What Body Types Have an Inflated Bmi

Overview

Weight Loss through the Bariatric & Metabolic Found

Cleveland Clinic Florida’s Bariatric & Metabolic Establish offers a multifariousness of surgical and nonsurgical weight loss options. Considering every weight loss journey is different, our team of specialists across southeast Florida, from Weston, Stuart, to Vero Beach, work closely with patients to determine the correct weight direction program for you.

In that location’s never been a improve fourth dimension to get-go working towards a healthier lifestyle. Weight loss surgery options are more accessible than ever, with wider coverage by Medicare and commercial insurance providers. Self-paid options also available; please contact a local Cleveland Clinic Florida insurance specialist to discuss your options.

Why Cull Cleveland Dispensary Florida’s Bariatric & Metabolic Plant?

We are committed to providing patients with a path to a healthier futurity. At that place are many reasons to cull Cleveland Clinic every bit a partner on your weight loss journey, including:

• Comprehensive team arroyo to your intendance, which includes a bariatric nurse and bariatric dietitian
• Number of bariatric surgery options available (including Gastric Sleeve, Gastric Bypass, Complex reoperations, and possible care of LapBand)
• Experienced bariatric surgeons with avant-garde grooming
• Back up groups
• Financing self-pay options available

National Bariatric Surgery Accreditation

Accreditation of our bariatric surgery programs at Cleveland Clinic Weston Infirmary and Cleveland Clinic Martin North Infirmary by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Plan (MBSAQIP®) acknowledges our commitment to quality comeback and condom efforts for patients undergoing metabolic and bariatric surgery. Our leadership and care teams continually work to improve outcomes and achieve additional accreditations across the region.

Industry Leadership in Research & Innovation

The bariatric surgeons at Cleveland Clinic Florida take performed over half dozen,000 weight loss surgeries making information technology 1 of the largest bariatric programs in Florida. They are internationally renowned for advancing surgical weight loss approaches through research — from gastric sleeve surgery and lap band procedures to all forms of gastric bypass surgery. They are too innovators in the use of obesity surgery to treat type two diabetes and as a bridge to organ transplantation candidacy.

Our team includes current and past presidents of the American Society of Bariatric and Metabolic Surgeons (ASMBS) and the Florida Chapter of the ASMBS equally well equally editors of leading industry publications, such as Surgery for Obesity and Related Diseases (SOARD), the official journal of the ASMBS, Bariatric Times, and the peer-reviewed journal Obesity Surgery.

• Download our costless bariatric surgery treatment guide
• Accept the First Step

How Do I Become Started?

Creating a personalized weight loss program for you.

At Cleveland Clinic Florida’s Bariatric & Metabolic Institute, our multidisciplinary squad works with our patients and their families to develop a personalized weight loss plan that works for them. Our dedicated team of physicians, dieticians, nurses, coordinators, and insurance specialists evaluate our patients with a thorough physical exam, diagnostic tools like blood work and imaging, and medical history to develop a consummate, comprehensive contour. Your evaluation volition determine which weight loss plan is best for yous. Nosotros offer both surgical and medical weight management programs.

With not-surgical weight loss plans, our registered dieticians offer patients personalized medical weight loss programs that include diet, do, lifestyle and behavior support. Our weight-loss specialists may also recommend medications to manage obesity and obesity-related weather condition.

If yous are a candidate for bariatric surgery, your weight loss program also will be personalized and include i-on-1 education, back up groups, regular physician consultations, and pre- and post-surgery follow-upwards intendance.

Cleveland Dispensary Florida’s weight loss programs are comprehensive and revolve effectually your well-being and healthy lifestyle goals. Get data nearly the programs we offer throughout Southward Florida and the Treasure Coast and frequently asked questions.

• Download our free bariatric surgery treatment guide

Schedule a Bariatric Programme Consultation

To schedule a consultation, call the Cleveland Clinic Florida location nearest you:

Weston – 877.463.2010
Stuart – 772.223.2890
Vero Beach – 772.770.6850

Virtually Obesity

What is Severe Obesity?

According to the Centers for Disease Command and Prevention (CDC), obesity is a label for ranges of weight that are greater than what is by and large considered good for you for a given peak. Astringent obesity is a chronic illness, with symptoms that build slowly over an extended period of time. An estimated 42.four% of Americans are considered obese. Obesity becomes “morbid” when it reaches the point of significantly increasing the gamble of one or more obesity-related wellness weather or serious diseases (likewise known as co-morbidities) that tin result either in significant physical disability or even death.

Related Links

• American Obesity Association
• American Diabetes Clan
• American Lodge for Metabolic and Bariatric Surgery

Causes of Severe Obesity

The underlying causes of severe obesity are not known. There are many factors that contribute to the development of obesity including genetic, ecology, metabolic and psychological. There are as well certain medical weather that may effect in obesity such as steroid utilize and hypothyroidism. That’s why information technology’southward important that yous work with your doctor to brand certain y’all practise not take a status that should be treated with medication and counseling.

Treatments For Obesity

Non-Surgical

For anyone who has considered a weight loss program, in that location are a number of choices. In fact, to qualify for insurance coverage for bariatric surgery, many insurers require patients to take a history of medically-supervised weight loss efforts.

Nearly medical weight loss programs are based on some combination of diet/behavior modification, medications and regular do. Cleveland Clinic Florida’southward Bariatric & Metabolic Constitute offers nutritional counseling and classes.

Surgical Weight-loss Options

Am I a Candidate for Bariatric Surgery?

If y’all’re significantly overweight and want to make a lifestyle change, you may be a candidate for bariatric surgery. At Cleveland Clinic Florida, we carefully evaluate all patients beingness considered for bariatric surgery. Nutritional and behavioral counseling are conducted, and patients are required to attend a support group session prior to weight loss surgery. A consultation with a bariatric surgeon is a mandatory step prior to surgery, and will assistance you screen for eligibility.

Generally speaking, advisable candidates for bariatric surgery:

• Have a BMI of 40 or greater or BMI of 35-39.ix with pre-existing co-morbidities such as diabetes, heart disease, sleep apnea, hypertension, GERD (heartburn), and others. BMI Calculator.
• Have been unable to achieve a healthy trunk weight for a sustained menstruum of time, even through medically-supervised weight loss programs for at to the lowest degree one to two years prior to surgery.
• Accept psychiatric clearance and be willing to commit to lifelong nutrition and beliefs changes.
• Do not smoke.

If yous are a woman of childbearing age and planning a pregnancy, information technology’s vital to know that you lot must not get pregnant within the starting time 18 months to two years post-obit surgery. The rapid weight loss and nutritional deficiencies associated with bariatric surgery make pregnancy very dangerous for you and for a developing fetus.

Why should someone consider having bariatric surgery?

Obesity is harmful to a person’southward wellness. Someone who is 40 per centum overweight is twice more than likely to die prematurely than an boilerplate-weight person. (This effect is seen after 10 to 30 years of being obese.) In this state alone, about 300,000 deaths per year can be blamed on obesity. Obesity is a risk factor for many conditions and life-threatening diseases, including:

• Cancer
• Chronic kidney disease
• Low
• Diabetes
• Fat liver disease
• GERD (Gastro Esophageal Reflux Affliction)
• Centre affliction
• Loftier claret force per unit area (hypertension)
• High cholesterol
• Infertility
• Menstrual irregularities
• Obstructive slumber apnea
• Osteoarthritis of weight-bearing joints
• Osteoporosis
• Stroke
• Urinary stress incontinence

What are the Benefits of Weight Loss Surgery?

Studies evidence that you volition see an comeback with comorbidities if you proceed to follow mail service-surgery guidelines. Within the beginning six months of having weight loss surgery, patients often no longer need to take medications for these weather condition. In add-on, women who struggle with infertility earlier surgery find that conception is possible after surgery. Other benefits include:

• Average of 50-75 pct of excess weight loss*
• Improved quality of life
• Increased energy
• Improved self-esteem and conviction
• Lower blood pressure
• Increased mobility, with less joint hurting
• Improved claret glucose and cholesterol levels
• Improved overall health and life expectancy

*Estimated weight loss is based on national averages. Success subsequently bariatric surgery is dependent on your power to make positive lifestyle changes including post-obit the behavioral and nutritional guidelines and exercising for at least an hour daily.

What bariatric surgical procedures are performed by surgeons at Cleveland Clinic?

Cleveland Clinic Florida’s Bariatric & Metabolic Institute offers many options for patients who are interested in bariatric surgery. For more than information on the weight loss surgery options available, visit our Surgery Options page.

What makes the Cleveland Dispensary Florida’s bariatric surgery program unique?

We accept a team of physicians, registered nurses, registered dietitians and support staff to ensure that you are guided throughout the programme to accomplish your weight loss goal. Prior to surgery yous will nourish education classes and learn how to live a healthier life every bit a bariatric patient. Our program also offers support groups and individualized care. You will have someone by your side every step of the way. Our program doesn’t end afterwards your surgery — we are here for you for the residue of your life to keep yous successful.

What is the recovery time following weight loss surgery?

Cleveland Dispensary Florida’s medical team has an immense wealth of feel in bariatric surgery. Combined with advances in the field of bariatric care, this means that most patients recover from surgery quickly and without complications. The average hospital stay for patients who undergo the Roux-en-Y gastric bypass is commonly one to three days.

What is my platonic body weight?

Cleveland Clinic Florida’s Bariatric and Metabolic Institute follows the guidelines ready out past the body mass index scale. This scale recommends a BMI of betwixt eighteen.v and 24.9. You can use the calculator to find your current BMI and ideal BMI.

Is there back up from surgeons and staff following weight loss surgery?

Cleveland Clinic Florida’s bariatric surgery health intendance team board-certified dieticians and nutritionists, specialty-trained nurses, bariatric program coordinators and schedulers in that location to guide patients after each process. Regular follow-upward visits are scheduled during the outset yr later on weight loss surgery to cheque overall physical and mental health, metabolism and nutritional condition. Support groups are also bachelor to help you through your weight loss journey.

How much weight loss can be expected?

Most patients volition lose between 66 and 80 percent of their backlog torso weight, virtually of which is lost eighteen to 24 months following bariatric surgery. Weight loss is dependent on several factors including the type of bariatric surgical procedure yous cull and your metabolism. However, the greatest factor is your ability to brand and maintain the lifestyle changes necessary for you to leverage surgery as a tool for success.

In addition to surgery, what other lifestyle changes must be made?

Successful treatment for morbid obesity also includes permanent lifestyle changes such as healthy food choices, reduced caloric intake, increased exercise and other behavior modifications. Counseling and support groups can help with these changes.

What are the restrictions following weight loss surgery?

Post-obit surgery, yous will need to follow specific eating guidelines. Registered dietitians work directly with patients to help program healthful, appropriate meals. Additionally, you lot will demand to finish smoking and discontinue utilize of NSAIDS.

What tin can I eat after having bariatric surgery?

The starting time month following surgery your meals will consist of protein shakes and soft or pureed foods. Your caloric intake gradually increases over fourth dimension to well-nigh 1,200 calories a 24-hour interval. Your nutrition must be advisedly balanced to include high-protein, low-fat, depression-saccharide foods. Poly peptide is especially important to ensure healing after surgery and to preserve musculus tissue. Yous will be able to swallow regular nutrient most four weeks subsequently surgery, without concentrated sweets, in half dozen pocket-size portions a mean solar day. You will have to eat only small amounts, chew your food well and eat very slowly. Our registered dietitian will review this information with you before and subsequently surgery.

How volition I brand sure my body gets all the nutrients it needs later on surgery?

You will demand to take vitamin and mineral supplements for the rest of your life after surgery. The Roux-en-Y Gastric Bypass surgery bypasses most of your stomach and duodenum, where vitamins are captivated so that your caloric intake of 1,200 calories a day cannot provide all the nutrients your torso needs. The Sleeve Gastrectomy, too chosen a stomach sleeve, and Lap Band procedures do non accept this malabsorptive cistron, but it is required to have a good quality vitamin for optimal health.

What volition keep me from losing too much weight?

Your body will slow down weight loss over fourth dimension and until it stabilizes. Nosotros also volition closely follow your weight loss to ensure you lot are maintaining adequate nutrition.

Is information technology possible to gain the weight back after surgery?

Bariatric surgery has an first-class long-term runway record for helping individuals with morbid obesity lose weight. Nevertheless, there are no guarantees with any method of weight loss, even surgery. Success is possible merely if you are committed to making lifestyle and dietary changes for the residuum of your life.

What are the risks for bariatric surgery?

All surgical procedures have risks, particularly when the patient is morbidly obese. Different procedures involve different risks, and depending upon your private circumstances, your risks may be higher or lower than boilerplate. It’due south as well important to know that bariatric surgeons with more than experience performing weight loss surgery written report fewer complications. Potential risks of surgery should exist discussed with your surgeon and then y’all tin can make an informed selection.

What are the most serious risks of bariatric surgery?

Any major surgery can be life-threatening. Obesity increases the run a risk of complications from blood clots and breathing problems. Surgery may be complicated by leaking from the suture lines, only the incidence of this occurring is pocket-size. As with whatsoever surgery, complications such equally bleeding and anesthetic problems may also occur.

Can bariatric surgery be reversed?

Depending on what type of procedure you accept determines if the process is reversible. Weight loss surgeries can be converted or revised to some other surgical procedure. Any potential reversals crave another operation with the aforementioned or greater risks.

I have a Lap Band from a unlike bariatric program. Can I come across 1 of your physicians for my follow-upwardly care?

Later on assessing the band, our physicians tin can brand adjustments to your existing Lap Band. Also, if you are having problems or concerns with your Lap Band, our physicians are trained in revision surgeries to remove the band and catechumen you to a gastric sleeve or gastric bypass.

I’ve already had surgery elsewhere and have some concerns. Tin I follow up with your program?

Yes, if you are a bariatric patient and take concerns you can meet 1 of our physicians. Also, if you are struggling with weight regain y’all can make an appointment with our bariatric registered dietitian to assistance go you back on track.

What if I need revision surgery?

Bariatric surgery is non a magic bullet and, while most patients are successful after weight loss surgery, there are instances where revision weight loss surgery is required. Regardless of the reason for seeking revision weight loss surgery — inadequate weight loss, weight regain, unresolved co-morbidities, or medical complications — a revision solution may be possible.

Revisional and Conversion Procedures Overview

Revisional and conversion bariatric surgery, regardless of the previous surgery, is always challenging. A Revision refers to a change to a electric current procedure to repair- or improve the existing bariatric anatomy, while a conversion is irresolute one past bariatric procedure to another type of procedure. They both require adequate expertise to achieve desired results. Centers accredited through the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Programme and Bariatric Centers of Excellence certified by the American Society for Bariatric Surgery provide a multidisciplinary team and facilities for managing patients requiring revision surgery. It is highly recommended that patients requiring any revisional or conversion surgery detect a surgeon at a bariatric heart that has much experience with those types of procedures.

Will insurance cover bariatric surgery?

Many insurance companies now recognize obesity as a substantial health risk and are paying for bariatric surgery. Contact your insurance provider to find out if bariatric surgery is a covered do good nether your insurance contract. Coverage for bariatric surgery is policy specific and needs to be verified by a Cleveland Dispensary insurance specialist and is subject to multiple clearances. The insurance specialist tin can as well help clarify what self-pay options may exist available.

What practise I need to know about pregnancy after gastric featherbed surgery?

During the first eighteen months later on your gastric featherbed surgery, your body is undergoing many changes. Weight loss is a major one. Your torso also is experiencing hormonal changes, increasing your fertility. Please be cautious during this time and employ a method of birth command to ensure that you exercise not become pregnant. If applicative, a pregnancy test will be conducted prior to your surgery.

Notwithstanding, afterward your surgery, pregnancy is possible if you manage it well with your Cleveland Clinic dr..

Much of the electric current research suggests that pregnancy in individuals with lower BMI is often safer than pregnancy with complications from obesity. If yous have had weight loss surgery and are considering pregnancy, consult your medico for prophylactic family planning. It would also exist beneficial to mention this to your doctors during the consult for your weight loss surgery so they can provide guidance and resources.

During the first xviii months after your gastric bypass surgery, your trunk is undergoing many changes. Until your weight begins to stabilize, it’s not advisable to become pregnant until at least eighteen months after surgery. Rapid weight loss immediately following surgery creates hormonal changes and might deprive a growing babe of important nutrients.

Insurance & Financial Eligibility

Insurance coverage varies for weight loss surgery procedures. Information technology is crucial that you telephone call your insurance provider to decide if your policy covers surgical weight loss. As an integral part of our team, a financial counselor can reply questions and requite you guidance when working with your insurance company to acquire approval.

It is a team effort between y’all and our financial counselor to ensure we do everything possible to gain an blessing for surgical weight loss procedures such as laparoscopic gastric bypass surgery.

Our navigation team volition verify your benefits and help y’all in agreement insurance requirements. Once you are accepted into the program, y’all volition be assigned a personal navigator to help y’all in your pre-operative weight loss journey.

Nosotros understand the importance of surgical weight loss procedures and will work with you lot every step of the way.

Cleveland Clinic Florida accepts almost major insurance carriers, including Medicare and Medicaid. Cash pay and financing options are also available.

If you take whatsoever further insurance or financial questions regarding surgical weight loss procedures, please call:

Weston – 954.659.6274
Stuart – 772.223.2890
Vero Beach – 772.770.6850

Surgery Options

Choosing Surgery

Although virtually patients enjoy an comeback in obesity-related wellness conditions (such as mobility, self-prototype and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the process. The goal is to live amend, healthier and longer. Proceed in listen that rapid weight loss will issue in remission of well-nigh comorbidities such as diabetes, hypertension, sleep apnea, high cholesterol, and others.

That is why y’all should make the conclusion to have weight loss surgery only subsequently careful consideration and consultation with an experienced bariatric surgeon. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that volition be required.

They may, equally part of routine evaluation for weight loss surgery, require that you consult with a dietician/nutritionist and a psychiatrist/therapist. This is to help establish a clear agreement of the mail service-operative changes in behavior that are essential for long-term success.

Weight Loss Surgery Options

The types of weight loss surgeries available fit into two categories:

• Restrictive procedures that decrease food intake
• Hypoabsorptive procedures that modify digestion, thus causing food to be poorly digested, incompletely captivated and eliminated in the stool

Laparoscopic Adjustable Gastric Banding (Lap Band)

Laparoscopic adjustable gastric banding, commonly referred to as Lap Band, is a procedure that requires a surgeon to use laparoscopic techniques and instruments to place an adaptable silicon band around the upper part of the individual’s stomach. This in plough creates a smaller restricted pouch, which becomes the new stomach and gives the feeling of being full later eating a small-scale amount of food.

‘Gastric Sleeve’ – Laparoscopic Sleeve Gastrectomy

Gastric sleeve surgery involves removing a meaning portion of an private’s stomach and leaving about 25 percent to create a gastric “tube” or “sleeve” equally the balance for a new stomach. Surgical staples are used on the new stomach to keep information technology enclosed. The process results in a reduction of the tum and removal of 80% of the appetite hormone (Ghrelin) producing cell mass, thus limiting the amount of ingested nutrient and decreasing the appetite. Similar to the gastric bypass, it also results in a positive alteration of the gastrointestinal hormones.

Gastric Bypass

Gastric bypass surgery is a procedure in which a small pouch is connected to the lower segment of the small intestine, making the patient’s stomach smaller. The purpose of gastric featherbed surgery is to restrict the intake of food and give the individual a feeling of being full with less nutrient. Also, bypassing role of the intestine results in decreased absorption of nutrients and alteration of the gastrointestinal hormones. The latter changes decide weight loss and have a positive influence on several of the co-morbid conditions, such as diabetes and loftier claret force per unit area. Roux-en-Y procedure reroutes a variable length of the pocket-sized intestine to connect to a newly created smaller stomach pouch, bypassing a portion of the digestive arrangement. The process promotes weight loss not only past limiting food intake, just besides by decreasing the absorption ability of the digestive system.

Intragastric Balloon

The Intragastric Balloon System is implanted in the tummy via a 30-minute minimally invasive endoscopic outpatient procedure while the patient is under mild sedation. One time in place, the balloon device is inflated with a sterile solution. The airship partially fills the stomach to provide a feeling of satiety. The balloon is removed after six months, at which time patients remain in a structured dietary program to maintain weight loss.

Duodenal Switch

Duodenal Switch is a combination of the gastric sleeve and gastric bypass process. The procedure creates a smaller stomach that is continued to the uttermost role of the small intestine. The duodenum, jejunum and office of the proximal ileum are bypassed so connected to a bespeak near the ileocecal valve. The surgery is constructive, but also riskier than other procedures. It is generally simply for people who have a BMI higher than 50.

Reoperative Bariatric Surgery

Bariatric surgery is considered successful if l percent of backlog weight is lost and maintained for at least v years, resulting in improvement of obesity-related conditions and quality of life. Revisions often involve converting a failed procedure of some other type to Roux-en-Y (RNY) gastric bypass, but patients who have received the RNY sometimes require revision of the procedure to clear up complications or to achieve further weight loss.

We perform highly complex re-interventions in patients that have complications from previous bariatric procedures. For patients who take experienced complications following either VBG, Sleeve Gastrectomy, or LAP-BAND, our surgeons perform a surgical revision, converting to Roux-en-Y (RNY) gastric bypass. While RNY is a technically challenging procedure that requires surgical expertise, it has been proven to be safely integrated into a bariatric treatment plan with skilful results.

Life After Surgery

The following identifies areas that will be of import for patients to follow subsequently weight loss surgery.

• Diet
  
  The modifications made to your gastrointestinal tract will require permanent changes in your eating habits that must exist adhered to for successful weight loss. Post-surgery dietary guidelines will vary by surgeon. Y’all may hear of other patients who are given different guidelines following their weight loss surgery. It is of import to retrieve that surgeons perform different types of weight loss surgery and the dietary guidelines will vary by surgeon and procedure. What is virtually important is that you adhere strictly to your surgeon’due south recommended guidelines.
  The post-obit are some of the generally accepted dietary guidelines associated with weight loss surgery:
  • When you get-go eating solid food it is essential that yous chew thoroughly. Y’all will need to start with small-scale or shredded pieces of meat.
  • Don’t drink fluids while eating. They will make you experience full before you lot have consumed enough food.
  • Omit desserts and other items with sugar listed as ane of the outset three ingredients.
  • Omit carbonated drinks, high-calorie nutritional supplements, high-fat foods and foods with loftier fiber content.
  • Avoid alcohol for the beginning year.
  • Limit snacking between meals.
  • Take smaller or more frequent meals, and limit snacking between meals.
• Going Back to Work
  
  Your ability to resume pre-surgery levels of activity will vary according to your physical status, the nature of the activity, and the blazon of weight loss surgery you have. Many patients render to full pre-surgery levels of activeness inside one to six weeks of their process. Patients who have a minimally invasive/robotic laparoscopic procedure may be able to return to these activities sooner.
• Birth Command & Pregnancy
  
  Information technology is strongly advised that women of childbearing age employ 2 forms of birth control during the first 12 to 18 months subsequently weight loss surgery. The added demands pregnancy places on your body and the potential for fetal impairment make this a most important requirement
• Long-Term Follow-Upwardly
  
  Although the short-term effects of weight loss surgery are well understood, there are withal questions to be answered virtually the long-term effects on diet and torso systems. Nutritional deficiencies that occur over the class of many years will need to be studied. You will need annual checks for anemia (low red blood cell count) and Vitamin B12, folate and iron levels. Follow-up tests will initially be conducted every three to six months or equally needed, and so every one to ii years. For surgery to be successful, patients must exist committed long-term.

Our Doctors

Appointments & Locations

Cleveland Clinic Florida makes scheduling easy. Whether a dr.’south date or diagnostic test, nosotros have locations throughout southeast Florida for your convenience.

Schedule a Bariatric Program Consultation

To schedule a consultation, call the Cleveland Clinic Florida location nearest you:

Weston – 877.463.2010
Stuart – 772.223.2890
Vero Beach – 772.770.6850

Virtual Visits

Yous can now stay connected to your healthcare squad through virtual visits, using your smartphone, tablet or figurer.

Why go virtual? It’s an easy, user-friendly and secure way to see your provider face-to-face without having to leave home. This saves you travel time, parking fees, and time spent in the waiting room — and yous can have a loved one or caregiver join y’all. If needed, you can also take a prescription sent to the pharmacy of your pick.

Many insurance companies cover the price of virtual visits, and so check with your insurer ahead of time. Interested in getting started? Phone call your provider to find out what virtual visit options are available.

• Learn more about virtual visits for scheduled appointments.

Locations

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