The risk of atherosclerosis over 10 years in a study of 5,448 adults aged 4584 years was 27% lower in the highest quintile of calcium intake (mean of 2,157 mg/day) than in the lowest quintile (mean of 313 mg/day) [64]. Use standard logic, and output 'X' if S = R = '1' at a rising clock edge. An observational study found an association between higher calcium intakes and lower prevalence of overweight or obesity in 6,696 children (51% male, mean age 6 years) in eight European countries, of whom 2,744 were re-examined 6 years later [86]. Postmenopausal women The bioavailability of calcium from other plants that do not contain these compoundsincluding broccoli, kale, and cabbageis similar to that of milk, although the amount of calcium per serving is much lower [3]. Br J Nutr 2006;95:539-45. Hypocalcemia (serum calcium level less than 8.5 mg/dL [2.12 mmol/L] or an ionized calcium level below 4.61 mg/dL [1.15 mmol/L]) is usually a result of a vitamin D or magnesium deficiency, impaired parathyroid hormone (PTH) production leading to hypoparathyroidism, impaired bone resorption of calcium, critical illness, or use of certain medications (e.g., bisphosphonates, cisplatin, or proton pump inhibitors) [22,23]. Higher dietary calcium intakes are associated with reduced risks of fractures, cardiovascular events, and mortality: a prospective cohort study of older men and women. Ask your doctor or pharmacist about possible interactions and which type of calcium supplement would work for you. Weaver CM, Heaney RP. Dietary calcium intake and adiposity in children and adolescents: Cross- sectional and longitudinal results from IDEFICS/I.Family cohort. Calcium plus vitamin D supplementation and health outcomes five years after active intervention ended: the Women's Health Initiative. Heaney RP. https://www.dietaryguidelines.gov/2020-advisory-committee-report. The large WHI study described above also found no benefit of supplemental calcium and vitamin D on cancer incidence [42]. [, Huncharek M, Muscat J, Kupelnick B. Colorectal cancer risk and dietary intake of calcium, vitamin D, and dairy products: a meta-analysis of 26,335 cases from 60 observational studies. When signs and symptoms do occur, they can range widely because low serum calcium levels can affect most organs and symptoms [24]. 6 effective vitamins and supplements for athletes - Medical News Today 1,500mg Approximately what percentage of body weight consists of minerals? Food Chem Toxicol 2017;109:585-648. Concomitant use of calcium supplements and dolutegravir can reduce blood levels of dolutegravir substantially, apparently through chelation [99,100]. The 6 Best Multivitamins for Women Over 50 of 2023 SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. The DRIs for calcium Age group Recommended Dietary Allowance (RDA) per day Tolerable Upper Intake Level (UL) per day; Infants 0-6 months: 200 mg : 1000 mg: Infants 7-12 months: 260 mg : 1500 mg: Children 1-3 years: 700 mg: 2500 mg: Children 4-8 years: 1000 mg: 2500 mg: Children 9-18 years: 1300 mg: 3000 mg: Adults 19-50 years: 1000 mg: 2500 mg . For example, the American College of Obstetrics and Gynecology states that daily supplementation with 1,5002,000 mg calcium might reduce the severity of preeclampsia in pregnant women who have calcium intakes of less than 600 mg/day [76]. Intense exercise increases magnesium losses. They also recommended a screening test for women . J Clin Pharmacol 2015;55:490-6. How much calcium you need depends on your age and sex. RDA for Calcium: How Much Calcium Do You Need Per Day? - Verywell Health Calcium / Vitamin D Dosage Guide + Max Dose, Adjustments - Drugs.com [, Bristow SM, Horne AM, Gamble GD, Mihov B, Stewart A, Reid IR. Int J STD AIDS 2017;28:4-15 [, Morini E, Catalano A, Lasco A, Morabito N, Benvenga S. L-thyroxine malabsorption due to calcium carbonate impairs blood pressure, total cholesterolemia, and fasting glycemia. The best sources of calcium are dairy products such as milk, yogurt and cheese. Dietary calcium intake and bone loss over 6 years in osteopenic postmenopausal women. Limits foods and beverages higher in added sugars, saturated fat, and sodium. The Canadian Hypertensive Disorders of Pregnancy Working Group [83], the International Society for the Study of Hypertension in Pregnancy [84], and the Society of Obstetric Medicine of Australia and New Zealand [85] have similar recommendations. Just 2 ounces of cheese or 1 cup of milk, yogurt or calcium-fortified beverage contains 300 milligrams of calcium, about 30 percent of your daily requirement. Vitamin D - Mayo Clinic Total calcium levels can be measured in serum or plasma; serum levels are typically 8.8 to 10.4 mg/dL (2. Calcium deficiency can also cause rickets in children and other bone disorders in adults, although these disorders are more commonly caused by vitamin D deficiency. J Hum Hypertens 2015;29:541-7. [, Wallace TC, McBurney M, Fulgoni VL, 3rd. The small ionized pool of calcium in the circulatory system, extracellular fluid, and various tissues mediates blood vessel contraction and dilation, muscle function, blood clotting, nerve transmission, and hormonal secretion [1,2]. Calcium from foods and dietary supplements is absorbed by both active transport and by passive diffusion across the intestinal mucosa [1,3]. Dietary supplement use and colorectal cancer risk: a systematic review and meta-analyses of prospective cohort studies. [, Singh N, Singh PN, Hershman JM. Supplements that bear the USP, CL or NSF abbreviation meet voluntary industry standards for quality, purity, potency, and tablet disintegration or dissolution. Vitamins for MS: Do supplements make a difference? Findings were mixed in two analyses of data from the WHI. [, U. S. Preventive Services Task Force, Grossman DC, Curry SJ, Owens DK, Barry MJ, Caughey AB, et al. Accessed Oct. 18, 2020. Calcium Intake for Adults over Age 55 - Mayo Clinic News Network [, Tang R, Tang IC, Henry A, Welsh A. Common calcium supplements may be labeled as: The two main forms of calcium supplements are carbonate and citrate. Certain compounds in plants (e.g., oxalic acid, phytic acid) can decrease calcium absorption by forming indigestible salts with calcium, decreasing its absorption [3]. Other forms of calcium in supplements include gluconate and lactate. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. However, says Mayo Clinic endocrinologist Dr. Robert Wermers, Americans aren't getting enough calcium in their diet. Nutr Rev 2002;60:360-7. Vitamin D for cancer prevention: valid assertion or premature anointment? Scientific report of the 2020 Dietary Guidelines Advisory Committee: Advisory report to the Secretary of Agriculture and the Secretary of Health and Human Services. Cambridge, Massachusetts: Wiley-Blackwell; 2020:321-48. Geneva: World Health Organization; 2018. A systematic review and meta-analysis of 22 observational studies in 2,346,368 participants aged 8 and older followed for 4.6 to 28 years also found no association between total dietary and supplemental calcium intake and cancer mortality [48]. [, Hofmeyr GJ, Lawrie TA, Atallah , Torloni MR. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Nutritionist Quiz Chapter 8: Minerals Question 1 Q: What is the daily recommended dosage of calcium for female athletes? In 12 trials in 2,334 women, doses of less than 1,000 mg/day (usually 500 mg/day) reduced the risk of high blood pressure by 47% and of preeclampsia by 62%. [, Donneyong MM, Hornung CA, Taylor KC, Baumgartner RN, Myers JA, Eaton CB, et al. A lack of calcium could lead to a condition called rickets in children, and osteomalacia or osteoporosis in later life. Calcium intake and colorectal cancer risk: dose-response meta-analysis of prospective observational studies. Evidence Research on use of folate and oral folic acid supplements for specific conditions shows: Birth defects. Recommended daily calcium intakes (IOM, NAM) Age. How much calcium do you really need? - Harvard Health Calcium intake and breast cancer risk: meta-analysis of prospective cohort studies. Calcium and vitamin D: Important at every age. The absorption of calcium from dairy products and fortified foods is about 30% [1]. J Womens Health (Larchmt) 2013;22:915-29. Calcium supplements can interact with many different prescription medications, including blood pressure medications, synthetic thyroid hormones, bisphosphonates, antibiotics and calcium channel blockers. The median dietary intake in the U.S. for women age 50 or older is 589-649 mg per day and 728-777 per day for men. PLoS One 2020;15:e0235042. Be sure to note the serving size (number of tablets) when determining how much calcium is in one serving. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Calcium carbonate is cheapest and therefore often a good first choice. Similarly, an evidence report and systematic review conducted for the USPSTF that included 11 RCTs of vitamin D, calcium, or both for 2 to 7 years in 51,419 adults aged 50 years and older found that supplementation with vitamin D alone or combined with calcium had no effect on CVD incidence [39]. When people eat many different types of foods, these interactions with oxalic or phytic acid probably have little or no nutritional consequence. Observational evidence does not support an association between higher calcium intakes and a lower risk of cancer mortality. Accessed Oct. 18, 2020. Levothyroxine Adults may have low bone mass, which is a risk factor for osteoporosis. Calcium Supplements: How Much Calcium Is Too Much? Calcium carbonate appears to cause more of these side effects than calcium citrate, especially in older adults who have lower levels of stomach acid [1]. Requesting patterns for serum calcium concentration in patients on long-term lithium therapy. However, in women, the CVD mortality rate was 16% lower with supplemental calcium intakes of 1,000 mg/day than with no supplemental calcium intakes. According to 20092012 NHANES data, rates of calcium inadequacy (intakes below the EAR) are higher among non-Hispanic Blacks and non-Hispanic Asians (4748%) than among Hispanics (30%) and non-Hispanic Whites (24%) in the United States [19]. https://www.consumerlab.com/aboutcl.asp. [, Schneyer CR. The calcium RDA is 1,200 mg for women older than 50 years (vs. 1,000 mg for younger women) to lessen bone loss after menopause [1]. An RCT in 5,292 adults aged 70 years or older (85% women) in the United Kingdom compared the effects of 1,000 mg calcium, 8,000 IU (200 mcg) vitamin D3, both, or placebo for 24 to 62 months [49]. Nutrients 2021;13:368. Other calcium forms in supplements include calcium sulfate, ascorbate, microcrystalline hydroxyapatite, gluconate, lactate, and phosphate [14]. J Am Heart Assoc 2016;5. Levels of ionized (or free) calcium, the biologically active form, in serum are also used to measure calcium status. Testofuel - Best Testosterone boosters for men over 50 for extreme sex . They are based on observational evidence from the WHI showing a link between higher intakes of supplemental calcium (1,000 mg/day for 7 years) and a greater risk of kidney stones [96,97]. Nutrients 2020;12. However, the dosage may need to be adjusted if you take . October 6, 2022 Geneva: World Health Organization; 2013. Am Fam Physician 2016;93:121-7. Children may not reach their full potential adult height. [, Liu C, Kuang X, Li K, Guo X, Deng Q, Li D. Effects of combined calcium and vitamin D supplementation on osteoporosis in postmenopausal women: a systematic review and meta-analysis of randomized controlled trials. [, Lappe J, Watson P, Travers-Gustafson D, Recker R, Garland C, Gorham E, et al. In one placebo-controlled clinical trial in Iran in 66 adults who were overweight and had type 2 diabetes and coronary heart disease, supplements of 5 mcg (200 IU) vitamin D, 90 mcg vitamin K, and 500 mg calcium for 12 weeks significantly reduced maximum levels of left carotid intima media thickness and improved metabolic status (including improvements in insulin resistance, insulin concentrations, beta-cell function, and quantitative insulin sensitivity check index) [95]. The recommended daily amount of vitamin D is 400 international units (IU) for children up to age 12 months, 600 IU for people ages 1 to 70 years, and 800 IU for people over 70 years. Lancet 2019;393:330-9. An 8 ounce glass of skim milk has only 80 calories and zero fat and supplies 1/3 of a teenager's recommended daily calcium intake. [, World Health Organization. Calcium, the most abundant mineral in the body, is found in some foods, added to others, present in some medicines (such as antacids), and available as a dietary supplement. http://naturalmedicines.therapeuticresearch.com. Iron is most notably known for its role in: Together, sodium, chloride, and potassium are known as what category of minerals? Dietary calcium intake and the risk of metabolic syndrome: a systematic review and meta-analysis. The effect of calcium or calcium and vitamin d supplementation on bone mineral density in healthy males: a systematic review and meta-analysis. Depending on your medications, you may need to take the supplement with your meals or between meals. The American Journal of Clinical Nutrition 2007;86:1804-5. Additional research is needed before conclusions can be drawn about the use of calcium supplements to improve bone health and prevent fractures in older adults. [. [, Keum N, Aune D, Greenwood DC, Ju W, Giovannucci EL. Calcium supplements cause few, if any, side effects. Check the ingredient list to see which form of calcium your calcium supplement is and what other nutrients it may contain. Implications for implementing national strategies of calcium fortification. For rickets and osteomalacia, the requirements for calcium and vitamin D appear to be interrelated in that the lower the serum vitamin D level (measured as 25-hydroxyvitamin D [25(OH)D]), the more calcium is needed to prevent these diseases [21]. Ritual prioritizes folate, B12, vitamin E, and omega-3 alongside bone "helper" nutrients including vitamins D3 and K2, and magnesium. [, Heine-Broring RC, Winkels RM, Renkema JM, Kragt L, van Orten-Luiten AC, Tigchelaar EF, et al. Recommended amounts are even higher for athletes, vegetarians, and vegans. A variety of foods and their calcium content are listed in Table 2. Public Health Nutr 2017;20:2577-86. Recommended Dietary Allowance (RDA): Average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%98%) healthy individuals; often used to plan nutritionally adequate diets for individuals. Dietary Supplements for Exercise and Athletic Performance More than 99% of calcium in the body is in the form of calcium hydroxyapatite, an inorganic matrix of calcium and phosphate that is stored in the bones and teeth [1,4,5]. J Natl Cancer Inst 2008;100:1581-91. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Serum 25-hydroxyvitamin D requirements to prevent nutritional rickets in Nigerian children on a low-calcium dieta multivariable renanalysis. [, Bonovas S, Fiorino G, Lytras T, Malesci A, Danese S. Calcium supplementation for the prevention of colorectal adenomas: A systematic review and meta-analysis of randomized controlled trials. [, Bailey RL, Zou P, Wallace TC, McCabe GP, Craig BA, Jun S, et al. [, Lappe JM, Travers-Gustafson D, Davies KM, Recker RR, Heaney RP. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. Regulatory and policy-related aspects of calcium fortification of foods. More evidence, including from well-designed clinical trials, is needed to determine whether higher intakes of calcium can reduce the risk of metabolic syndrome. Am J Kidney Dis 2003;42:1253-9. There is a problem with Earlier systematic reviews and meta-analyses found a positive relationship between calcium and vitamin D supplementation and increased BMD in older males [35] and between higher calcium intakes from dietary sources or supplements in adults over 50 and higher BMD [25]. Accessed Oct. 18, 2020. This content does not have an Arabic version. The American Journal of Clinical Nutrition 2008;87:792-. Calcium citrate is absorbed equally well when taken with or without food and is a form recommended for individuals with low stomach acid (more common in people over 50 or taking acid blockers), inflammatory bowel disease or absorption disorders. As with the evidence on the link between increased calcium intakes and reductions in BMD loss, the findings of research on the use of calcium supplementation to prevent fractures in older adults are mixed. Am J Clin Nutr 2010;92:1017-22. NIH Osteoporosis and Related Bone Diseases National Resource Center. Guidelines on Calcium and Vitamin D Supplements Experts recommend a daily intake of 600 IU (International Units) of vitamin D up to age 70. Present Knowledge in Nutrition. For those 51 and older, the limit is 2,000 mg a day. [. Some individuals who take calcium supplements might experience gastrointestinal side effects, including gas, bloating, constipation, or a combination of these symptoms. about your interest in, questions about, or use of dietary supplements and what may be best for your overall health. [, Cano A, Chedraui P, Goulis DG, Lopes P, Mishra G, Mueck A, et al. Mayo Clinic College of Medicine and Science, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Graduate Medical Education, Mayo Clinic School of Continuous Professional Development, Mayo Clinic on Incontinence - Mayo Clinic Press, NEW Mayo Clinic on High Blood Pressure - Mayo Clinic Press, Mayo Clinic on Hearing and Balance - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Financial Assistance Documents Minnesota, Nutritional Supplements at Mayo Clinic Store. You may opt-out of email communications at any time by clicking on the unsubscribe link in the e-mail. The World Health Organization recommends 1,5002,000 mg/day calcium for pregnant women with low dietary calcium intakes to reduce preeclampsia risk [82]. Br J Nutr 2015;114:1013-25. [, Yao X, Hu J, Kong X, Zhu Z. But evidence about such health benefits is not definitive. But one large clinical trial did find that calcium supplements reduce cancer risk. J Clin Endocrinol Metab 2012;97:614-22. Magnesium Dosage: How Much Should You Take per Day? - Healthline The recommended amount of iron to get each day is 11 milligrams for teenage boys, 15 milligrams for teenage girls, 8 milligrams for men to age 50, 18 milligrams for women to age 50, and 8 milligrams for older adults of both sexes. [, Song L. Calcium and bone metabolism indices. Ask ODS The evidence is mixed and more research is needed before doctors know the effect calcium supplements may have on heart attack risk. Menopause leads to bone loss because decreases in estrogen production reduce calcium absorption and increase urinary calcium loss and calcium resorption from bone [1]. Calcium citrate malate is a well-absorbed form of calcium used in some fortified juices [3]. [, Hofmeyr GJ, Betran AP, Singata-Madliki M, Cormick G, Munjanja SP, Fawcus S, et al. Check food and supplement labels to monitor how much total calcium you're getting a day and whether you're achieving the RDA but not exceeding the recommended upper limit. [, Cormick G, Ciapponi A, Cafferata ML, Belizn JM. Online Nutrition & Training on Instagram: "Feeling super tired and [, Brunner RL, Wactawski-Wende J, Caan BJ, Cochrane BB, Chlebowski RT, Gass ML, et al. For example, an analysis of 19992010 NHANES data from 14,408 adults (mean age 54 years) with obesity found that calcium intakes were 10% lower in adults with obesity and hypertension than in those without hypertension [62]. Cochrane Database of Systematic Reviews 2019. For breast cancer, observational studies have had mixed findings on whether higher calcium intakes are associated with a lower risk. Yogurt, cheese, and milk are excellent sources. This association was strongest in women, adults aged 2044 years, those who did not have diabetes, and, especially, women aged 2044 years. Calcium has the potential to interact with certain medications, and several types of medications might adversely affect calcium levels. Accessed Oct. 18, 2020. How Your Nutritional Needs Change as You Age - Healthline The effects of vitamin D, K and calcium co-supplementation on carotid intima-media thickness and metabolic status in overweight type 2 diabetic patients with CHD. JBMR Plus 2020;4:e10246. [, Chlebowski RT, Johnson KC, Kooperberg C, Pettinger M, Wactawski-Wende J, Rohan T, et al. The recommended daily intake is 400-420 mg for adult men and 310-320 mg for adult women. Support for such a link comes from an analysis of 20012006 NHANES cross-sectional data on 2,904 adults aged 60 and older (54.6% women) showing an association between higher dietary calcium intakes and greater lumbar spine BMD, but only in women [30]. Allergol Immunopathol (Madr) 2019;47:544-50. ConsumerLab.com. A systematic review and meta-analysis of 41 RCTs that examined the effect of dairy foods or calcium supplements (at least 300 mg/day) in 4,802 adults found that higher calcium intakes from dairy foods had no impact on body weight or body fat, although they did reduce body fat when combined with an energy-restricted diet [91]. In the WHI trial, 36,282 postmenopausal women were randomly assigned to daily supplementation with a combination of 1,000 mg calcium and 400 IU (10 mcg) vitamin D3 or placebo [42]. Use the library or the Internet to research common uses for sodium [, Crandall CJ, Aragaki AK, LeBoff MS, Li W, Wactawski-Wende J, Cauley JA, et al. include protected health information. [, Sempos CT, Durazo-Arvizu RA, Fischer PR, Munns CF, Pettifor JM, Thacher TD. 1-3% 4-6% 8-12% 16-20% Risk of heart failure among postmenopausal women: a secondary analysis of the randomized trial of vitamin D plus calcium of the women's health initiative. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. [, Booth AO, Huggins CE, Wattanapenpaiboon N, Nowson CA. Individuals taking these and other medications on a regular basis should discuss their calcium status with their health care providers. Br J Nutr 2016;116:158-66. Systematic review of the potential adverse effects of caffeine consumption in healthy adults, pregnant women, adolescents, and children. Am J Clin Nutr 2016;103:886-94. This is a fact sheet intended for health professionals. Long-term follow-up for mortality and cancer in a randomized placebo- controlled trial of vitamin D(3) and/or calcium (RECORD trial). Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. Osteoporosis increases the risk of fractures, especially of the hip, vertebrae, and forearms [1,7]. Effects were greatest in adults younger than 35 years and with doses higher than 1,500 mg/day calcium. See how much you need and how to get it. Hypertension in pregnancy. A similar controversy surrounds calcium and prostate cancer. What is the daily recommended dosage of calcium for female athletes? Nutrients 2017;9. Preeclampsia is defined as hypertension and proteinuria or thrombocytopenia during pregnancy, usually after 20 weeks gestation [74]. [, Gallagher JC, Yalamanchili V, Smith LM. This information is important if you have any health or dietary concerns. Magnesium is necessary for calcium absorption. Several recent systematic reviews and meta-analyses have found that supplementation with calcium alone or a combination of calcium and vitamin D increases BMD in older adults. In the United States, approximately 72% of calcium intakes come from dairy products and foods with added dairy ingredients [1]. Can vitamins help prevent a heart attack? [, Wallace RB, Wactawski-Wende J, O'Sullivan MJ, Larson JC, Cochrane B, Gass M, et al. Bottom line. Jama 2018;319:1600-12. Review/update the All rights reserved. Calcium. Before you consider calcium supplements, be sure you understand how much calcium you need, the pros and cons of calcium supplements, and which type of supplement to choose. Institute of Medicine. In general, however, absorption of calcium supplements is greater when they are taken with food, regardless of whether the users gastric acid is low [3]. Vitamin D and Calcium: Updated Dietary Reference Intakes Cancer incidence from all causes was 60% lower in women who took the combination and 47% lower in those who took calcium-only supplements than in the placebo group [44]. However, evidence on the relationship between calcium intakes from foods or supplements and different forms of cancer is inconsistent [4]. [, Li P, Fan C, Lu Y, Qi K. Effects of calcium supplementation on body weight: a meta-analysis. In people with low levels of stomach acid, the solubility rate of calcium carbonate is lower, which could reduce the absorption of calcium from calcium carbonate supplements unless they are taken with a meal [3]. Table 2 provides a list of various foods and their calcium contents. Jama 2000;283:2822-5. 1,500 mcg Approximately what percentage of body weight consists of minerals? If calcium levels cannot be met through dietary intake, then supplementation may be utilised in addition (Juzwiak, Amancio, Vitalle, Szejnfeld . Modern Nutrition in Health and Disease. What people with celiac disease need to know about osteoporosis. The meta-analysis of 10 RCTs that included 10,496 individuals described above found no impact of calcium supplementation on cancer mortality rates [43]. The effect of calcium plus vitamin D on risk for invasive cancer: results of the Women's Health Initiative (WHI) calcium plus vitamin D randomized clinical trial. Calcium might help reduce the risk of cancer, especially in the colon and rectum [1]. Vitamin D and calcium supplementation reduces cancer risk: results of a randomized trial. Prolonged diarrheaor vomiting, laxative abuse, diuretic use, eating clay, heavy sweating, dialysis, or using certain medications can cause severe potassium deficiency. Br J Nutr 2016;116:286-93. The following groups are among those most likely to need extra calcium. However, in analyses of results for various sources of calcium, only calcium from dairy foods was significantly associated with prostate cancer risk (2.9 times higher in men with intakes greater than 696 mg/day than in those with intakes less than 354 mg/day); calcium intakes from non-dairy sources were not significantly associated with prostate cancer risk.
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