr. Sharma has consistently promoted healthful lifestyle choices as a way to achieve a healthier and happier life – and the reality is that improved physical, and mental health is often a consequence of better choices. A healthier weight is often a consequence of comprehensive healthful choices. No one is arguing that it is *easy* to make comprehensive lifestyle change – Dr. Sharma would be the first to argue that it is difficult, and made more difficult by the environment in which most of us live today, an ‘obesigenic’ environment. But the reality is that consistent, longterm healthful choices often *do* result in improved health, and lowered risk factors for disease development.

    Excess weight, just like high blood pressure, is an ‘independent’ risk factor for disease (meaning, it raises risk of disease all by itself.) To deny this is simply to deny the scientific literature. And excess weight, just like excess blood pressure, does not always come down immediately with more healthful food choices, more exercise, stress reduction, and even medication. Individuals respond somewhat differently to different measures, and some need aggressive intervention in *all* of these areas, in order to achieve results, whether we are talking about blood pressure, or weight. Some people *do* have to work harder than others, to be healthy. It’s not fair, but it’s reality. And denying reality helps no one.

    So, for those who attack and misrepresent Dr. Sharma, you are directing your anger in the wrong direction. If you are obese, the reality is that our social environment does in fact make it easy to gain excess weight (to the point that it becomes a risk factor for other disease, and early death), hard to lose weight, and hard to achieve a balanced, healthful lifestyle. It is also true that weight prejudice and bias exists, and it is horrible, hurtful, and unfair. But these conditions, these attacks do not come from Dr. Sharma – in fact he has worked hard to try to change the obesigenic environment, and combat weight stigma/bias/prejudice. Those would attack Dr. Sharma, and are suffering, are misguided, and attacking one of their biggest allies. I do feel compassion for them, since these kinds of attacks generally come from people who have poor self-esteem, and/or are unwilling or unable (for a variety of reasons) to make the kind of intense, focused, comprehensive lifestyle changes that can lead to healthier blood pressure, blood glucose, and weight. Again, I include weight as a health parameter, because research has repeatedly demonstrated that excess weight itself can be a risk to health. Please, to the ‘haters’ who attack Dr. Sharma, I encourage you to look at yourself, your own motivations, search deep within yourself so you can get the strength and self-esteem to attack the real problems, not a person you are trying to ‘scapegoat.’ Attack the obesignenic environment, and weight prejudice, do not attack people who are ‘on your team.’

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  25. Dr. Sharma

    I really respect you and enjoyed your reply to Linda Bacon. I thought it was an excellent reply to a salesmen dogmatist.

    I agree with your points that while obesity is extremely complex- it needs to be treated with a scientific approach ( just as Dr. Friedman says). Being weight neutral and seeing patients continually gain is not good as you correctly point out.

    Linda acknowledges that “eat less, move more” has failed, but you at least seek for another treatment which is science based to fight obesity. Yours is the scentific stance.

    Weight neutrality is for book sales.

    You are a genuine scientist and doctor. Dr. Stephan Guyenet and Dr. Jeffrey Friedman are genuine scientists too.

    I can see from my buddy Urgelt ( who recognizes genuine doctors and scientists) that Linda is dogmatic about HAES and for sales. I am the biggest reason her site took off . Sadly, she never once acknowledged or thanked me for my efforts. However, I knew little about obesity back then. My blog was well read at one time, and several bloggers stole my posts linking to Linda Bacon etc.

    Knowing what I know now, I recommend your site, Stephan Guyenet’s articles and Dr. Friedman and Dr. Liebel’s lectures. I want your blog and Stephan to be heard much more than any salesmen.

    Thanks for all you do.

    Take care,

    Raz

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