The role of nutrition in heart health, disease prevention and disease management

The role of nutrition in heart health, disease prevention and disease management

Dale Pinnock
0 recipes
Published by
Quadrille Publishing
978 184949 542 4

It is a certainty that 90 per cent of cases of cardiovascular disease are ultimately preventable. That sounds like a bold statement, I know, but one I stand by. They are a result of our environment. This is of course partly the external environment we live in, such as stress, pollution and so on. But, when we talk of environment, we are referring to the internal biochemical terrain of the body. There is nothing that can influence this biochemical terrain more than our diet. With a few simple changes, we can guide our diet towards being cardio-protective. This means it can support cardiovascular health, potentially prevent the damaging issues and play a role in the management of any existing cardiovascular issues.

Omega 3, omega 6 and a question of balance

Many of you that are familiar with my work will have probably twigged by now that I am a little obsessed with dietary fats. It is my belief that the fat composition of our diet is one of the key factors in cardiovascular health and disease. The fixation with dietary fats and cardiovascular health is, however, the reason we have got into such a mess in the first place, with the huge prevalence of this disease globally. In the last four or five decades, the patterns of fat intake in our diet has changed drastically. This is mostly thanks to the work of a man by the name of Ancel Keys.

Keys was an American physiologist who came up with a hypothesis that the cause of cardiovascular disease was saturated fat intake. He was a very ambitious chap and set out to prove this hypothesis with vigour. He designed a 22-country study. It literally was as the name suggests, a study of 22 countries, searching for a correlation between saturated fat intake and cardiovascular disease. Now, the odd thing was, when this study was published, it was as ‘The Seven Countries Study’; only seven of the 22 countries’ results were used and the results looked very impressive indeed. The data produced a beautiful positive curve and essentially proved Keys’s hypothesis that saturated fat intake was indeed associated with cardiovascular disease. But hang on a minute. What about the other 15 countries? What’s going on here?

As it turns out, the seven countries selected were those that actually supported his theory. Had Keys used all 22 countries, the data would have shown absolutely no correlation whatsoever between saturated fat intake and cardiovascular disease. What was published was basically a fraudulent and engineered piece of reporting. Selective inclusion and exclusion of data that ‘proved’ something that didn’t exist. But, alas, this study was taken on board around the world and Keys became a hero.

Before long he appeared on the cover of Time magazine and his misleading study became the inspiration for the biggest public health cock-up known to man. In no time at all, the American government were developing a public health campaign that encouraged the population to ditch saturated fat and move towards a diet that was high in starchy foods and the supposed ‘heart-healthy’ oils such as sunflower oil and margarine. The same public health message made it to the UK soon after and then began to dominate the Western world. We took it on board. Didn’t we just! This is where the problem began.

You can actually see, by looking at data from institutions such as the World Health Organisation, that as these changes in our diets occurred and we moved towards more starchy foods and more polyunsaturated oils, the incidence of cardiovascular disease, type-2 diabetes and cancer began to soar and, all of a sudden, we saw an obesity epidemic.

So, why are these dietary changes an issue? Well, I will talk about the starchy foods in greater detail when I discuss the glycaemic effects of foods and their relevance to heart health. But, for now, let’s look at the oils that we started to consume in place of saturated fats. The message was that we needed to move towards a higher intake of vegetable oils, so sunflower, corn and soy oils and spreads became super-popular. Sickeningly they began (and still do) adding the ‘heart-healthy’ label to their products and advertising.

Omega 6

The problem that was completely overlooked in those early days was that most vegetable oils are incredibly high in things called omega 6 fatty acids. These are essential fatty acids that are vital to the body and must come from the diet as our body can’t make them itself. All good so far. The snag is, however, that we only need a very small and finite amount of omega 6. Once we go over this level, the body metabolises it in a slightly different way than it would when we are at safe levels and changes it for the worse. Fatty acids in the diet are the metabolic building blocks for several important structures and compounds in the body. One of the big and vital groups that they give rise to are a group of communication compounds called prostaglandins. One of the main roles that prostaglandins carry out in the body – and this is important – is in the management of inflammation.

There are three different types of prostaglandins: Series 1, Series 2 and Series 3. Series 1 are mildly anti-inflammatory. Series 3 are strongly anti-inflammatory, switching off or down and regulating inflammation, and regulating pain signalling. Series 2 prostaglandins, on the other hand, actually switch on and exacerbate inflammation. This isn’t a bad thing per se, providing that the body can be in a state of flux and produce sufficient amounts of these compounds to manage inflammation adequately.

But the balance of dietary fats in our bodies can disrupt this process. Different dietary fats are metabolised to form different series of prostaglandins. Omega 6 fatty acids are the metabolic precursors to – you guessed it – the Series 2 prostaglandins that switch inflammation on. The drastic shift in dietary fat intake in the last decades has meant that in the UK we take in almost 23 times more omega 6 fatty acids than we need per day!

We are essentially force-feeding metabolic pathways that manufacture prostaglandins, and our body’s expression of the pro-inflammatory Series 2 goes into overdrive. The end result is a state of subclinical (your foot doesn’t suddenly swell up, this is happening on a microscopic level within tissues), chronic (consistent and long-term) inflammation in the body. These compounds travel around the body in our circulation, so one of the first tissues to take a battering is, of course, the endothelium, as it is the tissue that is immediately exposed to their changing levels.

If you recall from the previous chapter, inflammatory damage within the endothelium sets the stage for plaque formation and, in essence, cardiovascular disease. The dietary change that was supposed to bring down cardiovascular disease ended up killing us faster. It was akin to trying to put out a bonfire with petrol.

Omega 3

This is the perfect time to bring in the other big dietary fatty acid, one you have probably heard a great deal about: omega 3 fatty acids. The benefits of omega 3 on heart health are well documented and have been studied widely for at least 20 years. These amazing fatty acids are the antidote to what we have just learned. There are three main types of omega 3: ALA, EPA and DHA. EPA and DHA are metabolised to form Series 3 prostaglandins (EPA more so). These are the most potently anti-inflammatory. So, eating good amounts of omega 3 fatty acids encourages our body to produce more anti-inflammatory prostaglandins.

A growing body of evidence is showing that fish and fish oil consumption appears to offer significant protective benefit against heart disease; indeed, several studies have shown that fish consumption is directly related to a reduced risk of heart disease. A review of three large-scale epidemiological studies found that men who ate at least some fish per week had lower incidence of heart disease than those who ate none. Similar patterns were also found in women. A 2002 report from The Nurses’ Health Study showed that, compared to women who ate no fish, risk of cardiovascular disease deaths were 21 per cent, 29 per cent, 31 per cent and 34 per cent lower for a fish consumption of respectively one to three times per month, once per week, two to four times per week, and more than five times per week.

Omega 3 fatty acids have also been shown to reduce levels of triglycerides. These are fats in the blood that can arise from dietary fat intake and from eating very high-GI foods. These fats are believed to be very susceptible to oxidative damage, which could cause or aggravate endothelial inflammation and oxidise LDL cholesterol. A 1997 review of human studies found that around 4 g per day of marine-derived omega 3 fatty acids reduced triglycerides in the blood by 25–30 per cent.

Post-prandial triglyceridemia is the elevation of fats in the blood following a meal. This elevation in triglycerides appears to be very sensitive to omega 3 fatty acids, with a dose of around 2 g per day reducing it significantly. These kinds of doses would come from supplementation. My approach – and my advice to you – is to eat fish and plenty of it and take supplements, too. Omega 3 fatty acids have also been shown both to deliver a dose dependent (that is, greater intake = greater result) reduction in blood pressure, and to reduce clotting factors that may offer some protection against thrombus formation.

The balancing act

So, as you can see, omega 3 fatty acids are a pretty important part of the picture, while too much omega 6 can cause a problem. So it is therefore vital that we get the balance right. With the current trends arising from research, the recommendation now is to aim for a 2:1 ratio in favour of omega 3. That basically means that you need to be eating twice as much omega 3 as omega 6 in order to maximise the potential benefits, and counteract any negative effects of omega 6 in the body. Thankfully, this is pretty easy to manage in practice.

The first step is to avoid most vegetable oils like the plague. These are the so-called ‘heart-healthy’ oils such as sunflower oil, corn oil or the generic vegetable oil. These are basically pure omega 6 and will send your levels rocketing up very fast.

In place of these oils there are two cooking oils to choose from. In most of my cooking I use olive oil. The dominant fatty acid in olive oil is something called oleic acid which comes into a third category: omega 9. Omega 9 fatty acids have zero influence on omega balance, so don’t particularly present a problem at all.

The other oil I use is coconut oil. This is best for high temperature cooking as it is completely heat stable. Also the fatty acids found in there, medium chain triglycerides, are rapidly broken down and used as an energy source, so their impact on postprandial lipaemia (elevation of blood fats after a meal) is minimal.

The next step in aiming for omega balance is to drastically cut back on processed foods. This is good advice for a million and one reasons but, in terms of omega balance, many processed foods use untold amounts of vegetable oils. They are cheap as chips and, for decades, food manufacturers have been under pressure to reduce saturated fat in foods, so have moved over to cheap vegetable oils as an alternative. Most ready meals, pre-made sauces, biscuits, cakes and so on will have a lot of omega 6 in them. Get back to basics, as we do in the recipes in this book, and get cooking from scratch as much as you can.

The second part of the solution is to up the levels of omega 3 in your diet. The first and most obvious place to start is by making sure you eat oily fish around three times every week. Then you could also consider taking supplements. I personally take an omega 3 supplement that contains 750 mg of EPA and 250 mg of DHA twice daily. (But if you are taking medication such as warfarin, or if you have recently had a heparin injection, please check with your doctor before using high-dose fish oil supplements as there is potential for interaction here.)

Know your numbers

For those of you that really want to be serious about getting your omega balance in check, there is now a home test available online that you can carry out which essentially tells you the ratio between omega 3 and omega 6 in your tissues.

The glycaemic response of foods

One area that is very often overlooked in cardiovascular health is the glycaemic response of foods. This basically describes the rate and extent to which a food raises our blood sugar. Different foods, because of their composition, will release their energy at different rates. Pure glucose, for example, will send blood sugar up very rapidly and vigorously. Glucose is actually the benchmark against which all other foods are measured. It is the simplest form of sugar, so requires no digestive effort. It is consumed, then goes straight into circulation.

Foods vary in their make up and complexity and certain factors will influence how rapidly foods release their energy. Fibre is one of the biggest factors. Let’s compare white and brown bread, for example. Brown bread has all the fibre from the wheat husk and many brown breads have additional seeds and fibres added to them. White bread, on the other hand, has had all of the wheat husks removed and so the fibre content is drastically lower. The fibre in the brown bread will simply make the sugars in the bread harder to get to and will require more digestive effort to release. With the refined white bread, on the other hand, the lack of fibre makes the sugar much easier to get at. In the higher fibre food, the sugar is released at a more slow and steady pace, whereas with refined foods (anything white is usually a culprit) it is released at a very rapid pace as it takes far less digestive effort in the gut to liberate the easy-to-get-at glucose.

Another influence on glycaemic response is the combinations in which you eat certain foods. Adding protein to your carbohydrates, for example, will require a great deal more digestive effort to liberate the glucose. This is because proteins are digested more slowly, so there is a lot more work for the digestive system to do when you eat a combination of protein and carbohydrate. The end result is that you will get a slow, even drip-feeding of glucose into the bloodstream, rather than the giant surge you get when eating refined carbohydrates.

But why does any of this matter? Well, an obvious reason is that it will greatly influence your energy levels and mood stability, but that is by the by for your heart, which is what we are concerned with in this book. The glycaemic response of your diet over the long term is of great importance to cardiovascular health.

When our blood sugar rises, our bodies secrete a hormone called insulin. This hormone basically tells our cells to take in glucose for converting into a substance called ATP, the energy unit that cells run off. So, the first reason insulin is secreted is so that the cells know there is glucose available for use. But the other factor to consider is that our blood sugar must stay at a very precise level. If it gets too high or too low, both states are potentially life threatening. In light of this, there are very precise balance homeostatic (homeostasis = the physiological control of balance in the body) mechanisms in place that control blood sugar. If it drops too low, the secretion of hormones that stimulate appetite is upregulated. Another hormone called glucagon is secreted from the pancreas which encourages the body to release glycogen, the storage form of glucose, for immediate use. If blood sugar gets too high, insulin production goes up, so at the same time our cells’ uptake of sugar increases.

However, this is where things can begin to go awry. Our cells only have a certain capacity for how much glucose they can take up at any given time, because if they take in more than they can readily metabolise and change into ATP, what is left over can oxidise and cause damage inside the cell. They can get full. If our cells are full to capacity and our blood sugar remains high, the excess sugar must be dealt with somehow and got out of the system as painlessly and effectively as possible before it does damage.

After filling cells up to their maximum with glucose, the next most satisfactory way of dealing with it is via a reaction called de novo lipogenesis. This is where the glucose gets converted into a fatty substance called triacylglycerol, a fat that can be taken to the adipose tissue (our bodies’ fat cells) for storage and taken away as rapidly as possible.

Another word for triacylglycerol is triglycerides… Sound familiar? They are often measured during routine blood tests that monitor cholesterol and other cardiovascular disease markers. These are the fats that, when in circulation, are susceptible to oxidative damage which can then cause damage to the endothelium. They also encourage oxidation of LDL, which can further damage the endothelium. Further, they make the LDL particles more susceptible to penetrating the endothelium as in the description of plaque formation. The clincher is that insulin also increases the likelihood of LDL oxidation, so you get a double whammy blow here. Higher blood sugar on a consistent basis means more triglycerides plus higher levels of insulin. None of this is good news!

Now if you recall from my discussion of fatty acids above, following the ‘healthy heart’ public health campaigns that arose from Ancel Keys’s work, we were all encouraged to fill up on more fruit and veg (that’s a good thing) and more starchy foods (that’s not a good thing). We started eating more and more bread, potatoes, pasta, grains and so on, every day and at every meal.

Now, before anyone thinks I’m trying to get everyone on the Atkins diet, there is nothing wrong with these foods, but in general in the Western world we are eating way more than we should and, in essence, the balance on our plates is all wrong.

Our preoccupation with fat and the advice to veer away from it and eat more starchy foods mean that we are eating a level that is harmful. These foods can raise our blood sugar notably. Now, once in a while that is no big deal. You will simply send out a bit more insulin, your cells will take in more glucose, problem solved. But, our intake isn’t just every now and again.

Let’s see if this sounds like an inaccurate or extreme picture: how many people would have cereal and a slice of toast for breakfast? A sandwich for lunch? Then perhaps meat, vegetables and potatoes – or maybe pasta – for dinner? That sounds pretty common, right? Well, do that every day for a week, a month, a year and you will soon find your body’s blood sugar staying consistently high and more insulin being produced, meaning more lipogenesis, more LDL oxidation, more endothelial damage. Nasty!

This situation is such an easy thing to remedy though, using a few simple steps:

–Reduce your intake of starchy foods: OK, so this may sound a bit obvious, but this is the place to start. For breakfast, go for a good source of protein such as eggs, smoked salmon or kippers. Ditch the cereal most days and, when you are craving cereal, opt for porridge, as oats have a low glycaemic response.

Lunches should be built around a good protein source, vegetables and salads. One of my lunch staples is salmon salad with a bit of feta and an olive oil-based dressing.

The evening meal is one where you can afford to have a bit of carbohydrate, as the carbs help the brain to take up the amino acid tryptophan, which helps us sleep. But this doesn’t mean scoffing a bowl of pasta or a big jacket spud. Instead, go for choices such as roasted squash or sweet potato. Maybe add some high-protein quinoa or fibre-filled bulgar wheat, or brown rice. These are all very low-GI options and will fill you up and satisfy your appetite. Still, I would advise you only have a very small portion.

–When you have carbs, also have protein and fat: This is one of the real keys to buffering the effects of the carbohydrates on blood sugar as much as possible. Both protein and fat really slow down the digestion of a meal, meaning that available sugar will be freed slowly and blood sugar will be drip-fed. This is really easy in practice. You could have poached egg and avocado on toast (delicious, trust me). Maybe a piece of grilled fish with roasted sweet potato and some buttered greens. It truly is pretty straightforward.

By making these simple changes, you prevent the blood sugar roller coaster that, aside from making you feel rubbish, can completely destroy your long-term health. From damaging your cardiovascular system, to causing long-term insulin resistance. See my book Diabetes: Eat Your Way to Better Health to see how this starch-laden diet that dominates the West is causing an epidemic of type-2 diabetes.

Dietary fibre

While we are on the subject of such foods, I wanted to add a little note on dietary fibre. We have all heard of the importance of dietary fibre. It is obviously beneficial for digestive health, but we won’t go into that now, because there are also many benefits for what we are concerned with here: the cardiovascular system.

Now, due to the conundrums surrounding cholesterol, I am sitting on the fence and watching what happens with the evidence as it unfolds. But, for many, lowering cholesterol is an important goal and until I can be more certain about what the evidence is really telling us, I won’t argue against that, despite what my own personal convictions may be. Well, dietary fibre is a useful tool here. As we have already discussed, cholesterol is made in the body naturally. A small amount of this cholesterol leaves the liver and goes straight into circulation. Most of it, however, takes a bit of a scenic route. It is released from the liver with bile, where it enters the digestive tract. Once it gets in there, it is then re-absorbed back into the circulation.

Certain types of fibre, known as soluble fibre, actually form a gel-like substance in the digestive tract which binds to this cholesterol and carries it away via the bowel before it gets the chance to be absorbed. As there is less cholesterol being absorbed, the liver takes more from the blood to make bile acids and for metabolic usage. This takes blood cholesterol levels down. This has been clinically proven with the fibre from oats, a particularly effective soluble fibre called beta glucan. The recipes in this book have a good fibre content and ingredients such as oats are well represented.

The magic of minerals

We always hear so much about the array of vitamins in our foods. Weird and wonderful fats and fatty acids (guilty) and more antioxidant compounds than you can shake a stick at. However, a group of nutrients that are often overlooked are minerals, some of the substances so vital for human health that even the most tiny microgram difference in intake can be detrimental to our health. In terms of heart health, there are four minerals that are relevant and three of which, if you increase your intake, can have a positive impact on the health of your heart and blood vessels.


Sodium and potassium are two of the most important minerals to be aware of in your daily diet, especially when it comes to managing blood pressure. Sodium has been at the forefront of heart health campaigns for many years and rightfully so. We have for a long time been encouraged to reduce our intake of salt. Why? Well, cheap table salts and most refined sea salts are predominantly composed of sodium chloride. Sodium is an important mineral in the body and we cannot be without it. An excess, however, can create real problems in the body.

Sodium has an important role to play in kidney function. Different minerals in different concentrations affect the rate at which fluids move through our kidneys. Sodium basically slows the movement down. When there are high concentrations of sodium in the body, the movement of fluid through the kidneys slows down sufficiently to cause the body to start retaining water. When this happens, the watery portion of our blood, the plasma, begins to increase in volume. This of course increases the volume of blood within the vessel. Which then increases the pressure against the vessel walls, simply because there is more blood in that tight space pushing against it.

Add to this picture the fact that the substance sodium can in itself be vasoconstrictive (cause contraction of the blood vessels, that makes them narrower) and it soon becomes a serious situation, where the risk of endothelial damage or the rupture of a plaque becomes very real.

Potassium, on the other hand, is like the mirror to this. It is a mineral that we certainly don’t get enough of, because its common sources are dark green leafy vegetables, and – admit it – these are definitely not top of the list of British favourites. Potassium can speed up the movement of fluid through the filtration mechanism of the kidneys (called the nephron). This can give a diuretic effect and soon begin to reduce plasma volume. In turn, this can take some burden off the vessel walls. The less volume within the vessels, the lower the pressure will be in them, as there is physically less pressing against the vessel wall. Potassium can also help to relax the blood vessel walls, giving a vasodilatory effect.

To reduce sodium intake, do not use table salt and also avoid refined sea salts. A natural sea salt should have a dull, dirty grey colour. Refined white sea salts have all the other vital minerals removed and are no better than table salt. One option is to go for a low-sodium/high-potassium salt. There is a subtle taste difference, but when you are using so many fantastic flavoursome ingredients – such as those in this book – you will never know about it and you will benefit your health in a big way. Also, again, avoid processed foods such as ready meals and shop-bought sauces. These contain untold amounts of hidden sodium. Get back to cooking from scratch as much as possible.

At the same time, increase your intake of potassium-rich foods. The best sources are bananas, sweet potatoes, greens, mushrooms, dairy produce, tomatoes and some fish, such as tuna and halibut.


Magnesium and calcium are joined at the hip! Well, not quite, but they do work in tandem with each other all day and all night. This partnership is particularly important in muscle, where they are potent partners in crime. Calcium stimulates muscle fibres to contract, whereas magnesium causes muscle fibres to relax. The two move back and forth, allowing muscles to contract and relax all day. So notable is the effect of these two minerals that they are often used therapeutically. For example, a popular drug for stubborn hypertension is a class of drug called a calcium channel blocker. This reduces the amount of calcium that can get into muscle cells and reduces contraction, in short encouraging muscles to relax.

Magnesium has also been studied as a potential hypotensive agent (something that lowers blood pressure). A 2012 meta-analysis (study of many other studies to determine the significance of results) of 1,173 people found that magnesium supplementation gave a reduction of both diastolic and systolic blood pressure, with the greatest reduction in intakes of over 370 mg/day.

I feel that supplements are worth considering here. As always, it’s all about the food and your emphasis should be on that, but a little extra magnesium in supplement form really wouldn’t hurt.

In terms of foods, greens are definitely at the top of the list. Green vegetables are rich in something called chlorophyll. This is what makes them green. Chlorophyll has a significant amount of magnesium bound to it by its very nature. So, if it’s green, it has got decent levels of magnesium in it. Nuts and seeds, oily fish and pulses are other rich sources, but greens definitely rule the roost!


There are a very exciting group of compounds that are rapidly becoming the new superstars of nutritional research in the field of heart health. These are the flavonoids. They are phytochemicals, biologically active, non-nutrient compounds derived from plants. (When I say non-nutrients, I mean that there is no recognised deficiency disease attached to them. Things such as vitamin C, for example, you can be deficient in. Its intake is absolutely essential for our body to function.)

Phytochemicals, on the other hand, are non-essential. You won’t die if you don’t consume them. But please don’t for a moment think that they are not useful! In fact, when it comes to heart health, I would go as far to say that they are essential. I think they have a vital role to play in a healthy diet.

The richness of phytochemicals in fruit and veg and the power of their activity is part of the motivation behind the five-a-day campaign and a big contributor to the disease protection that is observed in high fruit and veg consumers. Phytochemicals are biologically active, which means that they can directly affect cells, tissues, genes, hormones, enzymes, reactions… you name it! These compounds literally are like nature’s medicine cabinet. There are thousands of phytochemicals in plant foods and many that are being researched for every imaginable aspect of health. But, in terms of cardiovascular health, it seems to be the flavonoids that have come up trumps!

Flavonoids are very broadly distributed phytochemicals, found in almost all plants. In short, they are colour pigments and are responsible for colours in plants from yellow and orange, through to deep red and purple. For the most part, flavonoids are known to be powerful antioxidants, helping to protect cells and tissues from free radical damage. However, in recent years, research has uncovered that they may prove to be superheroes in the fight against heart disease. The initial observations here come from meta-analyses of epidemiological data that has, for example, found a correlation between tea drinking and reduced incidence of cardiovascular disease. It has been found that there is an average 11 per cent reduction in risk for every three cup increase of tea each day.

Probably the most well known of epidemiological observations is the curious relationship between wine consumption and heart disease. Many studies have shown that there is an observable dose-related (more intake = greater response, although with wine there is a fine line between benefit and risk) benefit to heart health from the regular consumption of wine. This is where the model of the French Paradox came from, the observation that the French, despite a diet high in dairy, meat and foods high in the saturated fats that were dietary heresy in terms of heart health, had a notably lower risk of cardiovascular disease than did the English, for example.

While these observations of association were being made decades ago, it is only in recent years that we have started to figure out how flavonoid-rich foods may actually be delivering their benefits to our hearts and protecting them from disease.

Think back to earlier in this book, when I described the structure of our blood vessels and the role that these structures played. We now understand that flavonoids interact with the endothelium and that is how the above results are most likely achieved.

We know that flavonoids actually get taken up by the endothelial cells. Once inside, they cause a little bit of chaos and act almost like an irritant. When this happens, the endothelial cells begin to secrete higher levels of nitric oxide.

If you recall, nitric oxide is a powerful vasodilator. The nitric oxide moves from the endothelial cells into the muscular walls of the blood vessel and causes the smooth muscle to relax.

As the muscle relaxes, the vessel dilates and gets bigger. As it gets bigger, the pressure within it drops. Evidence now tells us that consistent, regular consumption of flavonoids can have a notable lowering effect upon blood pressure.

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