Porto
Biomedical
Journal
h tt p://w w w . p o r t o b i o m e d i c a l j o u r n a l . c o m /Original
article
Adherence
to
the
Mediterranean
diet
in
children:
Is
it
associated
with
economic
cost?
G.
Albuquerque
a,
P.
Moreira
a,b,c,
R.
Rosário
d,e,
A.
Araújo
a,
V.H.
Teixeira
a,b,
O.
Lopes
f,
A.
Moreira
g,h,
P.
Padrão
a,c,∗aFacultyofNutritionandFoodSciences,UniversityofPorto,Porto,Portugal
bResearchCentreinPhysicalActivity,HealthandLeisure,UniversityofPorto,Porto,Portugal cEPIUnit–InstituteofPublicHealth,UniversityofPorto,Porto,Portugal
dEducationSchool,ChildStudyCentre,UniversityofMinho,Braga,Portugal eNursingSchool,UniversityofMinhoBraga,Portugal
fErdalAssociation,Guimarães,Portugal
gDepartmentofImmunology,FacultyofMedicine,UniversityofPorto,Porto,Portugal hDepartmentofImmunoallergology,HospitalofSãoJoão,Porto,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received17October2016 Accepted23January2017 Availableonline1March2017 Keywords:
Dietcost Mediterraneandiet Children
a
b
s
t
r
a
c
t
Objective: Toassesshowthedietcostisassociatedwithsocio-demographicfactorsandadherenceto Mediterraneandietinchildren.
Methods:Datawereobtainedfromacommunity-basedsurveyofchildrenselectedfrompublic elemen-taryschoolsinPortugal.Ofatotalof586childrenattendingtheseschools,464(6–12years),werestudied. Dietaryintakewasassessedbya24hourrecallandtheadherencetoMediterraneandietwasevaluated throughtheKIDMEDindex.Thecostofthedietwascalculatedbasedonthecollectionoffoodpricesofa nationalleadersupermarket,andexpressedasTotalDailyCost(TDC)andTotalDailyCost-Adjustedfor Energy(TDEC).Anthropometricmeasuresweretakenandsocio-demographicdataweregatheredfrom aquestionnairefilledbyparents.Logisticregressionwasusedtoquantifytheassociationbetweendiet cost,socio-demographicsandadherencetoMediterraneandiet.
Results:TheaverageTDCwas4.58D(SD=1.24).Mostchildren(69.1%)reportedmediumadherenceto Mediterraneandiet,and4.6%ratedthehigherscore.TDCwashigherforchildrenwithhighestadherence toMediterraneandiet,comparedtothosewithlowestadherence[TDC:OR=5.70(95%CI1.53,21.33),p fortrend=0.001;TDEC:OR=2.83(95%CI0.89,8.96,pfortrend0.018)].Nomeaningfulvariationinthe dietcostwithageandparentaleducationwasobserved.
Conclusion:HigheradherencetoMediterraneandietwasassociatedwithhigherdietcostinchildren. ©2017PBJ-Associac¸˜aoPortoBiomedical/PortoBiomedicalSociety.PublishedbyElsevierEspa ˜na, S.L.U.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
The Mediterranean Diet has been object of study since the 1950s1andisnowadaysrecognizedforitsnumeroushealth
ben-efits,namelyprotectionagainstweightgain,obesityanddiabetes mellitustype2,cardiovasculardiseases,certaintumorsandother oxidativestress-relateddiseases.2,3
However,itsoriginaldefining-characteristicsdonotfully cor-respondtothedietpracticednowadaysamongpopulationsliving
∗ Correspondingauthor.
E-mailaddress:patriciapadrao@fcna.up.pt(P.Padrão).
intheMediterraneanregion.4Thisdietarypatternwasfirstly
char-acterizedbyahighconsumptionoffruits,vegetablesandgrains; moderateconsumptionofdairyproductsandwineandlow con-sumption(andamount)ofredmeat.Oliveoilwouldbethemain sourceofdietarylipids.1Regrettably,thisdietarypatternisbeing
replacedbyunhealthierchoices,5,6 similarlytowhatis
happen-ingaroundtheworld.Alowconsumptionoffruitsandvegetables7
paralleltoagrowingconsumptionofhigh-densityenergyfoods –suchassnacks,sugar-richfood,fastfoodand softdrinks –is welldocumented and associated withlifestyle changes.8 These
dietarymodificationscontributetopoorerdietqualityandhave beenindictedas asignificantexplanation fortherising obesity rates,speciallyconcerninginchildren.8Thesamephenomenonhas
beenalsodocumentedinPortugal.9
http://dx.doi.org/10.1016/j.pbj.2017.01.009
2444-8664/©2017PBJ-Associac¸˜aoPortoBiomedical/PortoBiomedicalSociety.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Changesinthephysicalenvironmentandfoodsupplyhavebeen pointedrecentlyasmajorcausesoftheObesityepidemic,10which
isbecomingtobeperceivedfromaneconomicperspective.Infact, substantialresearchondiet cost hasbeenperformed in recent years,intheU.S.A.andsomeEuropeancountries.Theresults con-sistentlyshowthatthecostoffoodisaprimarydeterminantof foodchoice11,12andthathigherenergydensityfoods,whichare
lessnutrient-rich,areassociatedwithlowerprices.Ontheother hand,low-energy-densefoodssuchasfruitsandvegetablesappear tobemoreexpensive.11,13,14 In thiscontext, healthierdietsare
associatedwithhighercosts.14–17
TakingintoaccountthebenefitsoftheMediterraneandiet,its healthpromoterpotential,aswellastheimportanceofpriceasfood choicedeterminant,weaimedtoestimatethecostofchildren’sdiet accordingtothedegreeofadherencetoMediterraneandiet.Tothe bestofourknowledge,thisisoneofthefirstEuropeanstudieson thistopicinchildren,whichmayprovidenewinformationtohealth professionalsandpolicymakerssotheycanbettereducateandact towardtheavailabilityofhealthyeatingatlowcosttothe com-moncitizen.Theobjectivesofthisstudyweretoestimatethedaily costofdietandtoquantifyitsassociationwithsocio-demographic factorsandthedegreeofadherencetotheMediterraneandietin children.
Methods Participants
Thedatawerederivedfromacommunity-basedsurveyof chil-drenselectedfrom7oftheeightypublicelementaryschools in thecityofGuimarães,Portugal,betweenOctober2007andMarch 2008.Letters were distributed to allparents or guardians out-lining theaims of the study along with a consent form. From thetotalof586childrenattendingtheseschools,464(225boys and 239girls) between 6and 12 years acceptedto participate in the study. Anthropometric measurements and dietary data werecollectedfromall consentingchildren and questionnaires surveyingsociodemographicsandlifestyleinformationwere dis-tributedamongparentsor educationalguardians,of which405 haveanswered(87%).
ThestudywasapprovedbytheUniversityofPortoEthics Com-mittee, the schools where the study was carried out and the PortugueseDataProtectionAuthority(CNPD-ComissãoNacionalde Protecc¸ãodeDados,processnumber7613/2008).
Assessments
Heightandweightweremeasuredbypreviouslytrainedhealth professionals or students, following international standardized procedures.18,19Childrenworelightindoorclothingandwere
bare-footed.Weightwasmeasuredinanelectronicscale,withanerror of±100g(Seca®,Model703,Germany),andheightwasmeasured usingastadiometer,withtheheadintheFrankfortplane.BMIwas calculatedasweight(kg)/height2(m)20andchildren’sweight
sta-tuswascategorizedusingtheIOTFcriteriaandcut-pointsforBMI, definedspecificallyforsexandage.21Onlythreecategorieswere
consideredinanalysisofresults:normal,overweightandobesity. Dietaryintakeinformationwasassessedbya24hourrecall,in whichchildrenwereaskedtorecallallfoodandbeverages con-sumed in theprevious24h. A photographicmanual ofportion sizesandhouseholdmeasures(ManualofFoodQuantification)was used22asanauxiliarytooltoestimatesizesoffoodsandbeverages
consumed.
KIDMEDindex5 wasappliedtoverify theadherencelevelto
theMediterraneandiet.Thisindexwascreatedaccordingtothe
Table1
KidmedindexusedtoaccesstheadherencetotheMediterraneandiet.
Scoring
+1 Eatsafruitordrinksfruitjuice
+1 Eatsasecondfruit
+1 Hasvegetablesonce
+1 Hasvegetablesasecondtime
+1 Eatsfish
−1 Goestoafast-foodrestaurant
+1 Eatspulses
+1 Eatsriceandorpasta
+1 HasBreakfast
+1 Hasadairyproductforbreakfast
+1 Eatsbreadorcerealsatbreakfast
+1 Hasatleast2yoghurtsor40gofcheese
−1 Eatspastriesatbreakfast
+1 Eatsnuts
+1 Dietincludesoliveoil
−1 Eatssweetsandcandy
Mediterraneandietprinciplesandprovidesascorerangingfrom0 to12according16questions.Questionsdenotinganegative con-notationwithrespecttotheMediterraneandietwereassigneda valueof−1andthosewithapositiveaspect,+1.Thisscorewas appliedaccordingtothefoodconsumptionintheprevious24h, asdescribedinTable1.Inaccordancewiththesumobtained,3 classeswerecreated:>8,highadherencetotheMediterraneandiet; 4–7,medium adherencetotheMediterraneandietand ≤3,low adherencetotheMediterraneandiet(Table1).
Thesocioeconomicinformationandfamilycharacteristicswere collectedfromthesurveydistributedtotheparentsoreducational guardians.Itcontainedquestionsaboutgenderandageofchildren andparents’education,recordedinfivecategoriesofyears:0,1–4, 5–9,10–12,andmorethan12yearsofformaleducation.This infor-mationwasfurthergroupedforanalysisintofourcategories:upto 5years,between5and9years,10–12yearsandmorethan12years ofeducation.
Estimationofdietcost
Theestimationofdiet costwasdividedintwotasks.Firstly, thecollectionoffoodprices,thattookplacebetweenMarchand Aprilof2011.Thesourcewasanonlinesupermarket,belongingto aPortugueseleadersupermarketchain.Pricedatawasobtainedby gatheringmeanpricesofcorrespondentfoodorpackagesize,as wellasthepriceperkilogram.Measurementsweretakenon reg-ularprices,excludingdiscounts.Inthecaseofcomposeddishes, dietcostswerecalculatedusingrecipesavailableinFoodProcessor Plus®database(mostofthempreviouslyadaptedfromtraditional Portugueserecipes)andfromaPortuguesewebsiteoftraditional recipes.23Thepriceofthedrinkingwaterwasestimatedbythe
medianpriceofthebottlednaturalmineralwaterandofthe munic-ipalwater.
Afterthis procedure,fooditemswereassigned intodifferent groupsaccordingtothestaplefoodthatwasinitsorigin,andthe medianpricepergramwascomputed.Forexample,thepriceofrice wasobtainedbycalculatingthemedianofthepricesofthevarious brandsandtypesavailableinthesupermarketwebpage.Thechoice forusingthemedianratherthantheaveragepricewasbasedon thefactthatitbetterrepresentsthecentralvalues,minimizingthe effectoftheveryhighandverylowpricesforeachgroup.Finally, thecostofeachmealwascalculatedaccordingtothecontribution ofeachandeveryfoodingredienttakingintoaccountitsproportion. Atdietarylevel,twovariableswerecreated:“Totaldailycost” (TDC),representingthecostofeachindividual’sdietandobtained bysummingthecostofeachmeal,and“Totaldailycostadjusted forenergy”(TDEC)which eliminatedthepossibledifferencesin
Table2
Participants’characteristics.
Boys(n=225) Girls(n=239) Total(n=464)
n % N % n % Age(years) 6–7 52 23.1 55 23.0 107 23.1 8 59 26.2 68 28.5 127 27.4 9 63 28.0 52 21.8 115 24.8 10–12 51 22.7 64 26.8 115 24.8
Mothereducationallevel(years)*
<5 41 18.2 44 21.8.4 85 22.1 5–9 77 34.2 83 41.1 160 41.7 10–12 40 17.8 50 24.8 90 23.4 >12 24 10.7 25 12.4 49 12.8 Fathereducationallevel(years)*
<5 40 22.6 52 26.9 92 19.6 5–9 86 48.6 77 39.9 263 56.0 10–12 29 16.4 42 21.8 71 15.1 >12 22 12.4 22 11.4 44 9.4 Kidmedscore* Low 62 28.6 56 23.8 119 26.3 Medium 149 68.7 164 69.8 313 69.1 High 6 2.7 15 6.4 21 4.6
*Forthesevariables,samplesizeislower.
costsassociatedwithdifferentenergeticintakebetween individ-uals.TDECwascomputeddividingTDCbytheenergyconsumed (D/kcal)andexpressedasD/1000kcal,inordertopointdifferences notseenwithTDC.
Statisticalanalysis
The statistical analyses were performed using the software Statistical Package for the Social Sciences (SPSS), version 17.0. Descriptivestatisticswereusedtocharacterizethesample(mean andstandarddeviations).Atotalof342subjectsforwhom assess-mentofoveralldietaryintakewasavailablewereconsideredfor dataanalysis.
Unconditional binary logistic regression models were fitted toestimatethemagnitude oftheassociationbetweendiet cost (consideringtwo categories,usingthemedian valueasthe cut-off)andsocio-demographiccharacteristics(sex, ageandparents education)andthedegreeofadherencetotheMediterraneanDiet (Kidmedscore).5Thelevelofsignificancewassetat0.05.
Results
Participantcharacterization
Inthissampleof464children(51.5%girls),theprevalenceof overweightandobesitywere23.3%and7.3%,respectively. Approx-imatelytwo-thirdsofthestudypopulationhadparentswithless than10yearsofformaleducation.Themajorityofchildrenreported amediumadherenceleveltoMediterraneandiet(69.1%),andonly 4.6%ratedahigheradherencescore(Table2).
Dietcost
Theaverage(±standarddeviation)TDCwas4.58(±1.24)Dand theaverageTDECwas2.17(±0.42)D/1000kcal(Table3).No mean-ingfuldifferenceswereobservedbetweengender,ageorparental educationregardingTDCandTDEC.Accordingly,nomeaningfulor consistentvariationinthedietcostwithageandparents’education wasobserved(Table3).ConcerningKidmedscore,itisnoticeable anincreasinginthecostofthedietwithincreasinglevelof adher-encetotheMediterraneanDiet(TDCof4.79D inhighadherence
categoryvs.4.09D inlowadherencecategory,p=0.471;TDECof 2.19D/1000kcalinhighadherencecategoryvs.2.10D/1000kcalin lowadherencecategory,p=0.047).Consideringchildrenreporting thehigheradherencetoMediterraneandietincomparisonwith thosewiththelowestadherence,theoddsfavoringhigherdietcost was5.70(95%CI1.53–21.33,pfortrend=0.001)forTDCand2.83 (95%CI0.89–8.96,pfortrend=0.018)forTDEC(Table3).
Discussion
The present study showed that a higher adherence to the Mediterraneandietwasassociatedwithhigherdietcost.The aver-ageTDCfoundinthissampleofschool-agedchildrenwas4.58D. Asfarasweknow,onlyfewstudies24–26havefocusedonthe
esti-mationofdietcostamongchildren.Inastudyconductedwithina Spanishsampleaged2–24yearsold,researchersreportedamean dailydietcostof3.16D(datacollectedintheyear2000)and,more recently,twostudies25,26 conductedwithintheDONALDcohort
study,whichincludesGermanchildren,founddailydietcostsalso closeto3D.StudiesamongadultsinEuropeandUS,reported aver-agepriceshigherthan5D.12,14,17
One out every twenty children in this study reported high adherenceleveltotheMediterraneandietarypattern,resultsthat are in linewithpreviousstudies in Mediterraneancountries.27
The explored relationship between diet cost and adherence to theMediterraneandiethasbroughtinterestingresults,asitwas verifiedanincreasingcostwithahigheradherenceto Mediter-raneandiet.AsimilarstudyinSpanishyouth(participantswere agedbetween2and24years)24hasfoundsimilarresults.In
lit-erature,muchhasalreadybeendiscussedonthehighercostof healthydiets,13,14,25,29–31ofwhich Mediterraneandietisagood
example.12,15,16,28–31 There are a few pointed aspects
underly-ingthis phenomenon,which areimportanttorefer. Thefirstis thecontentinenergydensefoods that,apparentlycheapenthe diet,12–14,26,29associationthathasalreadybeendemonstratedin
thecurrent sampleofschool-aged children.32 In anotherstudy,
Rydén et al. verified higher cost of diet associated with its healthiness (assessedusing theHealthyEating Index),inwhich energy-densitywas low.31 Secondly, variety, a characteristic of
healthydietarypatterns,isassociatedwithalargenumberoffood groupsandfoodsamonggroups.33Hence,andaccordingtothe
lit-erature,healthiergroupsareassociatedwithhighercosts,making thedietmoreexpensive.Inaccordancetoourresults,fooditems thatplayanimportantroleintheMediterraneandietsuchasfruits andvegetables,butalsofish,wereassociated tohighercostsin different studies.12,30,31 Moreover,thecontribution of healthier
optionswithinthelattergroup,suchaslean meatsand low-fat products, was further associated in the current study withan increasedcost.Dataintheliteraturerelateshighercostsand health-ieroptionswithinthesamefoodgroup.31However,whenanalyzing
Mediterraneandietinthisperspective,Drewnowskietal.28stated
thatnotallnutrient-richfoodsnecessarilycostmoreandso,itshould bepossibletoconstructaMediterranean-styledietusingthelowercost optionsineverycategory.
Apossibleconsequence ofhigher costofhealthy diets,such as the Mediterranean,is thehigher prevalence of poorquality mealswithinlowsocioeconomicposition(SEP)families,who can-notaffordtospendmuchofthefamilybudgetonhealthyfoods.7,34
AstudyconductedinPortugalin2006byMoreiraetal.showed thatahighereducationwaspositivelylinkedtoa betterdietary quality,representedbyahigherfrequencyofmilk,vegetablesoup, vegetables,fruitand fishconsumption,35 allof whichare
com-monlyconsumedwithintheMediterraneanpattern.Thethreemost common SEPindicators are education, occupation and income. However,inthepresentstudy,onlyparentaleducationwas eval-uated,andnosignificantassociationwithdietcostwasfound.A
Table3
Dietcostandoddsratiofordietcostaccordingtosex,age,weightstatus,parents’educationandKidmedscore.
Totaldaycost Totaldayenergycost
Mean SD OR† 95%CI Mean SD OR† 95%CI
Sex
Girls 4.42 1.19 1 ref 2.18 0.37 1 ref
Boys 4.73 1.28 1.49 (0.88–2.52) 2.16 0.48 0.93 (0.59–1.48) p=0.475 p=0.259 p=0.485 p=0.872
Age(years)
06/jul 4.48 1.33 1 ref 2.15 0.40 1 ref
8 4.92 1.14 2.55 (1.12–5.90) 2.23 0.45 1.32 (0.66–2.63) 9 4.47 1.16 0.79 (0.35–1.78) 2.22 0.41 1.96 (0.98–3.95) 10/dez 4.43 1.30 1.31 (0.59–2.94) 2.08 0.41 1.10 (0.53–2.25)
p=0.468 pfortrend=0.868 p=0.424 pfortrend=0.803 Mothereducationallevel(years)
<5 4.34 1.43 1 ref 2.13 0.55 1 ref
5–9 4.62 1.17 1.02 (0.49–2.14) 2.17 0.37 1.08 (0.56–2.08) 10/dez 4.48 1.23 0.55 (0.19–1.54) 2.12 0.33 0.49 (0.20–1.19) >12 4.55 1.08 0.58 (0.18–1.19) 2.11 0.36 0.88 (0.31–2.49)
p=0.464 pfortrend=0.368 p=0.456 pfortrend=0.295 Fathereducationallevel(years)
<5 4.29 1.36 1 ref 2.09 0.43 1 ref
5–9 4.54 1.23 1.41 (0.69–2.89) 2.14 0.41 1.19 (0.63–2.26) 10/dez 4.76 1.10 3.51 (1.25–9.85) 2.23 0.41 2.19 (0.93–5.14) >12 4.41 1.12 1.47 (0.42–5.13) 2.12 0.32 1.29 (0.43–3.86)
p=0.464 pfortrend=0.167 p=0.527 pfortrend=0.279 Kidmedscore
Low 4.09 1.26 1 ref 2.10 0.34 1 ref
Medium 4.70 1.21 2.69 (1.32–5.48) 2.19 0.45 1.79 (1.00–3.20) High 4.79 1.10 5.70 (1.53–21.33) 2.19 0.47 2.83 (0.89–8.96)
p=0.471 pfortrend=0.001 p=0.047 pfortrend=0.018
Total 4.58 1.24 2.17 0.42
SD:standarddeviation;OR:oddsratio;95%CI:95%confidenceinterval.
† Adjustedforsex,age,parentaleducationlevelandKidmedscore.
subsequentstudycoveringdisposablefamilyincomecouldadda vitalsteptoovertakethislimitation,asitwasdescribedasabetter SEPmarkerwithregardtofoodbudgetchoicebyRydénetal.31
Somemethodologicallimitationsareworthnoting.First,dietary intakeandcostestimateswerederivedfroma24hrecall.Theuseof thisinstrumentmayhavecompromisedthecollectedinformation, sinceithasbeenrecognizedthatchildrenyoungerthan8years-old maynotaccuratelyrecallfoodsandestimateportionsizes.36
Nev-ertheless,onlyapproximatelyaquarterofoursamplewasyounger than8years-old.Inaddition,single24hrecallmaynotrepresent theusualdietaryintakeandmayfailtoincludefoodsandbeverages thatareeitherforgottenorconsumedinfrequently,influencingthe KIDMEDscore.Asmostparticipantswerenotabletodetailthe ingredientsoftherecipes(andthefatusedforcooking,especially concerningfortheitem“dietincludesoliveoil”)someassumptions weremade,basedontraditionalPortugueserecipes.However,this factmaybedilutedasawhole,giventhesamplesize.
Second,thefoodpricecollectionwasbasedonlyinonesource, whichmayhavebeenminimizedbythefactthatthe supermar-ketchainwherethepriceswerecollectedhasthelargestshare offoodmarketinPortugal.Also,foodpriceswerecollectedthree yearsafterthedietarysurveywasconducted,andsomechanges mighthaveoccurredinthatperiod.However,thisfactismitigated bytheexpectationthatpriceshavevariedinasimilarway,since theValueAddedTaxhasnotchangedduringtheperiodelapsed.In addition,theseasonalvariabilityoffreshfoodsproduction,namely fruitsandvegetables,mayhavecompromisedtheaccuracyofthe pricescollected, due tothefact thatfoodprices weregathered ina differentseasonof thesurvey.Nevertheless, itis expected that,in allseasons,thepricesof freshproductswhose produc-tionisseasonallyvariable,varysothattheriseinsomepricesis offsetbyadeclineofothers.Inturn,energydensefoodsarethe
mostresistanttoinflation.14Insomecases,alackofdetailsabout
foodconsumeddeterminedtheneedtouseaveragevalues (group-ingfreshandtannedfoods,forinstance).Theuseoftheaverage pricedoesnotcapturedifferencesbetweenbrandfoodsand con-sequentlyunderestimatethevariabilityoffoodpricesandofthe costsassociatedwithindividualfoodconsumption,37whichmay
contributeto explain thelack of association betweendiet cost andparentaleducation.Furthermore,sincethecurrentstudyhasa cross-sectionaldesign,wearelimitedtodemonstrateassociations andthedirectionoftheseassociations.
Nevertheless,thiswasanoriginalstudythat brought impor-tantinsightintodietarycostsofchildrenanditsassociationwith socio-demographicsandadherencetoMediterraneandiet,atopic becomingsignificantin termsof PublicHealthnutrition world-wide,especiallygiventheeconomiccrisisthathassettledinEurope andMediterraneancountries.Asfoodpriceisbecomingaprimary determinantoffoodchoice,thisnewinformationshouldconcern andbeconsideredbynutritionalhealthcareprovidersandpublic healthauthorities.Nutritionaleducationandpromotionofhealthy eatingshouldbeprovidedinacosteffectivemanner.
Conflictofinterests
Therewerenoconflictsofinterestdeclared. Author’scontribution
GA,PMandPPdesignedthestudy;GA,PM,RR,AA,VT,RB,OL,AM andPPconductedthestudy;RR,AAandOLcollectedthedata;GA, PM,VTandPPanalyzedthedata;GAandPPwrotethemanuscript. Allauthorsreadandapprovedthefinalmanuscript.
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