Abstract

Background

To examine whether youth use calorie information when it is available at fast food/chain restaurants and what factors are associated with using this information to make their food selection.

Methods

A cross-sectional analysis was conducted on a sample of 721 youth (9–18 years) using the 2010 YouthStyles and HealthStyles surveys. The outcome measure was reported use of calorie information at fast food/chain restaurants. Multivariable logistic regression was used to examine the associations between sociodemographic variables and the use of calorie information at fast food/chain restaurants.

Results

Of those who visited fast food/chain restaurants, 42.4% reported using calorie information at least sometimes. Girls were more likely than boys (adjusted odds ratio (aOR) = 1.8, 95% confidence interval (CI) = 1.2–2.5) and youth who were obese were more likely than those at a healthy weight (aOR = 1.7, 95% CI = 1.04–2.9) to use calorie information, and youth eating at a fast food/chain restaurant twice a week or more versus once a week or less were half as likely to report using calorie information (aOR = 0.5, 95% CI = 0.4–0.8).

Conclusion

Public health education efforts can benefit from research to determine how to increase usage among youth so that their food choices are appropriate for their caloric needs.

Introduction

The prevalence of childhood obesity has tripled in recent decades.1 Although the causes are multi-factorial, one potential contributor is consuming foods prepared away from home, such as those obtained from a fast food/chain restaurant. These foods are generally higher in calories, salt and fats than home-cooked meals.2–4 In addition, fast food is a major contributor to caloric consumption among youth.5,6 Fast food consumption is also associated with increases in body weight among adults.7

Initiatives that modify the food environment, such as requiring restaurants to label menus with calorie and other nutritional information, allows consumers to make informed choices at point of purchase.8 Policies requiring restaurants to post calorie and other nutritional information have been passed in some jurisdictions around the USA.9 Further, federal law requires restaurants with at least 20 locations nationally to list calorie information next to menu items on menus or menu boards.10 The law also requires restaurants subject to this law to place a prominent, succinct statement concerning suggested daily caloric intake on the menu.10 At the time of this research, national menu labeling has not been implemented, but some fast food/chain restaurants have begun to post this information voluntarily.11

Some cities and states have begun to evaluate the effect of their menu labeling policies.12–15 Elbel et al.1,6 examined New York City's (NYC) calorie labeling regulation among youth and found that 57% reported noticing calorie labels after labeling went into effect and 9% considered the information when ordering. More research has been conducted among adults. For example, Dumanovsky et al.17 examined whether adults at fast food/chain restaurants had seen calorie information and, if so, whether it had affected their purchase, before and after NYC's calorie labeling regulation. They found that the percentage who reported seeing calorie information increased from 25% before implementation to 64% after implementation. Further, among customers who saw calorie information post-enforcement, 27% said they used the information.17 In a separate study, Dumanovsky et al.12 conducted cross-sectional surveys before and 9 months after the enforcement of NYC's regulation to determine the caloric content purchased among adults who said that they used the calorie information. After enforcement, 15% of customers who reported using calorie information purchased 106 fewer calories than customers who did not see or use the calorie information. In King County, WA, total transactions and average calories per transaction were compared between fast food restaurants of the same chain located in King County and control locations of the same chain located in nearby counties not subject to the regulation. No differences were found in the number of calories purchased following implementation between control and intervention locations.13

To our knowledge, there are no studies examining the prevalence of using calorie information using a large, diverse sample of youth. The purpose of our research was to examine the proportion of youth who reported using calorie information when available at fast food/chain restaurants, and to determine whether this proportion differs by gender, age, weekly frequency of eating at a fast food/chain restaurant, parents' race/ethnicity, marital status, household income and region of the country.

Methods

Data source

Data from the HealthStyles and YouthStyles surveys, both conducted in the Fall 2010, were used for this cross-sectional study. HealthStyles and YouthStyles are mail surveys administered annually as follow-up surveys to ConsumerStyles, a consumer mail panel survey. ConsumerStyles participants are sampled from a consumer mail panel of ∼200 000 potential respondents using a sampling design stratified by region, household income, population density, age and household size, and includes an oversample of low-income/minority participants and households-with-children to ensure adequate representation of these groups.18 Respondents receive a small monetary incentive. The response rate for the 2010 ConsumerStyles Survey was 51.6%.

HealthStyles and YouthStyles are sent to mail panel households that return ConsumerStyles. HealthStyles is sent to US adults (≥18 years) and is designed to assess health-related attitudes, knowledge and behaviors. YouthStyles is sent to US youth (9–18 years) who had a parent or guardian who completes and returns ConsumerStyles, and assesses a variety of issues including but not limited to health-related knowledge and behaviors. YouthStyles data were weighted by gender and age of child, household size, household income, head of household age and race/ethnicity of adult in the study. The response rates for 2010 HealthStyles and YouthStyles were 66.9% (4184/6255) and 49.9% (1197/2401), respectively.18 Our study population was US youth (aged 9–18 years) who go to fast food/chain restaurants.

Outcome variable

The outcome variable for this study was youths' use of calorie information to make ordering decisions. This variable was determined using the question from YouthStyles, ‘When calorie information is available at a fast food/chain restaurant, how often does this information help you decide what to order?’ Response options included always, most of the time, sometimes, never, I have never noticed calorie information and I do not eat at fast food/chain restaurants. Responses were collapsed into the following categories: Yes (always, most of the time or sometimes), No (never), I have never noticed calorie information and I do not eat at fast food/chain restaurants. For multivariable logistic regression, we only included those in the categories of Yes and No.

Explanatory variables

Explanatory variables included youth-reported variables from YouthStyles and parent-reported variables from HealthStyles. The youth-reported variables included gender, age (9–11, 12–14, 15–16 and 17–18 years) and frequency of eating at a fast food/chain restaurant per week. Response options for the fast food/chain restaurant frequency question were never, once a week or less, two to three times/week, four to six times/week, every day and more than once per day; we excluded those responding never. The parent-reported variables included race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic and non-Hispanic other), marital status (married/domestic partnership and not married, which included widowed, divorced and single persons), household income (<$25 000, $25 000–<$40 000, $40 000–<$60 000 and ≥$60 000) and region of the country (New England, Middle Atlantic, East North Central, West North Central, South Atlantic, East South Central, West South Central, Mountain and Pacific). Lastly, we used the youth-reported variables of height and weight to calculate body mass index (BMI = weight/height2 (kg/m2)]. Underweight was defined as a sex- and age-specific BMI-for-age percentile of less than 5th, normal weight was 5–<85th, overweight was 85–<95th and obesity was ≥95th; these categories were based on the 2000 Centers for Disease Control and Prevention (CDC) growth charts.19

Selection of several of the explanatory variables were based on previous findings among adults for use of calorie information when provided on menu labeling or on the Nutrition Facts Panel. For example, women are more likely to read calorie information compared with men,12 obese adults (BMI ≥ 30) are more likely to read nutrition labels compared with normal weight adults (BMI between 18.0 and 24.9),20 adults in wealthier neighborhoods are more likely to report using calorie information than those in poorer neighborhoods12 and those who go to fast food restaurants are less likely to use calorie information compared with those who do not go to fast food restaurants.21

Sample

The parent-reported variables from HealthStyles were linked to YouthStyles data using a unique household identifier. Data were weighted on gender and age of child, household size, household income, head of household age and race/ethnicity of adult in this study. The data set included 1197 youth respondents with matched parental reported data. We excluded 13 respondents who were 19 years old because YouthStyles is designed for 9–18 year olds. Further, we excluded 97 respondents who replied that they never eat at fast food/chain restaurants and 207 respondents who replied they have never noticed calorie information (1197-13-97 = 1087; 207/1087 = 19% of 9–18 year olds who eat at fast food/chain restaurants have never noticed calorie information). A descriptive analysis of these 207 found that it comprised 61% boys, 42% 9–11 year olds, 70% non-Hispanic White and 46% were living in households with annual incomes of ≥$60 000. Further, we excluded 30 youth for a biologically implausible BMI value and respondents with missing data; 24 respondents lacked data for the frequency of eating at a fast food/chain restaurant, 10 respondents lacked data on the use of calorie information and 95 lacked height or weight data. The final analytic sample was 721.

Statistical analysis

We used bivariate logistic regression to estimate unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each explanatory variable. Multivariable logistic regression was used to estimate adjusted OR and 95% CIs for use of calorie information among youth who ate at fast food restaurants and noticed the information while ordering. Chi-square analysis examined whether those included in the regression analysis were different in their use of calorie information from those excluded from the analysis due to missing data or biologically implausible BMI data. We restricted this assessment to those who reported eating at fast food/chain restaurants and conducted this analysis for each explanatory variable that had missing data and did not find significant differences among youth included or excluded. In addition, a multivariable logistic regression sensitivity analysis was performed without BMI due to the large number of youth lacking this information. All statistical analyses were performed using Statistical Analysis Software,22 version 9.3. This analysis was exempt from the CDC Institutional Review Board process because personal identifiers were not included in the data provided to the CDC.

Results

Descriptive results are shown in Table 1. Our final sample had a higher proportion of boys (56.4%) and a higher proportion of respondents were in the 12–14-year-old age group (32.2%) than in the other age groups. Most youth were of a healthy weight (65.8%), while 13.3% were obese. Most parents/caregivers reported their race/ethnicity as non-Hispanic white (66.3%). Slightly over half had a parent-reported household income of ≥$60 000 (55.8%). The highest proportion of respondents were from the South Atlantic (20.0%), East North Central (17.6%) and Middle Atlantic (15.8%) regions.

Table 1

Demographics, prevalence of use of calorie labeling information, and unadjusted ORs and aORs for use of calorie labeling information while ordering at fast food or chain restaurants, YouthStyles and HealthStyles 2010

 Number (%) Number using calorie information (%) Unadjusted OR (95% CI) P value aOR (95% CI) P value 
Child demographics 
 Gender 
  Boys 404 (56.4) 153 (36.6) Reference  Reference  
  Girls 317 (43.6) 163 (49.9) 1.7 (1.2–2.5)a 0.002 1.8 (1.2–2.5)a 0.002 
 Age (years) 
  9–11 151 (23.6) 65 (43.3) Reference  Reference  
  12–14 220 (32.2) 96 (40.8) 0.9 (0.6–1.4) 0.61 1.0 (0.6–1.7) 0.97 
  15–16 178 (21.6) 85 (45.2) 1.1 (0.7–1.7) 0.47 1.2 (0.7–2.0) 0.48 
  17–18 172 (22.7) 70 (41.1) 0.9 (0.5–1.6) 0.74 1.1 (0.6–1.9) 0.77 
 Weight status 
  Underweight 38 (5.4) 14 (40.6) 1.0 (0.4–2.3) 0.64 1.1 (0.5–2.5) 0.87 
  Healthy weight 462 (65.8) 193 (40.2) Reference  Reference  
  Overweight 115 (15.6) 52 (45.2) 1.2 (0.8–2.0) 0.82 1.3 (0.8–2.1) 0.29 
  Obese 106 (13.3) 57 (50.6) 1.5 (0.9–2.5) 0.20 1.7 (1.04–2.9)a 0.04 
Parental demographics 
 Parent/caregiver race/ethnicity 
  Non-Hispanic White 486 (66.3) 207 (41.6) Reference  Reference  
  Non-Hispanic Black 76 (12.1) 32 (40.2) 0.9 (0.5–1.8) 0.44 1.1 (0.6–2.1) 0.80 
  Hispanic 103 (16.9) 45 (43.6) 1.1 (0.7–1.8) 0.76 1.1 (0.6–1.8) 0.81 
  Other 56 (4.7) 32 (55.2) 1.7 (0.9–3.2) 0.10 1.6 (0.3–1.1) 0.14 
 Marital status 
  Married or domestic partnership 615 (82.1) 261 (40.5) Reference  Reference  
  Not married 106 (17.9) 55 (51.0) 1.5 (0.8–2.8) 0.17 1.6 (0.9–2.9) 0.10 
 Annual household income 
  <$25 000 94 (12.2) 48 (48.2) 1.5 (0.8–2.5) 0.41 1.2 (0.6–2.3) 0.65 
  $25 000–<$40 000 70 (12.6) 30 (36.2) 0.9 (0.5–1.6) 0.19 0.8(0.4–1.4) 0.42 
  $40 000–<$60 000 119 (19.5) 58 (52.3) 1.7 (1.0–2.8) 0.09 1.7 (1.04–2.7)a 0.04 
  ≥$60 000 438 (55.8) 180 (39.1) Reference  Reference  
 Region of country 
  West South Central 72 (9.6) 28 (34.3) Reference  Reference  
  East North Central 131 (17.6) 54 (39.5) 1.3 (0.7–2.4) 0.88 1.3 (0.7–2.7) 0.41 
  East South Central 50 (6.7) 21 (41.4) 1.4 (0.6–3.2) 0.88 1.3 (0.6–3.2) 0.51 
  Middle Atlantic 117 (15.8) 57 (50.0) 1.9 (0.9–4.0) 0.11 1.7 (0.9–3.4) 0.13 
  Mountain 30 (4.2) 11 (39.5) 1.2 (0.5–3.2) 0.93 1.3 (0.5–3.5) 0.66 
  New England 26 (3.5) 7 (29.0) 0.8 (0.3–2.4) 0.27 0.8 (0.3–2.6) 0.77 
  Pacific 93 (13.0) 49 (49.7) 1.9 (0.9–3.9) 0.10 1.9 (0.9–4.1) 0.11 
  South Atlantic 145 (20.0) 67 (44.7) 1.5 (0.8–2.9) 0.35 1.5 (0.8–3.0) 0.23 
  West North Central 57 (9.6) 22 (35.4) 1.1 (0.4–2.5) 0.54 1.1 (0.5–2.5) 0.81 
Child behavior 
 Frequency of eating at a fast food or chain restaurant per week 
  Once a week or less 477 (65.6) 229 (47.3) Reference  Reference  
  2 times per week or more 244 (34.4) 87 (33.0) 0.5 (0.4–0.8)a 0.002 0.5 (0.4–0.8)a 0.001 
  Total 721 (100.0) 316 (42.4) 721  721  
 Number (%) Number using calorie information (%) Unadjusted OR (95% CI) P value aOR (95% CI) P value 
Child demographics 
 Gender 
  Boys 404 (56.4) 153 (36.6) Reference  Reference  
  Girls 317 (43.6) 163 (49.9) 1.7 (1.2–2.5)a 0.002 1.8 (1.2–2.5)a 0.002 
 Age (years) 
  9–11 151 (23.6) 65 (43.3) Reference  Reference  
  12–14 220 (32.2) 96 (40.8) 0.9 (0.6–1.4) 0.61 1.0 (0.6–1.7) 0.97 
  15–16 178 (21.6) 85 (45.2) 1.1 (0.7–1.7) 0.47 1.2 (0.7–2.0) 0.48 
  17–18 172 (22.7) 70 (41.1) 0.9 (0.5–1.6) 0.74 1.1 (0.6–1.9) 0.77 
 Weight status 
  Underweight 38 (5.4) 14 (40.6) 1.0 (0.4–2.3) 0.64 1.1 (0.5–2.5) 0.87 
  Healthy weight 462 (65.8) 193 (40.2) Reference  Reference  
  Overweight 115 (15.6) 52 (45.2) 1.2 (0.8–2.0) 0.82 1.3 (0.8–2.1) 0.29 
  Obese 106 (13.3) 57 (50.6) 1.5 (0.9–2.5) 0.20 1.7 (1.04–2.9)a 0.04 
Parental demographics 
 Parent/caregiver race/ethnicity 
  Non-Hispanic White 486 (66.3) 207 (41.6) Reference  Reference  
  Non-Hispanic Black 76 (12.1) 32 (40.2) 0.9 (0.5–1.8) 0.44 1.1 (0.6–2.1) 0.80 
  Hispanic 103 (16.9) 45 (43.6) 1.1 (0.7–1.8) 0.76 1.1 (0.6–1.8) 0.81 
  Other 56 (4.7) 32 (55.2) 1.7 (0.9–3.2) 0.10 1.6 (0.3–1.1) 0.14 
 Marital status 
  Married or domestic partnership 615 (82.1) 261 (40.5) Reference  Reference  
  Not married 106 (17.9) 55 (51.0) 1.5 (0.8–2.8) 0.17 1.6 (0.9–2.9) 0.10 
 Annual household income 
  <$25 000 94 (12.2) 48 (48.2) 1.5 (0.8–2.5) 0.41 1.2 (0.6–2.3) 0.65 
  $25 000–<$40 000 70 (12.6) 30 (36.2) 0.9 (0.5–1.6) 0.19 0.8(0.4–1.4) 0.42 
  $40 000–<$60 000 119 (19.5) 58 (52.3) 1.7 (1.0–2.8) 0.09 1.7 (1.04–2.7)a 0.04 
  ≥$60 000 438 (55.8) 180 (39.1) Reference  Reference  
 Region of country 
  West South Central 72 (9.6) 28 (34.3) Reference  Reference  
  East North Central 131 (17.6) 54 (39.5) 1.3 (0.7–2.4) 0.88 1.3 (0.7–2.7) 0.41 
  East South Central 50 (6.7) 21 (41.4) 1.4 (0.6–3.2) 0.88 1.3 (0.6–3.2) 0.51 
  Middle Atlantic 117 (15.8) 57 (50.0) 1.9 (0.9–4.0) 0.11 1.7 (0.9–3.4) 0.13 
  Mountain 30 (4.2) 11 (39.5) 1.2 (0.5–3.2) 0.93 1.3 (0.5–3.5) 0.66 
  New England 26 (3.5) 7 (29.0) 0.8 (0.3–2.4) 0.27 0.8 (0.3–2.6) 0.77 
  Pacific 93 (13.0) 49 (49.7) 1.9 (0.9–3.9) 0.10 1.9 (0.9–4.1) 0.11 
  South Atlantic 145 (20.0) 67 (44.7) 1.5 (0.8–2.9) 0.35 1.5 (0.8–3.0) 0.23 
  West North Central 57 (9.6) 22 (35.4) 1.1 (0.4–2.5) 0.54 1.1 (0.5–2.5) 0.81 
Child behavior 
 Frequency of eating at a fast food or chain restaurant per week 
  Once a week or less 477 (65.6) 229 (47.3) Reference  Reference  
  2 times per week or more 244 (34.4) 87 (33.0) 0.5 (0.4–0.8)a 0.002 0.5 (0.4–0.8)a 0.001 
  Total 721 (100.0) 316 (42.4) 721  721  

a95% CI does not include 1.0.

Of those who reported eating at fast food/chain restaurants, 65.6% reported going ≤1 week and 34.4% reported ≥2 times per week. When asked about using calorie information when it is available among those who reported seeing it, 42.4% of youth reported using calorie information when it was available always, most of the time or sometimes and 57.6% report never using it.

Multivariable logistic regression found that among those who ate at fast food/chain restaurants, girls were 80% more likely to report using calorie information than boys (aOR = 1.8, 95% CI = 1.2–2.5), obese youth were ∼70% more likely to report using calorie information compared with healthy weight youth (aOR = 1.7, 95% CI = 1.04–2.9), youth living with an annual household income of $40 000–$60 000 versus ≥$60 000 were 70% more likely to report using calorie information (aOR = 1.7, 95% CI = 1.04–2.7) and youth who ate at a fast food/chain restaurant twice a week or more were 50% less likely to report using calorie information compared with those who ate at these types of restaurants once a week or less (aOR = 0.5, 95% CI = 0.4–0.8). Our sensitivity analysis without weight status had similar results.

Discussion

Main findings of this study

Our estimate that 40% of youth who noticed calorie labeling information within a fast food/chain restaurant reported using calorie information is promising. Girls were more likely than boys to use calorie information, and obese youth were more likely to use calorie information than those at a healthy weight. And, those who eat at fast food/chain restaurant two or more times per week were less likely to use calorie information compared with those who frequent fast food/chain resturants less than twice a week.

What is already known on this topic

Girls in our study were more likely to report using calorie information than boys. We were unable to find other studies of youth with which to compare our findings. However, a study among adults conducted by Dumanovsky et al.12 found that women were more likely than men to report using calorie information. These findings are consistent with other studies examining use of Nutrition Facts Panels, where women tend to use this information more than men.20,23,24 A study of how young adults use nutrition facts panel information examined whether college students noticed and used nutrition information in college dining areas when making their food choices and found that girls sought foods to promote weight loss by selecting menu items with lower calories and fat.25

Our findings for weight status among youth are consistent with Satia et al.20 findings among adults. They found that normal weight adults were less likely to report reading nutrition labels than obese adults. Perhaps obese adolescents are more likely to use calorie information than normal weight adolescents, which can help inform development of public health interventions.

The association between more frequent use of calorie information when available and less frequent use of fast food/chain restaurants is notable. One study among adults reported that those noticing and using calorie labels consumed fast food less frequently compared with adults who did not notice the labels (4.9 versus 6.6 meals per week).21 Calorie labeling may inform those who typically avoid fast food/chain restaurants over concern that they cannot eat within their calorie limits, by identifying menu items lower in calories. In contrast, it is also possible those who frequent fast food/chain restaurants already know what is on the menu and know what they will order, thus they do not look at the menu or accompanying nutrition information while ordering.

We did not find significant associations by age, race/ethnicity, parents' marital status or region. Regarding age, our findings do not support that older adolescents use calorie information more frequently than younger children, as we hypothesized. This may be due to taste preferences, which Elbel et al.16 showed was the most important factor in meal selection among adolescents. We likely did not find that younger children used calorie information because parents may have ordered for them. This may not be surprising because although it has been shown that parents report greater nutrition information awareness after menu-labeling regulation has gone into effect, it has not been shown to translate to a decrease in calories purchased for children.15 Our lack of any significant associations for race/ethnicity is consistent with prior research that found no differences between race or ethnicity among adults when using the Nutrition Facts Panel.23 Finally, our lack of associations for region may be due to our sample from the Middle Atlantic states (which includes NYC) having too few youth from NYC or due to a number of voluntary labeling efforts across the nation.

For youth to notice calorie information, it may need to be highlighted on menu boards or menus, or be presented in a manner in which youth can relate. We found 19% (207 of the 1087) of youth did not report seeing calorie information. While we cannot determine what proportion of this 19% patronized restuarants that had calorie information available, this finding may indicate that establishments need to place their information in a consumer-friendly format. For example, one study found that when presented calorie information for calorically sweetened beverages, participants who were given a simple interpretation for amount of physical activity (in minutes of running) needed to burn off the number of calories had a reduced odds of purchasing calorically sweetened beverages compared with participants who were only provided with absolute caloric information or the percent daily value.26

What this study adds

Our finding that ∼40% of youth who ate at fast food/chain restaurants and noticed the information reported using calorie information when it was available to select menu items has not been reported from a nationally based survey to the best of our knowledge. This study adds to what is already known on significant associations regarding demographic and behavioral characteristics (i.e. gender, weight status and frequency of fast food consumption) with use of calorie information that is important for targeting public health education programs. These findings may provide important data for comparison when evaluating calorie labeling in fast food/chain restaurants once the requirement for calorie labeling in fast food/chain restaurants takes effect nationally.

Limitations of this study

This study used a convenience sample from a consumer panel. Although data were weighted to US demographics, participants in the panel survey may be different from those who did not participate on their use of calorie information. In addition, the survey was cross sectional; therefore, causality cannot be examined. Another limitation is the questions have not been tested for reliability and validity. Furthermore, for those who selected the option that they did not notice calorie information we could not determine whether the calorie information was available and they did not notice it or whether the calorie information was just not available. In addition, self-reported calorie use carries no assurance that respondents chose lower calorie items. For example, reported use of nutrition labels is high, but actual use of nutrition labeling during food purchase may be much lower due to other drivers.27 Another limitation is the income categories. We find it challenging to interpret our income findings; it may be that different household income levels have different food away from home consumption patterns that could lead to response bias. Additional research, including use of a measure such as the poverty income ratio which includes household size, may better explain whether this is a real effect or statistical anomaly. In addition, respondents received a small monetary incentive for completing the survey. Lastly, because of the need for brevity in a questionnaire, we were unable to define fast food/chain restaurants within the question.

Conclusion

Our findings are important given the prevalence of obesity among youth and the adverse health effects associated with obesity. It is encouraging that a large number of youth, particularly youth who are obese, are using the calorie information to inform their ordering selections. This may have potential to lead to improved food choices as a way to manage weight. More research is needed to assess whether youth know how many calories they should consume in a day given their activity level. Further research is needed to understand differences in motivation by gender in using calorie labeling. Public health practitioners, school nutrition services, retailers and other interested groups can implement education programs in various venues to assist development of this understanding as a way to improve health literacy.

Conflict of interest

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

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