Insulin Resistance Diet & Treatment

March 12, 2022

Insulin Resistance Diet & Treatment

Dr. Nicole Sundene, NMD

Female Hormone Specialist

“Insulin Resistance? Nobody cares about Insulin Resistance” was what one of my patients with severe insulin resistance told me she was told by her anesthesiologist when he asked if she was diabetic. She laughed as she told me that her Cardiologist was just as dumbfounded by these statements as I was! Her Cardiologist actually agreed with me on the insulin resistance causing her high blood pressure. 

I asked my patient… “Is it okay that I am about to now go on an Insulin Resistance blogging  rampage and tell this story?” She told me to go for it so please enjoy today’s rant about why doctors and patients need to stop ignoring insulin resistance! We must screen routinely for insulin resistance and implement the appropriate diet and supplements so patients can be successful with getting their “Fat Storage” hormone under control.

Because until they do the insulin resistance will cause them to just continue to gain more and more weight until they are type 2 diabetic and have high blood pressure.

Ignorance around Insulin Resistance is EXACTLY what is wrong with everyone in America! I have worked in women’s health for 23 years now and I am finding patients with severe insulin resistance in my practice every single day. Because I specialize in PCOS and hormone imbalance, I test for insulin on all of my routine hormone panels…and guess what? 

It is actually the #1 most common cause that women to gain weight. While everyone is hiring me to figure out if they have a thyroid condition causing their metabolism to slow down, what I find more often than not in this scenario is that insulin resistance is causing them to gain weight and gumming up their metabolism. Insulin is the evil enemy that grabs every carb and fat you eat and slaps it into fat storage. Leaving my insulin-resistant patients with chronic fatigue because they are not able to burn carbs or fat properly for energy and are then left with protein as their main source of fuel.   

Doctors should be checking every American’s insulin numbers to prevent diabetes, hypertension, weight gain, and PCOS the leading cause of hormone imbalance in women. 

I am so SICK of the SICK care system that fails to focus on prevention, and instead just waits until you have a stroke from high blood pressure caused by insulin resistance and only then will insurance pay for you to have expensive physical therapy to teach you how to walk and talk again… yet it doesn’t care about screening for insulin resistance. Frankly, I don’t even know why we are so obsessed with cholesterol numbers while totally failing to test insulin levels, when the majority of my hormone patients are challenged more by the inflammation from insulin causing them high LDL, high triglycerides, high blood pressure, hormone imbalance, mood swings, headaches, and PCOS. 

Patients with a fasting insulin number greater than 8 are on the fast track for diabetes, high cholesterol, high blood pressure and obesity. I see my patients with a fasting insulin >20 become Type 2 Diabetic within 5 years. Sometimes sooner. Oftentimes it is not possible for patients to get their insulin numbers under control merely with a low carb diet alone because wildly swinging blood sugar numbers trigger hypoglycemia which generally causes my patients to binge eat when they get too hungry. 

I find every single day of my career that patients with fasting insulin above >10 are completely unable to lose weight until the insulin numbers are corrected with herbs and supplements. This process generally takes 6-12 months of diligent work. Most of my patients with insulin resistance cannot adhere to the reality that there is no quick fix to their weight gain, and also need to be in counseling about their disordered eating patterns because there is generally an emotional component and physical component impacting the patient’s eating pattern. 

Instead of setting patients with weight gain and insulin resistance up for failure by telling them to simply follow a low to moderate carb diet that is low in saturated fat, we also must implement counseling along with herbs and supplements that help stabilize the blood sugar and improve sensitivity to insulin. 

In a country full of obesity we do not have time for doctors that are ignorant about insulin and do not care about insulin resistance. Especially with viruses circling around us that are more likely to cause long-term effects and increased mortality in those with impaired immune systems from Type 2 Diabetes as one of the leading factors of death and long hauler symptoms!

In order to properly address insulin resistance, we must understand what it is, and why it is occurring. 

What is Insulin Resistance?

Insulin resistance is an impaired body response to normal insulin levels in the body resulting in metabolic complications. The body cells fail to respond to insulin hormone stimulation, specifically in the muscles, adipose tissues, and liver.

Initially, the pancreas increases insulin hormone production and secretion, but eventually, pancreatic beta cells wear out, and insulin resistance worsens. The insulin no longer works efficiently, the insulin levels increase resulting in hyperinsulinemia.  High cholesterol, high LDL, high triglycerides occur as the metabolism of saturated fats, lipids and glucose get disrupted [1]. Today we will discuss diet prevention and treatment of insulin resistance. It is important patients are under the care of a doctor that specializes in insulin resistance as low blood sugar can potentially be dangerous. 

It is important to note that insulin resistance leads to prediabetes, non-alcoholic fatty liver disease (NAFLD), and type 2 diabetes mellitus. Plus, other consequences of insulin resistance include metabolic complications such as high cholesterol, high uric acid level, endothelial dysfunction, visceral adiposity, and high blood pressure. However, there are many preventive and treatment strategies to overcome insulin resistance and reduce the risk of prediabetes and type 2 diabetes mellitus [1].

What Causes Insulin Resistance?

Like other endocrine dysfunctions, the common causes of insulin resistance include poor diet (such as a diet high in carbs), physical inactivity, family history, and obesity. Other risk factors of insulin resistance are smoking, gestational diabetes, high cholesterol level, ethnicity, high blood pressure, hormonal disorders (Cushing syndrome, etc.), autoimmune disease, age, prediabetes symptoms, sleep problems, and certain drugs such as steroids, HIV medications, and antipsychotics. Note that African, Latino, or Native American and older individuals (>45 Yrs.) are at high risk of insulin resistance [1, 2, 15].

Insulin Resistance Symptoms

Common skin and Dermatology signs of insulin resistance are hormonal acne, skin tags (small skin growth) and acanthosis nigricans (darkened skin in the neck, back, groin, and armpits) significantly indicate insulin resistance. Patients with insulin resistance commonly complain of headaches, fatigue, joint pain, and weight gain. 

Lab Tests Indicating Insulin Resistance: 

The following blood markers help determine the diagnosis of insulin resistance. These include: 

  1. Blood pressure higher than 130/80 mm of Hg, 
  2. Fasting blood glucose level of more than 100mg/dl
  3. Fasting triglyceride levels of greater than 150 mg/dl
  4. HDL cholesterol levels less than 50 mg/dL and 40 mg/dL in women and men, respectively.
  5. Waist of more than 40 inches (for men) and >35 inches (for women) 
  6. Fasting insulin level above 8 indicates insulin resistance. Optimal insulin is <3

Patients with the above symptoms and findings almost always have insulin resistance and are therefore at extremely high risk of requiring medication for Type 2 Diabetes if they are not already on it.  [1, 2, 3].

Insulin Resistance Mechanisms

Insulin resistance is attributed to many factors and biochemical pathways. These include: hormonal disturbances (including the ratio of insulin to glucagon hormone, excess of catecholamines and glucocorticoid secretion), defects in insulin signaling at a cellular level, down-regulation of insulin, disturbed GLUT4 function, and also genetic polymorphism of insulin receptors [1, 2].

Insulin Resistance and Syndromes

Insulin resistance is highly associated with metabolic, clinical, and insulin resistance syndromes. Note that syndrome means a cluster of abnormalities that worsen the current condition and favors other chronic medical complications. The metabolic syndrome associated with insulin resistance involves high blood pressure, obesity, high fasting glucose level, and abnormal triglyceride and HDL cholesterol levels. 

Metabolic syndrome associated with insulin resistance increases the risk of various clinical complications, including type 2 diabetes mellitus, stroke, cardiovascular dysfunction, PCOS, sleep apnea, liver disease, and “essential hypertension” aka high blood pressure.

 Insulin resistance includes elevated pro-inflammatory markers, abnormal uric acid metabolism, endothelial dysfunction, glucose intolerance, and an increased testosterone secretion by the ovaries [2, 3].

Insulin Resistance and Type 2 Diabetes Mellitus (T2DM)

The most common medical consequence of uncontrolled Insulin resistance is Type 2 diabetes. Medical research studies reported that insulin resistance precedes T2DM development by 10-15 years. Initially, during insulin resistance, the pancreas increases insulin production and compensates for the tolerance to insulin. As a result, the pancreas elevates the insulin level that potentiates weight gain, aggravating insulin resistance condition. 

This compensatory cycle can negatively affect or even destroy the pancreatic beta-cell function (insulin production) with time. Thus, the insulin level does not meet the body requirement resulting in an abnormal glucose level in the blood and eventually Type 2 diabetes mellitus [2, 15].

Insulin Resistance and Polycystic Ovary Syndrome (PCOS) 

In addition to T2DM, insulin resistance is significantly associated with the development of PCOS in women. Medical research studies reported a relationship between insulin resistance, the severity of genetic defects in insulin sensitivity, and PCOS pathogenesis (the most common endocrine dysfunction in women). Studies reported that PCOS, obesity, and growth spurts in adolescents also damage insulin sensitivity. During insulin resistance, the high insulin level (hyperinsulinemia) in the body increases luteinizing hormone (LH) secretion and androgen production by the pituitary gland that causes ovarian dysfunction.

Insulin resistance combined with obesity increases estrogen production that further disrupt the hypothalamic-pituitary-gonadal axis. Further, the high insulin level suppresses sex hormone-binding globulin by the liver and increases the free androgen level in the body. As a result, the free androgen level further impacts insulin resistance and aggravates PCOS. Insulin resistance management can help ovarian function and improve PCOS symptoms [2].

Insulin Resistance and Hypertension

Essential hypertension or High blood pressure with no secondary causes is highly associated with insulin resistance. Medical research studies reported that hyperinsulinemia (during insulin resistance) increases sodium retention in the kidney and potentiates sympathetic nervous system activity causing high blood pressure. The further development of endothelial dysfunction due to insulin resistance and high blood pressure then cause a further elevation of blood pressure [2].

Insulin Resistance and Non-Alcoholic Fatty Liver Disease (NAFLD)

In insulin resistance, the muscle and adipose tissue enhance the free fatty acid delivery to the liver. In the liver, the synthesis of triglycerides increases except for the very-low-density lipoprotein (VLDL) triglycerides. High insulin increases the transport of VLDL triglycerides from the liver. As a result, insulin resistance increases the fat accumulation in the liver and significantly precedes NAFLD- Nonalcoholic fatty liver disease, or liver failure that is caused by consuming too much sugar and saturated fat. NAFLD generally progresses to various liver failure conditions, including steatohepatitis, cirrhosis, and non-alcoholic steatohepatitis [2].

Insulin resistance and Migraines/Headache

There is a common association between insulin resistance, diabetes, and migraine. Guldiken et al. in 2009 reported a high prevalence of migraine in individuals with diabetes mellitus (DM), greater waist circumference, and high body mass index (BMI). As blood sugar drops because insulin take the sugar and puts it in to fat cell storage, the patient then gets a migraine or headache from the sudden drop in blood sugar. The higher the insulin the worse the headaches become. 

Insulin resistance and High Cholesterol

Insulin resistance significantly affects and alters lipid metabolism resulting in dyslipidemia or lipid abnormalities. During insulin resistance, the level of plasma triglycerides and very-low-density lipoproteins (VLDL) increases, while the high-density lipoproteins level decreases and small dense LDL appears. As a result, combined with any endothelial dysfunction, the lipid abnormalities associated with insulin resistance potentially increase the risk of cardiovascular events [2, 4, 15].

Insulin Resistance Treatment

Insulin Resistance Lifestyle Modification Treatments

Lifestyle interventions play a significant role in the management of insulin resistance treatment. The most important lifestyle interventions are proper diet and regular physical activities. Diet must be optimized accordingly, as discussed in the Insulin Resistance Diet section. Regular exercise and  physical activity  improves calorie expenditure and insulin sensitivity. Patients should attend seminars, education programs, and anti-diabetic campaigns [1, 15].

Insulin Resistance Treatment Medications

In addition to lifestyle interventions, different type-2 diabetes mellitus medications also help insulin resistance management. However, note that they are not FDA-approved treatment options for insulin resistance. These therapeutic options include Metformin, Glucagon-like peptide-1 agonists, Sodium-glucose cotransporters-2 inhibitors, Thiazolidinediones, Dipeptidyl peptidase-4 inhibitors, and Insulin therapy [1].

  • Metformin is a first-line agent for T2DM treatment and is also recommended for PCOS management. Moreover, combined with lifestyle intervention, it effectively improves insulin resistance and prevents diabetes complications. 
  • Glucagon-like Peptide-1 agonists (GLP-1) act on the GLP-1 receptors in the pancreas, increase insulin production, inhibit glucagon secretion, and provide anti-obesity effects. As a result, it improves both weight loss and insulin resistance.
  • Sodium-glucose cotransporters-2 inhibitors (SGLT-2I) enhance glucose excretion via the kidney and help decrease blood glucose levels. Additionally, it supports weight loss and helps insulin resistance management. 
  • Thiazolidinediones (TZDs) increase insulin sensitivity and improve glucose disposal, but they are highly associated with weight gain and cardiovascular concerns. 
  • Moreover, using dipeptidyl peptidase-4 inhibitors increases endogenous GLP-1 activity, improves insulin release, and helps insulin resistance. 
  • Lastly, insulin therapy and surgery are recommended in severe T2DM.

Side effects of these medications for insulin resistance most commonly include: Weight gain, fatigue, headaches, diarrhea, nausea, vomiting, abdominal pain, constipation, stomach upset, cough, hoarseness, fever, chills, general feeling of discomfort, lower back or side pain, muscle pain, muscle cramping, eye twitching, and painful bladder or urination. Because many patients experience these side effects they often seek a Naturopathic treatment plan for insulin resistance. 

When using Naturopathic medicine for Insulin resistance we work with diet and supplements first to lower insulin, and then taper the patient off their medications gradually over a 3-12 month process. Patients with insulin resistance and type 2 diabetes should never suddenly stop taking their medications for insulin resistance as this can be dangerous and result in death. 

It is imperative to work with an experienced Naturopathic Hormone Doctor to reduce the need for medications for insulin resistance. 

Insulin Resistance Diet

Insulin resistance patients will not improve on the Keto Diet. When I tell patients to eat a low carb diet they often interpret this as, “I am going to go Keto,” only to gain more weight and return with worsened insulin numbers. Absolutely under no circumstance should this diet be implemented for insulin resistance. The problem with Keto is that it contains way too much saturated fat which also worsens insulin resistance so it is imperative that patients use a low glycemic index diet of low to moderate carbs and HIGH PROTEIN, paired with HIGH FIBER! Good fats are allowed in moderation, but Saturated fat consumption should be <10g daily for the insulin resistant patient to be able to lose weight. Most patients report to me they are actually  consuming 50-100g of saturated fat daily when they begin to track their macros. Sometimes even more than this which! Failing to track macros will result in failure with insulin resistance as this is the equivalent of writing as many checks from your checkbook as you want, simply because you have 100’s of checks. We must take into account the spending budget for insulin resistance patients. 

Please do not sign up to work with me as your Naturopathic doctor if you are not willing to track your macros for insulin resistance. It will just be a waste of everyone’s time and I will not be able to help you at all. 

Diet plays an important role in the prevention and management of various health complications. The same is true for endocrine disorders, including diabetes, prediabetes, and insulin resistance. It is important to note that there is no specific diet plan or single fit diet approach for insulin resistance management. However, research studies recommend using certain nutrients that help improve insulin resistance and reduce or delay the risk of insulin resistance complications. 

Studies reported the beneficial effects of complex, low-glycemic-index carbohydrates consumption in insulin resistance [7-9]. Also, American Diabetes Association does not recommend using a high-fat and low carbohydrate diet as it worsens the insulin resistance condition.

Insulin resistance patients should add a fiber-rich diet (beans, peas, and lentils, whole grains, raw fruit (be careful with portions= ½ cup of fruit generally is one serving), and non-starchy vegetables to their diet. Further, research studies confirmed the benefits of using a high-energy and low-glycemic-index breakfast in patients as such a diet plan increases calorific intake in the first half of the day. Additionally, after a proper diet plan, a slow and mindful eating approach significantly benefits insulin resistance patients [7, 8]. 

Insulin resistance and PCOS are inflammatory conditions worsened by inflammatory foods. Please don’t use processed foods, minimize foods containing high sugar (such as sugary sweets), avoid high salt, don’t consume artificial Trans fats, use olive oil, consume more fibers, add non-starchy vegetables instead of refined grains or starchy vegetables and reduce calorie intake coming from carbohydrates. 

Also, don’t eat starchy vegetables (unless used as a complex carb source), snacks, alcohol, beverages, dairy products, fried foods, chocolate, butter, and other items rich in saturated fats. Additionally, take certain nutrients, including magnesium, potassium, and calcium, to improve blood sugar levels [7-9].

Certain foods improve insulin resistance including dark leafy greens, vegetables, tomatoes, beans, peppers, citrus fruits, whole grains, broccoli, fish, soy, spinach, collards, asparagus, cabbage, carrots, kale, lean meats, omega-3s rich content, nuts, berries, and sweet potatoes. These healthy foods are demonstrated in research to improve insulin sensitivity and help insulin resistance patient [8, 9].

Natural Treatments for Insulin resistance: Medicinal Herbs, and Supplements

Various clinical trials are conducted on the beneficial effect of different herbs and supplements on insulin resistance. These trials reported positive effects of Cinnamon, Green Coffee Extract, Curcumin, Ginger, Berberine, Jinlida, Sancai Powder, Artemisia, Chamomile tea, Nigella sativa, Soybean leaf extracts (SLEs), Gymnema Sylvestre, Aloe Vera gel complex, and Fresh yellow onion [12].

Studies reported that Cinnamon significantly improves blood sugar level, total cholesterol, and triglyceride levels, helps liver enzymes, and decreases fasting blood glucose levels. Thus, cinnamon consumption helps insulin resistance and reduces the risk of NAFLD [10]. Additionally, Cinnamon contains flavonoids, terpenoids, coumarins, anthraquinones, glycosides, and tannins. Animal studies showed that optimal consumption of Cinnamon significantly suppresses post-meal blood glucose spikes and reduces the risk of diabetic complications. Besides, Cinnamon also helps reduce insulin levels in women and improve PCOS or reduce the aggravation of symptoms.

Regular use of ginger, curcumin, green coffee bean extract, and green tea extract reduces the fasting blood glucose level, helps abdominal obesity, decreases HbA1c, prevents atherogenic risks, and improves insulin resistance in type 2 diabetic patients. 

The beneficial properties of these herbs not only help insulin resistance but also reduce the risk of metabolic and clinical syndromes linked with insulin resistance [12]. Animal studies showed that various extracts of medicinal herbs, including Nettles (Urtica dioica), Anacardium occidentale, Symplocos cochinchinesis, and Helicterus Angustifolia, can improve insulin resistance and reduce plasma glucose levels. Also, other herbs like Pleurotus Ostreatus, Afzelia Africana, and Uvaria chamae consumption may help insulin sensitivity, improve fasting blood glucose level, and support regeneration of Islet of Langerhans in the pancreas [13]. 

Taking chromium can also be beneficial, but mainly in deficiency. Well-controlled trials are lacking about the use of Chromium for insulin resistance. Those in favor are considered insufficient due to poor methodology and low-quality research. However, animal studies reported that Chromium improves insulin resistance, relieves lipid abnormalities, and helps glycemia in diabetic patients[14]. Since farmers are not required to replete our soil with chromium it does not hurt an insulin-resistant patient to take 500mcg of chromium picolinate twice daily with food. Never take any supplements or treatments for blood sugar away from food as it will cause nausea and vomiting from low blood sugar!

If you would like my help with your insulin resistance, PCOS, or Type 2 Diabetes, I would be happy to help. I cannot help any patients with Naturopathic Medicine that are not open to making diet changes and taking supplements. I understand if you need to make diet changes in steps and struggle with them as I do, but realistically I will not be able to help you at all if you are not willing to remain committed to achieving a long term plan towards managing your insulin resistance, as this is one of the most challenging hormone conditions that I treat as a hormone doctor. To set up your new patient visit simply pop over to the SCHEDULE page.

Dr. Nicole Sundene

(480) 837-0900

Dr. Sundene is a Naturopathic Doctor in Scottsdale, Arizona, and is a Female Hormone Expert in Women's Health and Bioidentical Hormones. She specializes in Holistic Women's Health for Menopause,  Thyroid,  Hashimotos,  PMS, PerimenopauseAutoimmunePostpartumChronic Fatigue, DepressionAnxiety, Food Allergies,  DigestionDermatology, AcnePsoriasis Eczema, and Adrenal Hormonal Conditions. In 1999 she began working for a Hormone Doctor prior to starting Naturopathic Medical School. With over 23 years of experience in both Prescription and Natural women's health and hormones, she presents to women the best-integrated health solutions for their Chronic Disease. 

She has been an Herbalist for over 28 years and enjoys teaching women how to use herbs to balance their hormones, nutrition and optimize their health. Dr. Sundene relies on blood testing for her hormone metrics. The hormone testing is covered per the patient's insurance plan (not Medicaid) and conducted at certain points in the woman's menstrual cycle. To learn more about Hormone Testing for Women Visit: Bioidentical Hormones. Follow Dr. Sundene on InstagramTwitter, and Facebook for more tips on Women's Health, Female Hormones, and Naturopathy!

References

  1. Freeman AM, Pennings N. Insulin Resistance. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
  2. Wilcox G. (2005). Insulin and insulin resistance. The Clinical biochemist. Reviews, 26(2), 19–39.
  3. Reaven, G. M. (2005). THE INSULIN RESISTANCE SYNDROME: Definition and Dietary Approaches to Treatment. Annual Review of Nutrition, 25(1), 391–406. doi:10.1146/annurev.nutr.24.012003.132155
  4. Ighbariya, A., & Weiss, R. (2017). Insulin Resistance, Prediabetes, Metabolic Syndrome: What Should Every Pediatrician Know?. Journal of clinical research in pediatric endocrinology, 9(Suppl 2), 49–57.
  5. Özcan, R. K., & Özmen, S. G. (2019). The Association Between Migraine, Metabolic Syndrome, Insulin Resistance, and Obesity in Women: A Case-Control Study. Sisli Etfal Hastanesi tip bulteni, 53(4), 395–402.
  6. Fava, A., Pirritano, D., Consoli, D., Plastino, M., Casalinuovo, F., Cristofaro, S., Colica, C., Ermio, C., De Bartolo, M., Opipari, C., Lanzo, R., Consoli, A., & Bosco, D. (2014). Chronic migraine in women is associated with insulin resistance: a cross-sectional study. European journal of neurology, 21(2), 267–272.
  7. Gołąbek, K. D., & Regulska-Ilow, B. (2019). Dietary support in insulin resistance: An overview of current scientific reports. Advances in clinical and experimental medicine : official organ Wroclaw Medical University, 28(11), 1577–1585.
  8. Weickert M. O. (2012). Nutritional modulation of insulin resistance. Scientifica, 2012, 424780.
  9. Weickert M. O. (2012). What dietary modification best improves insulin sensitivity and why?. Clinical endocrinology, 77(4), 508–512.
  10. Askari, F., Rashidkhani, B., & Hekmatdoost, A. (2014). Cinnamon may have therapeutic benefits on lipid profile, liver enzymes, insulin resistance, and high-sensitivity C-reactive protein in nonalcoholic fatty liver disease patients. Nutrition research (New York, N.Y.), 34(2), 143–148.
  11. Chuengsamarn, S., Rattanamongkolgul, S., Phonrat, B., Tungtrongchitr, R., & Jirawatnotai, S. (2014). Reduction of atherogenic risk in patients with type 2 diabetes by curcuminoid extract: a randomized controlled trial. The Journal of nutritional biochemistry, 25(2), 144–150.
  12. Li, J., Bai, L., Wei, F., Zhao, J., Wang, D., Xiao, Y., Yan, W., & Wei, J. (2019). Therapeutic Mechanisms of Herbal Medicines Against Insulin Resistance: A Review. Frontiers in pharmacology, 10, 661.
  13. Choudhury, H., Pandey, M., Hua, C. K., Mun, C. S., Jing, J. K., Kong, L., Ern, L. Y., Ashraf, N. A., Kit, S. W., Yee, T. S., Pichika, M. R., Gorain, B., & Kesharwani, P. (2017). An update on natural compounds in the remedy of diabetes mellitus: A systematic review. Journal of traditional and complementary medicine, 8(3), 361–376.
  14. Hua, Y., Clark, S., Ren, J., & Sreejayan, N. (2012). Molecular mechanisms of chromium in alleviating insulin resistance. The Journal of nutritional biochemistry, 23(4), 313–319.
  15. Ndisang, J. F., Vannacci, A., & Rastogi, S. (2017). Insulin Resistance, Type 1 and Type 2 Diabetes, and Related Complications 2017. Journal of diabetes research, 2017, 1478294.
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