Ecercise in

Exercise Behavior and Knowledge among
the DM Type II Patients†
Navaporn Chadchavalpanichaya MD*,
Nualpis Intaratep MD*
†
This manuscript was presented on June 15, 2009 as poster presentation at the 5th World Congress of the International
Society of Physical and Rehabilitation Medicine Istanbul, Turkey
* Department of Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Objective: To study the exercise behavior and knowledge about physical exercise among diabetic patients.
The authors explored the correlation between the exercise behavior and knowledge of physical exercise.
Material and Method: DM type II patients aged more than 18 years, who attended the DM clinic, Siriraj
Hospital, Bangkok between April and August 2007 were randomly interviewed by using questionnaires while
they were waiting to see their doctors.
Results: One hundred and ninety six patients were interviewed. They were 62 males and 134 females with an
average age of 60.5 years. Most of them exercised regularly at least three times a week (65.8%). Most of them
exercised by walking (67%). They liked to exercise in their houses (48.7%), and in the morning (41.8%).
Health care providers provided knowledge about exercise (58.2%). The benefit of exercise known the least
was that it could increase endorphin release (61.2%). The aerobic exercise principle known the least was the
proper frequency of exercise (50.5%). In addition, the exercise principle in DM known the least was that the
DM patients should consult their doctors before starting to exercise (49%).
Conclusion: Most of the DM patients exercised regularly, but some had insufficient knowledge. The
researchers will take the results to provide the adequate knowledge to the DM patients in the future.

Keywords: Exercise behavior, Knowledge of physical exercise, DM patients

J Med Assoc Thai 2010; 93 (5): 587-93
Full text. e-Journal: http://www.mat.or.th/journal

Diabetes mellitus is the most common prescription (frequency 3-4/week, duration 20-60
endocrine disorder. It is no exaggeration to describe minutes and intensity 50%-80% VO2R or heart rate
diabetes as one of the major contributors to ill health reserve). Exercise is effective in glucose control because
and premature mortality worldwide. The prevalence of it has an insulin-like effect that enhances the uptake of
diabetes worldwide, from the World Health Organization glucose even in the presence of insulin deficiency.
(WHO) studies in 2000, was 171 million. If the current Regular aerobic and resistance training combined with
trend continues, the number of people with diabetes is individualized diet therapy promote improved glucose
expected to more than double by 2030. In Thailand, the tolerance, increased insulin sensitivity, improved
prevalence of diabetes is 1,536,000, and it is 46,903,000 cardiovascular function, improved lipids profiles, blood
in South East Asia(1). pressure reduction, weight management, increased
The favorable effects of regular exercise have physical work capacity, and improved well-being(2-7).
been reported for type II diabetes mellitus(2-4). If the On the other hand, the diabetes type II
diabetes patients performed the exercise correctly, they patients who perform the exercise incorrectly, such as
will gain benefits of the exercise. The basic element of performing a too high intensity exercise, having
correct exercise includes a cardio-respiratory exercise poor glucose control before performing exercise, or
lacking knowledge of signs of hypoglycemia will
Correspondence to: Chadchavalpanichaya N, Department of
Rehabilitation Medicine, Faculty of Medicine Siriraj Hospital,
likely get complications from exercise, such as acute
Bangkoknoi, Bangkok 10700, Thailand. Phone: 0-2411-2408, hypoglycemia, retinal hemorrhage, ischemic heart
Fax: 0-2411-4813. E-mail: drnavaporn@gmail.com disease, or sudden death(8).

J Med Assoc Thai Vol. 93 No. 5 2010 587

Objective were trained. Inter-rater reliability was done among
The purposes of the present study were interviewers.
to explore the exercise behavior and knowledge of The project was approved by the Ethics
physical exercise among the diabetes type II patients Committee of the Faculty of Medicine Siriraj Hospital
in DM clinic of Siriraj Hospital, Bangkok. The factors and was supported by Siriraj Routine to Research
correlated with the exercise behavior and knowledge Management Fund.
of physical exercise, were also explored. Furthermore,
when there was a lack of knowledge or misunderstand- Statistical analysis
ing about exercise, the health care providers planned Statistical analysis was done with SPSS
the correct strategies to improve the diabetes patient’s version 13.0.
knowledge. The frequency of demographic data, practice
pattern of physical exercise, and knowledge of exercise
Material and Method were reported as percentage. The unpaired t-test was
The diabetes type II patients, aged more used to explore the difference of two quantitative data
than 18 years old, who attended the DM clinic, groups and the Chi-square test and Fisher’s exact test
Siriraj Hospital between April and August 2007 were were used to explore the relationships among qualitative
randomized by Systematic random sample from the data. One-way analysis of variance (ANOVA) was used
registration order at the 1st, 4th, 7th, 10th, 13th, 16th, and to compare the difference of three or more groups of
so on. quantitative data. The Bonferroni method test was used
The inclusion criteria were to include the to identify the specific differences when the ANOVA
diabetes type II patients who attended the DM clinic, revealed significance.
Siriraj Hospital. The exclusion criteria were those
diabetes patients who had a brain or spinal cord lesion Results
or who had cardiopulmonary disease, with functional One hundred and ninety six diabetes type II
class two or more. patients were interviewed. There were 62 males and
The sample size was determined by using 134 females with an average age of 60.5 years old. Most
the n Query Advisor 5.0 programTM. One hundred of them were married (64.3%) and had graduated from
and ninety six patients were required. The maximum primary school (44.4%). Most of the diabetes patients
error of 15% was expected from the “should-be-right” were unemployed (41.3%) and had more than six hours
answers concentration. Furthermore, a 5% acceptable per day free time (35.7%). Monthly income range was
error has been defined. Moreover, 0.05 significant less than 5,000 Baht. Sixty-nine percent of them had
level and 95% CI was 0.15 + 0.05 have also been co-morbid diseases that included hypertension,
marked out. hyperlipidemia, and heart disease (39.1%, 29.4%, and
The diabetes type II patients were interviewed 14.7%, respectively) (Table1).
by using questionnaires and asking the questions Regarding the practice pattern of exercise,
in person while each one was waiting to see their most of the diabetes type II patients practiced exercise
doctors, which took about 15 minutes. Then the regularly at least three times a week (65.8%). The
questionnaires were brought back and brochures duration of exercise was 30-60 minutes (33.7%) with
showing how to exercise correctly with diabetes were 58.2% who had practiced regular exercise for more than
provided to the patients. The questionnaire has been 1 year. They liked to exercise alone at home in the
designed with regard to the reference provided by morning and paid no additional expenses. The physical
American Diabetes Association, Clinical practice exercises done most often among the diabetes patients
recommendation, 1999 guideline(9). It was divided into were walking (67%), calisthenics exercise, jogging,
three major parts, demographic data, practice of exercise, attending aerobic exercise class, using an exercise
and knowledge of exercise. This questionnaire was not machine, and Ti Chi. Thirteen percent of the diabetes
used as a tool to evaluate the level of knowledge but to patients did not practice exercise. The major reason
discover the points that the patients misunderstood. was not feeling healthy enough (46%) (Table 2).
The results are expected to emphasize the points The frequency of practicing the physical
that the patients misunderstood, thus, used to exercise among these patients was related to co-morbid
improve the patient education program in the future. diseases, acquisition of knowledge, and preference of
The interviewers, who were doctors and nurses, exercise (Table 3).

588 J Med Assoc Thai Vol. 93 No. 5 2010

Table 1. Demographic data Table 2. Practice Pattern of Physical Exercise

Characteristics Number (percent) Practice pattern of physical exercise Number (percent)

Gender Frequency
Male 62 (31.6) Every days 62 (31.6)
Female 134 (68.4) 3-5 times per week 67 (34.2)
Age group (year) 1-2 times per week 31 (15.8)
18-29 5 (2.6) 1-2 times per month 5 (2.6)
30-39 8 (4.1) Less than 1 time per month 5 (2.6)
40-49 17 (8.7) No exercise 26 (13.3)
50-59 47 (23.9) Duration
> 60 119 (60.7) Less than 30 minutes 59 (30.1)
Marital status 30-60 minutes 66 (33.7)
Single 70 (35.7) More than 60 minutes 11 (5.6)
Married 126 (64.3) Uncertain 34 (17.3)
Educational levels Continuation of exercise
Primary school 87 (44.4) Less than 3 months 22 (11.2)
Secondary school 10 (5.1) 3-6 months 14 (7.1)
Tertiary school 21 (10.7) More than 6 months-1 year 19 (9.7)
Certification 25 (12.8) More than 1 year 114 (58.2)
Bachelor degree 43 (21.9) Time of the day
Master & PhD 10 (5.1) Morning 82 (41.8)
Occupation Late morning 8 (4.1)
Unemployed 81 (41.3) Afternoon 4 (2.0)
Students 1 (0.5) Evening 45 (23.0)
Government employees 43 (21.9) Before bedtime 2 (1.0)
Working in private companies 16 (8.2) Uncertain 29 (14.8)
Others 55 (28.1) Place
Monthly incomes (Baht) House 96 (49.0)
Less than 5,000 74 (37.8) Nearby the house 45 (23.0)
5,000-10,000 48 (24.5) Park 25 (12.8)
10,001-30.000 54 (27.6) Sport club 16 (8.2)
30,001-50,000 13 (6.6) Stadium 6 (3.1)
More than 50,000 7 (3.6) Uncertain 8 (4.1)
Co-morbid disease Companions
No 61 (31) None 106 (54.1)
Yes 135 (69) 1-2 21 (10.7)
Hypertension 77 (39.1) 3-5 15 (7.7)
Hyperlipidemia 58 (29.4) More than 5 28 (14.3)
Heart diseases 29 (14.7) Expenses
Musculoskeletal problems 26 (13.2) Yes 51 (26.0)
Asthma/pulmonary problems 3 (1.5) No 145 (74.0)
Others 39 (19.8) Type of exercise
Free time (hours per day) Walking 132 (67.3)
None 10 (5.1) Calisthenic exercise 36 (18.4)
<1 3 (1.5) Jogging 25 (12.8)
1-2 38 (19.4) Attending aerobic exercise class 20 (10.2)
3-4 43 (21.9) Using exercise machine 18 (9.2)
5-6 32 (16.3) Tai Chi 9 (4.6)
>6 70 (35.7) Others 41 (20.9)
Self-pulse monitoring
No 139 (70.9)
Yes-some times 24 (12.2)
The mean VAS score of the prevalence of
Yes-every times 7 (3.6)
exercise and the perceived benefits of exercise were
7.49 and 8.42 respectively.


Table 2. (Cont.) Table 4. Knowledge of exercise and numbers of the DM
patients with correct responses
Practice pattern of physical exercise Number (percent)

Reason for no exercise (26) Items Number (percent)
Feel Unhealthy 12 (46.2)
Lack of time 10 (38.5) Part 1.
Benefits of exercise
No Motivation 5 (19.2)
Increase endorphin release 120 (61.2)
No Joy 5 (19.2)
Prevent osteoporosis 131 (66.8)
No Companions 2 (7.7)
Enhance lipid control 147 (75.0)
Others 12 (46.2)
Enhance BP control 149 (76.0)
Enhance DM control 168 (85.7)
Improve GI function 168 (85.7)
Table 3. Factors related to high frequency of exercise Strengthen muscles 180 (91.8)
Reduce stress 183 (93.4)
Factors p-value Increase cardiopulmonary fitness 187 (95.4)
Part 2.
Gender 0.29 How to do aerobic exercise
Age 0.35 Proper frequency of exercise 99 (50.5)
Proper intensity of exercise 118 (60.2)
Occupation 0.14
Proper duration of exercise 125 (63.8)
Education 0.30
Need to cool down 195 (99.5)
Monthly income 0.39
Need to warm up 196 (100)
Co-morbid diseases 0.03*
Part 3.
Free time 0.76
How to do exercise in the DM patient
Acquisition of knowledge 0.04*
Should consult their doctors 96 (49.0)
Perceived benefits 0.91 for proper program
Preference of exercise 0.001* Should stop exercise when 119 (60.7)
getting a cold
* Significant at p-value < 0.05 Should not do heavy exercise alone 125 (63.8)
Should practice aerobic exercise 139 (70.9)
Should wear proper shoe 170 (86.7)
Should have regular exercise at 170 (86.7)
Regarding the knowledge of exercise, there least 3 times/week
were four parts of knowledge of exercise being explored. Should stop exercise when 171 (87.2)
The first part was the benefits of exercise. There were having abnormal symptom
minimum responses concerning the fact that exercising Part 4.
can increase endorphin release. The second part Hypoglycemic symptoms
was how to do aerobic exercise. There were minimum Dizziness 32 (16.3)
responses stating that the proper frequency of Hungry 110 (56.1)
Sweating 130 (66.3)
exercise should be 3-5 times per week. The statistically Syncope 140 (71.4)
significant factors related to both parts of the knowledge Tachycardia 149 (76.0)
were the perception of exercise benefit and the Symptom for terminating exercise
preference for an exercise type. The third part was how Severe leg pain 138 (70.4)
the diabetes type II patients should exercise properly. Dysnea 139 (70.9)
There were minimum responses stating that patients Nausea & vomiting 143 (73.0)
should consult their doctors for proper exercise Dizziness 161 (82.1)
Loss of balance 163 (83.2)
programs before first beginning to exercise. The factor Chest discomfort 169 (86.2)
related to this part of knowledge was the perception of The acquisition of knowledge
exercise benefits. The fourth part was the knowledge Never 13 (6.6)
about abnormal symptoms. There were minimum Health care provider 114 (58.2)
responses that dizziness was a hypoglycemic symptom Mass media 113 (57.7)
and that a severe leg pain symptom signaled the need Reading 75 (38.3)
to terminate the exercise. There was no statistically Attending the course 48 (24.5)
others 13 (6.6)
significant factor related to the fourth part. The diabetes


Table 5. Factors related to the level of knowledge of exercise

Factors p-value

Benefits of How to do How to do Hypoglycemic When to
exercise aerobic exercise exercise in the symptoms stop exercise
DM patient

Acquisition of knowledge (yes-no) 0.8 0.12 0.71 0.41 0.85
Perceived benefits of exercise (VAS >7-<7) 0.009* <0.001* 0.021* 0.39 0.65
Preference of exercise (VAS >7- <7) 0.005* 0.03* 0.09 0.71 0.18
Frequency of exercise (<3->3 times/week) 0.98 0.75 0.21 0.40 0.17

* Significant at p-value < 0.05

type II patients acquired their exercise knowledge from get helpful recommendations from the health care
a health care provider (58.2%) rather than from other providers.
channels. There was no statistical difference between Nonetheless, there were 13.3% of the diabetes
the level of knowledge and the method of acquisition type II patients who did not exercise. The major reason
of knowledge (Tables 4, 5). given was not feeling healthy enough. Many studies
reported that many older people did not participate in
Discussion leisure time physical activities(12-14). Undoubtedly, they
Because the present study selected the basically understood the benefits of exercise but they
diabetes type II patients by systematic randomization, were worried about their health. In the present study,
the authors should assume that it could represent the the high frequency of physical exercise among these
average diabetes type II patients that attended the DM patients was related to co-morbid diseases, the
clinic at Siriraj Hospital. Moreover, the data was acquisition of knowledge, and preference of exercise.
collected by personal interview. No directed questions Three items can help the diabetes type II patients
were used during the interview. exercise with more confidence and regularity. Firstly,
According to the guidelines of American clear advices from their doctors about their physical
College of Sport Medicine (ACSM)(10) and American abilities. Secondly, advice from their doctors about the
Diabetes Association(9), aerobic exercise, or the exercise proper practice pattern of exercise, suitable for their
that the type II diabetes can gain the most benefit conditions. Lastly, recommendation from their doctor
from, was an exercise performed for at least 30 minutes about the types of exercise that could easily be
per day and 3 to 5 days per week. From the present practiced at no additional expenses, such as walking
study, the number of the type II diabetes who exercised and bicycling, or the types of exercise that the patients
at least 30 minutes per session were reported at 65.8%. could enjoy such as Thai Traditional Folk Dances or
The percentage of the type II diabetes patients Tai Chi.
exercising is greater than the percentage of the Bangkok In the present study, the frequency of
resident exercising(11)(57.8%). The practice patterns of performing exercise and the acquisition of knowledge
exercise showed that they liked to exercise by walking in exercise were not factors related to the level of
at home, in the morning, and paid no additional exercising knowledge. Most of the diabetes type II
expenses. This was similar to the inhabitants of patients practiced exercise regularly at least three times
Bangkok. The possible reasons that the number of the a week (65.8%). Moreover, most of them reported that
type II diabetes who exercised regularly more than the they have already acquired the exercise knowledge
number of the inhabitants of Bangkok were three folds. (93.4%). Furthermore, most of the patients knew
Firstly, most of the diabetics were old. Secondly, most that they should have stopped doing exercise when
of them were unemployed and had more than six hours abnormal symptoms occurred (87.2%). Additionally,
of free time per day to exercise. Lastly, most of the more than 70% of patients knew that syncope and
diabetes type II patients received continuous treatment tachycardia were symptoms of hypoglycemia, one of
in the hospital, so they had numerous chances to the serious complications from doing exercise in the


DM patients. However, only half of them (56%) consult their doctors before starting an exercise
knew that hunger could have been a symptom of program (49%).
hypoglycemia. Yet, only 16% realized that dizziness The researchers will take these results and
could have been a warning symptom of hypoglycemia. provide the correct knowledge to the diabetes type II
The present study revealed that although the patients by emphasizing the items that are the least
patients exercised regularly, they might have done it known and the warning symptoms of exercise
improperly. Furthermore, it showed that the health care complications in the future.
providers, such as doctors and nurses, should be
aware of when they recommend their patients to Acknowledgements
practice exercise. They should advise them more The authors thank the Assistant Professor
clearly and emphasize the critical parts, such as the Cherdchai Nopmaneejumruslers MD, Mr. Sutthipol
hypoglycemic symptoms and the symptoms that the Udompunturak, and the Staff of the DM clinic, Siriraj
patients should promptly terminate the exercise as well. Hospital for their assistance in completing this study.
According to the present study, although
the diabetes type II patients acquire the exercise References
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other channels (58.2%), nearly half of them did not Internet]. Diabetes programme: Facts & Figures:
acquired that knowledge from doctors and nurses. This prevalence of diabetes: number of persons with
data reflected the information that the health care diagnosed diabetes, Worldwide, WHO region of
providers may have missed some patients or they the Americas, WHO South-East Asia region, year
had insufficient time for their patients. Due to a huge 2000. 2007 [cited 2007 Sep 2]. Available from: http://
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to serve each day, they may not have been able to 2. Albright A, Franz M, Hornsby G, Kriska A,
provide each patient enough time. The data from the Marrero D, Ullrich I, et al. American College of
present study can help them so that they can give the Sports Medicine position stand. Exercise and type
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CDs, or other media. In addition, they should emphasize 3. American College of Sports Medicine and
only the items of exercise knowledge that is the least American Diabetes Association joint position
known in each part of knowledge. For the benefit of statement. Diabetes mellitus and exercise. Med
exercise, patients are not aware that exercise can Sci Sports Exerc 1997; 29: i-vi.
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their doctors for proper exercise programs before of physical training on glucose tolerance and
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should not only include the benefits and the ways to 1979; 28 (Suppl 1): 89-92.
practice exercise, but also the symptoms of exercise 6. Paternostro-Bayles M, Wing RR, Robertson RJ.
complication that the diabetes type II patients may Effect of life-style activity of varying duration
experience. on glycemic control in type II diabetic women.
Diabetes Care 1989; 12: 34-7.
Conclusion 7. Kaplan RM, Hartwell SL, Wilson DK, Wallace JP.
Most of the diabetes type II patients practiced Effects of diet and exercise interventions on
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by walking (67%), and in-house exercise (48.7%) and dependent diabetes mellitus. J Gen Intern Med
most of them practiced exercise in the morning (41.8%). 1987; 2: 220-8.
The knowledge about exercise was provided from a 8. Ruderman N, Devlin JT, SchneiderSH. Diabetes
health care provider (58.2%). The benefit of exercise and exercise: the risk-benefit profile revisited
known the least was that exercise could increase and the exercise prescription. In: Ruderman NB,
endorphin release (61.2%). The exercise principle in Devlin JT, Schneider SH, Kriska A, editors.
DM known the least was that the DM patients should Handbook of exercise in diabetes. 2 nd ed.


Alexandria, VA: American Diabetes Association; 12. Dallosso HM, Morgan K, Bassey EJ, Ebrahim SB,
2002: 4-17, 269-88. Fentem PH, Arie TH. Levels of customary physical
9. American Diabetes Association: clinical practice activity among the old and the very old living
recommendations 1999. Diabetes Care 1999; 22 at home. J Epidemiol Community Health 1988; 42:
(Suppl 1): S49-53. 121-7.
10. American College of Sports Medicine. Other clinical 13. Yusuf HR, Croft JB, Giles WH, Anda RF, Casper
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พฤติกรรมและความรูเกียวกับการออกกำลังกายของผูเป็นเบาหวาน
้ ่ ้

นวพร ชัชวาลพาณิชย์, นวลพิศ อินทรเทพ

วัตถุประสงค์: เพือศึกษาพฤติกรรม และความรูเกียวกับการออกกำลังกายของผูเป็นเบาหวานรวมทังปัจจัยทีเกียวข้อง
่ ้ ่ ้ ้ ่ ่
วัสดุและวิธีการ: สุ่มสัมภาษณ์โดยใช้แบบสอบถามสำรวจพฤติกรรม และความรู้เรื่องการออกกำลังกายในผู้เป็น
เบาหวานชนิดที่ 2 ทีมีอายุตงแต่ 18 ปีข้นไป และมารับบริการทีคลินกเบาหวาน โรงพยาบาลศิรราช ตังแต่เดือน เมษายน
่ ้ั ึ ่ ิ ิ ้
ถึง สิงหาคม พ.ศ. 2550 ระหว่างรอพบแพทย์ที่คลินิกเบาหวาน โรงพยาบาลศิริราช
ผลการศึกษา: ผูเข้าร่วมศึกษาจำนวน 196 คน เป็นชาย 62 คน หญิง 134 คน อายุเฉลีย 60.5 ปี พบว่า ส่วนใหญ่
้ ่
ออกกำลังกายสม่ำเสมออย่างน้อย 3 ครัง ต่อสัปดาห์ (ร้อยละ 65.8) ผูเป็นเบาหวานนิยมออกกำลังกาย ด้วยการเดิน
้ ้
(ร้อยละ 67) สถานที่ที่นิยมออกกำลังกายคือในบ้าน(ร้อยละ 48.7) และช่วงเวลาที่ชอบมากที่สุดคือหลังตื่นนอนใน
ช่วงเช้า (ร้อยละ 41.8) ผู้เป็นเบาหวานส่วนใหญ่ได้รับความรู้เรื่องการออกกำลังกายจากบุคลากรทางการแพทย์
(ร้อยละ 58.2) ประโยชน์ของการออกกำลังกายที่ผู้เป็นเบาหวานทราบน้อยที่สุด คือ การออกกำลังกายทำให้
สารความสุขหลั่งเพิ่มขึ้น (ร้อยละ 61.2) หลักการออกกำลังกายแบบแอโรบิกที่ผู้เข้าร่วมศึกษาทราบน้อยที่สุด คือ
ความถีทเหมาะสมในการออกกำลังกาย (ร้อยละ 50.5) และหลักการออกกำลังกายในผู้เป็นเบาหวานทีผ้เข้าร่วมศึกษา
่ ่ี ่ ู
ทราบน้อยที่สุด คือควรปรึกษาแพทย์ก่อนเริ่มออกกำลังกาย (ร้อยละ 49)
สรุป: ผู้เป็นเบาหวานส่วนใหญ่มีการออกกำลังกายอย่างสม่ำเสมอ แต่ยังมีข้อที่ไม่รู้เกี่ยวกับการออกกำลังกาย
อย่างถูกวิธี ซึ่งทางผู้นิพนธ์จะนำข้อมูลที่ได้มาสอนเน้นย้ำข้อที่ผู้เป็นเบาหวานยังไม่ทราบต่อไป


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