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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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December 09, 2015

Is There Really an Obesity Paradox?

By Mark Sisson
49 Comments

ObeseA couple weeks ago, I linked to an article discussing the “obesity paradox”—the idea that across many different studies and populations, people with slightly overweight and even obese BMIs often have the lowest mortality risk. The author is Harriet Brown, a supporter of the “Health At Every Size” movement, comes down hard on the side of overweight/obesity as safe and even beneficial. At first glance, she makes a strong case. She appears to cite compelling research. She talks to obesity researchers who’ve found protective links between higher BMIs and better health and been lambasted by their colleagues. And if the general consensus is right, and carrying extra weight is so unhealthy, why are obesity and overweight consistently associated with a lower risk of death?

Brown claims that no other researchers “have been able to make the paradox go away.” She highlights and dismisses two possible explanations for the paradox. First, that heavier people visit the doctor more often and receive more and better medical treatment than normal weight people. Although Brown calls this “the most popular” of the explanations before proceeding to (rightly) demolish it, I haven’t heard many obesity researchers give it serious thought. The second explanation is the “unhealthy weight loss” one. If people who are normal weight because they lost weight due to cancer, smoking, sarcopenia, or another wasting condition are lumped in with people who are normal weight because they’re lean, fit, and healthy, the correlation between normal BMI and mortality is skewed. After admitting “there’s some evidence to back up this argument,” Brown pivots to the opinion of a single researcher, who says “it certainly does not seem to make the paradox go away.”

Okay. How comprehensive was Brown’s coverage of the explanations for the paradox? Did she leave anything out?

As it turns out, there are several other explanations for the obesity paradox.

Body fat as glucose sink for diabetics.

Somewhat higher BMIs than normal are associated with improved mortality risk in type 2 diabetics. We often forget that body fat isn’t just there for the hell of it; it acts as a storage facility for excess fat and glucose that cause health problems if allowed to circulate unchecked. Having high levels of sugar circulating throughout your body is dangerous. Unchecked hyperglycemia creates too many reactive oxygen species, depletes glutathione, increases AGE formation, and hyper-activates the enzyme responsible for many diabetes complications; it can increase the risk of complications requiring amputation, cause neurons to shrink, pancreatic beta cells to die, and endothelial function to plummet. When you’re insulin-resistant and your tissues aren’t responsive to insulin-mediated glucose transport, body fat becomes a useful, if unattractive glucose sink. That may be why a recent study found that among type 2 diabetics who’d just had heart attacks, the obese patients had lower rates of kidney disease (which is a byproduct of unchecked hyperglycemia) and lived longer than the normal weight patients. It also explains why increased BMI (at least until you hit extreme obesity) lowers the risk of amputation in diabetics.

Of course, that doesn’t mean everyone worried about diabetes should gain weight. For one, losing weight is a great way to reduce one’s chances of becoming diabetic in the first place. Two, diabetics who attempt to lose weight live longer than those who don’t and those who successfully lose weight enjoy drastic improvements to lifespan. Only unintentional weight loss was linked to increased mortality.

BMI as marker of lean mass reserve in heart disease patients.

BMI measures weight, nothing else. It doesn’t distinguish between muscle, bone, fat, tendon, or the rolls of quarters in your pockets. If gravity acts on it, it’ll show up in BMI. One study examined BMI, body composition, and mortality risk in men with coronary heart disease. Sure enough, overweight BMIs were the most protective against mortality in this population. But when you looked closer and incorporated body composition in the analysis, it turned out that lean muscle mass was responsible for the high BMI-low mortality link. Another study found that among heart failure patients, BMI was a better predictor of lean mass than body fat.

Low-normal BMI as marker of disease.

When an obese person develops cancer, they’ll often lose enough weight (from the disease itself and the treatments) to reach a normal or even underweight BMI. If they die from the disease, their BMI is noted and that death counts as a “normal BMI death.” But the thing that killed them happened when they were obese. A recent study examined this exact issue, using “maximum BMI” to control for the disease-induced weight loss confounder. They found that “the percentage of mortality attributable to overweight and obesity among never-smoking adults ages 50-84 was 33% when assessed using maximum BMI. The comparable figure obtained using BMI at time of survey was substantially smaller at 5%.” when you include the obese and overweight people who got sick and then lost weight before they died, obesity and overweight is responsible for a third of deaths in non-smoking elderly. When you don’t, obesity and overweight is only responsible for 5% of deaths.

I’m sorry. I’m not buying it. There’s no paradox. The relationship between bodyweight and mortality is complex and complicated, but there’s always an explanation—and it’s not “being obese is healthy!” Higher BMIs might be associated with improved mortality, particularly in certain populations. But what exactly do you mean when you say “BMI”? Body fat? That contributes to BMI. Muscle? That, too. What about the distribution of the body fat? Does that matter?

Yes. “Weight” doesn’t have an effect. What comprises the “weight” determines the effects.

BMI isn’t the best way we have to assess obesity and the associated health and mortality risks. It’s just the easiest and the cheapest.

It comes down to body fat. If you’re of normal weight but obese based on the amount of body fat you carry, you have a much higher cardiometabolic mortality risk.

It comes down to where you carry your body fat. Abdominal obesity is consistently associated with poorer health outcomes, metabolic dysfunction, and mortality.

It comes down to gender. In women compared to men, slightly higher body fat levels in general and lower body fat (within reason) in particular are linked to better health.

It comes down to muscle mass, the single best predictor of longevity in the elderly. If you’re strong, you’ll live longer than if you weren’t.

When you factor in things like disease-induced weight loss, smoking-related low BMI, and loss of lean mass, the ideal BMI for health and longevity is actually around 20-21. That’s exceedingly normal. Overweight is 25-29. Obese is 30 and up. Having a decent amount of lean muscle will increase the “low-mortality” BMI allowance.

If you want a simple measurement that can replace BMI, waist circumference—the distance around your belly—is a better predictor, and it lines up with conventional views on health and obesity. Higher waist circumference, worse health outcome and higher mortality.

And even if you take at face value the author’s claim that being overweight or obese either improves or has no impact on lifespan and only “slightly” increases the risk of heart disease and “other life threatening conditions,” what about the other things that matter, things that might not show up in studies? What about climbing the stairs without huffing and puffing? What about chronic joint pain preventing a heavy person from going on hikes, starting a training program, keeping up with their kids? What about sex drive and frequency, both of which studies show drop in the overweight and obese and increase with weight loss?

I’m not disparaging overweight or obese people. Heck, they’re the people I set out every day to help! I care deeply about them. And I know how hard weight loss can be.

I just don’t think articles like these are helpful. The author ignores a huge body of research showing the damaging health effects of excess body fat and tries to normalize an extremely dangerous mindset: complacency and apathy. After her review of the evidence, Brown even wonders if there’s “any point trying to diet to lose weight.” Yes, for the majority of people, there absolutely is a point. Just ask my readers.

Losing weight isn’t easy, but it’s not impossible. Losing weight may not be a panacea, but it’s certainly not a waste of time and it does provide health benefits across the board. Intentional weight loss—the kind achieved through dieting, rather than wasting away from disease or smoking—is actually linked to a 15% reduction in all-cause mortality.

That’s where I stand. There’s no paradox. There’s just a complicated relationship between bodyweight, muscle, body fat, body fat allocation, and health that shouldn’t be reduced to “gaining weight is healthy.” That’s just dishonest and it does the people who need the most help a major disservice.

What do you think, everyone? Where do you stand on the obesity paradox?

Thanks for reading, everyone.

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49 Comments on "Is There Really an Obesity Paradox?"

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Groktimus
9 months 18 days ago

I thought I was getting healthier, now I know I’m just increasing my gravitational field.

Mo
Mo
9 months 18 days ago

Use of BMI as a measurement is, itself, a paradox. It is over 200 years old and tells us really nothing about anything. It is, however, easy to use. This makes it an excellent way to sell books and diet products.

Zachary Rusk
9 months 17 days ago

Waiting for the army to stop using it… Callipers at least are supposed to be better right?

Benn
Benn
9 months 16 days ago

I’ve known many a Marine who’s career was ruined because they tended to be outside the Marine Corps BMI standards more times than was acceptable. And these were good, capable people we should’ve worked to retain. Unfortunately, it’ll never go away for either of our services, because whether it’s healthy or not, we have to look good in uniform.

Erik
Erik
9 months 10 days ago

Measuring neck and waist circumference is more accurate than BMI…

Michele
9 months 18 days ago

Definitely interesting. I’m certain that when things don’t make sense, there’s usually a better explanation that does. And BMI just doesn’t give enough info for any situation.

Chad G
Chad G
9 months 18 days ago

Essentially, it is the same mistake over and over again. People tend to conflate leanness, low BMI, and/or fitness, with health. As I have learned from Mark you can be very fit, very lean, have a low BMI and still be unhealthy. One factor does not make you healthy. You need to be lean, strong and relatively fit. Weight/BMI in a of itself tells you very little and by itself is more likely to leave you misinformed.

Elizabeth
9 months 18 days ago

Wow, a lot to think about here. Bottom line is, it’s a complex situation. I know people that would be considered overweight, but live active, full lives, eat well, and are enjoying life. And I know people who probably have what would be considered excellent BMIs that are putting processed crap into their bodies and have lots of aches and pains. Either way, I completely agree with Mark. There is no obesity paradox. You can’t make a blanket statement that gaining weight is healthy. Or that
losing weight is healthy. It’s much more involved than that.

alan2102
alan2102
9 months 16 days ago

“There is no obesity paradox. You can’t make a blanket statement that gaining weight is healthy. ”

That’s not what the obesity paradox purports to say. It is not that “gaining weight is healthy”; it is that higher bodyweights are much less risky than was thought.

Bob Niland
9 months 18 days ago

BMI is perhaps leading (most useless) measure in the Pantheon of such muddled measures that also includes the common: LDL-C, PSA, TC and TSH.

If one were to correlate BMI with health outcomes a century ago or earlier, it might be suggestive. Today, it’s junk [science].

I would not be the least bit surprised if the majority of slender people today are so due to pathologies (including pathological diets). The number who are slender due to being on optimal diets for their phenotypes is a tiny fraction of the data set.

CRunner
CRunner
9 months 18 days ago
I can’t agree more with the BMI item. Whenever I go to the doctor, I trigger the weight management item and they always ask me if I am aware that I need to monitor my weight. I am a 5’4 female weighing 165. But when I ask my body-building brothers, or anyone else, to guess my weight – they usually put it in the 130s. I have a lot of muscle and wear size 8 pants. But you can’t tell that from a scale. I used to be 2 sizes larger at 155. Weight tells a very small part of… Read more »
JoanieL
JoanieL
9 months 18 days ago
Until genetics start getting factored into all these studies, I’m going to pretty much shrug when I read them. Looking at photos of my grand and great grandparents, there were few who would be considered thin by today’s standards. With the exception of one of my great aunts, they all lived to be over 85. My parents, products of a “convenience food” world didn’t fare so well. Looking at trends is a good thing, but the results should be taken with a grain of salt. The stress of trying to be a certain weight when your genes are screaming to… Read more »
ShaSha
ShaSha
9 months 18 days ago

Right on Mark! Glad you took on this one. As a “moderately overweight/mildly obese” female, I can say that this helps me feel better. I’ve always known, long before my BMI was regularly tested that I have a bit of muscle and a lot of fat, mostly in the wrong places. I don’t need some new book, or philosophy to tell me its “all ok, I’m not so fat after all”. I know better and it helps me to hear you say it. That is REAL encouragement. Thanks for all you do.

Marge
Marge
9 months 18 days ago

Mark, your explanation makes sense. What needs to happen is a change in the lingo!

Instead of saying “You need to lose weight”, we need to say “You need to lose fat, and gain muscle”. That is the mindset we need to encourage!

Gabriella
Gabriella
9 months 16 days ago

So true! Imagine if everyone focused on the muscle percentage, not the weight number.

Anastasia
Anastasia
9 months 18 days ago
I’ve once read an article about sudden death and heart attacks during marathons, and it said that young people having a heart attack have a much lesser chance of survival than old ones. That’s not because age is a “protective factor”, but because the younger an athlete, the more serious and unusual the cause of the attack in the first place, and the more rapidly it progresses. So when I heard about the “obesity paradox” it was the first thing that came to mind: this thing needs a more bayesian approach, since it deals with a posterior distribution and doesn’t… Read more »
SC
SC
9 months 17 days ago
Evolution favored body fat retention – to a point – as protection against starvation. Now, of course, TOO much body fat can be detrimental. But that doesn’t mean that we were all meant to walk around in an ultra-lean state or anything like that. The fact that hunter-gatherer populations DO often have defined, sinewy muscles is an artifact of the very real possibility of starvation and the constant search for calories. So basically, it makes sense that we should be able to carry more than a baseline amount of fat as starvation insurance, without damaging our health. Now, if lean… Read more »
Amy
9 months 17 days ago
THANK YOU. I recently spent 2 weeks working on a farm, and the farm owner is 70 years old. She’s not what anyone would call thin or svelte, but she’s STRONG. She’s absolutely not “fat,” but she does have some meat on her bones, which is crucial for healthy aging. She makes farmstead cheese with the milk of her own dairy herd, and lemme tell ya, that is hard work! Lots of heavy lifting, bending, hauling equipment — and she was on it better than a lot of folks would be capable of at half her age. Aesthetics and the… Read more »
Ben
Ben
9 months 17 days ago
Mark, Thank you for refuting Harriet Brown’s crap. As someone who has been struggling to live a healthier life, I find her drivel to be annoying at best and harmful at worst. It provides arrows to sling at me when I pass on the cake and ice cream at a party or say no to drinks. I don’t want to count how many times her crap has been posted to my facebook page by “friends” trying to convince me that losing weight is a bad idea. Here is the rub. I have the weight to lose. When I started my… Read more »
Hedgie
Hedgie
9 months 17 days ago

well done, bud! That amount of weight loss inspires me.

Pat McPeak
Pat McPeak
9 months 17 days ago

Congratulations on what you’ve accomplished so far! I hope to read your success story someday, even well short of whatever your target is. The 70+ pounds that you’ve already lost is significant!

Susan
Susan
9 months 17 days ago

Congratulations, Ben! A 170# weight loss is a huge accomplishment! I second the request for a success story regardless of your ultimate goal.

Kelda
9 months 17 days ago

Amazing, and great to hear you say ‘I feel better’. So often we miss that simple aspect amidst all the ‘science’ and ‘dogma’ spouted.

Karl Kelman
9 months 17 days ago

BMI also doesn’t take into account body type and genetics. I once had a Samoan coworker about my height, not overweight, or a weightlifter. He probably weighed 70 lbs. more than me, and his knees and wrists (bone structure) appeared to twice as big around. At similar levels of fitness, we should weigh very different amounts depending on our ethnic backgrounds and individual genetics.

Toss your scale and get an occasional DEXA.

Jed
Jed
9 months 17 days ago

You see old people, and you see fat people. But you never see old, fat people. Why is that?

Wan
9 months 17 days ago

I understand the point you’re trying to make, but I see old fat people all the time, lol.

SuzU
SuzU
9 months 16 days ago
I know quite a lot of old, fat people – who are healthy and active. My MIL is 92 and she’s fat. Been fat most of her life. Blood pressure is low, no diabetes, never any brush with cancer, no heart disease despite familial hypercholesteremia. Three of my uncles were quite tubby, and they all lived into their 90s. A family friend, rotund, but very active, died at 98, having survived liver cancer for 40 of those years. Let’s look at my mother: decidedly obese, very unhealthy, 78 years old. BUT all her health conditions started when she was young… Read more »
Gary Ogden
Gary Ogden
9 months 17 days ago

Excellent article. Thank you very much. My own take on health: High-quality food, frequent activity, occasional high-intensity exercise, sufficient social interaction, plenty of laughter, of music, and frequent practice of kindness and thankfulness.

CJ
9 months 17 days ago

The timeliness of this article was amazing as I just heard a story about this on public radio yesterday. While I don’t think it is their intention, I hate that these articles suggest that it’s ok, or even healthy, to be obese. If they signal to even one obese person that it’s OK for them to be sedentary and eat junk, then that’s tragic.

eb
eb
9 months 17 days ago
I have mixed feelings about this article. As someone who has spent much of her life at a low to normal bmi (anywhere from 15 to 20) I can say that there’s definitely a reason that low bmi is associated with higher mortality than a normal to slightly overweight bmi- while I thought pursuing my leanest possible body would bring health benefits, instead I lost my period for 4 years, developed osteoporosis at age 22, developed jaundice and liver disease. It wasn’t until my GP recommended I gain enough weight to put my bmi at 21-25 that I finally began… Read more »
Amy
9 months 17 days ago
YES!! Thank you, eb! I think being “obese” (whatever the exact definition might be, in terms of pounds or BMI) is probably not healthy, but being 5-15 pounds above one’s “ideal” weight? (Again, whatever the exact definition might be.) That’s probably not a problem at all, if other measurable markers are where they should be — or, rather, where we *currently* believe they should be, in order to ward off chronic degenerative conditions. (HDL, trigs, CRP, AST, ALT, glucose, insulin, and all the rest.) I firmly believe that carrying around a few extra pounds is likely less detrimental to long-term… Read more »
Shary
Shary
9 months 17 days ago

“I’m sorry. I’m not buying it. There’s no paradox.”

Thanks, Mark, for interjecting some sanity into the rising notion that obesity is the new “normal.” While it’s not okay to discriminate against fat people, it is also not okay to delude them into thinking that being overweight is in any way healthy.

Heather B
Heather B
9 months 17 days ago

Thanks for this analysis, Mark. I wasn’t sure what to make of the Harriet Brown article, so I appreciate your weighing in (at an “exceedingly normal” BMI)!

ntrojnky
ntrojnky
9 months 17 days ago

Maybe that’s why it’s always so hard to “lose that last 10 pounds”, maybe your body is telling you it wants to hold on to that little extra bit for “dear life” (pun intended)

SC
SC
9 months 17 days ago
Right? Research has demonstrated that hunter-gatherers burn the same amount of calories each day that an office worker does, because their metabolisms have adapted to the energy demands of their lifestyle. At 3500 calories a pound, ten extra pounds is 35,000 calories a person can use to sustain their life when times get tough. If we assume the average person burns 2500 calories a day, ten pounds is potentially two weeks of food stored on one’s body. Evolution would be stupid to create animals (us) whose optimal physical state can only exist on the brink of starvation. The life-saving benefits… Read more »
Kelda
9 months 17 days ago

Interesting viewpoint – as a recovered IM triathlete I can attest to the fine-line aspect of “lean ness” and “trained ness”.

Coaches often push athletes to that very fine line to maximise performance, but 1 % over and you break, are ill, lose performance rapidly and often get injured to boot.

SC
SC
9 months 17 days ago

Exactly! When human survival was a tightrope act, evolution wanted to make sure we would have a caloric safety net in the form of stored fat. Are we potentially faster, stronger, or more agile without the net? Possibly. But the benefits of the net far “outweigh” the costs, up to a certain point.

No hunter-gatherer would ever have intentionally taken themselves down to the “fine line” you mention – in societies that are food-insecure, there is simply too much at stake.

ntrojnky
ntrojnky
9 months 17 days ago

Hmmm maybe the junk food companies are really behind that article, if overweight people feelbetter justified about being overweight then maybe they’ll keep buying the junk food.

Chris D
Chris D
9 months 17 days ago
This is a case of the data being artificially skewed. In 1998 the NIH changed the criteria for overweight and obese, lowering the numbers of what constituted a healthy weight. Why? Who knows but I bet it wasn’t because of sound science. Effectively a female who was 5’4 and 155 would have been considered healthy but the change would have required her to drop to 145 under the new guidelines. Makes sense right? For example I’m 5’8 170 lbs and 14% BF by caliper. No six pack here but I’m healthy by any reasonable standard yet I’m technically overweight. I… Read more »
Travis
Travis
9 months 17 days ago

Who cares about mortality rate. Isn’t the point of Primal living to be healthy now. To enjoy eating nourishing, life giving food. Sure an unhealthy person will lose weight as a byproduct of primal living, but that is not a worthy goal in my opinion. Mark makes a good point that this kind of article is irresponsible, but selling weight loss as the solution is also a never ending cycle of lose/gain. If we aren’t in it for all the life giving benefits, we will never know long term success.

Travis
Travis
9 months 17 days ago
After struggling with the aches and pains and added weight as the direct result of my sugar addiction, I a can honestly say that life extension is not one of my goals.. As the saying goes “it’s not about the years in your life, it’s about the life in your years.” My entire nutritional goal is just to restore my health so that I can enjoy the things I was able to do in my twenties. Who cares if you can live to be a 100 if you can’t enjoy a quality of life for the last 40 years. What… Read more »
Elisa
Elisa
9 months 17 days ago

Tee hee… obesity writer “ignores a huge body of research”.

Les
Les
9 months 16 days ago
There seems to be a lot of mention of BMI here today. But none of the anti-BMI contributers so far seem to realise that there are alternatives hovering in the background, some even catching the attention of the medical profession!. About a year ago I came across a father and son team who devised an alternative. I could not find my browser reference to their (?) site, but have unearthed a reference to their work and a few alternatives. Although I’m a little over-fat/under-muscle my weight is about right, but as a T2 diabetic my main concern is viseral fat,… Read more »
SuzU
SuzU
9 months 16 days ago
There seems to be more animus against HAES than is justified, in my opinion. HAES does not in any way support gorging on junk food or lying on the couch with a remote control in one’s hand. To the contrary – there’s strong emphasis on eating healthfully, and finding some form of pleasurable physical activity. There’s a lot of emphasis on looking at health markers. Where the uncrossable divide comes in, as I see it, is that HAES believes that you can be healthy at every size! They’re trying to get the focus off body size, especially large sizes, and… Read more »
Amy
9 months 15 days ago

I want to give you a thank-you hug, SuzU! You’ve said this so well. There are obese triathletes, obese marathoners, and obese people who eat very well but have other issues complicating fat loss. The HAES movement is really not at all about glorifying obesity. It emphasizes lifestyle habits and healthy diets, rather than the effects those habits might or might not have on the size of one’s pants. As a nutritionist, I’ve worked with plenty of people at “healthy” (or “normal”…ugh) BMIs who were complete trainwrecks on the inside.

alan2102
alan2102
9 months 16 days ago
Mark, with all due respect, I want to point out what I see to be a contradiction in what you say. You write: “I’m not buying it. There’s no paradox.” And yet, you then go on to give a bunch of possible reasons for the paradox — i.e. assuming the paradox to exist — like abdominal adiposity, muscle mass/strength, and so on. And I agree with you! Those ARE reasons for the paradox. But that means that there IS a paradox — at least with respect to the common (generally unquestioned) conception that overweight = big huge health risk. As… Read more »
Raphael
Raphael
8 months 20 days ago
Well. The study “A pooled analysis of waist circumference and mortality in 650,000 adults.” http://www.ncbi.nlm.nih.gov/pubmed/24582192 seems to suggest (image 3) that being slightly overweight (BMI between 25 and 30) carries lower risk than hitting your optimal BMI of 20-21. You can have 10 to 15 cm more belly before reaching the lowest documented risk of the low-normal BMI range! That bears further thought. Maybe being in that 25-30 often means packing more muscle, or at least more added muscle than fat compared to the 20-22.5 group. But that’s in line with the general message of this article: low BMI alone… Read more »
Aquarius Moon
8 months 1 day ago

Thank you for your sensible points refuting what is a pseudo-science article masquerading as research. There are benefits to eating well and it isn’t as tough as what the fat acceptance camp likes to think.

Most of us are normal folks working in normal jobs. Thus, our lifestyles and eating habits can be a little more flexible. It isn’t an excuse, however, to eat any quantity of any food we want without being physically active.

Lydia
Lydia
7 months 5 days ago
Another factor that is rarely discussed when talking about “weight” as a measure of health is HOW a person reached that weight. If a calorie means anything, then in theory, overeating broccoli and steak can still make a person gain extra weight that gets stored as fat. The balance between the calories taken in and their nutritional composition might tell more about the individual’s health outcome. That said, it is unlikely that a person who gains weight eating broccoli and steak is going to reach massive adipose proportions. But the flip side of that is that I think the health… Read more »
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