Abstract: Low- and no-calorie sweeteners (LNCS), intensely sweet compounds that virtually contain no calories, are used to replace added sugars in food and drinks. Knowledge about different LNCS data in Spanish foods and added sugar sources in Spain is limited, therefore our aim was to identify and compare their presence across main food groups consumed. Food and beverage products (n = 434) were obtained from the ANIBES Study (anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles), a cross-sectional study of a representative sample of the Spanish population (9–75 years old; n = 2009) carried out in 2013. Food records were obtained from a three-day dietary record using a tablet device. Label data from 1,164 products of different brands were collected and reviewed for content of added sugars and LNCS. LNCS were present in diet soft drinks (100%), “other sweets” (89%), soya drinks (45%), and yogurt and fermented milks (18%). Added sugars were present mainly in sugar soft drinks (100%), energy drinks (96%), sports drinks (96%), bakery and pastry (100%), chocolates (100%), ice cream (100%), breakfast cereals/bars (96%) and jams (89%). Main LNCS were acesulfame K, aspartame, cyclamate and sucralose. Sucrose, dextrose, glucose-fructose syrup, caramel and honey were the main added sugars. Our results show the diversity of foods groups including these ingredients. These data are not compiled in food composition databases, which should be periodically updated to include LNCS and added sugars to facilitate their assessment and monitoring in nutritional surveys.
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Introduction
Over the past decades, it has become evident that an excessive intake of added sugars has many detrimental effects on health, being a contributing factor for increased overweight and obesity rates, higher risk of diabetes and cardiometabolic effects, among others [1]. The World Health Organization (WHO) defines “free sugars” as monosaccharides and disaccharides added to foods and drinks by the manufacturer, cook, or consumer, and sugars naturally present in honey, syrups, fruit juices, and nectar juices [2]. According to the first definition, “free sugars” are similar to added sugars, as the term includes all sugars and syrups added to foods; however, “free sugars” also refers sugars naturally present in fruits. For the purpose of the present work, the term “added sugar” will only apply to those added extrinsically during processing [3]. In 2003, the WHO issued the population nutrient intake goals, which comprised the limitation of free sugar intakes to less than 10% of total energy (TE) [4]. In 2015, WHO published the updated guidelines on free sugar intakes for adults and children in relation to body weight and oral health recommending further reductions [2].
At present, processed food products are one of the main sources of added sugar in our diets and there has been a significant increase in the availability and purchase of these foods in most developed countries including Spain, in which it has almost tripled between 1990 and 2010 (from 11.0% to 31.7%) [5]. The ANIBES Study (anthropometric data, macronutrients and micronutrients intake, practice of physical activity, socioeconomic data and lifestyles), a cross-sectional study of a representative sample of the Spanish population (9–75 years old; n = 2009) carried out in 2013, had the objective of updating the main food and beverage group intake and their contribution to the total energy intakes of the population [6]. In this study, results showed that median total sugar intake of participants contributed to 17% of TE intake: 7.3% for added and 9.6% for the intrinsic sugar intake [3]. Furthermore, differences were observed by age groups for added sugars, being highest in children and adolescents. Regarding intrinsic sugars, however, a higher contribution to TE was observed in the elderly. Moreover, 58.2% of children fulfilled WHO recommendations (<10% TE), lower for adolescents (52.6%) and markedly higher in adults (76.7%) and elderly (89.8%) [3].
Low- and no-calorie sweeteners (LNCS) are used as sugar substitutes and their presence in foods and beverages has increased rapidly over the past 30 years [7]. This trend is expected to continue to rise after the publication of a Collaboration Plan for the improvement of the composition of food and beverages, by the Spanish Ministry of Health, Social Services and Equality, through the Spanish Agency for Consumer Affairs, Food Safety and Nutrition that, among other measures, encourage manufacturers to reformulate and reduce the energy density and added sugar of food products [8]. This plan targets specific food subgroups such as sugar sweetened beverages, cakes and pastries and breakfast cereals, and suggests that added sugar reduction should reach around 10% by the end of 2020. By definition, LNCS are also referred to as artificial sweeteners, nonnutritive sweeteners, high-intensity sweeteners, and non-caloric sweeteners [9]. There are nineteen authorized LNCS in Europe: sorbitol (E-420), mannitol (E-412), acesulfame K (E-950), aspartame (E-951), cyclamate (E-952), isomalt (E-953), saccharine and its Sodium, Potassium and Calcium salts (E-954), sucralose (E-955), thaumatin (E-957), neohesperidine DC (E-959), steviol glycosides or “stevia” (E-960), neotame (E-961), salt of aspartame-acesulfame (E-962), polyglycitol syrup (E-964), maltitols (E-965), lactitol (E-966), xylitol (E-967), erythritol (E-968) and advantame (E-969) [10,11]. These food additives are used as substitutes because they have fewer calories (aspartame provides 4.0 kcal/g but it is 180 times sweeter than sugar [12]). Food composition databases and tables might not reflect these rapidly occurring changes in the food supply as most databases lack information on these ingredients in foodstuffs (presence and quantity), therefore their main dietary sources remain unknown [13]. Nutrition research requires comprehensive nutrient and component databases capable of capturing newly introduced or reformulated products in the marketplace [7,14]. Moreover, very few studies using comparable methodologies have been published at present.
As there is an increased consumer interest in reducing added sugars intake, food products including LNCS have become popular as a measure to control weight and to avoid other potential health adverse effects [15]. The role of LNCS in weight management is a still a subject of controversy as some researchers showed no benefit from their consumption and even weight gain, metabolic syndrome or type 2 diabetes [15,16,17]. A recent review from cross-sectional and prospective cohort studies evaluating the effects of LNCS on metabolism, weight, and obesity-related chronic diseases concluded that, although their consumption is associated with higher body weight and metabolic disease in observational studies, randomized controlled trials demonstrate that LNCS may support weight loss, especially when used in combination with behavioral weight loss support [18]. Therefore, detrimental effects remain under active discussion and underline the need to assess and monitor the consumption of these additives.
Research from the United States of America (USA), Australia, Mexico and Canada shows that, in their current food supply, LNCS are widely used in thousands of beverages such as fruit nectars, juice soft drinks, plant beverages, diet soft drinks and other food products such as desserts and dairy products, yoghurts and fermented milks, ice cream, jellies, candies, chewing gum, cakes, etc. [7,9,19]. Food manufacturers often use a blend of LNCS or a blend of sugars and LNCS to improve their flavor acceptability for reducing sugar intake [20,21].
Extensive scientific research has established the safety of all LNCS allowed for food use in the European Union. It is documented by the results of several in vitro and in vivo animal studies, tests in humans and in some cases epidemiological studies [12]. Furthermore, they have been evaluated through a risk assessment process covering hazard identification and characterization, exposure assessment and risk characterization [22]. All additives, including LNCS, have an Acceptable Daily Intake (ADI) level that represents a quantity guideline for health safety purposes; international regulatory bodies (i.e., Joint FAO/WHO Expert Committee on Food Additives) establish these levels. The ADI is defined as the amount of an authorized additive that can be consumed in a person’s daily diet (food or drink) over an entire lifetime without any appreciable risk to health. LNCS declaration in product labeling is mandatory [10,11] and, in addition, if aspartame is used as an ingredient, it is also required to declare the name and the phrase “a source of phenylalanine” on the labeling [10,23]. Beverages and specifically diet-carbonated beverages comprise the largest proportion of LNCS consumption worldwide, followed by tabletop non-caloric sweeteners and LNCS-containing foods [21]. Although added sugar intake was assessed in the ANIBES Study [3], the distribution and type of LNCS among food groups has not been studied due to the lack of information in Spanish food composition databases.
As their role in weight management and health remains a topic of continued debate, in 2014, a group of scientists signed the Chinchón declaration [24] which stated “the need to strengthen research on LNCS in Spain, to incentivize the monitoring of LNCS intake levels in different population groups and facilitate the execution of multidisciplinary projects on the subject”. More recently, in the Ibero–American Consensus on LNCS, a panel of worldwide experts, provided a comprehensive analysis and evaluation of the role of LNCS in food safety, their regulation and the nutritional and dietary aspects of their use in foods and beverages [25]. Amongst their conclusions, it was underlined that “LNCS are some of the most extensively evaluated dietary constituents, and their safety has been reviewed and confirmed by regulatory bodies globally including the WHO, the US Food and Drug Administration and the European Food Safety Authority” and that “consumer education about these products must be strengthened in a rigorous, objective way, based on the best scientific evidence and regulatory processes”. Regarding the relative safety of consumption of LNCS, international scientific experts in food, nutrition, dietetics, endocrinology, physical activity, pediatrics, nursing, toxicology and public health developed a consensus that emphasizes the long process of scientific risk assessment that it is demanded [25]. Regulatory bodies require data on reproductive and developmental toxicity, as well as mutagenicity/genotoxicity, carcinogenicity, immunotoxicity, neurotoxicity, from a battery of acute and chronic studies before a food additive can be considered for use [25]. Furthermore, the safety of approved compounds is continuously re-evaluated to consider new and relevant scientific data.
LNCS intakes are difficult to assess because manufacturers provide no labeling values of added quantities and consumption of LNCS is likely to be under-estimated [9]. Updated information regarding LNCS intake and distribution amongst food groups is limited in Spain and, to our knowledge, there is no monitoring or assessment of LNCS in foods and beverages sold and consumed in Spain. Thus, the aim of the present work was to identify the presence and types of added sugars and LNCS consumed through food groups according to the consumption patterns observed in the ANIBES study.
Supplementary Materials
The following are available online at https://www.mdpi.com/2072-6643/10/9/1265/s1, Table S1: Food group classification and included subgroups assessed in the ANIBES Study (Adapted from Pérez-Rodrigo et al. (1)).
Author Contributions
M.d.L.S.-V. and E.R. designed and wrote the manuscript. T.P. contributed to the design of the manuscript, and to the interpretation and discussion of the results. J.A.-B., A.G., M.G.-G., R.M.O. and L.S.-M. are members of the Scientific Advisory Board of the ANIBES study. These authors were responsible for the careful review of the study protocol, design and methodology; providing scientific advice to the study; and the interpretation of the results. They also critically reviewed the manuscript. G.V.-M., the Principal Investigator, was responsible for the design, protocol, methodology, and follow-up/checking of the study. G.V.-M. also revised the manuscript. All authors approved the final version of the manuscript.
Funding
This research was funded by a grant from Coca-Cola Iberia through an agreement with the Spanish Nutrition Foundation (Fundación Española de la Nutrición (FEN).
Acknowledgments
The authors would like to thank Coca-Cola Iberia and IPSOS for its support and technical advice, particularly Rafael Urrialde and Javier Ruiz.
Conflicts of Interest
The study was financially supported by a grant from Coca-Cola Iberia through an agreement with the Spanish Nutrition Foundation (Fundación Española de la Nutrición (FEN)). The funding sponsor had no role in the design of the study, the collection, analysis nor interpretation of the data, the writing of the manuscript, nor in the decision to publish the results. The authors declare no conflict of interest.
References
1.Popkin, B.M.; Hawkes, C. Sweetening of the global diet, particularly beverages: Patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2016, 4, 174–186. [Google Scholar] [CrossRef]
2.Guideline, W. Sugars Intake for Adults and Children; World Health Organization: Geneva, Switzerland, 2015. [Google Scholar]
3.Ruiz, E.; Rodriguez, P.; Valero, T.; Ávila, J.; Aranceta-Bartrina, J.; Gil, Á.; González-Gross, M.; Ortega, R.; Serra-Majem, L.; Varela-Moreiras, G. Dietary Intake of Individual (Free and Intrinsic) Sugars and Food Sources in the Spanish Population: Findings from the ANIBES Study. Nutrients 2017, 9, 275. [Google Scholar] [CrossRef] [PubMed]
4.Consultation, J.W.F.E. Diet, nutrition and the prevention of chronic diseases. World Health Organ. Tech. Rep. Ser. 2003, 916, 54–55. [Google Scholar]
5.Latasa, P.; Louzada, M.L.D.C.; Martinez Steele, E.; Monteiro, C.A. Added sugars and ultra-processed foods in Spanish households (1990–2010). Eur. J. Clin. Nutr. 2017. [Google Scholar] [CrossRef] [PubMed]
6.Ruiz, E.; Ávila, J.; Castillo, A.; Valero, T.; del Pozo, S.; Rodriguez, P.; Bartrina, J.; Gil, Á.; González-Gross, M.; Ortega, R.; et al. The ANIBES Study on Energy Balance in Spain: Design, Protocol and Methodology. Nutrients 2015, 7, 970–998. [Google Scholar] [CrossRef] [PubMed]
7.Dunford, E.; Taillie, L.; Miles, D.; Eyles, H.; Tolentino-Mayo, L.; Ng, S. Non-Nutritive Sweeteners in the Packaged Food Supply—An Assessment across 4 Countries. Nutrients 2018, 10, 257. [Google Scholar] [CrossRef] [PubMed]
8.Ministerio de Sanidad, Servicios Sociales e Igualdad. Agencia Española de Consumo, Seguridad Alimentaria y Nutrición. Plan de Colaboración Para la Mejora de la Composición de los Alimentos y Bebidas y Otras Medidas 2017–2020. 2018. Available online: http://www.aecosan.msssi.gob.es/AECOSAN/docs/documentos/nutricion/PLAN_COLABORACION_2017-2020.pdf (accessed on 10 April 2018). [Google Scholar]
9.Sylvetsky, A.C.; Rother, K.I. Trends in the consumption of low-calorie sweeteners. Physiol. Behav. 2016, 164, 446–450. [Google Scholar] [CrossRef] [PubMed]
10.Pérez-Rodrigo, C.; Gil, Á.; González-Gross, M.; Ortega, R.M.; Serra-Majem, L.; Varela-Moreiras, G.; Aranceta-Bartrina, J. Clustering of dietary patterns, lifestyles, and overweight among Spanish children and adolescents in the ANIBES study. Nutrients 2016, 8, 11. [Google Scholar] [CrossRef] [PubMed]
11.Nissensohn, M.; Sánchez-Villegas, A.; Serra-Majem, L. Beverage consumption habits amongst the Spanish population: Association with total water and energy intake. Findings of the ANIBES study. Nutr. Hosp. 2015, 32, 10325. [Google Scholar] [PubMed]
12.Kroger, M.; Meister, K.; Kava, R. Low-calorie Sweeteners and Other Sugar Substitutes: A Review of the Safety Issues. Compr. Rev. Food Sci. Food Saf. 2006, 5, 35–47. [Google Scholar] [CrossRef]
13.Piernas, C.; Ng, S.W.; Popkin, B. Trends in purchases and intake of foods and beverages containing caloric and low-calorie sweeteners over the last decade in the U.S. Pediatr. Obes. 2013, 8, 294–306. [Google Scholar] [CrossRef] [PubMed]
14.Poti, J.M.; Yoon, E.; Hollingsworth, B.; Ostrowski, J.; Wandell, J.; Miles, D.R.; Popkin, B.M. Development of a food composition database to monitor changes in packaged foods and beverages. J. Food Compos. Anal. 2017, 64, 18–26. [Google Scholar] [CrossRef] [PubMed]
15.Bellisle, F.; Drewnowski, A. Intense sweeteners, energy intake and the control of body weight. Eur. J. Clin. Nutr. 2007, 61, 691. [Google Scholar] [CrossRef] [PubMed]
16.Swithers, S.E. Artificial sweeteners produce the counterintuitive effect of inducing metabolic derangements. Trends Endocrinol. Metab. 2013, 24, 431–441. [Google Scholar] [CrossRef] [PubMed]
17.Nichol, A.D.; Holle, M.J.; An, R. Glycemic impact of non-nutritive sweeteners: A systematic review and meta-analysis of randomized controlled trials. Eur. J. Clin. Nutr. 2018, 72, 796–804. [Google Scholar] [CrossRef] [PubMed]
18.Sylvetsky, A.C.; Rother, K.I. Nonnutritive Sweeteners in Weight Management and Chronic Disease: A Review. Obesity 2018, 26, 635–640. [Google Scholar] [CrossRef] [PubMed]
19.Bernstein, J.T.; Schermel, A.; Mills, C.M.; L’Abbé, M.R. Total and Free Sugar Content of Canadian Prepackaged Foods and Beverages. Nutrients 2016, 8, 582. [Google Scholar] [CrossRef] [PubMed]
20.Gardner, C.; Wylie-Rosett, J.; Gidding, S.S.; Steffen, L.M.; Johnson, R.K.; Reader, D.; Lichtenstein, A.H. Nonnutritive sweeteners: Current use and health perspectives: A scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2012, 126, 509–519. [Google Scholar] [CrossRef] [PubMed]
21.Martyn, D.; Darch, M.; Roberts, A.; Lee, H.; Yaqiong Tian, T.; Kaburagi, N.; Belmar, P. Low-/No-Calorie Sweeteners: A Review of Global Intakes. Nutrients 2018, 10, 357. [Google Scholar] [CrossRef] [PubMed]
22.Mortensen, A. Sweeteners permitted in the European Union: Safety aspects. Scand. J. Food Nutr. 2006, 50, 104–116. [Google Scholar] [CrossRef]
23.Aranceta Bartrina, J.; Pérez Rodrigo, C.; Alberdi Aresti, G.; Varela Moreiras, G.; Serra-Majem, L. Controversies about population, clinical or basic research studies related with food, nutrition, physical activity and lifestyle. Nutr. Hosp. 2015, 3, 15–21. [Google Scholar]
24.Serra-Majem, L.; Serván, P.R.; Cortés, S.B.; Navarro, A.A.; Bartrina, J.A.; Vargas, E.F.; García-Closas, R.; Gómez-Candela, C.; Sancho, E.H.; La Vecchia, C. Chinchón declaration; decalogue on low-and no-calorie sweeteners (LNCS). Nutr. Hosp. 2014, 29, 719–734. [Google Scholar] [PubMed]
25.Serra-Majem, L.; Raposo, A.; Aranceta-Bartrina, J.; Varela-Moreiras, G.; Logue, C.; Laviada, H.; Socolovsky, S.; Pérez-Rodrigo, C.; Aldrete-Velasco, J.; Meneses Sierra, E.; et al. Ibero–American Consensus on Low- and No-Calorie Sweeteners: Safety, Nutritional Aspects and Benefits in Food and Beverages. Nutrients 2018, 10, 818. [Google Scholar] [CrossRef] [PubMed]
26.European Union. Regulation (EU) 1169/2011 of the European parliament and of the Council of 25 October 2011 on the provision of food information to consumers, amending Regulations (EC) No 1924/2006 and(EC) No 1925/2006 of the European Parliament and of the Council, and repealing Commission Directive 87/250/EEC, Council Directive 90/496/EEC, Commission Directive 1999/10/EC, Directive 2000/13/EC of the European Parliament and of the Council, Commission Directives 2002/67/EC and 2008/5/EC and Commission Regulation (EC) No 608/2004 (Text with EEA relevance). Off. J. Eur. Union 2011, L304, 18–63. Available online: https://eur-lex.europa.eu/legal-content/EN/ALL/?uri=CELEX%3A32011R1169 (accessed on 13 June 2018). [Google Scholar]
27.Nissensohn, M.; Sánchez-Villegas, A.; Ortega, R.; Aranceta-Bartrina, J.; Gil, Á.; González-Gross, M.; Varela-Moreiras, G.; Serra-Majem, L. Beverage Consumption Habits and Association with Total Water and Energy Intakes in the Spanish Population: Findings of the ANIBES Study. Nutrients 2016, 8, 232. [Google Scholar] [CrossRef] [PubMed]
28.Husøy, T.; Mangschou, B.; Fotland, T.Ø.; Kolset, S.O.; Nøtvik Jakobsen, H.; Tømmerberg, I.; Bergsten, C.; Alexander, J.; Frost Andersen, L. Reducing added sugar intake in Norway by replacing sugar sweetened beverages with beverages containing intense sweeteners—A risk benefit assessment. Food Chem. Toxicol. 2008, 46, 3099–3105. [Google Scholar] [CrossRef] [PubMed]
29.Buffini, M.; Goscinny, S.; Van Loco, J.; Nugent, A.P.; Walton, J.; Flynn, A.; Gibney, M.J.; McNulty, B.A. Dietary intakes of six intense sweeteners by Irish adults. Food Addit. Contam. Part A 2018, 35, 425–438. [Google Scholar] [CrossRef] [PubMed]
30.Le Donne, C.; Mistura, L.; Goscinny, S.; Janvier, S.; Cuypers, K.; D’Addezio, L.; Sette, S.; Catasta, G.; Ferrari, M.; Piccinelli, R. Assessment of dietary intake of 10 intense sweeteners by the Italian population. Food Chem. Toxicol. 2017, 102, 186–197. [Google Scholar] [CrossRef] [PubMed]
31.Acton, R.B.; Vanderlee, L.; Hobin, E.P.; Hammond, D. Added sugar in the packaged foods and beverages available at a major Canadian retailer in 2015: A descriptive analysis. CMAJ Open 2017, 5, E1–E6. [Google Scholar] [CrossRef] [PubMed]
32.Ng, S.W.; Slining, M.M.; Popkin, B.M. Use of Caloric and Noncaloric Sweeteners in US Consumer Packaged Foods, 2005–2009. J. Acad. Nutr. Diet. 2012, 112, 1828–1834. [Google Scholar] [CrossRef] [PubMed]
33.Probst, Y.C.; Dengate, A.; Jacobs, J.; Louie, J.C.Y.; Dunford, E.K. The major types of added sugars and non-nutritive sweeteners in a sample of Australian packaged foods. Public Health Nutr. 2017, 20, 3228–3233. [Google Scholar] [CrossRef] [PubMed]
34.Zupani?, N.; Miklavec, K.; Kušar, A.; Žmitek, K.; Fidler Mis, N.; Pravst, I. Total and Free Sugar Content of Pre-Packaged Foods and Non-Alcoholic Beverages in Slovenia. Nutrients 2018, 10, 151. [Google Scholar] [CrossRef] [PubMed]
35.Biro, G.; Hulshof, K.; Ovesen, L.; Cruz, J.A. Selection of methodology to assess food intake. Eur. J. Clin. Nutr. 2002, 56, S25. [Google Scholar] [CrossRef] [PubMed]
36.Lieffers, J.R.; Hanning, R.M. Dietary assessment and self-monitoring: With nutrition applications for mobile devices. Can. J. Diet. Pract. Res. 2012, 73, e253–e260. [Google Scholar] [CrossRef] [PubMed]
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María de Lourdes Samaniego-Vaesken 1,†?, Emma Ruiz 2,†?, Teresa Partearroyo 1?, Javier Aranceta-Bartrina 3,4,5?, Ángel Gil 6,7?, Marcela González-Gross 6,8?, Rosa M. Ortega 9?, Lluis Serra-Majem 4,6,10? and Gregorio Varela-Moreiras 1,2,* ?
1 Department of Pharmaceutical and Health Sciences, Faculty of Pharmacy, CEU San Pablo University, 28668 Madrid, Spain
2 Spanish Nutrition Foundation (FEN), 28010 Madrid, Spain
3 Department of Food Sciences and Physiology, University of Navarra, Pamplona, 31009 Navarra, Spain
4 Research Institute of Biomedical and Health Sciences (IUIBS), University of Las Palmas de Gran Canaria, 35016 Las Palmas, Spain
5 Department of Physiology, Faculty of Medicine, University of the Basque Country (UPV/EHU), 48940 Leioa, Vizcaya, Spain
6 CIBEROBN, Biomedical Research Networking Center for Physiopathology of Obesity and Nutrition, Carlos III Health Institute, 28029 Madrid, Spain
7 Department of Biochemistry and Molecular Biology II, Institute of Nutrition and Food Sciences, University of Granada, 18010 Granada, Spain
8 ImFINE Research Group, Department of Health and Human Performance, Universidad Politécnica de Madrid, 28040 Madrid, Spain
9 Department of Nutrition and Food Science, Faculty of Pharmacy, Madrid Complutense University, 28040 Madrid, Spain
10 Service of Preventive Medicine, Complejo Hospitalario Universitario Insular Materno Infantil (CHUIMI), Canary Health Service, Las Palmas de Gran Canaria, 35016 Las Palmas, Spain*
Correspondence: gvarela@ceu.es; Tel.: +34-91-372-47-26 or +34-91-447-07-59†
These authors contributed equally to this work.
Received: 6 July 2018 / Accepted: 5 September 2018 / Published: 7 September 2018
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