Abstract
Aim: The Fukushima Daiichi Nuclear Power Plant accident dramatically changed the lifestyle of residents who lived near the plant. We evaluated the association of metabolic syndrome (MetS) with specific lifestyle- and disaster-related factors in residents following the accident.
Methods: This cross-sectional study included 20,920 residents who underwent both the Comprehensive Health Check and the Mental Health and Lifestyle Survey from June 2011 to March 2012. Associations between MetS and lifestyle- and disaster-related factors, including psychological distress (post-traumatic stress disorder [PTSD]), were estimated using logistic regression analysis, adjusted for demographic and lifestyle factors, in 2019.
Results: MetS was present in 30.4% of men and 11.5% of women. There were significant differences in smoking, drinking status, and PTSD prevalence between subjects with and without MetS. Multivariable logistic regression analysis showed that age, quitting smoking, and low physical activity were significantly associated with MetS. Moreover, PTSD and light to moderate drinking were also significantly associated with MetS in women.
Conclusions: Lifestyle- and disaster-related factors, including PTSD, were associated with MetS among subjects who lived near the Fukushima Daiichi Nuclear Power Plant accident.
Keywords: Metabolic syndrome, Lifestyle, Post-traumatic stress disorder, Disaster
Introduction
The Great East Japan Earthquake, and the associated tsunami and accident at the Fukushima Daiichi Nuclear Power Plant, occurred in March 2011. The Japanese government designated the high-level radiation exposure (> 20 mSv/y) area around the Fukushima Daiichi Nuclear Power Plant as an evacuation zone, and more than 160,000 residents of Fukushima Prefecture were evacuated following the accident. Prolonged evacuation changed not only lifestyle factors for evacuees, such as physical exercise habits, diet, smoking status, and alcohol consumption, but also affected mental status.
Unhealthy lifestyle factors can contribute to metabolic syndrome (MetS) due to an increase in visceral obesity1). Moreover, mental status is also associated with MetS2–4). In the Comprehensive Health Check of Fukushima Health Management Survey (FHMS), we showed that evacuation was associated with various health problems, including MetS5–11). Moreover, the Mental Health and Lifestyle Survey in FHMS reported changes in mental status and lifestyle factors following the disaster12).
Previous studies in the FHMS6–12) were evaluated independently, and thus lifestyle factors associated with MetS were limited to items assessed during an ordinary health check-up. Consequently, the association between MetS and disaster-related factors has not been estimated.
The present study's aim was to elucidate factors associated with MetS following the Fukushima Daiichi Nuclear Power Plant accident by connecting the results of the Comprehensive Health Check of the FHMS and the Mental Health and Lifestyle Survey of the FHMS. Our hypothesis is that disaster-related factors, including mental status, influenced MetS in residents who experienced the disaster.
Methods
Study Population
The subjects were residents of evacuation-designated areas near the Fukushima Daiichi Nuclear Power Plant. They were evacuated from all areas of Hirono-machi, Naraha-machi, Tomioka-machi, Okuma-machi, Futaba-machi, Namie-machi, Kawauchi-mura, Katsurao-mura, Iitate-mura, and part of Tamura City, Minamisoma City, Kawamata-machi, and Date City, with total populations of 260,749 in 2011. Within these communities, residents aged 40–74 years have had annual health check-ups for MetS. The number of participants aged 40–74 years who completed the Comprehensive Health Check of the FHMS from June 2011 through March 2012 was 34,265 participants (14,397 men and 19,868 women), and 44,045 participants (20,127 men and 23,918 women) completed the Mental Health and Lifestyle Survey of the FHMS. A total of 24,527 participants (10,321 men and 14,206 women) completed both the Comprehensive Health Check and the Mental Health and Lifestyle Survey. We excluded 3,607 participants due to insufficient data on diagnoses of MetS, lifestyle- and disaster-related factors, or psychological distress. Ultimately, 20,920 participants (8,810 men and 12,110 women) were eligible for our analyses.
The Ethics Committee of Fukushima Medical University approved this study (#29064). Informed consent was obtained from community representatives to conduct an epidemiological study based on guidelines of the Council for International Organizations of Medical Science. All participants in the FHMS provided written informed consent.
Definitions and Data Collection
Body weight (kg) and height were measured without shoes and in light clothing. Body mass index (BMI) was calculated as weight (kg)/height (m)2, and overweight was defined as BMI ≥ 25 kg/m2. Waist circumference was measured above the navel at minimal respiration. Blood pressure was measured by trained technicians.
The following laboratory data were collected under overnight fasting conditions: high-density lipoprotein cholesterol (HDL-C); low-density lipoprotein cholesterol (LDL-C); triglycerides (TG); fasting plasma glucose (FPG); and hemoglobin A1c (HbA1c).
MetS was diagnosed based on the definition of the Japanese diagnostic criteria13): visceral obesity (waist circumference ≥ 85 cm in men and ≥ 90 cm in women) in addition to the presence of at least two of the following three abnormalities: (1) TG ≥ 150 mg/dL and/or HDL-C < 40 mg/dL, or being treated for dyslipidemia; (2) systolic blood pressure ≥ 130 mmHg and/or diastolic blood pressure ≥ 85 mmHg, or being treated with antihypertensive drugs; (3) FPG ≥ 110 mg/dL or being treated for diabetes (if the participant was not fasting, HbA1c > 5.6% was used instead).
Diabetes and dyslipidemia were defined as previously reported6). Evacuation was defined by residential area and housing status, as previously reported14). In the Mental Health and Lifestyle Survey, the Japanese versions of the Kessler 6-item scale (K6)15) and Posttraumatic Stress Disorder Checklist (PCL-S)16) were used to assess participants' mental health. The K6 consists of six brief questions about depressive and anxiety symptoms during the past 30 days, with overall scores ranging from 0 to 24. We defined psychological distress as corresponding to a K6 score ≥ 13 17). The PCL-S is a tool to evaluate symptoms of posttraumatic stress disorder (PTSD) during the past 30 days. The PCL-S consists of 17 items, and the overall score ranges from 17 to 85. We classified participants as having probable PTSD if their overall PCL-S score was ≥ 44 16). In addition to the K6 and PCL-S, the questionnaires included medical history and various lifestyle factors, such as physical activity, sleep dissatisfaction, cigarette smoking, alcohol intake, and job status. Job status included unemployment or a change in job after the accident.
Statistical Analysis
The data analysis was conducted in 2019. Participants with and without MetS were compared using the χ2 test and Fisher's exact test for categorical variables and the Mann-Whitney U-test for continuous variables. We tested associations between MetS after the accident and other primary factors using simple and multivariable logistic regression analyses. The following variables were considered primary factors: age, sex, evacuation (yes or no), current smoking (yes or no), quitting smoking (yes or no), alcohol intake (non-drinker, light to moderate drinker [< 44 g/day] or heavy drinker [≥ 44 g/day]), physical activity (< 4 times a week or every day), change of job (yes or no), unemployment (yes or no), sleep dissatisfaction (yes or no), psychological distress (yes or no), and PTSD (yes or no). SAS version 9.3 (SAS Institute, Cary, NC, USA) was used for all statistical analyses. All probability values for statistical tests were two-tailed, and p values < 0.01 were considered statistically significant.
Results
Characteristics of Participants With and Without Mets
Overall, MetS was observed in 19.5% of the 20,920 participants. The prevalence of MetS was significantly higher in men than women (men 30.4% vs. women 11.5%, p < 0.01). For both sexes, the MetS group was significantly older than the non-MetS group. In addition, there were significant differences in laboratory data, such as HDL-C, TG, FPG, and HbA1c, between the non-MetS and MetS groups (Table 1).
Table 1. Clinical and biochemical characteristics of 20,920 participants.
| Men |
Women |
|||||
|---|---|---|---|---|---|---|
| Non-MetS | MetS | p value | Non-MetS | MetS | p value | |
| Participants | 6,132 | 2,678 | 10,719 | 1,391 | ||
| Age (years) | 59.1 (9.2) | 62.0 (8.2) | < 0.01 | 57.7 (9.4) | 62.0 (8.0) | < 0.01 |
| Body weight (kg) | 64.7 (9.4) | 73.3 (9.2) | < 0.01 | 53.7 (8.0) | 66.5 (9.4) | < 0.01 |
| BMI (kg/m2) | 23.5 (2.8) | 26.7 (2.7) | < 0.01 | 22.7 (3.1) | 28.6 (3.5) | < 0.01 |
| Waist circumference (cm) | 83.8 (7.8) | 93.0 (6.2) | < 0.01 | 80.6 (8.4) | 97.1 (6.3) | < 0.01 |
| SBP (mmHg) | 130.3 (15.3) | 138.5 (14.1) | < 0.01 | 126.5 (16.1) | 138.2 (14.8) | < 0.01 |
| DBP (mmHg) | 80.2 (10.0) | 83.9 (9.6) | < 0.01 | 76.4 (10.1) | 82.2 (9.8) | < 0.01 |
| Triglycerides (mg/dL) | 125.0 (93.3) | 160.9 (124.6) | < 0.01 | 99.7 (54.8) | 132.4 (67.4) | < 0.01 |
| HDL-C (mg/dL) | 57.6 (14.3) | 50.6 (13.4) | < 0.01 | 65.2 (15.1) | 57.0 (12.8) | < 0.01 |
| LDL-C (mg/dL) | 124.4 (32.4) | 125.1 (32.9) | 0.35 | 130.4 (32.3) | 130.5 (33.2) | 0.95 |
| FPG (mg/dL) | 97 (91–104) | 110 (99–124) | < 0.01 | 93 (88–100) | 104 (96–118) | < 0.01 |
| HbA1c (%) | 5.4 (0.7) | 6.0 (0.9) | < 0.01 | 5.4 (0.6) | 6.0 (0.9) | < 0.01 |
| Overweight (BMI ≥ 25) | 28.0 | 72.7 | < 0.01 | 21.4 | 87.6 | < 0.01 |
| Hypertension (%) | 45.7 | 79.3 | < 0.01 | 36.2 | 80.5 | < 0.01 |
| Dyslipidemia (%) | 51.4 | 80.6 | < 0.01 | 54.3 | 83.7 | < 0.01 |
| Diabetes (%) | 8.8 | 32.3 | < 0.01 | 5.1 | 26.9 | < 0.01 |
Values are expressed as mean (standard deviation), except for FPG, which is reported as median (25–75 percentile).
MetS, metabolic syndrome; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HDL-C, high-density-lipoprotein-cholesterol; LDL-C, low-density-lipoprotein-cholesterol; FPG, fasting plasma glucose; HbA1c, hemoglobin A1c.
Lifestyle Characteristics and Disaster-Related Factors of Participants With and Without Mets
Lifestyle characteristics and disaster-related factors are shown in Table 2. For both sexes, the prevalence of current smokers was significantly higher in the non-MetS group than in the MetS group. Among men, the prevalence of quitting smoking was significantly higher in the MetS group than in the non-MetS group (p < 0.01). The prevalence of quitting smoking among women also tended to be higher in the MetS group than in non-MetS group (p = 0.06). In addition, the prevalence of PTSD was significantly higher in the MetS group than in the non-Mets group in both sexes (p < 0.01).
Table 2. Lifestyle characteristics of 20,920 participants.
| Men |
Women |
|||||
|---|---|---|---|---|---|---|
| Non-MetS | MetS | p value | Non-MetS | MetS | p value | |
| Participants | 6,132 | 2,678 | 10,719 | 1,391 | ||
| Evacuee (%) | 2,750 (44.9) | 1,214 (45.3) | 0.67 | 4,751 (44.3) | 621 (44.6) | 0.82 |
| Smoking status | ||||||
| Current smoker (%) | 1,927 (31.6) | 647 (24.3) | < 0.01 | 808 (7.8) | 73 (5.5) | < 0.01 |
| Quit smoker (%) | 2,659 (43.7) | 1,391 (52.3) | < 0.01 | 679 (6.5) | 105 (7.9) | 0.06 |
| Drinking status | ||||||
| < 44 g/day (%) | 3,172 (51.9) | 1,328 (49.7) | 0.06 | 3,101 (29.4) | 295 (21.7) | < 0.01 |
| ≥ 44 g/day (%) | 1,311 (21.5) | 586 (22.0) | 0.61 | 238 (2.3) | 17 (1.3) | 0.02 |
| Physical activity | ||||||
| < 4 times a week (%) | 4,997 (82.2) | 2,185 (82.6) | 0.73 | 9,227 (87.2) | 1,214 (88.7) | 0.11 |
| Change of job | 3,558 (59.1) | 1,502 (57.3) | 0.13 | 5,777 (56.5) | 701 (54.3) | 0.14 |
| Unemployment | 1,403 (22.9) | 644 (24.1) | 0.23 | 2,813 (26.3) | 339 (24.4) | 0.13 |
| Sleep dissatisfaction (%) | 3,140 (60.1) | 1,335 (59.2) | 0.43 | 6,578 (72.7) | 818 (71.5) | 0.38 |
| Psychological distress (K6 ≥ 13) | 700 (11.4) | 304 (11.4) | 0.93 | 1,788 (16.7) | 243 (17.5) | 0.46 |
| Post-traumatic stress disorder (PCL-S ≥ 44) | 1,030 (16.8) | 516 (19.3) | < 0.01 | 2,486 (23.2) | 394 (28.3) | < 0.01 |
MetS, metabolic syndrome; K6, Kessler 6-item scale; PCL-S, Post-traumatic Stress Disorder Checklist.
Lifestyle and Disaster-Related Factors Associated with MetS Following the Accident
Multivariable logistic regression was used to elucidate lifestyle- and disaster-related factors associated with MetS following the accident (Table 3). In both men and women, age, quitting smoking, and lack of physical activity were significantly associated with MetS (p < 0.01 for all). The association between MetS and quitting smoking was somewhat greater in women than in men. The multivariable-adjusted odds ratio (OR) of MetS was 1.60 (95% confidence interval [CI] = 1.23, 2.07) for women and 1.30 (95% CI = 1.14, 1.48) for men. PTSD and light to moderate drinking were significantly associated with MetS in women.
Table 3. Logistic regression analysis of factors influencing metabolic syndrome after the disaster among 20,920 participants.
| Men (8,810) |
Women (12,110) |
|||
|---|---|---|---|---|
| Odds ratio (95% CI) | p value | Odds ratio (95% CI) | p value | |
| Age (1-year increase) | 1.04 (1.03–1.05) | < 0.01 | 1.06 (1.05–1.07) | < 0.01 |
| Evacuation (ref: non-evacuation) | 1.07 (0.96–1.20) | 0.19 | 1.00 (0.86–1.15) | 0.94 |
| Smoking (ref: non-smoker) | ||||
| Current smoker | 0.97 (0.84–1.12) | 0.65 | 1.04 (0.77–1.39) | 0.81 |
| Quit smoker | 1.30 (1.14–1.48) | < 0.01 | 1.60 (1.23–2.07) | < 0.01 |
| Alcohol intake (ref: non-drinker) | ||||
| < 44 g/day | 0.86 (0.76–0.97) | 0.01 | 0.71 (0.61–0.84) | < 0.01 |
| ≥ 44 g/day | 0.97 (0.84–1.12) | 0.68 | 0.65 (0.37–1.14) | 0.13 |
| Physical activity (ref: every day) | ||||
| < 4 times a week | 1.23 (1.07–1.41) | < 0.01 | 1.42 (1.15–1.75) | < 0.01 |
| Change of job (ref: no change) | 0.98 (0.87–1.10) | 0.73 | 0.98 (0.83–1.15) | 0.78 |
| Unemployment (ref: no) | 1.04 (0.91–1.20) | 0.57 | 1.16 (0.97–1.40) | 0.11 |
| Sleep dissatisfaction (ref: yes) | 1.02 (0.91–1.14) | 0.75 | 0.94 (0.81–1.10) | 0.45 |
| Psychological distress (ref: K6 < 13) | 0.93 (0.77–1.12) | 0.46 | 0.89 (0.72–1.09) | 0.25 |
| Post-traumatic stress disorder (ref: PCL-S < 44) | 1.12 (0.95–1.31) | 0.17 | 1.29 (1.08–1.55) | < 0.01 |
Logistic regression analysis was used (dependent variable: metabolic syndrome, independent variable of interest: presence versus absence of each lifestyle factor, adjustment variables: age and sex). CI, confidence interval; K6, Kessler 6-item scale; PCL-S, Post-traumatic Stress Disorder Checklist.
Discussion
We previously reported that evacuation following the accident was associated with an increased incidence of MetS as well as obesity or other metabolic diseases, such as hypertension, diabetes, and dyslipidemia7–11). However, the associations between various health problems and detailed lifestyle factors have not been elucidated except for our recent report about hepatobiliary enzyme abnormalities14). In this cross-sectional study, we first investigated the associations between MetS and detailed lifestyle- and disaster-related factors following the accident. After adjusting for potential confounders, we found significant associations between MetS and age, quitting smoking, light to moderate drinking, physical activity, and PTSD.
Subjects in the present study had strong post-traumatic responses related to the Fukushima Daiichi Nuclear Power Plant explosion and the following crisis. The proportion of PTSD in adults, based on the (PCL-S), was 21.6% at 10 months after the accident12), which was similar to 20.1% reported in study of workers after the 9/11 World Trade Center attacks in the United States18). PTSD is a risk factor for developing MetS through its impact on unhealthy factors such as a sedentary lifestyle, smoking, alcohol intake, consuming saturated fats and refined sugars, and consuming low amounts of fruit4). In the present study, the association between PTSD and MetS was found only in women, possibly because PTSD has a different impact on MetS-related lifestyle factors between men and women. Compared to participants without PTSD, those with PTSD had a higher prevalence of alcohol consumption of ≥ 44 g/day in women (Supplement Table 1). Moreover, we previously found that, following the disaster, PTSD was associated with changes in food intake, such as reduced vegetable intake or increased juice intake. These changes place people at a higher risk for MetS, and these associations are predominantly observed in women19). On the other hand, the sex differences of hypothalamic-pituitary-adrenal (HPA) axis20) can support our results. HPA is a potential mechanism associated with both PTSD and metabolic disease21). Although psychological stress elevates cortisol levels22), it could not be observed in only male samples23). Moreover, estrogen activates HPA axis response to stress 24). Taken together, these results suggest that, following the disaster, PTSD was more likely to lead to MetS in women than in men.
Supplementary Table 1. Comparison of lifestyle characteristics between with and without post-traumatic stress disorder.
| Men |
Women |
|||||
|---|---|---|---|---|---|---|
| PCL-S < 44 | PCL-S ≥ 44 | P value | PCL-S < 44 | PCL-S ≥ 44 | p value | |
| Participants | 7,264 | 1,546 | 9,230 | 2,880 | ||
| Evacuees (%) | 3,102 (42.7) | 862 (55.8) | < 0.01 | 3,831 (41.5) | 1,541 (53.5) | < 0.01 |
| Smoking | ||||||
| Current smoker (%) | 2,143 (29.7) | 431 (28.3) | 0.29 | 624 (6.9) | 257 (9.4) | < 0.01 |
| Quit smoker (%) | 3,342 (46.3) | 708 (46.5) | 0.87 | 593 (6.6) | 191 (7.0) | 0.50 |
| Current drinker | ||||||
| < 44 g/day (%) | 3,760 (51.9) | 740 (48.1) | < 0.01 | 2,616 (28.7) | 780 (27.8) | 0.36 |
| ≥ 44 g/day (%) | 1,554 (21.5) | 343 (22.3) | 0.48 | 171 (1.9) | 84 (3.0) | < 0.01 |
| Physical activity | ||||||
| < 4 times a week (%) | 5,916 (82.3) | 1,266 (82.7) | 0.69 | 7,966 (87.4) | 2,475 (87.3) | 0.94 |
| Change of job | 3,925 (55.0) | 1,135 (75.4) | < 0.01 | 4,649 (52.7) | 1,829 (67.7) | < 0.01 |
| Unemployment | 1,500 (20.7) | 547 (35.4) | < 0.01 | 2,225 (24.1) | 927 (32.2) | < 0.01 |
| Sleep dissatisfaction (%) | 3,389 (54.7) | 1,086 (84.7) | < 0.01 | 5,223 (67.0) | 2,173 (91.0) | < 0.01 |
| Psychological distress (K6 ≥ 13) | 286 (3.9) | 718 (46.4) | < 0.01 | 513 (5.6) | 1,518 (52.7) | < 0.01 |
Logistic regression analysis was used (dependent variable: metabolic syndrome; independent variable of interest: presence versus absence of each life styles; adjustment variables: age, sex, evacuation, smoking, alcohol intake, physical activity, change of job, unemployment, sleep dissatisfaction, psychological distress, and post-traumatic stress disorder). CI, confidence interval; K6, Kessler 6-item scale; PCL-S, Post-traumatic Stress Disorder Checklist.
Smoking is a risk factor for MetS development25). On the other hand, the proportion of smokers among residents of evacuation-designated areas decreased after the disaster in spite of the increase in MetS26). Smoking cessation increases body weight27–28) or short-term risk of diabetes29). Moreover, without educational instruction, stopping smoking could promote MetS development30). These previous studies support present findings that quitting smoking, but not current smoking, is a risk factor for MetS. However, the association between smoking and MetS after the disaster needs future, long-term evaluation.
Alcohol intake increases the risk of hypertension31). On the other hand, moderate alcohol intake decreases the risk for diabetes32) and increased TG levels33). In the present study, alcohol intake < 44 g/day was associated with significantly lower MetS occurrence in women. This result is in accordance with a previous meta-analysis, which associated light alcoholic consumption with a reduced prevalence of MetS34–35). However, heavy alcohol consumption is a risk factor for developing MetS35). Following the disaster, 9.6% of non-drinkers before the disaster began drinking, of which 18.4% were heavy drinkers. Moreover, post-disaster heavy drinkers were likely to continue heavy drinking36). Therefore, intake of alcohol, and in particular the amount of alcohol, should be a considered in the prevention of MetS following a disaster.
A low level of physical activity is associated with MetS37). In the present study, this association was confirmed among residents of a disaster-affected region. Early evacuation after the accident decreased radiation exposure levels among residents living around the Fukushima Nuclear Power Plant. The United Nations Scientific Committee on the Effects of Atomic Radiation reported no distinct increases in the incidence of radiation-related health effects based on the during first-year data of residents exposed to low or very low doses of radiation38). Therefore, the causes of MetS are unlikely to be due to direct radiation exposure. However, residents tended to avoid going out because of fears of radioactive exposure after Fukushima Daiichi Nuclear Power Plant accident. In fact, the proportion of residents who exercised was lower following the accident, especially for residents in the evacuation zone11). Therefore, fear of radioactive exposure can potentially increase the risk for MetS by decreased physical activity. Moreover, relieving anxiety due to radioactive exposure may contribute to overcoming MetS in residents following the accident.
Limitations
Several limitations of the present study should be considered. First, subjects with bad mental health status were not included in the present study because mental status might affect the response rate to the survey39). Therefore, it is impossible to deny the possibility of sample bias. Moreover, PTSD in the present study was based on a 12 month survey, 9 months after the Fukushima Daiichi nuclear power plant accident. The relation between PTSD and MetS, including elapsed time from the accident, should be examined in a future longitudinal survey. Second, food intake, which can affect MetS, was not estimated in the present study because of lack of information. The dietary effects on MetS following the disaster will be an important element of future investigations. Third, because there is no information about lifestyle factors before the Fukushima Daiichi Nuclear Power plant accident, we could not evaluate changes in these factors in the pre- and post-accident periods. Furthermore, the lifestyle itself before the accident may directly affect MetS in present participants. A future longitudinal study of changes in both MetS and lifestyle factors will help clarify the true associations between MetS and lifestyle factors after the Fukushima Daiichi Nuclear Power Plant accident. Despite these limitations, the strength of present study was that it was a large-scale survey of residents of evacuation-designated areas near the Fukushima Daiichi Nuclear Power Plant. Moreover, the present survey is the first report showing an association between MetS and PTSD related to the Nuclear Power Plant accident.
Conclusions
Several lifestyle- and disaster-related factors were associated with MetS after the Fukushima Daiichi Nuclear Power Plant accident. These findings could provide information relevant to the prevention of MetS, regardless of evacuation status.
Acknowledgements
We thank the expert committee members, advisors, and staff of the Fukushima Health Survey Group for conducting this survey and for their support. This work was supported by the National Health Fund for Children and Adults Affected by the Nuclear Incident. The findings and conclusions of this article are solely the responsibility of the authors and do not represent the official views of the Fukushima Prefectural Government.
All authors participated in study conception and design. A. Takahashi, T. Ohira, and K. Okazaki performed statistical analysis of the data. H. Ohira supervised the project. All authors participated in interpretation of the results and drafting of the manuscript, and approved the final version.
Conflicts of Interest
All authors have no financial disclosures.
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