Bulimia – New Research Sheds Light on What Causes and Maintains the Binge/Purge Cycle

Bulimia - New Research Sheds Light what Causes and Maintains the BingePurge Cycle

Bulimia nervosa is a serious condition that involves a potentially devastating assault on the mind and the body. The cause of bulimia is unknown, but it’s likely to involve a number of factors which, separately, could touch any of us. What we know for certain is that it has nothing to do with courage, character or strength.

From the outside, or through the eyes of somebody who has never had any experience of bulimia, the act of binging then purging might seem to make no sense at all. As with so many of the confusing things that we humans do, the only things stopping it from making sense are the right pieces of information. Those pieces are always there – somewhere – and whether they lie in biology, physiology, history, or anything else that makes us who we are, the only thing standing in the way of a complete understanding is ‘enough’ information. New research around bulimia has helped move us towards this. 

What is bulimia?

Bulimia involves repeatedly eating unusually large amounts of food in a relatively short period of time (generally within about two hours). The binging comes with a sense of loss of control, and is immediately followed by feelings of guilt and shame. In response to these feelings, a person with bulimia will try to compensate for the overeating by vomiting, fasting, overexercising, or misusing laxatives or diuretics. 

What are the warning signs?

Bulimia can often stay well-hidden because it doesn’t always come with an obvious weight change. People with bulimia will tend to maintain a fairly average weight for their height. Sometimes they might be a little above or below average, but not to the extent that would cause the people close to them to be concerned. Having said this, if someone is struggling with bulimia, there will be signs. On their own, these signs might not necessarily mean bulimia. It’s the combination, intensity and duration of symptoms that tends to signal and warning. Many of the symptoms exist on a spectrum, but the clue that something isn’t right will come from the level of intrusion into relationships, work, school, study, and day to day life in general. Something becomes a problem when it starts causing problems. Here are some signs to watch out for.

Behavioural.
  • Dieting (fasting, calorie counting, avoiding particular food groups such as fats or carbs);
  • Evidence of binging (large amounts of food disappearing, lots of empty wrappers);
  • Change in eating habits (eating in private, avoiding meals, uncomfortable eating around others, skipping meals);
  • Food rituals (excessive chewing, insisting meals must be at a certain time, eating slowly, eating with a teaspoon, cutting food into small pieces and eating one piece at a time);
  • Focus on food preparation and planning (shopping for food, planning, preparing and cooking meals, reading nutritional guides).
  • Change in food preferences (e.g. avoiding foods that were once enjoyed; replacing meals with drinks);
  • Focus on body shape and weight (weight-loss websites, dieting strategies, images of thin people)
  • Disappears after eating, often to go to the bathroom;
  • Evidence of vomiting, laxatives, diuretics, weight loss pills, appetite suppressants;
  • Excessive use of mints, mouthwash, gum;
  • Change in dress (e.g. baggy clothes)
  • Change in exercise habits (e.g. exercising despite weather, illness, injury or fatigue, distressed if not able to exercise)
  • Secretive around food (e.g. hiding food, eating in secret, saying they’ve eaten when they haven’t, saying they’ll eat later or that they aren’t hungry, secretly throwing out food);
  • Hoarding food;
  • Withdrawing from friends or usual activities;
  • Mood swings;
  • Repetitive or obsessive body checking (checking in mirror for any flaws, pinching waist or wrists to check body fat, weighing self).
Physical.
  • Sudden or frequent change in weight (loss or gain). (Body weight may also be within normal range for height);
  • Change in menstruation;
  • Fainting or dizziness;
  • Tired or lethargic;
  • Signs of regular vomiting (swelling around cheeks or jaw, calluses on knuckles, bad breath; discoloured or stained teeth; enamel erosion, cavities);
  • Sensitivity to the cold (feeling cold often, even when the temperature is warmer);
  • Abnormal lab results (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate);
  • Dry skin;
  • Slower to heal from injuries or more frequent illnesses.
Psychological.
  • Preoccupation with eating, food, weight;
  • Anxiety or irritability at meal times;
  • Rigid black and white thinking (foods are either ‘good’ or ‘bad’);
  • Distorted body image (believing they are overweight when they are actually a healthy weight or underweight);
  • Comfort eating (eating to deal with stress, anxiety, boredom or depression);
  • Feelings of worthlessness, shame, guilt, self-loathing.

How does bulimia happen?

There is no simple explanation for the cause of bulimia. We humans are a beautiful and complex mix of so many elements – genetics, environment, upbringing, culture, history. It’s likely that a combination of all of these, or at least some of these, contribute to bulimia.

A review of the research found that social factors (such as media exposure, the pressure to be thin, and the expectation of thinness), personality traits (negative emotionality, perfectionism, and the tendency to act impulsively when distressed) were risk factors for developing the symptoms of eating disorders. These risk factors then seem to interact with genetic factors to increase the vulnerability to disordered eating.

The urge to eat becomes altered.

Appetite and the drive to eat come from a part of the brain called the hypothalamus. The urge to eat is instinctive. Our bodies and our brains are designed to motivate us towards food when we’re hungry, and to keep the nutrients inside us when we take them in. 

In people with bulimia though, the primal, powerful instincts to seek nutrition, and to keep the body nourished, are altered. Researchers have uncovered the neurological reason for this. In a study published in the journal Translational Psychiatry, researchers found that in people with bulimia (and anorexia), the powerful signals to eat that are sent out by the hypothalamus are overwhelmed by a different part of the brain, effectively shutting down the urge to eat. The pathways to the hypothalamus are found to be much weaker in people with bulimia, and the direction of information seems to travel the other way – rather than sending out signals to eat, the hypothalamus receives signals not to eat. This ultimately overrides the urge to eat.

According to the study, we humans are programmed from birth to like the taste of sweet (breast milk is half sugar and half fat). In people with an eating disorder the fear of gaining weight steers them away from sweet food. The researchers suggest that this avoidant behaviour, driven by the fear of gaining weight, could impact the taste-reward pathways in the brain and reduce the influence of the hypothalamus, making it easier to ignore the urge to eat.

But if the urge to eat is shut down, what makes people binge?

Binging is not about hunger. People who binge might be hungry, but the loss of control that comes with binging and the quick and vast intake of calories are driven by other powerful factors. New research published in Journal of Abnormal Psychology has shed light on what contributes to, and maintains, the binging part of the cycle. The research was conducted in women, though it is important to note that bulimia in men is an equally serious issue.

Stress is known to be a trigger for binge eating in people with bulimia, but the research has found that the response to food after stress seems to differ between people with bulimia and those without. The researchers found that women with bulimia have a different brain reaction to images of food after stress, compared to the women without bulimia. Magnetic resonance imaging scans (MRIs) showed that following stress, when women without bulimia were shown pictures of food they had an increased blood flow to a part of the brain called the precuneus. This is a part of the brain associated with self-reflection. An increased blood flow to the region suggests that the person is engaged in self-reflection, rumination or self-criticism.

In women with bulimia however, blood flow to this part of the brain decreased. Following stress, the food cues seem to decrease the activity in the part of the brain involved in negative self-reflection or self-criticism.

The researchers believe that for people with bulimia, food shuts down self-criticism or negative thoughts about the self. Food seems to offer something else to focus on, other than emotional pain, and or anything about themselves which is a source of self-criticism or self-loathing.  

‘Our findings are consistent with the characterization of binge-eating as an escape from self-awareness and support the emotion regulation theories that suggest that women with bulimia shift away from self-awareness because of negative thoughts regarding performance or social comparisons and shift focus to a more concrete stimulus, such as food.’ – Brittany Collins, .

The results were replicated across two studies – a stressful activity increased feelings of stress, but activity in the part of the brain associated with negative thinking and self-criticism decreased when the women viewed food cues.

The food cues seemed to decrease self-reflection, but they also increased food craving. The relief that comes with binging might be short-lived, but in the moment, it’s something. The consequences of this are a catastrophic cycle of binging for relief, then purging to compensate for the overeating and the increased shame, guilt, self-criticism and negative thinking that comes with binging.

Recovering from bulimia.

Bulimia is tough, and the binge/purge cycle is a fierce one. At times it can seem so impossible to move through, but recovery is absolutely possible. It’s important to be aware that the healing process might take time. There may be many backwards steps along the way, and at times healing might seem hopeless, but the backward steps and stalls are all part of the healing process, not the end of it.

Research has found that after about nine years, almost 70% of people with bulimia will fully recovered, and stayed recovered over time.

“These findings challenge the notion that eating disorders are a life sentence … While the road to recovery is often long and winding, most people will ultimately get better. I’ve had patients say to me, ‘Food and my body are only parts of who I am now; neither defines me anymore,’ or ‘My life became more full, and there just wasn’t room on my plate anymore for the eating disorder.'” Kamryn Eddy, PhD, associate professor of Psychology in the Harvard Medical School Department of Psychiatry.

Where to go for support. 

Chances of long-term recovery seem to be greatly increased if the symptoms are changed in the early stages, so an early response is vital. If you or a loved one is struggling with bulimia, speak to a doctor or therapist. They’ll have the resources to find you the support you need, and will be able to refer to you a professional who specialises in eating disorders.

Recent research found that online group therapy was as effective as face to face therapy for bulimia (though a little slower to start with). The Butterfly Foundation for Eating Disorders is a wonderful organisation and they run a number of online support groups for people aged 16 and over who are working to recover from an eating disorder, as well as groups for carers, siblings and young carers. Find more information about their online support groups here. They also have an online chat for anyone who needs support or information (including carers).

(For a worldwide list of eating disorder support organisations (by country), see here.)

And finally …

Bulimia is a confusing, complicated illness that can have serious consequences, not only for the people who struggle with the illness, but also for the people who love them. Eating disorders are not a life sentence. The road through can be a difficult one, and requires the outside support of doctors and health professionals, but recovery is possible.

The most important thing for anyone struggling with an eating disorder is to reach out for support as soon as possible. Whether that support is from a doctor, a therapist, an online group, an online chat, or a trusted someone – any reach for help is a step out of the shadow and control of bulimia, and a step closer to healing. There is no shame in asking for help, and there is no need to know exactly what to ask for – that’s what professional support is for. We all have things we struggle with that we need extra help sometimes. The sooner the reach for support, the greater the chance of healing and reclaiming a strong, healthy, happy life.

15 Comments

KP

Thank you for this very educational and inspirational article on bulimia. My stepdaughter has recently been diagnosed. The family and herself are seeking out professional help. But it seems everyone (especially my husband, her Dad) is beating themselves up over how this could have happened. Thank you for this very informative read. I look forward to further reads on this subject.

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Jean Tracy, MSS

This is a fascinating article, well-written, and detailed. Thanks so much for this important information, Karen. I’ll be sending it to my social media sites.

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Tammy

Thanks for shedding some light on this rarely understood mental illness. The spectrum of disordered eating seems to be growing. I’d be interested in reading an article discussing other types of eating disorders, as well as an article dedicated to anorexia nervosa.

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Kimberley

Great article! However, in the section on why people binge it refers in paragraph 2 and 3 to women without bulimia but I think one of the examples is meant to be talking about women WITH bulimia. Please could you take a look? Thanks. Sorry if it is me misreading it!

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Karen Young

The articles reads correctly, but I understand your confusion. You would expect that the blood flow to the self-reflective part of the brain would be increased in people with bulimia, but the fascinating thing about this research is that it has found that food cues decreased the activity in the self-reflective part of the brain following stress. It’s normal following stress that we might reflect on what we might have done better, how we handled things, whether or not we coped ok etc. A little bit of self-reflection is healthy and normal. Of course sometimes this can come with negative thinking and criticism, but this tends to ease when the stress does. For women with bulimia, food seems to reduce this self-reflection, negative thinking, or self-criticism. This is how the binge/purge cycle becomes such a powerful one. Food is associated with a decrease the uncomfortable feelings that come with self-reflection or negative thinking. This is why the blood flow to the self-reflective part of the brain decreases (after stress) when there are food cues. Stress leads to self-reflection and self-critical thinking, but when food cues are introduced, this self-reflection and negative thinking decreases. I hope this makes sense. I’m grateful to you for raising the issue. It can seem counter-intuitive at first – you might expect self-criticism to be worse in people with bulimia – but it’s about why makes people continue to binge – food reduces activity in the precuneus which means that when there is food, there is also less self-reflection and less self-criticism.

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jennifer

I think the confusion the above reply is referring to is: under “But if the Urge to Eat is Shut Down…”

The second paragraph reads …”when women without bulimia were shown pictures of food they had an increased blood flow…”

The third paragraph reads… “In women without bulimia, however, blood flow to this part of the brain was decreased…”

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Karen Young

Ahhh – I see the confusion. The third paragraph has a typo. It should read, ‘In women WITH bulimia …’ This has been amended in the text – thank you for pointing it out.

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L

I suffered from Bulimia for over 20 years, from mid teens to my mid 30s. I thought it was going to kill me and I was never going to be free. For years I used willpower and other self soothing tools to help me recover but of course kept falling of the wagon and would find myself starting the cycle. It was with my then even when I was ok- like an alcoholic that is in recovery- always there; a possibility to relapse anytime. Then, in my late 30s, I trained as a Kundalini yoga teacher and developed my Pilates business. The esteem, confidence and clarity and connection I was developing finally changed me from recovering to recovered. Now it’s gone and I never binge and vomit or think about it. It’s just not part of my life anymore. Although the irony of having a job where my body is kept in shape is not lost on me and perhaps still figuring it out, I am no longer bulimic or worry about eating. I am free.

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Karen Young

Laura thank you for sharing your story. I’m sure it will give hope to others. The power of ‘me too’ to heal is remarkable.

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Vanessa

Was wondering if there was some kind of support group or some kind of way to talk to other people with this disease I have been struggling with this for about 8 years nobody knows and I do not know anybody else who does it I would really just like some support thank you

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Jane

I’ve found i become bulimic when i am down and feel I have no control of where or what is happening in my life. I eat for the comfort, then feel like an even bigger looser, then can gain the control again by vomiting. It first started in my early 20’s when i was lost in life at University & struggling, then a guy i thought i wanted to be with told me i was too fat. Any relapse i’ve had since is when my self esteem is low and transition periods. I’m always surprised when it comes back, but am learning my own triggers now and try to control them.

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Karen Young

Jane what you have said makes so much sense. You are NOT a loser! Don’t believe the words of anyone who makes you feel like you aren’t enough – including the words you use against yourself in your vulnerable times. You are so much more than enough and you always will be. Talk to yourself as you would a small child. There is a small child in all of us that needs love, protection, and someone to fight for us. Be that person for you. It sounds like you are well on your way to doing this – that takes strength, guts, wisdom and insight. Backward steps are part of the growth, not the end of it.

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Sally

I struggled with bulimia in my twenties… after graduating from college and having NO idea how to function in my new expectations.
I am now retired from a successful career in education. i still look for answers to the “why” I got so caught up in this complicated behavior, but I did find help in a support group and a program at the U of MN. Your article, once again helped me to increase my understanding…much appreciated!

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How we are with them, when they are their everyday selves and when they aren’t so adorable, will build their view of three things: the world, its people, and themselves. This will then inform how they respond to the world and how they build their very important space in it. 

Will it be a loving, warm, open-hearted space with lots of doors for them to throw open to the people and experiences that are right for them? Or will it be a space with solid, too high walls that close out too many of the people and experiences that would nourish them.

They will learn from what we do with them and to them, for better or worse. We don’t teach them that the world is safe for them to reach into - we show them. We don’t teach them to be kind, respectful, and compassionate. We show them. We don’t teach them that they matter, and that other people matter, and that their voices and their opinions matter. We show them. We don’t teach them that they are little joy mongers who light up the world. We show them. 

But we have to be radically kind with ourselves too. None of this is about perfection. Parenting is hard, and days will be hard, and on too many of those days we’ll be hard too. That’s okay. We’ll say things we shouldn’t say and do things we shouldn’t do. We’re human too. Let’s not put pressure on our kiddos to be perfect by pretending that we are. As long as we repair the ruptures as soon as we can, and bathe them in love and the warmth of us as much as we can, they will be okay.

This also isn’t about not having boundaries. We need to be the guardians of their world and show them where the edges are. But in the guarding of those boundaries we can be strong and loving, strong and gentle. We can love them, and redirect their behaviour.

It’s when we own our stuff(ups) and when we let them see us fall and rise with strength, integrity, and compassion, and when we hold them gently through the mess of it all, that they learn about humility, and vulnerability, and the importance of holding bruised hearts with tender hands. It’s not about perfection, it’s about consistency, and honesty, and the way we respond to them the most.♥️

#parenting #mindfulparenting
Anxiety and courage always exist together. It can be no other way. Anxiety is a call to courage. It means you're about to do something brave, so when there is one the other will be there too. Their courage might feel so small and be whisper quiet, but it will always be there and always ready to show up when they need it to.
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But courage doesn’t always feel like courage, and it won't always show itself as a readiness. Instead, it might show as a rising - from fear, from uncertainty, from anger. None of these mean an absence of courage. They are the making of space, and the opportunity for courage to rise.
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When the noise from anxiety is loud and obtuse, we’ll have to gently add our voices to usher their courage into the light. We can do this speaking of it and to it, and by shifting the focus from their anxiety to their brave. The one we focus on is ultimately what will become powerful. It will be the one we energise. Anxiety will already have their focus, so we’ll need to make sure their courage has ours.
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But we have to speak to their fear as well, in a way that makes space for it to be held and soothed, with strength. Their fear has an important job to do - to recruit the support of someone who can help them feel safe. Only when their fear has been heard will it rest and make way for their brave.
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What does this look like? Tell them their stories of brave, but acknowledge the fear that made it tough. Stories help them process their emotional experiences in a safe way. It brings word to the feelings and helps those big feelings make sense and find containment. ‘You were really worried about that exam weren’t you. You couldn’t get to sleep the night before. It was tough going to school but you got up, you got dressed, you ... and you did it. Then you ...’
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In the moment, speak to their brave by first acknowledging their need to flee (or fight), then tell them what you know to be true - ‘This feels scary for you doesn’t it. I know you want to run. It makes so much sense that you would want to do that. I also know you can do hard things. My darling, I know it with everything in me.’
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#positiveparenting #parenting #childanxiety #anxietyinchildren #mindfulpare
Separation anxiety has an important job to do - it’s designed to keep children safe by driving them to stay close to their important adults. Gosh it can feel brutal sometimes though.

Whenever there is separation from an attachment person there will be anxiety unless there are two things: attachment with another trusted, loving adult; and a felt sense of you holding on, even when you aren't beside them. Putting these in place will help soften anxiety.

As long as children are are in the loving care of a trusted adult, there's no need to avoid separation. We'll need to remind ourselves of this so we can hold on to ourselves when our own anxiety is rising in response to theirs. 

If separation is the problem, connection has to be the solution. The connection can be with any loving adult, but it's more than an adult being present. It needs an adult who, through their strong, warm, loving presence, shows the child their abundant intention to care for that child, and their joy in doing so. This can be helped along by showing that you trust the adult to love that child big in our absence. 'I know [important adult] loves you and is going to take such good care of you.'

To help your young one feel held on to by you, even in absence, let them know you'll be thinking of them and can't wait to see them. Bolster this by giving them something of yours to hold while you're gone - a scarf, a note - anything that will be felt as 'you'.

They know you are the one who makes sure their world is safe, so they’ll be looking to you for signs of safety: 'Do you think we'll be okay if we aren't together?' First, validate: 'You really want to stay with me, don't you. I wish I could stay with you too! It's hard being away from your special people isn't it.' Then, be their brave. Let it be big enough to wrap around them so they can rest in the safety and strength of it: 'I know you can do this, love. We can do hard things can't we.'

Part of growing up brave is learning that the presence of anxiety doesn't always mean something is wrong. Sometimes it means they are on the edge of brave - and being away from you for a while counts as brave.
Even the most loving, emotionally available adult might feel frustration, anger, helplessness or distress in response to a child’s big feelings. This is how it’s meant to work. 

Their distress (fight/flight) will raise distress in us. The purpose is to move us to protect or support or them, but of course it doesn’t always work this way. When their big feelings recruit ours it can drive us more to fight (anger, blame), or to flee (avoid, ignore, separate them from us) which can steal our capacity to support them. It will happen to all of us from time to time. 

Kids and teens can’t learn to manage big feelings on their own until they’ve done it plenty of times with a calm, loving adult. This is where co-regulation comes in. It helps build the vital neural pathways between big feelings and calm. They can’t build those pathways on their own. 

It’s like driving a car. We can tell them how to drive as much as we like, but ‘talking about’ won’t mean they’re ready to hit the road by themselves. Instead we sit with them in the front seat for hours, driving ‘with’ until they can do it on their own. Feelings are the same. We feel ‘with’, over and over, until they can do it on their own. 

What can help is pausing for a moment to see the behaviour for what it is - a call for support. It’s NOT bad behaviour or bad parenting. It’s not that.

Our own feelings can give us a clue to what our children are feeling. It’s a normal, healthy, adaptive way for them to share an emotional load they weren’t meant to carry on their own. Self-regulation makes space for us to hold those feelings with them until those big feelings ease. 

Self-regulation can happen in micro moments. First, see the feelings or behaviour for what it is - a call for support. Then breathe. This will calm your nervous system, so you can calm theirs. In the same way we will catch their distress, they will also catch ours - but they can also catch our calm. Breathe, validate, and be ‘with’. And you don’t need to do more than that.
When things feel hard or the world feels big, children will be looking to their important adults for signs of safety. They will be asking, ‘Do you think I'm safe?' 'Do you think I can do this?' With everything in us, we have to send the message, ‘Yes! Yes love, this is hard and you are safe. You can do hard things.'

Even if we believe they are up to the challenge, it can be difficult to communicate this with absolute confidence. We love them, and when they're distressed, we're going to feel it. Inadvertently, we can align with their fear and send signals of danger, especially through nonverbals. 

What they need is for us to align with their 'brave' - that part of them that wants to do hard things and has the courage to do them. It might be small but it will be there. Like a muscle, courage strengthens with use - little by little, but the potential is always there.

First, let them feel you inside their world, not outside of it. This lets their anxious brain know that support is here - that you see what they see and you get it. This happens through validation. It doesn't mean you agree. It means that you see what they see, and feel what they feel. Meet the intensity of their emotion, so they can feel you with them. It can come off as insincere if your nonverbals are overly calm in the face of their distress. (Think a zen-like low, monotone voice and neutral face - both can be read as threat by an anxious brain). Try:

'This is big for you isn't it!' 
'It's awful having to do things you haven't done before. What you are feeling makes so much sense. I'd feel the same!

Once they really feel you there with them, then they can trust what comes next, which is your felt belief that they will be safe, and that they can do hard things. 

Even if things don't go to plan, you know they will cope. This can be hard, especially because it is so easy to 'catch' their anxiety. When it feels like anxiety is drawing you both in, take a moment, breathe, and ask, 'Do I believe in them, or their anxiety?' Let your answer guide you, because you know your young one was built for big, beautiful things. It's in them. Anxiety is part of their move towards brave, not the end of it.

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