{"id":94240,"date":"2023-08-23T12:11:21","date_gmt":"2023-08-23T10:11:21","guid":{"rendered":"https:\/\/aprifel-pp.mentalworks.biz\/?post_type=article_revue&#038;p=94240"},"modified":"2023-08-23T12:16:37","modified_gmt":"2023-08-23T10:16:37","slug":"effective-interventions-to-increase-fruit-and-vegetables-intake-in-children-used-at-least-three-behavior-change-techniques","status":"publish","type":"article_revue","link":"https:\/\/aprifel-pp.mentalworks.biz\/en\/global-fv-newsletter-article\/effective-interventions-to-increase-fruit-and-vegetables-intake-in-children-used-at-least-three-behavior-change-techniques\/","title":{"rendered":"Effective interventions to increase fruit and vegetables intake in children used at least three behavior change techniques"},"content":{"rendered":"\n<figure class=\"wp-block-image size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"900\" height=\"450\" src=\"https:\/\/aprifel-pp.mentalworks.biz\/wp-content\/uploads\/2023\/08\/Article-2-ok-1.jpg\" alt=\"\" class=\"wp-image-94437\"\/><\/figure>\n\n\n\n<p><strong>While health benefits of fruit and vegetables are well-known for children, their intake remains insufficient among this population in the US. A growing number of interventions are designed to promote their intake at preschool age, as this stage of life may be an optimal time for dietary interventions. The impact of those interventions is assessed by numerous reviews, yet those present key gaps and inconsistencies. A recent systematic review was therefore conducted, taking into account all these gaps, to assess interventions\u2019 effectiveness in improving fruit and vegetables intake. According to this work, multicomponent interventions, including nutrition education and behaviour change techniques (BCT) are the most effective.<\/strong><\/p>\n\n\n\n<p>With <strong>only 40%<\/strong> and <strong>7% <\/strong>of <strong>all US children<\/strong> (2-18 years old) <strong>meeting the recommended intake<\/strong> <strong>for fruit and vegetables<\/strong> respectively, it is <strong>essential <\/strong>to <strong>develop strategies <\/strong>to <strong>improve <\/strong>their <strong>consumption <\/strong>in children as these foods are <strong>critical <\/strong>to <strong>support proper brain and body development<\/strong> (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/24354763\/\">Wachs et al, 2014<\/a>).<strong> Preschool age<\/strong> (2-5 years old) may be an <strong>optimal time <\/strong>for <strong>dietary interventions<\/strong> as during this stage, children begin developing their own dietary habits by gaining autonomy over their food choices (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/32182889\/\" target=\"_blank\" rel=\"noreferrer noopener\">Lioret et al, 2020<\/a>).<\/p>\n\n\n\n<p>Numerous scientific reviews aimed to evaluate the impact of dietary interventions in promoting fruit and vegetables in children, yet they present <strong>key gaps and inconsistencies<\/strong>. A recent review (<a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC10239084\/\" target=\"_blank\" rel=\"noreferrer noopener\"><strong>Hasan et al, 2023<\/strong><\/a>) was therefore conducted to systematically identify published <span class='tooltipsall tooltip_post_id_custom_ecda85a727de5fcb6bb7646d3a76eab6 classtoolTipsCustomShortCodeOnlyForMultiTooltips'>randomized controlled trials<\/span><script type=\"text\/javascript\">jQuery(\"document\").ready(function(){ toolTips('.tooltip_post_id_custom_ecda85a727de5fcb6bb7646d3a76eab6',\"Prospective studies that measure the effectiveness of a new intervention or treatment. Randomization reduces bias and provides a rigorous tool to examine cause effect relationships between an intervention and outcome.\",'0'); });<\/script> (RCTs) evaluating childcare- or preschool-based interventions designed to increase <strong>objectively measured intake of fruit, vegetables<\/strong>, <strong>or both in US preschool children<\/strong> (aged 2-5 years). In addition, the review also aimed to <strong>identify whether each study used or not BCTs<\/strong> (see box) and to assess their <strong>effectiveness <\/strong>in improving fruit and vegetables intake.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Interventions that include nutrition education components were consistently effective at improving fruit and vegetables intake, especially if they contain multiple components<\/h2>\n\n\n\n<p>A total of nine interventions were identified according to the <span class='tooltipsall tooltip_post_id_custom_9e9a6260bec4e5f268048a1a6cb821da classtoolTipsCustomShortCodeOnlyForMultiTooltips'>eligibility criteria<\/span><script type=\"text\/javascript\">jQuery(\"document\").ready(function(){ toolTips('.tooltip_post_id_custom_9e9a6260bec4e5f268048a1a6cb821da',\"Eligibility criteria were randomized controlled trials published between 2012 and 2022 of interventions to improve diet or FV intake in preschoolers in childcare or preschool settings.\",'0'); });<\/script> of the review, six of them significantly increased fruit and vegetables intake. The <strong>use of nutrition education<\/strong> was incorporated in <strong>five of the six effective interventions<\/strong>.<\/p>\n\n\n\n<p>All interventions based on nutrition education were interactive for children and improved their fruit and vegetables intake. Merely the knowledge of the importance of fruit and vegetables led to increases in consumption.<\/p>\n\n\n\n<p>Other similar reviews to this work showed comparable findings. Particularly, interventions related to experiential learning of nutritional concepts and healthy eating improved significantly fruit and vegetables preference and intake in young children, compared to those relying on parental involvement or contingent reinforcement (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/25889098\/\" target=\"_blank\" rel=\"noreferrer noopener\">Dudley et al, 2015<\/a>), and especially if they contain multiple components or strategies (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/33050980\/\" target=\"_blank\" rel=\"noreferrer noopener\">Charlton et al, 2021<\/a> ; <a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/34682570\/\" target=\"_blank\" rel=\"noreferrer noopener\">Varman et al, 2021<\/a>).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Manipulating the feeding environment was not consistently effective solely and need to be accompanied by an additional component<\/h2>\n\n\n\n<p><strong>Changing the feeding environment<\/strong> was <strong>not consistently effective<\/strong> according to this work. The <strong>only manipulation that was effective at improving fruit<\/strong> <strong>intake<\/strong>, but not vegetable, was <strong>serving fruit and vegetables five minutes before the rest of the meal <\/strong>(<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/22546262\/\" target=\"_blank\" rel=\"noreferrer noopener\">Harnack et al, 2012<\/a>).<\/p>\n\n\n\n<p>Conversely, interventions that manipulated the feeding environment by providing pre-portioned meals at preschool (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/22546262\/\" target=\"_blank\" rel=\"noreferrer noopener\">Harnack et al, 2012<\/a>) or sent fruit and vegetables for children to take home without directly educating children, showed inconsistent results including decreases in fruit and vegetables intake. These findings suggest that an improvement of fruit and vegetables intake amongst preschoolers cannot be achieved solely by making them more available but <strong>an additional component<\/strong>, such as <strong>nutrition education<\/strong>, may be required (<a href=\"https:\/\/pubmed.ncbi.nlm.nih.gov\/28166788\/\" target=\"_blank\" rel=\"noreferrer noopener\">Nicklas et al, 2017<\/a>).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Effective studies used at least three \u00ab Behavior change techniques \u00bb, although no association was observed between their use and the intervention effect<\/h2>\n\n\n\n<p>According to the review, studies with no significant improvement in fruit and vegetables intake used fewer BCTs whereas effective studies used at least three BCTs and covered at least two domains of the 16. The <strong>most commonly used domains<\/strong> were \u201c<strong><span class='tooltipsall tooltip_post_id_custom_28d3ffa281b014630666851393aecd87 classtoolTipsCustomShortCodeOnlyForMultiTooltips'>Antecedents<\/span><script type=\"text\/javascript\">jQuery(\"document\").ready(function(){ toolTips('.tooltip_post_id_custom_28d3ffa281b014630666851393aecd87',\"The BCTs used in this domain are restructuring the physical environment, restructuring the social environment and adding objects to the environment\",'0'); });<\/script><\/strong>\u201d with the BCT \u201c<strong>Adding objects to the environment<\/strong>\u201d and \u201c<strong>Identity<\/strong>\u201d with the most commonly used BCT \u201c<strong>Framing\/reframing<\/strong>\u201d. The <strong><span class='tooltipsall tooltip_post_id_custom_4990eda31f72129597bbbf1015538916 classtoolTipsCustomShortCodeOnlyForMultiTooltips'>most frequently used domains<\/span><script type=\"text\/javascript\">jQuery(\"document\").ready(function(){ toolTips('.tooltip_post_id_custom_4990eda31f72129597bbbf1015538916',\"total number of BCTs within this domain used within studies\",'0'); });<\/script> <\/strong>were \u201c<strong>Antecedents<\/strong>\u201d and \u201c<strong><span class='tooltipsall tooltip_post_id_custom_f04bf1e91c1961acc0f97f88a2af5b6a classtoolTipsCustomShortCodeOnlyForMultiTooltips'>Repetition and substitution<\/span><script type=\"text\/javascript\">jQuery(\"document\").ready(function(){ toolTips('.tooltip_post_id_custom_f04bf1e91c1961acc0f97f88a2af5b6a',\"The BCTs used in this domain are behavioral practice\/rehearsal, habit formation and graded tasks.\",'0'); });<\/script><\/strong>\u201d.<\/p>\n\n\n\n<p>However, overall, findings suggest that <strong>no association was observed between use of BCTs and intervention effect<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Key gaps are still present in this field despite the promising results<\/h2>\n\n\n\n<p>Despite the promising results reported by some of the studies identified in this review, there are still key gaps in this field. The authors stressed the need for more studies to test fruit and vegetables interventions in US childcare settings that:<\/p>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Use <strong>robust designs<\/strong> with objective measures of dietary intake,<\/li>\n\n\n\n<li><strong>Directly compare<\/strong> intervention <strong>components and BCTs<\/strong> using a factorial model,<\/li>\n\n\n\n<li>Include <strong>follow-up measures<\/strong> to assess long-term behavior change.<\/li>\n<\/ol>\n\n\n\n<p><\/p>\n\n\n\n<p><strong>Based on<\/strong>: Hasan F, et al. Preschool- and childcare center-based interventions to increase fruit and vegetable intake in preschool children in the United States: a systematic review of effectiveness and behavior change techniques. Int J Behav Nutr Phys Act. 2023 Jun 3;20(1):66.<\/p>\n\n\n\n<div class=\"block__about\">\n    <strong class=\"block__about__title\">Behavioural change techniques  <\/strong>\n    <div class=\"block__about__content\"><p>Behavioural change techniques are the concrete components used in an intervention to change behaviour. These techniques are listed together in a <a href=\"https:\/\/academic.oup.com\/abm\/article\/46\/1\/81\/4563254?login=false\" rel=\"noopener\" target=\"_blank\">taxonomy of behavioural change techniques<\/a>. This classification was elaborated by researchers at the Center for Behavior Change and is based on a range of studies in behavioral sciences and psychology. A total of <a href=\"https:\/\/digitalwellbeing.org\/nudge-psychology-all-93-behavior-change-techniques-listed-and-summarised-free-app\/\" rel=\"noopener\" target=\"_blank\">93 techniques divided into 16 domains<\/a>, supported by practical examples are gathered in this taxonomy.  <\/p>\n<\/div>\n<\/div>\n\n\n\n<div class=\"block__stylized-list\">\n    <div class=\"block__stylized-list__leading\" id=\"block__stylized-list__leading\">\n        <i class=\"fa-classic fa-regular fa-pen-to-square\" aria-hidden=\"true\"><\/i>\n        <strong>Methodology<\/strong>\n    <\/div>\n    <div id=\"block__stylized-list__content\" style=\"display: none;\"><ul>\n<li>This systematic review was completed adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.<\/li>\n<li>Inclusion criteria were randomized controlled trials (RCTs) published between 2012 and 2022 of interventions to improve diet or FV intake in preschoolers (aged 2-5 years) in childcare or preschool-settings.<\/li>\n<li>A search of four databases was conducted in September 2022 using search terms pertaining to the study&#8217;s primary aim (FV consumption), age group (preschool-aged), settings (US childcare or preschool settings), and study design (RCT).<\/li>\n<li>Additional criteria were objective measures of FV consumption or skin carotenoids, as a proxy for FV intake. Included studies were narratively synthesized based on intervention type, measured effect, and use of theory and BCTs.<br \/>\n<\/div>\n<\/div>\n\n\n\n<div class=\"block__solid-colored\">\n    <div class=\"block__solid-colored__leading\">\n        <i class=\"fa-classic fa-regular fa-square-check\" aria-hidden=\"true\"><\/i>\n        <strong>Key messages <\/strong>\n    <\/div>\n    <div class=\"block__solid-colored__content\"><ul>\n<li>The most consistent evidence observed is that inclusion of nutrition education components were consistently effective at improving fruit and vegetables intake.<\/li>\n<li>Interventions based on manipulating the feeding environment, by providing pre-portioned meals at preschool or sending fruit and vegetables for children to take home, without directly educating children, produced inconsistent results including decreases in intake.<\/li>\n<li>There was no observable pattern between the use of BCTs and effectiveness of the studies.<\/li>\n<li>While several studies have shown promising results, this review highlights key gaps in this field.<br \/>\n<\/div>\n<\/div>\n\n\n\n<div class=\"block__reference\">\n    <div class=\"block__reference__leading\" id=\"block__reference__leading\">\n        <i class=\"fa-classic fa-solid fa-share-from-square\" aria-hidden=\"true\"><\/i>\n        <strong>References<\/strong>\n    <\/div>\n    <div class=\"block__reference__entries\" id=\"block__reference__entries\" style=\"display: none;\">\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Wachs TD, et al. Issues in the timing of integrated early interventions: contributions from nutrition, neuroscience, and psychological research. Ann N Y Acad Sci. 2014;1308:89\u2013106. <\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Lioret S, et al. Lifestyle patterns begin in early childhood, persist and are socioeconomically patterned, confirming the importance of early life interventions. Nutrients. 2020;12(3):724.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Livingstone MB, et al. Issues in dietary intake assessment of children and adolescents. Br J Nutr. 2004;92(Suppl 2):S213\u2013S222.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health Psychol. 2008;27(3):379\u2013387.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Dudley DA, et al. Teaching approaches and strategies that promote healthy eating in primary school children: a systematic review and meta-analysis. Int J Behav Nutr Phys Act. 2015;12:28. <\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Charlton K, et al. Characteristics of successful primary school-based experiential nutrition programmes: a systematic literature review. Public Health Nutr. 2021;24(14):4642\u20134662.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Varman SD, et al. Experiential learning interventions and healthy eating outcomes in children: a systematic literature review. Int J Environ Res Public Health. 2021;18(20):10824.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Varman SD, et al. Experiential learning interventions and healthy eating outcomes in children: a systematic literature review. Int J Environ Res Public Health. 2021;18(20):10824.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Harnack LJ, et al. Results from an experimental trial at a Head Start center to evaluate two meal service approaches to increase fruit and vegetable intake of preschool aged children. Int J Behav Nutr Phys Act. 2012;9:51.<\/span>\n            <\/div>\n                    <div class=\"block__reference__entry\">\n                <i class=\"fa-classic fa-solid fa-share\" aria-hidden=\"true\"><\/i>\n                <span>Nicklas T, et al. Motivational theater to increase consumption of vegetable dishes by preschool children. Int J Behav Nutr Phys Act. 2017 Feb 7;14(1):16.<\/span>\n            <\/div>\n            <\/div>\n<\/div>\n","protected":false},"template":"","class_list":["post-94240","article_revue","type-article_revue","status-publish","hentry"],"acf":{"auteur":"","source":"","revue":[{"ID":94237,"post_author":"25","post_date":"2023-08-23 12:11:05","post_date_gmt":"2023-08-23 10:11:05","post_content":"<!-- wp:image {\"id\":94275,\"sizeSlug\":\"full\",\"linkDestination\":\"none\"} -->\n<figure class=\"wp-block-image size-full\"><img src=\"https:\/\/aprifel-pp.mentalworks.biz\/wp-content\/uploads\/2023\/08\/Edito-ok.jpg\" alt=\"\" class=\"wp-image-94275\"\/><\/figure>\n<!-- \/wp:image -->\n\n<!-- wp:paragraph -->\n<p>While the <strong>health benefits of fruit and vegetables<\/strong> are <strong>well-known for children<\/strong>, their <strong>intake <\/strong>remains <strong>insufficient <\/strong>among this population. A growing number of interventions are designed to promote their intake as this <strong>stage of life may be an optimal time for dietary interventions<\/strong>. Numerous reviews and scientific studies assessed the impact of those interventions and initiatives on children in various settings.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:paragraph -->\n<p>The Global Fruit and Veg Newsletter of this month presents three articles <strong>to determine interventions and initiatives that could effectively increase fruit and vegetable consumption in children<\/strong>.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:paragraph -->\n<p>The first review has examined which <strong>strategies <\/strong>have shown a <strong>positive impact on fruit and vegetables intake<\/strong> and <strong>nutrition knowledge<\/strong> in <strong>children <\/strong>aged between <strong>4-12 years old<\/strong>. According to this work, <strong>providing fruit and vegetables in school is the most effective strategy<\/strong> <strong>to increase fruit intake<\/strong> in children, whereas <strong>online games<\/strong> and <strong>activities (for example, challenges to eat more fruit and vegetables, virtual cooking sessions...) could increase vegetable intake<\/strong>. Yet, this review confirms a generally observed result : implementing <strong>multiple interventions simultaneously<\/strong> is <strong>more effective<\/strong> than individual strategies alone.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:paragraph -->\n<p>The second review systematically identified published randomized controlled trials (RCTs) evaluating <strong>childcare- or preschool-based interventions<\/strong> <strong>designed to increase objectively measured intake of fruit<\/strong>, <strong>vegetables<\/strong>, or <strong>both <\/strong>in <strong>US preschool children<\/strong> (aged 2-5 years). The <strong>most consistent evidence <\/strong>observed is that<strong> inclusion of nutrition education components, if interactive, was consistently effective at improving fruit and vegetables intake<\/strong>, while <strong>manipulating the feeding environment without directly educating children<\/strong>, produced <strong>inconsistent results<\/strong>.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:paragraph -->\n<p>The third article determined the <strong>associations between family socio-economic status<\/strong> and <strong>children\u2019s<\/strong> <strong>fruit and vegetables consumption<\/strong> wether it was mediated by parental role-modeling and food availability. The results showed that <strong>parental educational level<\/strong> is a <strong>stronger predictor of children\u2019s fruit and vegetables consumption<\/strong> than relative family income in Finland. This <strong>association <\/strong>was <strong>mediated <\/strong>by <strong>parental role modelling<\/strong>, <strong>higher availability of fruit and vegetables<\/strong> and <strong>lower availability of sugary food and drink<\/strong>.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:paragraph -->\n<p>These three articles show that there is a <strong>wide range of interventions<\/strong> proposed<strong> to promote fruit and vegetables among children<\/strong>, the <strong>effectiveness <\/strong>of which <strong>varies <\/strong>according to <strong>several factors<\/strong>, including age group, food environment and parental feeding practices. They emphasize that <strong>there is no single approach<\/strong> to ahcieve higher F&amp;V but rather several strategies which shouldbe adapted to local situations.<\/p>\n<!-- \/wp:paragraph -->\n\n<!-- wp:acf\/pictureable {\"name\":\"acf\/pictureable\",\"data\":{\"authors_0_fully_name\":\"Sophie Nicklaus\",\"_authors_0_fully_name\":\"field_pictureable_author_fully_name\",\"authors_0_profession\":\"Director of Research\",\"_authors_0_profession\":\"field_pictureable_author_profession\",\"authors_0_information\":\"National Research Institute for Agriculture, Food and Environment (INRAE), France\",\"_authors_0_information\":\"field_pictureable_author_information\",\"authors_0_picture\":94238,\"_authors_0_picture\":\"field_pictureable_author_picture\",\"authors\":1,\"_authors\":\"field_pictureable_authors\"},\"align\":\"center\",\"mode\":\"auto\"} \/-->\n\n<!-- wp:acf\/about {\"name\":\"acf\/about\",\"data\":{\"title\":\"About the author\",\"_title\":\"field_about_title\",\"content\":\"Sophie Nicklaus is Director of Research 1st class at INRAE, at the Centre for Taste and Feeding behavior (Centre des Sciences du Go\u00fbt et de l\u2019Alimentation) in Dijon, France. Since 2017, she has been leading the team \u201cDeterminants of eating behaviour across the life course, relationships with health\u201d at this center. She is particularly interested in the impact of early food experiences on later eating behaviour and their contribution to health. She has published over 110 original articles and 21 reviews in international peer-reviewed journals; 22 book chapters; 1 edited book and a book for the public on these topics. She is currently collaborating with public health authorities in France to develop and evaluate updated recommendations on infant feeding. \",\"_content\":\"field_about_content\"},\"align\":\"center\",\"mode\":\"auto\"} \/-->","post_title":"Effective interventions to increase fruit and vegetables consumption in children","post_excerpt":"","post_status":"publish","comment_status":"closed","ping_status":"closed","post_password":"","post_name":"effective-interventions-to-increase-fruit-and-vegetables-consumption-in-children","to_ping":"","pinged":"","post_modified":"2024-10-24 17:28:20","post_modified_gmt":"2024-10-24 15:28:20","post_content_filtered":"","post_parent":0,"guid":"https:\/\/aprifel-pp.mentalworks.biz\/?post_type=revue&#038;p=94237","menu_order":30,"post_type":"revue","post_mime_type":"","comment_count":"0","filter":"raw"}],"position":"2","references":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v23.6 (Yoast SEO v23.6) - 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