Wednesday, August 22, 2012

How Effective is Lifestyle Management of Obesity?

Sara Kirk, PhD., Canada Research Chair in Health Services Research, Dalhousie University, Halifax, Nova Scotia

Sara Kirk, PhD., Canada Research Chair in Health Services Research, Dalhousie University, Halifax, Nova Scotia

Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Apr 15, 2011:

Perhaps one of the most overused (and many would say ‘useless’) pieces of advise is that obesity management requires a lifestyle change.

While this may be true – there is nothing special about obesity when it comes to this recommendation, because guess what: living with diabetes requires lifestyle change, living with high blood pressure requires lifestyle change, living with asthma requires lifestyle change, living with celiac disease requires lifestyle change, in fact living with any chronic health problems requires lifestyle change.

So although, there is nothing special about recommending lifestyle change to help people better manage their weight, the question remains whether simply giving such lifestyle advise or following it actually works.

This was the topic of a paper just published by Sara Kirk (Dalhousie University, Halifax) and colleagues in the International Journal of Obesity, which presents an extensive review of the literature on lifestyle interventions for obesity with the aim to determine the most effective and promising practices for obesity management in adults.

From this review, three themes were derived from the highest level of available evidence.

These were targeted multi-component interventions for weight management, dietary manipulation strategies and delivery of weight management interventions, including health professional roles and method of delivery.

Not surprisingly, individually tailored multi-component long-term interventions were found to be the most effective (in fact there is little data to suggest that single (e.g. diet or exercise alone) or even double (e.g. diet + exercise) component interventions delivered in the short term are of any use at all).

This is of course very much in line with the fact that obesity should be viewed as a complex, chronic condition, requiring sustained contact with and support from trained health professionals (whether delivered in person or through web-based technologies).

The authors identified an important limitation of all intervention studies and thus any emerging remommendations in that:

“All of the current recommendations essentially look at obesity as a homogeneous condition that is amenable to treatment either simply by caloric reduction and/or increasing activity. No attempt is made to distinguish between different causes of obesity or even stages of obesity. The importance of identifying and thereby addressing the etiological determinants of positive energy balance is therefore critical to improving obesity management. Health professionals need to be aware of, and supportive to, these issues if individual behavior change is to be successful, and this is an area worthy of further consideration and review.”

In addition, although not the topic of this review, the authors acknowledge that more severe obesity will unlikely be managed by lifestyle interventions alone and will require the addition of pharmacological and/or surgical treatments as indicated.

The authors also note that:

“People seeking weight-loss support often present with a range of other issues that may hinder their ability to lose weight, including mental health issues, chronic pain and family or social barriers.”

These barriers may need to be addressed before any meaningful success in weight management (by lifestyle alone or otherwise) can be expected.

Overall, this paper makes it clear that there is very little evidence to support the rather simplistic lifestyle advice (‘eat less – move more’ = ELMM) often given to people trying to manage their weight – a fact that most people who have ever tried this approach are already well aware of.

In contrast, there is good evidence that individualised interventions that take a more holistic approach and are delivered by a multi-disciplinary team of health professionals in a manner consistent with best-practices in chronic disease management are most likely to succeed in the long-term. (note the word ‘likely’ in the previous sentence – as with any medical condition – there are no guarantees).

So, although none of this should come as a surprise to the regular readers of these pages, they will perhaps be happy to see that these thoughts are now finding their way into the mainstream obesity literature.

Hopefully, they will not just sit there but will actually become standard practice in obesity management.

AMS
Edmonton, Alberta

Kirk SF, Penney TL, McHugh TL, & Sharma AM (2011). Effective weight management practice: a review of the lifestyle intervention evidence. International journal of obesity (2005) PMID: 21487396

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27 Responses to “How Effective is Lifestyle Management of Obesity?”

  1. DeeLeigh says:

    This is of course very much in line with the fact that obesity should be viewed as a complex, chronic condition, requiring sustained contact with and support from trained health professionals

    ROFL. Or, it could be considered a body type that’s natural and has always been present in the human population, that has a mixed impact on health, and that doesn’t require any intervention at all. I, personally, stay healthy by eating a balanced diet, staying physically active, and avoiding the medical establishment as much as possible. I believe that the medical bias toward intervention is dangerous to my health and well being.

    Doctors are worse than automotive mechanics. They try to fix something and in the process, break 3 other things. If they obviously don’t know what they’re doing in a particular area (as with weight management), then its best not to let them experiment on you. Drugs or surgery to try to make me thin? I don’t think so. Modern medicine has an abysmal track record when it comes to that stuff. Redux and phen fen? Good thing I wasn’t stupid enough to damage my heart valves for some minor and temporary weight loss. And don’t even get me started on the surgery.

    If I break a leg or am suffering from a bacterial infection, I’m confident that a doctor can fix that. But I really wish that doctors would get it through their heads that they don’t know how to fix everything that people want them to fix, and that the null case should always be the default. If your intervention are not providing a clear, long term benefit, then hands off!

  2. Arya M. Sharma, MD says:

    “it could be considered a body type that’s natural and has always been present in the human population, that has a mixed impact on health, and that doesn’t require any intervention at all.”

    Many of the causes and/or consequences of obesity are insidious and will remain undetected without professional help – on the other hand (as regular readers of these pages should know) – many people with excess weight are remarkably healthy and likely to outlive their skinny counterparts.

    The role of the medical profession is to acknowledge both – identify and help the people who need and seek obesity treatments and guide them to the most effective treatments (which clearly don’t work for all but do for many) tailored to their needs and situations and, on the other hand, reassure and counsel AGAINST weight loss those who are perfectly healthy large people.

    Readers may recall a previous post, where I have asked whether weight-loss recommendations are unethical.

    In my practice I probably counsel as many patients to not worry about their weight and certainly not pursue unrealistic weight goals, as I counsel patients, who have significant health problems due to their excess weight, to seek appropriate treatment.

    Medicine is not there to push tests and treatments on those who don’t want them – it is there to help those who have health problems and are seeking professional help.

    In the automative analogy; you can take your car to the garage for a regular checkup and hopefully, if there is nothing wrong with it, you’ll be on your way for a small fee. However, if there is something wrong with it – hopefully this will be recognised and fixed.

    If the mechanic regularly creates more problems than he fixes, I’d change the garage – I would never say all garages are useless or all mechanics are quacks.

  3. NewMe says:

    Amen, DeeLeigh!

    I appreciate, Dr. Sharma, that you recognize that there are many reasons why certain people are overweight, however I heartily agree with DeeLeigh, that “over”weight can be a perfectly normal state too. We are not all genetically programmed to be slim.

    Like DeeLeigh, I fear that we are often creating even greater problems by insisting first and foremost on a so-called healthy weight. Since it is practically impossible for people to achieve and more importantly maintain a significantly lower weight, we must begin stressing the value of healthy living over the value of simply losing weight. We must also be much more pro-active in promoting nourishing foods as opposed to the frankenfoods that make up so much of the typical North-American diet, promoting preventive health care (which is inimical with the promotion of private health care) and improving the social determinants of health (including massive improvements to the mental health sector).

    The whole issue of what is “healthy” in terms of what we eat and the physical activity we engage in (as well as how much activity) is in itself quite fraught and everyone has their own definition. However, I continue to believe that there is much public health authorities can do to promote something positive (good, all-round–pardon the pun–health) rather than to constantly push the population to strive for what is usually a futile pursuit: reaching a so-called normal weight.

    I also believe that we are woefully ignorant of the actual negative results of yo-yo dieting, in particular the very real possibility (I demand RESEARCH!) that it leads to further weight gain — in other words, the opposite of what we “should” be aiming for.

    It is abundantly clear that permanent weight loss is only slightly more prevalent than winning the lottery. Why then, do we insist on promoting this goal to the detriment of our long-term health?

  4. Arya M. Sharma, MD says:

    You will pe pressed to find the term “healthy weight” anywhere on this blog (unless it is an intended quote) – you may also recall my posts that health cannot be measured on a scale and the issue of yo-yo dieting as a major driver of the obesity epidemic.

    But I also try not to fall into dichotomous ‘all or none’ thinking – excess weight is never simply good or bad – nor are the treatments.

    If I ever thought my actions were on average causing more harm than benefit, I’d go back to saving lives by putting people on dialysis.

  5. DeeLeigh says:

    In the automative analogy; you can take your car to the garage for a regular checkup and hopefully, if there is nothing wrong with it, you’ll be on your way for a small fee. However, if there is something wrong with it – hopefully this will be recognised and fixed.

    In a perfect world.

    But “breaking three things trying to fix one” isn’t always due to incompetence. It can also be intervention bias or even straightforward profit motive.

    If you’re a mechanic and you make your money by fixing cars, then you benefit financially if you can find more things to fix. The same thing is true of doctors in a private health care system (not Canadian doctors, obviously). It’s especially true of weight loss surgeons. They are just as ruthlessly profit-driven as cosmetic surgeons. But I’d argue that most doctors are intervention-biased when it comes to weight. It’s a combination of the whole obesity epidemic insanity and the pressure coming from fat patients who are sick of being treated like garbage, blame all of their problems on their weight, and would do anything to become thin. And who can blame them?

    But it’s more important to fix the social bias against fat people than it is to make them thin. I’m weird that way.

  6. DeeLeigh says:

    Meant “But I think it’s more important to fix the social bias against fat people than it is to make them thin.”

  7. Rosemary Dinsdale says:

    Hi there,

    I am one of those overweight most of my life people, naturally predisposed to extra curves and rolls due to many factors. I finally coped with this mentally by becoming comfortable in my own skin by living in the acceptance of I have big bones, Big is Beautiful, Big Beautiful Woman, its in my genes, I can’t exercise due to physical limitations,I can be overweight and still be healthy etc., for many years. Over those years I gradually increased weight from a pleasingly plump size 14 to becoming morbidly obese and size 26-28. Oh if only I had known to work on lifestyle modifications when I was size 14!

    I finally reached a point in my life where I wanted to lose weight to be more healthy. My weight was making it difficult for me to function. Putting on my shoes for example and walking any distance were getting difficult. My search for an all inclusive and supportive weight loss program for help began. It was a lengthy search.

    Luckily for me, I was fortunate enough to find and be accepted into the Weight wise program. I have done a total 180 in lifestyle changes. All in baby steps, one lifestyle change at a time.

    These have included and are not limited to:

    An eight week modified exercise program twice a week through Alberta Health (no charge) to teach me safe ways to increase my mobility and cardio type exercise,

    Waterworks program endorsed by Canadian Arthritis Foundation

    Weight wise Clinic counseling and follow up with a Registered Nurse, Dietician, Occupational Therapist, Physiotherapist, Physician, Psychiatrist. In addition i will soon to be counseled by a Psychologist for issues with compulsive overeating.

    I have also attended all but two of the ten Weight Wise modules, available to the general public through Alberta Health at no charge.

    My point here in all of this is that an all inclusive lifestyle change has been the only way for me to lose the weight permanently. We can’t just work on one or two lifestyle changes and expect to lose weight and keep it off. We need to look at all areas of our lives and remove the barriers to weight loss one at a time.

    Health care providers, like yourself and your team, is what I needed to support my ongoing weight loss/ maintenance goals. I do believe I can do it now. I may not get to size 14, but I will be in at a much healthier body weight for me.

    I am very grateful for my lifestyle changes and your teams continued support in getting me there.

    Rosemary in Edmonton

  8. NewMe says:

    Dr. Sharma.

    Despite the perceived tone of my comment, I would like you to know that I consider you one of the only doctors in the weight world worth reading and listening to. I have you on my blog roll.

  9. Arya M. Sharma, MD says:

    Thanks :)

  10. Lauren says:

    DeeLeigh, I’m not sure what “ROFL” means and I may be taking the following out of context but it seems to me that statements like this one contribute the the obesity epidemic:

    “Or, it could be considered a body type that’s natural and has always been present in the human population, that has a mixed impact on health, and that doesn’t require any intervention at all.”

    To me, that is like saying the huge muffins you buy at grocery clubs and the restaurant portions we are served should also be viewed as the norm just because they are the “norm”. A shift in perception that just because many people are overweight, that this has become the “norm” is a dangerous perception. Many people struggle to even accumulate 30 minutes of exercise several days per week. I feel sure this hasn’t always been a problem present in the human population. I feel sure previous generations accumulated much activity walking to the grocery, working in fields, and kids enjoying physical education on a regular basis. I personally do not believe that an increased BMI has a “mixed impact on health”; I have met very few people who are considerably overweight who have experienced positive health consequences associated with their weight. If people are not assisted in their weight loss efforts, they will likely face other medical interventions in the future to deal with the negative health consequences of obesity, such as lower extremity amputations and dialysis for uncontrolled type II diabetics. While I applaud your efforts to stay healthy through a healthy diet and regular physical activity, you are probably the exception rather than the rule. And, while you may not need assistance in these endeavors, many patients do.

  11. Anonymous says:

    Dr Sharma,

    I, a 5’3″ woman, was 250 lbs.

    I asked my doctor for help losing weight, but I had no “real” health problems, and I “moved well” (I guess I walked into the doctors office unaided and that was sufficient, I certainly couldn’t jog, or run).

    I was advised to be satisfied with a stable weight or a small loss.

    If that sounds like good advice to you, try this:
    Get an actors fat suit, which will mimic the bulk of obesity
    Then get scuba divers weights, or something similar (Maybe Edmonton has few scuba shops) and add 130 lbs to your body, to mimic carrying the extra weight of obesity.

    Wear this 24 hrs a day (you may remove it to shower, keep it on to make love)
    Do this for 4 weeks.

    I am not joking. (well, maybe you can take it off to make love)
    People who treat arthritis patients wear clumsy gloves to simulate diminished hand movement. People who treat disabled people spend days in a wheelchair to learn the problems patients face. I think it would help anyone who treats obesity to spend some time walking in the patients shoes, so to speak. (Maybe this is done already and I am unaware of it)

    If someone spends a fairly significant period if time dealing with both the bulk and the weight of a lot of extra fat, I think they’ll be more empathetic about the difficulties obese people deal with.
    I’m not talking about fat bias, which is another issue, I’m just talking about the plain physical crippling effect of obesity. Some obese people don’t care about that, but it is a real source of distress for many.

    I understand that limited health care resources must be given to the obese patients who do have real diseases and can’t even walk.
    However, I hope a doctor telling someone they don’t need to lose weight for disease reasons will be empathetic enough to realize they are leaving the patient to cope with a problem which is crippling.

    If you think I’m exaggerating, please, wear that 130 lb fat suit nonstop for a month.
    Let me know haw it goes.

  12. DeeLeigh says:

    Anonymous says,
    I’m just talking about the plain physical crippling effect of obesity. Some obese people don’t care about that, but it is a real source of distress for many.

    That’s more of a fitness issue than a weight issue. I have friends who are heavier than you who can run and jog and even do so regularly, for exercise. A lot of people don’t like to run or jog long distances (I wouldn’t for example – too hard on the joints), but there are lower impact things you can do like skiing, rollerblading, biking, swimming, and dancing.

    I’ve never been 250 pounds, but at 5′-4″ and 220, I could do everything I just listed. Hell, I can hike 10 miles a day with a 50 pound backpack, and the backpack makes me heavier than you. Oh, and I can also run and jog short distances with the backpack, so I wonder why you’re saying that you can’t do those things at all. Maybe you should start out by walking briskly for 1/2 hour everyday and then start running short distances?

    As heavier people, we do have to watch out for our joints and physical activity is a little harder for us than it is for lighter people – but it’s not that much harder. You can improve your level of fitness no matter what you weigh.

  13. DeeLeigh says:

    Rosemary, didn’t the fact that you kept gaining weight tell you that something was wrong? Size acceptance is good and certainly our weight isn’t always stable; it goes up and down a bit due to changes in circumstances. But, if I kept on having to buy new, larger wardrobes, I’d be looking for a reason why.

    I’ve been involved in size acceptance for almost 20 years, and I’m the same weight at 41 that I was at 19. Now, that’s a little misleading, because I hit my highest weight at 19 when I put on the freshman twenty, got a little lighter when I went on my HAES kick in my twenties, and got a little heavier again when an old car accident injury came back to haunt me in my late thirties. So, I’m actually heavy (for me) right now. Going from very active to temporarily disabled without making an effort to change my eating habits triggered a fifteen pound weight gain.

    But, how do you gain 100+ pounds without yo-yo dieting? The only person I know who put on that much weight without dieting had binge eating disorder. And binge eating disorder is something that any fat acceptance advocate will tell you to seek treatment for.

    Now, maybe it wasn’t that for you. Everyone’s body is different.

    But, people involved in fat acceptance don’t, as a rule, put on a whole bunch of weight. We tend to stay pretty stable, perhaps losing a little weight if we’re involved in HAES (health at every size) or gaining a little because we’ve normalized our eating habits (from a very restrictive baseline). But ‘gaining a little’ would generally not amount to 12 sizes.

    I’m not disbelieving you. I’m just saying that you’re not typical of people who are comfortable in their own skin and believe that being fat and healthy is possible. It’s not even typical of people who can’t exercise due to physical limitations (I’ve been there. I’m one size bigger). It’s actually very unusual.

  14. DeeLeigh says:

    Rosemary,

    Sorry about my last post. I see from another thread that you have fibro. That explains the weight gain. It sounded like you were blaming it on being size accepting, and that didn’t ring true to me.

  15. Lucy A. says:

    Dear Dr. Sharma:

    Thank you for the artical on evening and mid-nighttime eating; as well as the posting on lifestyles–they seem to go together very well. One thing you need when going to a doctor is trust; trust that he or she will not make things worse–just like you need when you choose a machinac. The one thing I found when I was going through my group theropy was that I needed to be more educated on what and why certain things were done.

    Even a little bit of unexpaianed information will help me freak out:”recently I was at my obgyn and he wanted an endometrial byopsy–by not explaining why it was needed and my only knowing at that time that it was the ‘only way to rule out cancer or menopausal changes I freaked out–not good”. Because I do not drive I am not as familiar with machanics as I am with my own body, but I am sure that if I did drive I would never be stranded, but a vehicle not starting, or freaked out because it makes this or that odd noise. Note:(Women who do drive and often have children in there vehicles and are concerned about a odd noise should clean out “all” of the toys and take a test drive to see if it is not a childs toy making the noise.)

    I have since worn out google and the Mayo Clinic web sites and learned to spell the lower reproductive organ names and varations corretly; with my ADHD this is some chalenge because I can easily transpose letters. The google searches ar more forgiving of misspelled words then The Mayo clinicn is. If I don’t understand how one words fits to the dictionary definition I will google just that word.

    I have taken all of the weight wise modules–they were very helpful am am waiting to get into The Adult Weight Management Clinic, which will be more than 6 months from now. However, the nutrition modules have put all the information that I had stored up into a format that I could apply it. Because a calorie is a unit of measure and that means something I am able to use proper portions at home and still lose the industry standard of one pound per week. I only go to my doctors office once amonth for weigh-ins and other medical issues. Because he is only a GP I do not expect very wise comments on how to do better-and I do not let him treat me like a mushroom by just telling me the results I need to see them for myself.

    Since I had the Arthrotec changed to Celebrex I do not need as much of a bed time snack to keep from having reflux–which I am on a medication for. This change should make weight lose a little bit easier. Not every doctor can fis everything for exaple Dr. Sharma would not do well at treating a stomach ulser or a blood disorder or mental illness–therefore I think that too much is expected of the GP’s; and when too much is expected of an indiviual they can often fail. With arthiritis my activity level is not the greatest. Cost cisideration is one issue that keeps me from organized activities.

    While many would refer to me as being low income there are may factors that make low income hazardous;
    -addictions such as those the street people have, or often have.
    -low ability to read these ones will not realize that applicants is your name if you are applying for a program or survice. They will not know how to access gorverment assistance other that welfare or AISH(asurred income for the severely handicapped–I have been diagnose with Aspergers).
    -the next group are not as hard done by as those with low reading levels but they are the starving students.
    -there ones that are a bit better off because they are in subsidized housing-not that this is always the best option for everyone.
    -then there is the goup of people who only buy the TV promoted products mindlessly thinking that they are goodand are unable to do much in the way off cooking because they iether haven’t learned or can not read very well.
    -then there is the university grad who can not find or does not like the job he or she recieved traing for.
    -then there are persons like myslef who are one AISH and in subsidized housing with very good reading and better writing skills than many who are at a identical income level.
    Therefore, when people say low income I feel like they are prejugdicing me just like they are prejugding my weight

  16. Rachel says:

    “individualised interventions that take a more holistic approach and are delivered by a multi-disciplinary team of health professionals in a manner consistent with best-practices in chronic disease management are most likely to succeed in the long-term” I believe you are right. All my experience tells me that this assessment on how to treat obesities (that need treating) is correct-I worry though that this will never be available to everyone who needs it. It sounds very expensive and society already resents spending money on overweight people. Its a lot cheaper to tell us to just go on a diet and walk more. Is there any reason to hope that one day we will be able to access this type of care?

  17. Dulsea says:

    The holistic approach really is really the best method.

  18. ResearchBlogging.org News » Blog Archive » Editor’s Selections: sweet cancer, hormone therapy debate, lifestyle and obesity says:

    [...] There are many touted ‘cures’ for obesity, and without fail the vast majority are utterly useless. Dr. Sharma discusses a new review paper assessing the effectiveness of lifestyle management as a mea…. [...]

  19. Harry says:

    Obesity, as such, is not a disease.

    It’s merely a natural response to food abundance, in the context of our genetic predispositions (including to eat tasty foods, to limit unnecessary movement, to eat until full etc.).

    As such, the decision to lose weight (especially if you want to get lean and “attractive”) is a decision to do something decidedly “unnatural”.

    Sure, it has benefits (extra mobility, sex appeal, self-esteem, possibly extra longevity) but it also comes at a price (exercising food control, experiencing some hunger every day, incorporating movement into your lifestyle).

    Bottom line, it’s a price most people aren’t willing to pay, given the constant inducements our ‘obesogenic’ society offers to eat ‘naturally’.

    Cheers
    Harry

  20. Maia Cairns says:

    I’d have to test with you here. Which is not something I often do! I take pleasure in studying a post that will make folks think. Also, thanks for permitting me to remark!

  21. Anonymous says:

    From Harry’s post:

    price (exercising food control, experiencing some hunger every day, incorporating movement into your lifestyle).

    benefits (extra mobility, sex appeal, self-esteem, possibly extra longevity)

    I’m going for the benefits. The price is worth it for me.
    (“some hunger” is manageable – being hungry before meals how non-overweight people live anyway)

    If other people decide they’d rather keep the food and keep the fat, that’s their decision.

  22. dr Allen E Gale says:

    I regularly read the helpful articles on your blogs but cannot recall whether you have addressed the phenomenon of “Sarcopenia of ageing”. There is an excellent article on this
    http://www.racgp.org.au/afp/200603/200603taaffe.pdf
    Resistance exercises appear to be one of the keys to controlling sarcopenia.
    I look forward to your comments
    Allen

  23. dr Allen E Gale says:

    Also, it seems to me that one diet does not fit all. The newborn baby that doubles its birthweight within the first few months; the teenager with a growth spurt; the female between menarche and menopause; the deskbound office worker; the manual labourer; the olympic athlete or footballer; the pregnant or the lactating mum, all must surely have differing caloric and nutritional needs.
    But the what about genetic influences and intrauterine impact of our mothers dietary imbalance on all of us?
    Furthermore small for dates babies, lean young women with PCO, 1st generation descendants of diabetics and Pima Indians are “insulin resistant”… (or more precisely these individuals have “increased insulin resistance” in my understanding)
    It just gets SO complicated.

  24. Arya M. Sharma, MD says:

    @ dr Allen E Gale: oh yes, sarcopenia is one of the most important issues – especially in so called ‘normal weight obesity’. Also, maintaining muscle or lean body mass is always a challenge with rapid weight loss – much of this can be avoided by maintaining high protein intake and resistance exercise – but in the end, weight loss is almost alway associated with a loss of LBM.

  25. Dr. Charles' Fat Loss Factor says:

    Hi Dr. Sharma I just want to say that your blog is awesome. i love it. Bookmarked!

  26. dr Allen E Gale says:

    Happiness is getting a reply from Dr Sharma on his Christmas day!
    Thx a lot.
    Over the break I plan to understand how to implement an effective program for myself, thanks to my iPad. But I despair of implementing the exercises for my “Oldies” who sit all day in their tub chairs with dual incontinence and recurrent urinary tract infections.
    Allen
    Taking a break from fulltime Specialist & GP sessions
    Boxing day downunder!
    PS dob Nov 3 1932

  27. Arya M. Sharma, MD says:

    Thanks Dr. Charle’s – Happy Holidays!

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