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Original Article

Journal of Evidence-Based
Complementary & Alternative Medicine
Nutritional Aspects to Prevent Heart 2015, Vol. 20(1) 57-64
The Author(s) 2014

Diseases in Traditional Persian Medicine Reprints and permission:


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DOI: 10.1177/2156587214553939
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Gholamreza Kordafshari, MD1, Hoorieh Mohammadi Kenari, MD2,


Mohammad Mehdi Esfahani, PhD1,
Mohammad Reza Shams Ardakani, PhD1,
Mansoor Keshavarz, PhD1, Esmaeil Nazem1,
Maryam Moghimi, MD2, and Arman Zargaran, PharmD3,4

Abstract
Cardiovascular diseases are major health complications currently in various societies. Management of heart diseases as a
prevention step or as treatment with low-cost procedures like lifestyle modifications including nutrition are important current
trends. Although the term nutrition dates back to 2 past centuries, Persian physicians contributed to this term at least from
1000 years ago. Rhazes (865-925 AD) was one of the pioneers in this field. He preferred using foods in treating illnesses. Foods
and drinks were 1 subject from 6 principles (Setteh Zarorieh) that Persian physicians believed can affect human health. In this
review, we described some medieval Persian views on the role of nutrition in heart diseases and compare their prescriptions with
current findings. Interestingly, current investigations mostly support Persian medicine principles. Historically, this work shows
that the concept of nutrition in heart diseases has had a successful background at least from 1000 years ago in Persia.

Keywords
nutrition, heart diseases, traditional Persian medicine

Received July 8, 2014. Accepted for publication July 22, 2014.

Introduction may affect people in families not only because of genetics but
also as a matter of familys behavioral routine and nutritional
Cardiovascular diseases as well as heart diseases are major
habits.3
health complications currently in various societies. Manage-
Heart disease complications are not only burdensome for the
ment of heart diseases as a prevention step or as treatment with person himself/herself but also increase emotional and eco-
low-cost procedures like lifestyle modifications are important
nomic burden for the family and the society. One of the most
current trends.1,2
important strategies for reducing these consequences is to cor-
Before 1900, infectious diseases and malnutrition were the
rect unhealthy family diets.3,5,6
most prevalent reasons of death in the world. It was about
Although attention to the importance of diet as a preventive
40% in high-income countries and 28% in low- to moderate-
factor in heart diseases dates back to past decades,7 historically,
income countries. One fourth of these was sudden deaths.
Changing diseases and death factors in the 20th and 21st cen-
turies has caused a global increase of heart diseases. Nowadays, 1
School of Traditional Medicine, Tehran University of Medical Sciences,
heart diseases are the most widespread and serious diseases in Tehran, Iran
2
developed societies and their prevalence in underdeveloped Qoran, Hadis and Teb Sciences Research Center, Tehran University of
countries is increasing very fast. This change is mainly because Medical Sciences, Tehran, Iran
3
Pharmaceutical Sciences Research Center and Department of
of rapid industrialization, civilization, and, as a result, changing Phytopharmaceuticals (Traditional Pharmacy), Shiraz University of Medical
lifestyles across the entire world, including all races, family Sciences, Shiraz, Iran
4
groups, and cultures. One of the most important changes is peo- Research Office for the History of Persian Medicine and Department of
ples diet.3 In fact, heart diseases are rooted in peoples lifelong History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
unhealthy diet.4
Corresponding Author:
Development increases the use of processed food and hydro- Hoorieh Mohammadi Kenari, MD, School of Traditional Medicine, Tehran
genated vegetable oil and also low level of natural food and University of Medical Sciences, Tehran, Iran.
vegetables utilization, which is the basis for heart diseases. It Email: hmk1358@gmail.com

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58 Journal of Evidence-Based Complementary & Alternative Medicine 20(1)

Figure 2. Sette Zaroorieh (6 principles to keeping health) in traditional


Persian medicine.

Persian physicians views about the role of nutrition in preven-


tion of heart diseases.
Figure 1. A romanticized image of Rhazes (865-925 AD) visiting sick Medieval Persian physicians such as Ibn Sina (Avicenna)
children. and Zakaria Razi (Rhazes) believed that the heart is one of the
most important body organs. Also in historical Persian medi-
nutrition and diet were important subjects for Persian physicians cine references, it is mentioned as one of the chief organs in the
during the medieval age. Rhazes (865-925 AD) was one of the body. Its action is to supply vita to the whole body. The bodys
first pioneers in this field (Figure 1).8 He wrote many special health, strength, and equability is dependent on the health of the
manuscripts on nutrition and dietary regimen in medicine, such heart, because it is the base of human creation and the body is
as Manfe al aghzie va mazareha (Benefits of Food and Its alive and stabled with.12,13
Harmfulness), Atame al marza (Food for Patients), In this study, we provide a description of heart diseases,
Ma iaghdam men al favakeh va al aghzieh va ma yoakhar complications, nutritional facts related to 2 aspects of heart
(Fruits Before or After Meal), Keifiat al eghteza (Tempera- health and heart disease treatment, and also the mechanisms
ment and Quality of Foods), and Al aghziat al mokhtasareh affecting the heart in Persian medicine references such as
(Brief Facts About Foods).8,9 A thousand years ago, he advised Qanon fi al-Teb (Canon of Medicine),12 Exir e Azam (Great
physicians as follows: If a physician can treat a patient with Elixir),13 Teb e Akbari (Akbaries Medicine),14 Mojarrabat e
food he has been fortunate; if patient was not cured, he should Farangi (Foreign Experiences),15 Qarabadin e Kabir (Great
use simple drugs and as last line use compound drugs, or If Qarabadin/Pharmacopea),16 and Makhzan al Adviyeh (Store-
physician can treat a patient with food, he achieves bliss!10 house of Medicaments)17 (Table 1). Also their useful and harm-
After him, attention to nutrition was one of the important princi- ful components from different nutritional groups are discussed
ples to keep health in Persian medicine. Overall, Persians and compared with current findings in medicine. Furthermore,
believed that 6 main subjects (called as Sette Zaroorieh, or 6 nutritional strategies to prevent and treat heart diseases are
principles) can affect body health including air (cleanness, tem- being evaluated and then useful and harmful nutritional compo-
perature, and geographical situation), nutrition (food and drinks), nents are discussed based on traditional Persian medicine.
exercise, sleep and wake, exertion of unnecessary materials from
the body, and finally physiological concepts (Figure 2). Persian
physicians believed prevention of diseases is in following the
Persian Medicine
principles well.11 The history of Persian medicine is divided into 2 main parts:
Regarding to this brief explanation about the importance ancient era (before Islam, from the beginning of history to
of nutrition to prevent diseases, we aim to consider Medieval 637 AD) and Islamic period (medieval age).18,19 Persian med-
icine started from ancient times.20 It seems that Persians started

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Kordafshari et al 59

Table 1. The List of Persian Manuscripts Used in This Article. Table 3. The List of Medicinal Plants Mentioned in the Article.

Persian Name of English Translation Date of English


Manuscript of Manuscript Title Author Writing Persian Common Scientific
Name Name Name Family
Qanon fi al-Teb Canon of Medicine Avicenna 1025 AD
Teb e Akbari Akbaries Medicine Arzani 1700 AD Sib Apple Malus domestica Borkh., Rosaceae
Makhzan al Storehouse of Medicaments Aghili Shirazi 1771 AD 1803
Adviyeh Golabi Pear Pyrus syriaca L. Rosaceae
Qarabadin e Great Qarabadin/ Aghili Shirazi 1772 AD Beh Quince Cydonia oblonga Mill. Rosaceae
Kabir Pharmacopea Reyhan Basil Ocimum basilicum L. Lamiaceae
Exir e Azam Great Elixir Azam Khan 1810 AD Nana Peppermint Mentha  piperita L. Lamiaceae
Mojarrabat e Foreign Experiences Doon Kheiri 1838 AD Gol Sorkh Damask rose Rosa damascena Mill. Rosaceae
Farangi Pesteh Pistachio Pistacia vera L. Anacardiaceae
Zaferan Saffron Crocus sativus L. Iridaceae
Sir/Soom Garlic Allium sativum L. Amaryllidaceae
Table 2. Four Temperaments in Persian Languages. Limoo Persian limes Citrus  latifolia Tanaka Rutaceae
Anar Pomegranate Punica granatum L. Lythraceae
Common Sassanid Pahlavic Medieval Zereshk Barberry Berberis vulgaris L. Berberidaceae
English (Ancient Persian) Persian Narenj Sour orange Citrus  aurantium L. Rutaceae
Name Name Name Quality Darchin Cinnamon Cinnamomum verum Lauraceae
J.Presl
Blood Xon Xon-Dam Hot and wet Zireh Sabz Cumin Cuminum cyminum L. Apiaceae
Phlegm Blagm Balgham Cold and wet Mikhak Clove Syzygium aromaticum (L.) Myrtaceae
Yellow bile Wis i suxr Safra Hot and dry Merrill & Perry
Black bile Wis i sya Soda Cold and dry Hel Cardamom Amomum subulatum Zingiberaceae
Roxb.
Ananas Pineapple Ananas comosus (L.) Merr. Bromeliaceae
the paradigm of humorism for the first time and then it became Sfenaj Spinach Spinacia oleracea L. Amaranthaceae
a worldwide theme of medicine in ancient age and later in Kadoo Pumpkin Cucurbita pepo L. Cucurbitaceae
medieval age.21 This paradigm was based on 4 temperaments Piaz Onion Allium cepa L. Amaryllidaceae
including blood, phlegm, black bile, and yellow bile (Table 2). Mash Vetch Vicia spp. Fabaceae
Ancient Persia was the time of great empires. Achaemenids Badam Almond Prunus amygdalus Batsch Rosaceae
Otroj Citron Citrus medica L. Rutaceae
(550-330 BC), Parthians (247 BC-224 AD), and Sassanids Tamr Tamarind Tamarindus indica L. Fabaceae
(224-637 AD) were the main ancient Persian dynasties. They Geshniz Coriander Coriandrum sativum L. Apiaceae
were the main civilized and powerful governments in the ancient
world. Medicine was well organized in these empires, especially
in the Sassanid period. Advanced medical organizations and 1. Sometimes after hunger and insufficient food intake for
laws, medical councils, hospitals, medical universities, and so some days, low-quality blood will be made in the body,
forth, are some examples of advanced structures in ancient Per- which causes body weakness. Then we have to use the
sian times.21,22 In the Sassanid dynasty, Jundishapour University foods that strengthen the heart such as meat gravy, soft
and Hospital in south west Persia was the main medical center in boiled egg, apple (Malus domestica Borkh., 1803), pear
the whole world.23 In the early Islamic period, when Persians (Pyrus syriaca L.), quince (Cydonia oblonga Mill.),
lost their political strength, they showed more interest toward basil (Ocimum basilicum L.), peppermint (Mentha 
science, especially medical knowledge. Medical science was piperita L.), rose water, pistachio (Pistacia vera L.),
popularized and spread by Persian scientists such as Akhawayni, and saffron (Crocus sativus L.).13
Rhazes, Avicenna, Hally Abbas, Jorjani, and others during 9th to
12th century AD.24-29 During later centuries, the growth of med- Also, we can see some combination foods such as formula-
ical sciences decreased but continued in Persia until Renais- tions given below:
sance. After Renaissance, gradually the Persian holistic
paradigm of medicine (humoral theory) was replaced by the cur-  Apple regimen: 7 to 8 glasses of apple juice, or couple of
rent concept of medicine (molecular paradigm) worldwide.30 cups from apples faloodeh (a traditional formulation) or
10 to 15 apples per day.
 Saffron syrup is very useful for heart diseases and body
Result weakness. Put 1 teaspoon of saffron in 2 glasses of hot
water and let it infuse. Then add some water, rosewater,
Nutritional Strategies for Heart Disease Treatment
honey, or sugar and drink it.
In medieval Persian manuscripts, we can find some main stra-
tegies about using foods and drinks in heart-related complica- 2. Persian physicians believed that sometimes heart vessel
tions. Some of these strategies are listed below. obstruction occurs following ingestion of foods that

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60 Journal of Evidence-Based Complementary & Alternative Medicine 20(1)

make low-quality blood in the body. So for resolving 5. Patients who have moist temperament on heart and
the obstructions and also treating high blood pressure, symptoms such as excitement rapidly influencing the
the instruction given below was suggested by the patient the effect disappearing soon.14 In such diseases
Persian physicians: the most important strategy is decreasing the amount of
food intake. Some simple foods suggested by Persian
physicians are the following:
Add 30 garlic (Allium sativum L.) beans to 5 fresh limes (Citrus
 latifolia Tanaka) (with peels having some cuts on them) and  Chicken soup with bread
mix them until a paste was formed. The resultant paste must be  Grilled chicken meat
added to 1 liter of water and boiled on a low flame. Let the mix-  Apple syrup
ture get cold. Then filter and keep it in the refrigerator. Drink  Minted pomegranate syrup
50 cc before breakfast for 40 days. Repeat it every 6 months  Sekanjabin (Oxymel): Mix the same amount of honey
to 1 year.15 and vinegar. Then boil it on mild flame for 15 seconds
to be homogenous.12-15,17

6. Patients who have dry temperament on heart and the


3. Patients who have heat temperament on heart, with
symptoms are leanness, insomnia, and dry cough and
symptoms of palpitation, restlessness, thirst, and feel
also can be explained as excitement not easily affecting
the need for breathing in cold air.14
the patients, but if they do, the effect remains for long
time.14
 Avicenna said the following: Eating fruit sauce, espe-
cially apple and quince sauce, is the treatment for such In such conditions, Persian physicians believed that patients
patients.22 have to eat moisturizing foods, and if coldness is also there with
 Drinking apple, pomegranate (Punica granatum L.), dryness, they must avoid cold water. Some of suggested foods
quince, and lime syrup with rosewater and sugar is use- and drinks are the following:
ful. Barberry (Berberis vulgaris L.) and verjuice are also
helpful.13-15  Fresh milk (in case of no fever)
 Lime syrup: Pour some sugar in a jar and add as much as  Pineapple (Ananas comosus (L.) Merr.) juice
lime juice to cover it up. Then close the jar and put it in  Spinach (Spinacia oleracea L.), potage, pumpkin
room temperature for 24 hours. Then filter the resultant (Cucurbita pepo L.), kid or lamb meat cooked with
mixture and boil with some more lime juice. Dilute it onion (Allium cepa L.), and dried vegetables with spices
with water on administration. useful for heart
 Sour orange (Citrus  aurantium L.): Boil the sour  Peeled vetch (Vicia spp.) with almond (Prunus amygda-
orange juice (400 g) with 2/3 of that from sugar and lus Batsch) oil, spinach, and cucurbit.
some rosewater on a mild flame.16  Porridge cooked from wheat flour, almond oil, milk, and
 Pomegranate syrup: Boil the pomegranate juice with sugar.12,13,15
rock candy. Even in favor of heart health or regarding heart disease treat-
 Rice and chicken, flavored with lime juice, verjuice, and ment, laxatives have to be taken to avoid constipation, so that
barberry. accumulation of harmful substances and their vapors cannot
 Chicken soup with pomegranate juice, verjuice, or lime harm the heart.12,13
juice.13-15
7. Prohibiting advices for general heart complications.
4. Patients who have cold temperament on heart with People have to avoid the conditions listed below, even
symptoms of slow pulses, shallow breathing, pallid for retaining heart health or to treat heart diseases:
skin, and total body weakness, anxiety, and phobia.14
Persian physicians suggested the following:  Excessive use of cold tempered food without adjuster
 Surfeiting foods that make harmful vapors, like onion
 Patient has to avoid eating cold temperament foods and  High-fat foods, high-density tea, coffee, cocoa, and
cold water as much as possible. excessive use of meat12,13
 Birds meat such as partridge, pet hen, pigeon, sparrow,
and francolin cooked with hot temperament spices such
as cinnamon (Cinnamomum verum J. Presl), saffron,
Some Examples of Nutrients Effective in Retaining
cumin (Cuminum cyminum L.), clove (Syzygium aroma-
ticum (L.) Merrill & Perry), and cardamom (Amomum
Healthy Heart
subulatum Roxb.). Hakim Azam Khan, one of the last medieval Indo-Persian phy-
 Soft boiled yolk with cinnamon.13-15 sicians, categorized some of the nutrients that are suggested to

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be effective in heart health in his great medical encyclopedia view, useful meats for heart health such as young lamb and
Exir Azam: chicks contain different nutrients, can be digested fast and eas-
ily, and cause good blood production in the body.
Meats: Fat-less lamb or young kid, small fishes, birds Persian physicians believed that eating the heart of animals
with soft meat such as pet hen, sparrow, francolin, used regularly for their meat causes merriment in patient and so
pigeon, and the heart of halal animals is useful for the heart. The aforementioned fruits and vegeta-
Fruits: Sweet and ripe apple and pear, quince, pomegra- bles also contain nutrients and vitamins, reinforce the heart,
nate, lime, sour orange, citron (Citrus Medica L.), and avoid the accumulation of harmful substances in heart and
tamarind (Tamarindus indica L.), and pineapple vessels.12-17
Vegetables: Peppermint, basil, coriander (Coriandrum From traditional medicine point of view, eating apples is
sativum L.) joyful and is heart reinforcing, especially if used with rose-
Others: Lamb, kid or above-mentioned birds meat gravy, water.12,13,17 Modern medicine articles also claimed that eating
soft boiled yolk, rose water, saffron, cardamom, cinna- apple and apple juice reduces the low-density lipoprotein oxi-
mon, pistachio, fruit juices, syrups, and jams made dation in a healthy person31 and prevents hypercholesterole-
from aforementioned fruits.13 mia, oxidative stresses,32 and arthrosclerosis,33 and so
reduces risk of heart diseases.
Some examples of useful foods frequently advised by
According to Persian medicine, sweet pear also regulates the
Persian physicians for heart that are made from above-
blood and is breezy and heart reinforcing agent.17 A study in
mentioned materials are as follows:
Mexico in 2010 claims that having a pear every day will
Medical Jollab syrup: Boil 1 kg of sugar with 3 kg rose- decrease the cholesterol level in smoking people34 and so pre-
water on a mild flame; put the foam away until it vents heart diseases in people who have 2 risk factors of smok-
reaches half its size. Then add 1 g powdered saffron. ing and high cholesterol level.
Keep the resultant mixture in a jar; dilute it with water Aghili Shirazi mentioned that pistachio is also very aromatic
at the administration time and drink. and so heart reinforcing in his manuscript.17 A study in United
Apple Faloodeh: Mix grated apples with little bit of rose- States in 2012 showed that pistachio decreases systolic blood
water and honey. pressure in dyslipidemic patients.35 Another study claimed that
Apple syrup: Put some apple juice on the flame to reach pistachio decreases the plasma level of oxidized low-density
half in volume. Then filter and put it aside for 1 night. lipoprotein in hypercholesterolemic patients.36 Also, smelling
Then again put it on the flame to be concentrated. Fil- aromatic fruits and vegetables such as apple, quince, and basil
ter it again and pour it in a jar. If it is summer time, is effective in heart reinforcement.
expose it in sunshine for some days to vaporizing its Although all the mentioned food substances are good for
water. Keep it in a glass bottle. If you want it sweet, keeping the heart healthy, different foods will be chosen
add 450 g sugar per 3 kg apple juice and consolidate depending on the nature of the patient and disease and also the
it.12-17 patients temperament (individual medicine).
Among the foods effective in retaining health and also for
All the plants mentioned in this article listed in Table 3. cardiac patients, saffron has a special role. From the traditional
medicine point of view, saffron increases the tendency and
penetration of nutrients and medicines to the heart. Also, it
Discussion is breezy and a heart reinforcing agent. Avicenna and other
From the medieval Persian physicians point of view, heart Persian scholars recommended adding saffron to the combina-
cannot tolerate regular diseases because of its sensitivity and tion of medicines for patients with heart diseases so that leading
key function, and therefore, its affliction to some of these dis- and penetration of medicines to the heart will be better.12,13
eases causes death. So it deserves to have the physicians high- From the modern medicine perspective, saffron prevents
est attention toward its health and diseases prevention.12,13 cholesterol, triglycerides, and low-density lipoprotein elevation
Modern medical references concede that general health was and also avoids their residuum in vessels.37
mainly based on primary prevention (health improvement) and Also in patients who have a history of cardiac infarction,
in next level on secondary prevention (treatment and rehabili- saffron decreases the size of the infarcted area and prevents
tation) in prior time.4 myocardial ischemia-reperfusion damage.38 Also, it retains
Persian scholars have mentioned some facts useful to retain hemodynamic balance and protects left ventricle action against
heart health, such as avoiding awful odors and smelling aro- myocardial defection.39 Antihypertensive effects of saffron
matic plants and fruits instead and stopping anger, sorrow, have also been proved in some investigations.40
obsessive thoughts, sudden excitements, longsome awakening, Persian physicians believed that to eliminate cardiovascular
excessive activities, massive sports, and also paying attention obstructions and also reduce blood pressure, a mixture of garlic
to the nutritional facts, which is very important.12-14 and lime can be used. From the traditional medicine point of
Foods affecting the heart can prevent heart diseases with dif- view, garlic is blood diluter and eliminator of harmful and thick
ferent mechanisms. From Persian traditional medicine point of substances.17 Lime is also an anti-inflammatory agent and the

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62 Journal of Evidence-Based Complementary & Alternative Medicine 20(1)

eliminator of improper and harmful substances.17 In current temperament are highly recommended by Persian physicians of
medicine, the efficacy of garlic in reducing blood pressure has the medieval age. Many of their recommendations also are con-
been shown.41-43 firmed by current medical findings. Their medical views on the
Medieval Persian physicians believed that aforementioned role of nutrition in heart diseases are historically important and
fruits such as apple, pomegranate, and citrus are effective in can show a part of history of cardiology in medieval time. Also,
heart with hot temperament, and are also anti-inflammatory, by comparing them with current findings, some new ideas can
heart heat eliminator, and anti-thirst agent.12-17 In modern be formed to help current approaches to prevent heart diseases
medicine, eating pomegranate is very effective on the vascu- using natural foods and drinks.
lar system. It decreases atherosclerotic area and also intima-
media thickness in cardiac patients vessels under medical Authors Note
treatment.44 Pomegranate decreases systolic blood pres- This work is a part of a PhD thesis (No. 101) presented in the School of
sure,45 and citrus will prevent negative oxidative stresses Traditional Medicine, Tehran University of Medical Sciences.
on myocardium.46
Aghili Shirazi mentioned that barberry and verjuice as food Author Contributions
spices can be used in these diseases, reliving thirst and resol-
GK, HMK, and MM wrote the preliminary draft and contributed in
ving the heat temperament heart symptoms.17 In current stud- data gathering and first idea of starting this project. AZ rewrote the
ies, antihypertensive and vessel dilating effects of barberry draft and contributed in data gathering and writing the final version
have been reported.47 Also, barberry has been shown to prevent of the article. The other coauthors contributed in the guidance, revi-
myocardial ischemic-reperfusion defects.48 According to Per- sion, and correction of the article.
sian medicine, in food regimen for patients with cold tempera-
ment on heart, hot tempered spices such as cinnamon, saffron, Declaration of Conflicting Interests
cumin, and cardamom should be included, which are effective The authors declared no potential conflicts of interest with respect to
for treatment.17 the research, authorship, and/or publication of this article.
One of the important suggestions in moist temperamental
heart diseases is to use Sekanjabin (Oxymel). In traditional Funding
medicine, Sekanjabin is moderately hot tempered (moderate
The authors received no financial support for the research, authorship,
heat) and is useful to eliminate excessive moist.16 In dry tem-
and/or publication of this article.
pered heart diseases, suggested foods to return moistness to the
body are milk, spinach, vetch, almond, and cucurbit. According
Ethical Approval
to Persian medicine, fresh milk is body reinforcing and fatten-
ing agent and also can retain body moisture. Spinach is fast Ethical approval is not required for this study as no human subjects
digested and can produce high-quality blood in the body and were involved.
returns the moisture to the body. Cucurbit also produces good
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