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“Breast Cancer Survivorship Lifestyle Guidelines – Part I – Healthy Weight and Physical Activity”

Body weight and exercise and their relationship to something as complex as breast cancer may seem too daunting to consider, but a fairly large body of evidence suggests that these factors absolutely relate to risk and outcome. A 2003 paper in the New England Journal of Medicine looking at the relationship of body weight and malignancy found that the heaviest participants were at greatest risk of developing multiple malignancies.

This week’s post is the first of a three-part series sharing insights and highlights from “Cancer Survivorship Lifestyle Guidelines: Time for Action”, a session I attended in October at the Academy of Nutrition and Dietetics Food and Nutrition Conference and Exhibition.

With a strong nod to reducing recurrence risk, this session focused on two specific areas of research; nutrition and physical activity, with the often-cited 2012 ACS Guidelines Nutrition and Physical Activity (currently undergoing a revision expected to be available soon) serving as the starting point.

This two-part program: (1) achieving and maintaining a healthy weight/physical activity presented by Dr. Jennifer Ligibel, Dana Farber Cancer Institute breast oncologist, and (2) diet, nutrition, functional foods, and supplements presented by Dr. Wendy Demark-Wahnefried, RD, chair of nutrition sciences and board member/advisory panel for ASCO Energy Balance Working Group and National Comprehensive Cancer Network, Survivorship Panel presented research supporting up-to-the-minute recommendations, and highlighted the challenges in sharing those recommendations with the cancer community and beyond.

The program was so content-rich, I actually need three posts to get it all in, so this week we’ll begin with an overview and background of obesity and physical activity.

Where’s the Evidence?

An overview of the data suggests that obesity and inactivity are linked to a higher risk of recurrence and mortality in early stage, potentially curable disease. Although Dr. Ligibel is a breast oncologist, she presented research supporting this connection for a number of cancers, including colorectal and prostate. Because I speak to the breast cancer community, I’ll focus on those outcomes in this post, but please keep in mind that regardless of the type of cancer you’re looking to reduce your risk of, or have been diagnosed with, this information applies.

One of the questions Dr. Ligibel posed was; “What happens when we take someone diagnosed who is overweight or obese and not exercising, and we help them lose weight and exercise more – how do those interventions affect outcomes and quality of life?”

Obesity and Breast Cancer Outcomes

Observational Evidence

Weight and exercise and their relationship to something as complex as breast cancer may seem too daunting to consider, but a fairly large body of evidence suggests that these factors absolutely relate to risk and outcome. A 2003 paper in the New England Journal of Medicine looking at the relationship of body weight and malignancy found that the heaviest participants were at greatest risk of developing multiple malignancies. (1)

Studies linking body weight at time of diagnosis to risk of recurrence and mortality is best studied in breast cancer, with over 100 studies looking at the relationship of a woman’s weight at time of diagnosis of breast cancer and risk of breast cancer mortality.

A meta-analysis summarized 82 reports of >162,000 women with early cancer. Women who are obese when diagnosed with breast cancer have a 35% higher risk of dying from breast cancer as compared to women of normal body weight. The relationship of obesity and poor outcomes in early cancer was seen in both younger and older women; suggesting “a prognostic factor for a large group of breast cancer patients.” (2)

Criticism

Prospective cohort studies don’t include a lot of information about the treatment women received, yet we do have current studies indicating how chemotherapy treatment that is both different and the same impact outcomes.

Dr. Ligibel shared that obesity is a disease that can influence oncologists’ prescribing of chemotherapy. For example, a doctor may not prescribe as aggressive a chemotherapy regimen for an obese versus a leaner patient.

Chemotherapy is prescribed based on body surface area, indicating that heavier women would require an increased dose. The oncologist may “cap the dose”, or use ideal versus actual body weight, a practice that can influence outcomes. If not enough chemo is used, obese patients may do poorly, not because of their weight, but because of the treatment they received. (3)

A study from the late 1990’s that tested common chemo drugs still used today, in concert with a more recent study looking at BMI (body mass index) and outcomes in node-positive breast cancer, indicate that women with a BMI in the normal range have better outcomes, lower risk of recurrence, and better overall survival compared to women who were overweight or obese.

BMI was shown to be an independent predictor of recurrence and overall mortality; each unit increase in BMI corresponded to a 1.5% increase in the risk of recurrence, for example: BMI 22-27 = 8% increase, 22-32 17% increase, despite the fact that all women received identical chemotherapy treatment. (4)

Physical Activity, Cancer Risk and Outcomes

There is a growing body of literature, although at this point not quite as vast as the hundreds of studies on obesity and breast cancer, linking physical activity patterns after diagnosis and the risk of cancer-related and overall mortality, as well as cancer risk and outcomes.

For breast cancer, there is a relatively limited number of studies – yet consistent findings – indicating that engaging in physical activity can lower the risk of cancer-related and overall mortality when compared to women who are inactive.

Inactivity in cancer survivors is common, with only approximately one-third of cancer survivors engaging in regular activity, and a full one-third not engaging in any physical activity at all. Of course, physical activity certainly can be impacted by cancer diagnosis and treatment: studies have indicated that women decrease exercise by an average of one-third after diagnosis. (5)

Intervention – Can It Help?

We know that obesity and inactivity are linked to poorer outcomes at diagnosis and are definite risk factors, yet health professionals can intervene and help to improve prognosis by helping patients exercise more and lose weight.

Dr. Ligibel posed this question, “Can we help change by intervening? What do we really know about weight loss and physical activity interventions in people with cancer?”

We know that health professionals can actually help people at this phase of their lives change behavior, exercise more and lose weight.

Dr. Ligibel asked, “Why would losing weight and exercising more be different for breast cancer patients than any other person?” Her response, “This is hard for people in general, but there are different aspects that make it easier in some ways – people are very motivated in seeking change. Yet there are also barriers; cancer therapy leaves people tired, gives side effects like neuropathy, and other things that make implementing exercise more difficult.”

So what does this accomplish? How does it make people feel when they change their fitness levels? Does this have an impact on long term outcomes, risk of recurrence and overall mortality?

Join me next week as I wrap up this section with exciting outcomes highlighting what current literature shows.

RESOURCES

(1) Overweight, Obesity, and Mortality from Cancer in a Prospectively Studied Cohort of U.S. Adults

(2) Body mass index and survival in women with breast cancer—systematic literature review and meta-analysis of 82 follow-up studies

(3) Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741.

(4) Body Mass Index, PAM50 Subtype, and Outcomes in Node-Positive Breast Cancer: CALGB 9741 (Alliance).

(5) Changes in Body Fat and Weight After a Breast Cancer Diagnosis: Influence of Demographic, Prognostic, and Lifestyle Factors

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“Why You MUST Make This a December to Remember”

 

What is it about the holiday season that sends us into frenzied, wild abandonment of the tried and true habits that keep us sane, fit, limber, focused, grounded, nourished and strong (mentally AND physically) the remaining 11 months of the year?

I honestly don’t know.

Well, that’s not entirely true. From my years in private practice I have a few ideas (with science to back me up), but I don’t know what it is that drives YOU into the space of wild abandonment.

As we welcome December, what do you say we make it one to remember by taking a different approach – a more centered, deliberate, mindful approach – in an effort to greet January with open arms rather than a laundry list of regrets.

If you’re anywhere on the breast cancer path; newly diagnosed, in treatment, in survivorship, or living with metastatic, daily decisions about the food you put into your body, the exercise you do (or don’t), the time you get yourself to bed (and up in the morning), the people you surround yourself with, the dialogue in your head, the multitude of self-care choices you make every, single minute of every, single day can take on a new urgency.

Especially during the holidays, and it doesn’t matter which one you observe – Christmas, Hanukkah, Kwanzaa or a mish-mosh of them all – the volume of self-care decisions also escalates. Successfully navigating the special holiday foods, booze, late nights, restaurant meals, and power-shopping fortified with fast-food stops and gigantic, seasonal, coffee-as-dessert drinks is enough to make you throw your hands up and simply cave to “taking care of myself takes a backseat”

There’s a litany of research suggesting the “best” approach to breast cancer and food/fitness/sleep/self-care, yet those well-intentioned recommendations can make you feel like one false move is enough to invite a new or escalated bout of breast cancer – and aren’t the holidays just riddled with landmines of false moves?

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Angst-Producing Issue #1 – “Am I eating the “right” foods?

Consider. . .You’re so afraid of eating the “wrong” things that you restrict the holiday foods you enjoy the most, only to end up bingeing when no one’s looking on candied sweet potatoes, rugelach, or sugar cookies.

The Science. . .We don’t yet have definitive guidelines on specific foods that absolutely reduce risk of breast cancer recurrence or mortality, but we do have good data to suggest that dietary PATTERNS and the synergy of nutrients are just as important as individual foods. The science supports a dietary pattern heavy on fruits, vegetables and fiber, and light on added sugars and fats. How to reconcile THAT recommendation with sugar plums and mac-n-cheese? (1)

December to Remember Approach. . .

  • Aim to reduce added sugar and fat when you bake or cook.
  • For most recipes, you can easily reduce the sugar by at least one-third (typically more) without compromising taste or texture. (2)
  • Cut back on the amount of oil used in sauteing (or substitute wine, water or broth instead) and in salad dressings. Healthy fats are important for healthy diets, but remember, “Yes, Virginia, there is a calorie connection.”
  • Combine butternut squash with a reduced amount of cheese in that mac-n-cheese dish to reduce fat AND increase fiber/veggies.

Be Kind to Yourself. . .Don’t deny yourself any special holiday foods, and kick to the curb the guilt you feel for enjoying those special foods. Guilt is a useless emotion, so give away its place at the holiday table.

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Angst-Producing Issue #2 – “Am I exercising enough and doing the “right” type of exercise?

Consider. . .You’re either heading into the holiday season de-conditioned and feeling overwhelmed (and again, guilty) about it, or already fit and looking to ratchet up your activity to counteract all of that holiday eating. You either wallow in guilt and eat to ignore how you feel about being out of shape, or kill yourself to fit in your workout even when sleep may be a better option (see #3 below).

The Science. . .We know that exercise can reduce the risk of diagnosis and recurrence, improve energy and reduce pain for advanced breast cancer, and helps everyone in managing stress, anxiety and depression. Current recommendations are for 150 minutes per week of deliberate physical activity, using a combination of cardiovascular, strength training, and flexibility and balance exercises (3, 4).

December to Remember Approach. . .

  • Schedule and prioritize your exercise; use a calendar, set a reminder, make a date with a friend/family member to “meet and move”. Scheduled gets DONE!
  • A little bit is better than none. Hard to believe, but your body responds to even the slightest increase in physical activity, so yes, doing 15 minutes at times you can’t find 30 is still beneficial.
  • Do exercise that you enjoy. This sounds old and trite, but it’s so true! If you try to do a type of exercise that you hate, you will not do it. Ever. Stop trying to trick yourself. . .it won’t work.
  • Get the exercise in consistently, but don’t forget to also pay attention to food portions and quality. You simply can’t out-run/lift/swim/dance a crappy diet (5).

Be Kind to Yourself. . .Missing a workout doesn’t mean your previous hard-won efforts evaporate. Just get right back to consistency as soon as you can. A break in a workout schedule doesn’t mean a break-up with your fitness routine. And if you’re just starting out? Start slowly, listen to your body, and keep going!

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Angst-Producing Issue #3 – “Am I sleeping enough or too much?

Consider. . .You cut back on sleep in order to bake one more batch of cookies, wrap a couple of gifts, send out a few more invitations, or fill your online cart in the wee hours of the night. It just feels so productive, doesn’t it? Not so fast, you creator of “must-be-perfect-holiday” you.

The Science. . .There is interesting research to suggest that getting less than the recommended amount of sleep (7-8 hours/night for adults) may be connected to some cancers, breast cancer included. Connection doesn’t mean causation, and the jury is still out on the definitive science here. But it is important to realize there’s something there, so adding good sleep hygiene to your arsenal of breast cancer management tools isn’t a bad idea. Not to mention, inadequate sleep can throw off appetite, hunger and satiety, which can lead to overeating and choosing foods that are less than nourishing (6, 7).

December to Remember Approach. . .

  • Establish a bedtime routine. It works for kids (if you have/had them, you made sure they followed it!), and you’re just a grown-up kid – it’ll work for you, too.
  • Take a hot bath/shower, climb into your cozy bed and read a (non-stimulating, non-backlit) book, sip herbal tea.
  • Buy yourself special holiday pajamas; they’re not only fun, they’ll signal BEDTIME in your mind when you wriggle into them at the end of a long day.
  • Set a reminder, timer or a schedule to GO TO BED. Seriously. If you disregard your body’s signals to sleep, sometimes a little extra (auditory)  nudge can help.

Be Kind to Yourself. . .Sleep is cathartic. It heals, it energizes, it restores. Why do you think sleep deprivation is considered a torture tactic?? Because, it is. Do yourself a favor and get your zzzzz’s.

Sources:

(1) Foods That Fight Cancer

(2) Is It Possible to Reduce Sugar in a Baking Recipe?

(3) Physical Activity and Cancer

(4) Exercise Can Counteract Treatment Side-effects, Improve Cardiovascular Fitness in Women with Advanced Breast Cancer

(5) Diet Tops Exercise for Cutting Weight, Cancer Risk

(6) Lack of Sleep Increases Your Risk of Some Cancers

(7) Good Sleep May Improve Breast Cancer Survival

_____________________

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“How a FULL Fridge, Gas Tank, Home & Heart Can Help Your Health”

“Contentment is not the fulfillment of what we want, but the appreciation for what we have.”

Just as I drifted off to sleep last night, the word “FULL” popped into my mind, and I heard (yes, heard) the message that “FULL” needed to be the theme for my blog this Thanksgiving week (to all of my readers outside the U.S., please indulge today’s focus on this very American holiday!).

A quick blog it will be – as well as a bit of a departure from my usual writing topics – as I’m heading off to spend a significant amount of time in my kitchen preparing for the Thanksgiving festivities. . .lucky me!

So here goes.

FULL is what I wish for your refrigerator, your gas tank, your home during the holidays (and beyond,) your heart.

And here’s why.

FULL = bounty. BOUNTY = sharing. SHARING = caring (for yourself and others.)

__________________________

A FULL refrigerator is not something everyone has, and something we often take for granted.

  • A refrigerator FULL of food provides the means to nourish yourself, your friends and family, and anyone else you happen to welcome into your home. A FULL refrigerator offers choice, variety, a feeling of contentment.

A FULL gas tank is not something everyone has, and something we often take for granted.

  • A gas tank FULL of gasoline means FREEDOM. You can go wherever you want, whenever you want; and when you run low on gasoline, you can drive yourself off to get more. You can drive to the gym, the grocery store (to make your refrigerator FULL), the in-laws, a friend’s house, the park, a vacation, a party. Or, you can let the car sit and go NOWHERE, content in the knowledge that you can if you want to.

A FULL home is not something everyone has, and something we often take for granted.

  • A home FULL of love, peace, joy, contentment and gratitude offers a respite from a world that can be cruel and harsh. While we can’t completely avoid that cruelty and harshness, having a safe place to land at the end of the day, a place where WE’RE in charge of what we allow into our mind, our psyche, our soul, is critical to our well-being. And if your home is FULL of family and good friends during the holidays and beyond, so much the better.

A FULL heart is not something everyone has, and something we often take for granted.

  • A heart FULL of all the things that make you feel grounded, content and centered (see the list above) supports living from a place of gratitude. Sure, there are days when our heart may feel empty of all the good stuff – yet we are in charge of refilling it. FULL hearts are the drivers of good things – and we can all use more of THAT.

_____________________________

That’s it.

What’s all this have to do with wellness, health, breast cancer risk reduction, and all the other topics I generally write about?

It’s all connected, my friends.

“Self-care” is at the root of all the work I do, and if you’re feeling empty in any area of your life, you may not feel like practicing “self-care.”

And that’s when things start to slip.

And that feeling of contentment (did you notice a pattern with that word?!)?

It takes off too, leaving you struggling to figure out exactly what it is you need more of to feel better, when typically it’s something you need LESS OF (junky food, alcohol, self-medication, screen-time, sedentary-ness) in order to make room for the stuff that truly helps.

My goal for you this week? Work to FILL UP the areas of your life that need a little tending. . .it will serve you well as you move into the full-blown holiday season.

Wishing you joy.

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“How Targeted Nutrition May One Day Eliminate Your Breast Cancer Risk”

Purchased this in 2007! #aheadofmytime

“Essentially, “nutrigenomics” is the study of the effects of foods and food constituents on gene expression. Identifying the effects of individual nutrients or an entire nutritional plan based on an individual’s genotype allows for a customized nutritional “prescription” targeting unique and specific health needs. | What I love about nutrigenomics is the focus on wellness and prevention rather than the treatment of disease. While nutrigenomics is not yet mainstream, consumer awareness and demand combined with robust scientific evidence (the ability to replicate studies) is moving us toward the day when a prescription for a targeted eating plan will be as common as a prescription for penicillin.”  – Cathy Leman, MA, RD, LD

Nutrigenomics [nutri-gen-O-mics] is a term that may be new to you, and why wouldn’t it be?

Unless you’re steeped in the world of nutrition (and genetics) and prevention, nutrigenomics wouldn’t necessarily be on your radar, yet it’s a fascinating area of nutrition and I’m excited to give you a quick introduction here.

My first experience with nutrigenomics was somewhere in the early 2000’s when I attended a workshop on functional nutrition. I’ll never forget how Ruth DeBusk, PhD, RD (a nutrigenomics guru, btw) shared the concept of using nutrition to “switch” certain genes off and on. I was captivated by what that could mean for the future of nutrition and disease management and prevention, and my work continues to be influenced by that idea today.

Consider this. A simple DNA cheek swab reveals breast cancer genes that could be modified with targeted dietary advice. What if that advice was simply to eat an apple every day, because nutritional constituents identified in that apple were known to reduce or eliminate that particular individual’s risk of developing breast cancer. For someone else, the same cheek swab reveals apples INCREASE the risk of developing breast cancer. Advice to skip the apple and eat the fruit(s) identified to decrease risk would be life-changing.

Can you imagine?

Essentially, nutrigenomics is the study of the effects of foods and food constituents on gene expression. Identifying the effects of individual nutrients or an entire nutritional plan based on an individual’s genotype allows for a customized nutritional “prescription” targeting unique and specific health needs.

What I love about nutrigenomics is the focus on wellness and prevention rather than the treatment of disease. While nutrigenomics is not yet mainstream, consumer awareness and demand combined with robust scientific evidence (the ability to replicate studies) is moving us toward the day when a prescription for a targeted eating plan will be as common as a prescription for penicillin.  

At the recent Academy of Nutrition and Dietetics conference, I attended “Nutrigenomics: Is It Ready for Prime Time?”, presented by Ahmed El-Sohemy, PhD, adjunct professor in the Department of Nutritional Sciences at the University of Toronto, and the Canada Research Chair in Nutrigenomics, who outlined a solid argument for why we should even “bother” to consider nutrition and genetics/genomics.

Quite simply, one nutritional protocol does not fit all.

Take caffeine, one example highlighted during the talk. Depending on an individual’s genotype (the underlying genetic information encoded in a chromosome), caffeine can have an increased, decreased, or zero effect on health outcomes. If you’re someone who experiences elevated blood pressure or heart rate when you eat or drink anything with caffeine – wouldn’t you want to know more about how to manage that?

For now, we use broad nutrition recommendations supported by research that, while effective,  aren’t always as targeted as we’d like. The idea of applying nutritional recommendations that match each person’s health needs is absolute nirvana to me. I simply can’t wait until that’s the norm in how we practice dietetics.

Until then, stay tuned for more on the topic of nutrigenomics. The implications for each of us in taking control of our health is monumental.

FYI, a couple of recommendations for further reading on this topic, both penned by Dr. DeBusk, RD:

“Genetics The Nutrition Connection”   |  “It’s Not Just Your Genes”

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“Are We A Moderation Nation? Always, Sometimes, Rarely.”

Diet advisor: “Eat everything in moderation.”

You: “Everything?”

Diet advisor: “Yes.”

You: “What about donut holes? And miniature peanut butter cups?”

Diet advisor: “Yes. Moderation still.”

You: “My donut hole moderation runs anywhere from 1-1.5 dozen, depending on my craving, and my peanut butter cup moderation is strictly determined by the number remaining in the bag, PLUS how much stress I’ve encountered before reaching for said bag.”

Diet advisor: “I’m firing you. Rules are rules.”

You: “But if you could just be more specific, maybe I could stick with the rules. Puh-leeezze don’t fire me.”

Diet advisor: “Specifics don’t exist. You should know your own level of moderation. Still fired. And furthermore, until you get your moderation in check, don’t even THINK about calling me for help.”

___________________________

Sound familiar? Lord, I hope not – at least not as an exchange with a live person. But perhaps that’s the message you hear swirling about in the world of dieting and eating “clean”; simply find the right moderation for YOU, don’t deviate from it, and you’re good.

That’s good ‘ole moderation for ‘ya – too loose, too vague, too unhelpful.

Especially when you try to rely on moderation in situations where basic nutrition isn’t even a consideration; like stress eating. Or emotional eating. Or eating when you don’t feel well. Or eating when you’re over-hungry, over-tired, or just over-everything.

The scenario in the intro is 100% fabricated by moi. Yet, there are nuances of truth. Most people working one-on-one with me struggle with emotional or stress eating – it’s far more common than you can even imagine.

And in my breast cancer community? If you were a stress eater BEFORE your diagnosis, the behavior certainly won’t suddenly be replaced with “balanced eating habits supportive of recovery.

Ummm, no.

In fact, those stress eating behaviors are likely to ESCALATE, potentially spiraling out of control as you obsess over the “right” way to eat for your cancer.

All of which leads me to share some ideas in figuring out the whole “moderation” thing.

The red light, yellow light, green light approach to moderation and choice, aka “Stoplight Nutrition” is used most often in child nutrition, but it also resonates with adults. While I like the general concept, it can still leave too much open to interpretation, and for good reason. You can’t bog kids (or adults!) down with too much detail before you lose them.

Red Light Foods = Stop & Think!

Very little, if any, nutritional value. Tend to be high in calories, sugar and fat. Considered a treat, limit to a couple each week.

Yellow Light Foods = Slow Down!

Whole grains and lean proteins. Contain nutrients, could be moderately high in calories and fat, still important to be aware of portion size. Make up most of the diet.

Green Light Foods – Go!

Fruits, veggies, water, nonfat milk. High nutritional value, low in calories, sugar and fat. The healthiest choice, include most often.

Stoplight Nutrition is also portrayed as:

Red = Rarely (Whoa!)

Yellow = Sometimes (Slow!)

Green = Anytime (Go!)

Here’s my pared down way of using this information. Every time you make a decision about what and how much to eat, of ANY food (on its own or in combination) use these two steps:

Step I

Is the food something I would eat. . . .

  • Always
  • Sometimes
  • Rarely

You don’t even need me to give you examples here – you KNOW what goes into these categories!

Step II

Ask yourself (and be honest!):

  • Am I hungry?
    • Yes = eat.
    • No = wait.
  • What type of hungry am I?  
    • “I would eat an apple” hungry = eat.
    • “I wouldn’t eat an apple, but I would eat cake” hungry = wait.

Notice I didn’t say “Don’t eat!”, I said “Wait.” If you’re NOT truly hungry, the urge to eat will leave you, especially if you get involved doing something else. If you ARE truly hungry, you won’t get “unhungry” simply by waiting – you’ll get hungrier (it’s why that apple sounds so appealing.)

Practice, practice, practice. You’ll get really good at this, but be patient – changing hard-wired habits takes time.

P.S. This post is courtesy of a week where time scurried away, leaving me unable to do a deep dive into the remaining three topics I want to cover from FNCE . . .but, they’re on the way.

If you want more nutrition and breast cancer information and updates on programs and services, shoot me an email at cathy@cathyleman.com.

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Easy. Peasy.