A snide remark from a coworker. Airplane seats that only fit a certain size. A provider’s insistence that your knee pain is due to overweight. More than 40% of U.S. adults have experienced stigma due to their weight. But where does it come from, and how can it come between you and your healthcare?
On this episode of On Nutrition, we talk with psychologist Dr. Afton Koball about the harmful impact of weight bias, and how providers and patients can push back against stereotypes, in the medical field and beyond.
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Read the transcript:
What is weight bias?
Tara Schmidt: This is “On Nutrition,” a podcast from Mayo Clinic where we dig into the latest nutrition trends and research to help you understand what’s health, and what’s hype. I’m Tara Schmidt, a registered dietician with Mayo Clinic in Rochester, Minnesota. On this episode: weight bias. Why and how size-based stigma seems to be everywhere. In pop culture, on the playground, even at the doctor’s office. And what patients and providers can do to stop that stigma in its tracks.
What are the different types of weight bias?
Weight bias is a topic that frustrates both myself and my guest, Dr. Afton Koball.
Dr. Koball is a psychologist specializing in eating and weight disorders at Mayo Clinic in Rochester, Minnesota. She’s done extensive research on how the perception of someone’s weight can impact their medical care. Hi, Dr. Koball.
Dr. Afton Koball: Hi. I’m so glad to talk about this topic with you. It’s always fun when we get a chance to talk.
Tara Schmidt: I agree. This is not, though, a fun topic. Weight bias is the term that we’re talking about today. But we have all these categories, internal, external, implicit, explicit. Do you mind defining a few of those for us?
Dr. Afton Koball: Of course, weight bias generally is defined as negative stereotypes or negative actions against people related to their weight, their body size, their body shape. And you’re right, there’s so many different forms.
What is the difference between internal and external weight bias?
External is sort of the messages that society may have about, or actions that they take towards people of larger body sizes, and internal might be when people take those messages that our society so commonly projects now. The message isn’t coming from outside of their brain. It’s them saying to themselves. So internalizing those stereotypes and those messages and believing them about themselves, which a lot of research has suggested, is really harmful.
What is implicit vs. explicit weight bias?
We get into implicit versus explicit, which can be important as well. Explicit is when you can kind of really see and notice some of the actions or words that people might use that are derogatory around weight or shape or size.
And implicit is where it’s a little bit less easy to see, more covert. That happens so often for our patients. And we probably can talk about lots of examples that will really highlight how pervasive that is.
How does weight bias affect medical care?
Tara Schmidt: The worst example that I can think of is when I had a patient come to me for weight management and they told me this story about their history with weight bias. They were at a different facility, so not Mayo, but they were at maybe their original healthcare facility and had knee pain. Brought it up, and the initial reaction from their provider was, you should lose weight.
Can weight bias lead to misdiagnosis in healthcare?
I don’t argue that, right? Losing weight does help our joints. But the problem with this scenario is that they brought it up more than once, and they were actively losing weight, and they were eating healthy, and they just had a feeling this wasn’t just about the weight on their joints.
They come to Mayo and they have a tumor in their knee that is cancer. We’re not blaming anyone, but those are the kind of stories you and I hear that just crush us.
Dr. Afton Koball: Absolutely. You just feel for people who have experienced that for a lifetime.
Tara Schmidt: In that example of the patient with the tumor in their knee. Would their doctor’s response be categorized as implicit external?
Dr. Afton Koball: Probably. I mean, it doesn’t sound like the provider was really outwardly making negative comments about the person’s weight. They probably believed it.
What is internal weight bias?
Because our society perpetuates this idea that if you lose weight, that’s the big thing. If your weight is down, then your health will automatically be better. That has to be what is explaining this. I agree with you. It probably was more implicit on the provider’s part.
Tara Schmidt: That’s an example of implicit, external bias. But on the other side, when you were talking about internal bias, I kept thinking that even when our patients have lost weight, they have been successful, intentionally losing excess weight, sometimes they still have those thoughts. They think of themselves in their previous body shape or previous body size, let’s say, and that’s really hard for them.
How did society shift toward a preference for thinness?
Dr. Afton Koball: I’ll have people look in the mirror and they’ll say, I know when I look at the scale, I’ve lost X number of pounds, but when I look at myself in the mirror, I don’t have this ideal body shape or size. I still really feel hard on myself about it or I don’t notice the weight loss as it’s happened.
Tara Schmidt: We know that hundreds of years ago, having excess weight was positive. Having enough food to eat meant that you had enough money to purchase said food, and now it’s completely flipped. Do you have any idea where this shift came from?
Dr. Afton Koball: It’s really been a slow evolution of sort of cultural messages around thinness and thin being more the ideal because you’re so right. That hasn’t always been the case. Certainly there are, even to this day, kinds of cultural differences that can impact preferred body shapes and sizes. I mean, I even think about the last 10 to 30 years about how some of those preferences have changed in terms of ideal body sizes, but absolutely.
There’s been this slow cultural shift that is focused more for women on thinness and for men on kind of muscularity as sort of this ideal body shape, and size for people. And that interestingly has come alongside the global phenomenon we’ve seen around people’s weights increasing.
Where do people commonly experience weight bias?
I don’t really love the term epidemic because that can be really pejorative and kind of place the onus and the blame on individuals that they caused, their weight gain or something like that. We see this cultural focus and desire for thinness coupled with body sizes that are increasing.
And you would think then that as our society gets larger that there would be more acceptance around different body sizes. And that just has not been the case. If anything, there’s been sort of this wider gap.
Tara Schmidt: What kind of settings do your patients experience weight bias in?
Dr. Afton Koball: There’s tons of great research in this area that weight bias is so pervasive in a variety of areas. Certainly working in health care. We see it very often, but it happens to children and schools, from parents and from peers. It happens in the workplace. It happens pretty much anywhere that people exist.
Is weight bias a global issue?
Tara Schmidt: Walking down the street…
Dr. Afton Koball: Walking in the street, we see it in the media, we see it on TV shows, all sorts of ways and places where it occurs. A patient who had undergone bariatric surgery told me that more doors were being opened for them. I said, what are you talking about? And they said, people in public now open the door for me more often. I was shook, literally and figuratively more doors are being opened.
I hear that all the time from my patients that it feels different being in a smaller body and that they have more access to a raise at work, or that job promotion, or dating feels a little bit different, or they get different responses from other parents at their kids’ schools.
Tara Schmidt: Is this unique to the United States or do we see this kind of bias in other countries as well?
Dr. Afton Koball: It’s really a global phenomenon. Some great research has highlighted that again, there are cultural differences in terms of what body shapes are more preferred or more acceptable, but we absolutely see weight bias happening on a global scale.
What are examples of institutional weight bias?
Tara Schmidt: Let’s go into some cultural examples. Institutionally, or maybe even physically, we see bias in our environment. Airplanes, seat sizes. Maybe workplaces. Do you have any examples of institutional bias?
Dr. Afton Koball: You named some great ones and there are really people who believe that people of larger body sizes should have to pay for two seats, or should have some sort of punishment for having a seat belt extender, those sorts of things. The environment I work in, in healthcare, I just moved into a new office and when I started in my office there, I had my desk chair, but then there were four small chairs for my patients to sit on with arms. Immediately I thought to myself how not conducive the space was to people of many sizes, right?
Immediately I had asked for different chairs that can accommodate different body sizes because how awful would it feel for any of us to walk into a space and to automatically feel as though we’re not welcome because there’s a chair that won’t accommodate our body?
It sort of lets you know that the space and the person in that space doesn’t think about you and that something’s wrong with you and that you’re not normal.
Those sorts of spaces can be important in healthcare. Of course we think about down sizes or exam tables that can accommodate varying body sizes, scales. Blood pressure cuffs. Absolutely.
Tara Schmidt: One thing that I am proud of at Mayo is that we are actually audited for these things because we are a bariatric center. And I kind of love it because they will go around in the waiting room and make sure that there are enough larger chairs without arms. They will go to the hospital and make sure that the hospital beds, one, are big enough, but also can support the weight.
It’s amazing.
Weight bias is all too common. Unfortunately more than 40% of U.S. adults say they’ve experienced it. And it can come in many forms. Weight bias can be internal, like the disregard someone can feel for their own health or worth based on their size. Or external.
Weight bias can be implicit – like standard-size seats on an airplane that may not fit every passenger. Or explicit – like a casting call for models below a size 6. People of a range of sizes can experience weight bias in the workplace, among their peers, or even alone in the mirror. It’s pervasive, stemming from this cultural and systemic desire for thinness. But let’s explore where exactly this bias is coming from.
Tara Schmidt: We know that a lot of bias is about assumptions and false assumptions. Let’s talk about some of those assumptions, if you don’t mind.
Dr. Afton Koball: Yeah, absolutely. I think what we tend to see is that there’s this idea that people who carry excess weight have excess weight because they have some sort of moral failing. They did that to themselves. If they only would have been more strong-willed, less lazy, or more adherent, then they would have been able to lose the weight.
But we also know that people of higher body sizes often have certain characteristics attributed to them, like less intelligent or sloppy, or even some that could be seen as more positive, but are still pretty stereotyping, like the jolly stereotype.
Tara Schmidt: I was going to say something funny, like the funny kid.
Dr. Afton Koball: Yeah. Yeah, absolutely.
How is weight bias portrayed in the media?
Tara Schmidt: Let’s talk about the media. One example I’m aware of is in the movie “Bridget Jones’ Diary.” The character is seen as having a little bit of excess weight. She’s going to be more beautiful as she loses weight and the weight that they show in the movie is 135 pounds. I choose not to share my weight today, but holy buckets, people. 135. What are other stigmatizing experiences that we see in the media?
Dr. Afton Koball: Things like that, like the idea that the lead attractive person in a movie or a TV show should be thin, and that the love interest wants or prefers a thin romantic partner as opposed to people of sizes. That’s not universal. We’re slowly getting better, but it’s really not the norm.
We’ll see these kinds of one-off television shows or movies that do a better job of incorporating lots of body sizes, but that’s definitely not the norm. We see people again who are kind of in these stereotypical roles where they make fun of themselves for their weight or their weight as part of the joke.
You even see that with kid actors. Like you see children in roles where their weight is to be made fun of, and they’re supposed to be goofy or even lazy or sloppy or something like that. I see it all the time in reality TV shows. That’s actually an area I’m really interested in, and that I’ve done a little bit of publishing in former research as well.
How do reality TV shows like “The Biggest Loser” reinforce weight bias?
“The Biggest Loser.” Do you realize that 300,000 people are dying from obesity every single year? The stakes are high. Don’t you get it? What is it going to take for you to make that change? And, I’m sure about the premise, right? You bring people who have higher body weights and they go to the ranch and they work out for probably eight to 10 hours a day.
They get berated by their coaches about how terrible they are. They need to work harder. And then they lose these exorbitant amounts of weight week to week and they weigh in every week in front of the world. And at the end, it’s a competition for who can lose the most weight, essentially?
A research group that I was in, in my graduate training, we were really interested in how that show, in particular, or kind of messages like that from reality television might relate to people’s levels of weight bias who watch the show. On the one hand, we would hear patients who talk about when they watch shows like that, they feel excited and empowered. Like, if they can do it, “I can do it.” And it motivates me. Absolutely.
But then you also hear patients talk about how it’s sort of discouraging and they don’t love every piece of it. We had some participants come into our lab setting and they watched either an hour of “The Biggest Loser” episode or a totally non-related TV show. And after one hour of watching “The Biggest Loser,” people automatically had higher beliefs about the controllability of weight, which is a form of weight bias.
Again, this idea of weight being totally under our control, just eat less, exercise more rather than being because of a variety of complex factors. And also after just an hour, the participants had higher levels of dislike of people of higher body sizes as well. Clearly those messages, like you’re bad, you’re lazy, you did this to yourself, you didn’t work hard enough, that comes through so powerfully that after just one hour of that, people internalize those messages.
Tara Schmidt: It’s so funny that you studied “The Biggest Loser” because I reference “The Biggest Loser’s” study often in nutrition conversations because of the metabolism research that we have. That show has just given us more science than we thought we needed.
Dr. Afton Koball: I think so, too.
Tara Schmidt: We know weight bias thrives on assumptions – false assumptions about someone’s beauty, intelligence, or even their morality – based on their body. Not only can these assumptions impact your social life and your chances at that promotion; there are whole media empires built on these assumptions, too.
Weight bias is all over pop culture, from rom-coms to reality shows. If we do see characters with obesity, they’re often portrayed as undesirable, sloppy, or the butt of some universal joke. Time and time again we’ve seen characters of any size aspire to lose weight and gain admiration – even if they weigh 135 pounds.
We know through research that popular shows like “The Biggest Loser” only reinforce this stigma in the real world. But weight bias isn’t something to run from or laugh at. There are actual consequences for the stereotypes we see on TV.
Let’s talk about the physiological effects of weight bias, and what healthcare providers and patients can do to combat it.
I want to talk about the ways we see weight bias in the environment you and I are most familiar with, in healthcare. What are the more subtle ways assumptions can enter that space?
How can healthcare providers combat weight bias?
Dr. Afton Koball: I was thinking about patients that I’ve had who are parents, who have children of varying body sizes and some of the judgments that they experience as well. If a parent is of a higher body size, but if their child is as well, the parent might internalize their own messages about why that’s bad for their own body to be where it is, but also that they failed as a parent because they did this to their child, or they must not be feeding their child healthy foods.
I’ve had patients describe kind of going to the doctor with their kid and provider. Right away, starting with, “Okay, well, let’s talk about what fruits and vegetables.” Not asking about what the home environment looks like, but really making assumptions. I have met patients who are so active, who eat so well. And I talk to them all the time about how we really don’t know about someone’s health or their health behaviors just by looking at them. But again, yet our society tells us that we do, that people of higher body sizes must eat unhealthily and must eat way too much.
Tara Schmidt: I’m reminded of that when I see patients that I work with who describe how active they are and how healthy they eat and how much nutrition knowledge they have. Many folks that I work with are experts at this and it’s not that they don’t have enough knowledge. This is likely not their first rodeo. They are very well-informed because of their history.
Dr. Afton Koball: You’re so right. It’s also about not, like you said, assumptions, not assuming that because someone has a higher body weight that they should or that they want to lose weight. The structures of our healthcare system and our training models really don’t support providers and helping patients feel good about their bodies at all shapes and sizes and to focus more on health rather than weight specifically.
Tara Schmidt: I am very passionate as well about using people’s first language. The best place that I learned this was my first year in my career. I was at a conference and someone raised their hand and asked the speaker a question that started with, when I have an obese diabetic patient, what do you think blah, blah, blah.
The speaker was so happy and said, “Stop right there. You do not have an obese diabetic patient. You have a patient with obesity and diabetes.”
It was shocking to me, and I loved it, and I’ve been really strict with people in my life and at my job ever since.
Dr. Afton Koball: Absolutely. Well, even the word “obesity” has some controversy around it as well. I even think as a healthcare provider who works with people who are thinking about bariatric surgery or working on their weight or their health, it was back in 2013 that obesity was classified as a disease. For many people that is so helpful because it, again, takes it away from this moral failing. It talks more about the biological pieces of it. The challenging side of it is what we present to the world or what the world sees of us. Our body shape. And so for some people, it can make them feel that it means that my body is bad. My body size is a disease. I feel a little mixed myself.
I had a patient the other day who was like, tell it to me straight. I feel like what I need is for somebody to really just tell me what it is so that my motivation goes up and I can make changes in my weight. And I said, “Well, what about that would be helpful for you?” This person has really internalized the message. We have to be hard on people and tell them the real deal, sort of like The Biggest Loser. If we just give it to them straight and we’re blunt—
Tara Schmidt: You’re in class three. You’re gonna die.
Dr. Afton Koball: Then that helps. But research has shown that that is not the case. It actually ends up reducing motivation, so I’ll tell that to patients, but I’ll say it to colleagues, because I have colleagues who feel that as well. Like, I don’t want to be too sensitive, or I don’t want to beat around the bush. I want to just be direct about it and almost like a scared straight. Once patients know, then they’re going to be more motivated, but there isn’t any empirical support for that.
Tara Schmidt: Another example I was thinking of when you were just talking was the BMI chart behind your doctor’s head, like on the bulletin board. It’s green if you’re normal weight, and it’s yellow if you are overweight, and it’s red if you have obesity. And we have enough knowledge that we do not simply focus on BMI. I want to rip that thing off the wall because providers will point to it. Like, this is how tall you are and this is how much you weigh, so you are in the red zone. And what a crush to their experience.
Dr. Afton Koball: I’m hopeful that we’re making some small strides in that area. It was just June 2023 that the AMA, the American Medical Association came out with a statement that BMI should not be the end all be all metric used to define health, which was amazing as a first step. It’s not everything, but it lets us know that the BMI charts have a lot of flaws and they don’t do a very good job at the individual level of predicting health for any one person.
Tara Schmidt: When that came out, my first thought was, duh. I was upset that they had to make that statement. I was like, who thought that that was true? This is sad.
Dr. Afton Koball: I do understand that because primary care, for example, visits are so short, I understand the desire for physicians or healthcare providers to have like a quick and dirty metric that they can use, and BMI has felt like that for so long.
Tara Schmidt: It’s free. It’s fast.
Dr. Afton Koball: We’ve used it, in a way that disadvantages patients and does a real disservice.
Tara Schmidt: Let’s talk more about the healthcare setting. Whenever I get asked to speak about obesity or nutrition counseling at conferences, I always put like five slides at the front about weight bias. No one’s ever asked me to talk about it, but I’m like, if I get the stage, we’re going to talk about it.
Dr. Afton Koball: It’s like we’re level-setting. We’re all on the same team.
Tara Schmidt: Yes, because unfortunately, in healthcare, this happens. I have this slide that has this circle on it, and it’s patient with obesity and providers spend less time with those patients. They spend less time counseling them on lifestyle change because they don’t inherently believe that the patient’s going to do it.
Now the patient didn’t have an appropriate appointment, but they had a provider who didn’t believe in them. Now they are less likely to be successful because they weren’t given the right tools. They’re likely to not go back to that jerk. And now we’re starting over possibly even with a higher weight opposite of what the intention was.
Dr. Afton Koball: Absolutely. When there’s this fear that every time I have an interaction with a healthcare provider that they’re going to talk about my weight, no matter what I’m there for, that feels bad. It feels like I’m not getting great care. And kind of going beyond what you mentioned. They’re more likely to talk about lifestyle changes than other, maybe more effective strategies for weight management. I’ll give you a clinical example.
I’ve had patients who are pursuing a transplant. And they need to lose over a hundred pounds. And when their doctor only talks about diet and exercise for them, it’s not the right level of intervention for the outcome that they need to have a transplant. If we had somebody with cancer, we wouldn’t say, “You could try chemotherapy, but it’s pretty extreme. Instead, we should try to just eat better and use some essential oils.”
We would never say that. We would say let’s go right to the most effective intervention for you and your health goals, but again, because there’s so much stigma around weight and this idea of it being a personal choice, it’s not seen the same way.
Tara Schmidt: You’re a psychologist. Let’s talk about the effects weight bias can have on our psychology.
Dr. Afton Koball: Absolutely. I see it every day with the patients I get to work with. I see that weight bias can lead to people experiencing depression or anxiety, avoidance of certain situations like healthcare or social situations, or trying to go up for that promotion at work. It can lead to significant body image disturbance, even extreme examples like body dysmorphia, where people develop this hatred around themselves or parts of their body.
Then we see it with behaviors as well. We can see the development of eating disorders, binge eating. Those sorts of things we can see with less motivation for physical activity, more sedentary behavior and avoidance of things that kind of would put them in situations where they could be further stigmatized. “I don’t want to go to the gym if I know that people are going to be making judgments about my body when I’m there.” People can avoid those sorts of situations.
Tara Schmidt: What do you think we can do? We’re healthcare providers. Both of us specialize in obesity. What can we do to counteract these biases?
Dr. Afton Koball: For all of us, the first step is increasing our awareness. That’s never enough. We always have to go beyond that. But I do think because of the culture that we live in and the training that we as healthcare providers go into, we don’t get enough information about weight bias. And then, of course, we know that when people experience weight bias, not only are they more likely to gain weight, but there’s greater levels of morbidity and mortality. It causes harm for us as healthcare providers to have weight bias.
What resources are available to reduce weight bias in healthcare?
The first step is awareness and that’s so important. There are some ways that we can do that. There’s some great organizations and other places that can offer some great training opportunities for healthcare providers. One that comes to the top of my mind is the Obesity Action Coalition. They have a number of resources for providers and for patients. They do a lot of advocacy work as well.
Another great resource is the Rudd Center. Just based out of University of Connecticut. They have scripts that you can use to talk about weight in a helpful way with patients to kind of open the door to talk about it and then to have the conversation in a really motivating and empowering way. They also have a media gallery, because something that so often happens in our culture is that there aren’t great representations of people of a variety of body sizes doing healthy things.
They have an awesome free media gallery with a diverse group of patients, adults, and children that providers can use for presentations as well.
Tara Schmidt: Normal weight female eating an apple. And again, I may hit all of those categories, and that is fine, but that can’t be the only person that we see that represents health.
Dr. Afton Koball: Absolutely.
Tara Schmidt: That’s also how they always depict dietitians. Like white women in lab coats with an apple and a scale somewhere near them.
Dr. Afton Koball: That’s funny. They probably present psychologists as, like, older white men with a cardigan at spectacles.
Tara Schmidt: Say a provider is aware of their own weight bias and educating themselves – what can they do to spread that awareness?
How can patients address weight bias in their healthcare?
Dr. Afton Koball: The next step is advocacy and coming alongside our patients to support them in health, as opposed to weight loss only. Sometimes that means advocating with them to our colleagues because we all have blind spots. It’s important for us to remember it’s systemic. Most of us aren’t intending to cause harm to our patients or have belief systems that aren’t helpful for our patients.
And sometimes we have to be willing to feel uncomfortable and to challenge our belief systems in order to get better. We have to be courageous to help our colleagues do that too.
Tara Schmidt: Okay, we’ve talked through weight bias on the provider’s end. What can patients do when they experience weight bias in their medical care?
Dr. Afton Koball: It’s sort of tricky because we know, as we’ve talked about, the systemic and cultural influences around weight bias. We never want to put the onus on people who are experiencing it to have to be the ones who are combating it themselves. And yet, if and when patients can find a provider that they connect with, that hopefully they can join with that provider to continue to advocate for their health and their appropriate care.
Patients can hopefully feel empowered to share their experiences with their healthcare provider so that it’s a learning moment. Sometimes we don’t know that the language we’re using isn’t correct until it’s brought to our attention. And sometimes that’s most powerful when it comes from our patients.
Tara Schmidt: And that goes all the way back to the beginning of that provider does not have intentional bias. It’s just what they have been swimming in, in society for a long time.
Dr. Afton Koball: I also wouldn’t want patients to feel guilty if they don’t feel comfortable talking with their healthcare provider about it because there’s a real power differential there. When I have to go to my doctor and they hold the keys to my prescription that I need, that makes me approach our discussions a little bit differently. And I guess in some situations, if the patient experienced or felt as though they experienced weight bias in a clinical setting, and was uncomfortable saying that face to face with the provider, which I absolutely understand, they could always contact that healthcare institution and share their experience.
It’s not tattling. We’re not trying to get anyone in trouble, but that institution may take that comment and do something differently. We have obesity bias training that all of us have to do. We have to do our fire safety training and what do you do in a tornado? We also have obesity bias training.
Tara Schmidt: We do. I just took it.
Dr. Afton Koball: When I think about our mission at Mayo and the needs of the patient come first and that really should mean all patients. It’s so important that we have invested in making sure that the spaces that we work in can accommodate all patients and not just accommodate, but really support and allow for excellent care of all of our patients.
Tara Schmidt: Dr. Koball, I could speak to you forever. Thank you so much for being here.
Dr. Afton Koball: Thanks, Tara. It was really great to talk with you about this topic.
Tara Schmidt: Here’s what we know about weight bias – it’s harmful. A doctor spending less time with a patient with obesity, or simply telling them to lose weight instead of exploring underlying issues, can have big risks. It can be demoralizing, depressing, and discourage the patient from returning to that provider. Weight bias can get in the way of real preventative care. It makes providers less effective at doing their job.
The good news is that there are resources available for providers to educate themselves and learn to advocate for their patients. Sometimes the most impactful lesson for providers is when patients speak up about what they’re experiencing.
Awareness and advocacy are two steps anyone can take to reduce weight bias from our workplaces and families, to the medical field and beyond.
That’s all for this episode. But if you’ve got a question or topic suggestion, you can leave us a voicemail at 507-538-6272. We might even feature your voice on the show! For more “On Nutrition” episodes and resources, check us out online at mayoclinic.org/onnutrition. Thanks for listening! And until next time, eat well, and be well.
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