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B
Iron Deficiency Anemia: A Synthesis of Current Scientific Knowledge and U.S. Recommendations for Prevention and Treatment
Peter R. Dallman
Iron deficiency anemia is a relatively common nutritional problem in the United States, particularly among infants, adolescents, and women of childbearing age. Its prevention deserves a high priority because iron deficiency anemia has serious consequences, yet its prevalence can be substantially reduced at modest cost. There has been great progress in preventing iron deficiency anemia among infants and children, but the prevalence among pregnant women of childbearing age remains high. The purpose of this appendix is to provide a brief review of the characteristics of iron deficiency anemia and to review recent guidelines for its prevention in primary health care settings.
This appendix provided background information for the Committee on the Prevention, Detection, and Management of Iron Deficiency Anemia Among U.S. Children and Women of Childbearing Age of the Food and Nutrition Board, Institute of Medicine. It also incorporated revisions and additions suggested after review of the paper by the committee, but does not indicate universal concurrence with its content. The committee then developed summary guidelines for children, nonpregnant women of childbearing age, and pregnant women that are contained in the main report.
Review of Knowledge
Metabolism and Physiology
Iron in the Body
The total amount of iron in the body of an adult woman averages 2.3 g (Bothwell et al., 1979), about the weight of a dime. Figure B-1 shows the distribution of this iron, which is similar in women of reproductive age and in children. An average of about 85 percent of total body iron can be classified as essential because it serves well-defined physiologic functions. Essential iron
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B Iron Deficiency Anemia: A Synthesis of Current Scientific Knowledge and U.S. Recommendations for Prevention and Treatment
Peter R. Dallman
Iron deficiency anemia is a relatively common nutritional problem in the United States, particularly among infants, adolescents, and women of childbearing age. Its prevention deserves a high priority because iron deficiency anemia has serious consequences, yet its prevalence can be substantially reduced at modest cost. There has been great progress in preventing iron deficiency anemia among infants and children, but the prevalence among pregnant women of childbearing age remains high. The purpose of this appendix is to provide a brief review of the characteristics of iron deficiency anemia and to review recent guidelines for its prevention in primary health care settings.
This appendix provided background information for the Committee on the Prevention, Detection, and Management of Iron Deficiency Anemia Among U.S. Children and Women of Childbearing Age of the Food and Nutrition Board, Institute of Medicine. It also incorporated revisions and additions suggested after review of the paper by the committee, but does not indicate universal concurrence with its content. The committee then developed summary guidelines for children, nonpregnant women of childbearing age, and pregnant women that are contained in the main report.
Review of Knowledge
Metabolism and Physiology
Iron in the Body
The total amount of iron in the body of an adult woman averages 2.3 g (Bothwell et al., 1979), about the weight of a dime. Figure B-1 shows the distribution of this iron, which is similar in women of reproductive age and in children. An average of about 85 percent of total body iron can be classified as essential because it serves well-defined physiologic functions. Essential iron
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Figure B-1 Distribution of iron in women of childbearing potential (total body iron, 2.3 g—the weight of a dime).
Source: Values are from Table 1, p. 2, in Bothwell and Charlton (1981).
compounds include hemoglobin, which accounts for about three-quarters of total body iron and functions in the transport of oxygen from the lungs to tissues. Because hemoglobin circulates in the blood and accounts for a large proportion of essential body iron, its concentration often best reflects iron status. Other essential iron compounds include myoglobin, the red iron protein of muscle, and the mitochondrial iron proteins, which are essential for the oxidative production of cellular energy in the form of adenosine triphosphate. Iron deficiency is not associated with physiologic impairment until the production of essential iron compounds is diminished (Dallman, 1986).
A second category of iron compounds is referred to as storage iron. Storage iron compounds include ferritin and hemosiderin, which are present primarily in the liver, spleen, and bone marrow. They serve as a reserve that ensures an adequate supply of iron for the production of essential iron compounds, and they maintain body iron homeostasis by regulating the amount of iron absorbed from the diet. Storage iron is less abundant in women and children than in men: about 14 percent of total body iron, on average (Figure B-l), and about 25 percent respectively. The serum ferritin concentration provides an estimate of storage iron reserves.
Iron Homeostasis
Body Iron Regulation
Body iron is regulated primarily by modifying the percentage of food iron that is absorbed. Among healthy, nonpregnant women, body iron remains relatively stable, because the amount of iron absorbed each
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Figure B-2 Iron balance in women of childbearing potential.
Source: Based on Bothwell et al. (1979).
day is roughly equivalent to the amount of iron lost (Figure B-2) and is less than 0.05 percent of total body iron (Bothwell et al., 1979). Iron homeostasis is normally maintained because iron absorption is inversely proportional to the mount of storage iron. When storage iron decreases, as it does during pregnancy or rapid growth, iron absorption increases (Figure B-3). This homeostatic adaptation is greatest with diets containing high levels of available iron (Cook, 1990). Low iron stores per se indicate that an individual is vulnerable to developing iron deficiency anemia, but as long as the production of essential iron remains intact, there are no known physiologic handicaps from having low iron reserves (Dallman, 1986).
Iron Loss and Absorption Differences between Women and Men
Women have greater iron losses and absorb a greater percentage of iron from food than do men. During their childbearing years, women typically have less storage iron than men primarily because of menstrual blood loss (Bothwell et al., 1979). They compensate by absorbing, on average, about twice as much iron from the diet as men, 12 versus 6 percent (Table B-1).
Average menstrual blood loss is about 30 ml/month (Hallberg et al., 1966), but 10 percent of women regularly lose more than 80 ml/month (Figure B-4) and are likely to become anemic because their iron loss is usually greater than that which can be compensated for by increased absorption of iron from the
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Figure B-3 Non-heme iron absorption from three different types of diets as the percent absorption of non-heme iron by individuals with no body iron stores and with 250-, 500-, and 1,000-mg iron stores. As iron stores decrease, the percentage of iron absorbed increases, helping to maintain homeostasis. This compensatory mechanism is less effective with diets of low iron bioavailability (common in developing countries) than with diets with medium and high levels of iron bioavailability, which are more typical in the United States. A daily diet of low iron bioavailability is one containing fewer than 30 g of meat, poultry, or fish (lean, raw weight) or less than 25 mg of ascorbic acid. The comparable figures for a diet of medium iron bioavailability are 30 to 90 g of meat, poultry, or fish or 25 to 75 mg of ascorbic acid, whereas a diet of high iron bioavailability is one containing more than 90 g of meat, poultry, or fish or more than 75 mg of ascorbic acid. Alternatively, it is one containing 30 to 90 g of meat, poultry, or fish plus 25 to 75 mg of ascorbic acid. SOURCE: Data from Monsen and coworkers (197g), in Bothwell et al. (1979).
diet. Unfortunately, such women are typically unaware of their high levels of blood loss. Consequently, the most practical way to identify them is by screening for anemia as part of a periodic health maintenance checkup (LSRO, 1991).
Menstrual blood loss varies with some methods of contraception (Figure B-5), roughly decreasing to half with oral contraceptives (the pill) and doubling with intrauterine devices (IUDs) (Bothwell and Charlton, 1981), Thus, inquiring about the method of contraception helps to predict the risk of iron deficiency; the risk is greatest in women who use an IUD.
Iron Needs During Pregnancy
Pregnancy imposes increased iron needs for the growth of the fetus and for expansion of maternal blood volume (Hallberg, 1988; IOM, 1990a) (Figure B-6). Even women who are not iron deficient at the beginning of pregnancy (on the basis of the hemoglobin concentration) are at risk of developing an iron-responsive depression in hemoglobin concentration in the third trimester unless they receive supplemental iron (Table B-2). Among women who are already iron deficient when they become pregnant, the severity of the deficiency will usually increase as pregnancy progresses unless they take an iron supplement.
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TABLE B-1 Iron Balance in Women Compared with That in Men
Iron Parameter
Women
Men
Total body iron, g
2.3
3.5
Storage iron, g
0.3
1.0
Food iron, mg/day
11
15
Iron absorption, percent
12
6
Iron absorption, mg/day
1.3
0.9
Iron loss, mg/day
1.3
0.9
SOURCE: Based primarily on data in Bothwell et al. (1979).
Figure B-4 Frequency distribution of menstrual blood loss. Although the mean menstrual blood loss is about 30 ml/month, about 10 percent of women lose more than 80 ml/month. SOURCE: Data from Hallberg et al. (1966), adapted from Bothwell et al. (1979).
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Figure B-5 Menstrual blood loss by method of contraception as mean ± standard deviation menstrual blood loss in three groups of women. The control group comprised normal women, the pill group comprised normal women taking the combination variety of oral contraceptives, and the IUD group comprised women using intrauterine devices (IUDs).
Source: Figure from Bothwell and Charlton (1981).
Figure B-6
Schematic representation of the need for absorbed iron during pregnancy. Iron requirements increase markedly during the second and third trimesters.
Source: From Bothwell et al. (1979).
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TABLE B-2 Effects of Iron Supplementation on Mean Hemoglobin Concentration in Late Pregnancy
Dose of Elemental
Irona
Number of Subjects
Hemoglobin, g/dl, at 35-36 weeks of Gestation
Reference
Supplemented
Controls
Supplemented
Controls
Differenceb
30 mg/day as ferrous
49
46
12.4
11.4
1.0
Chanarin and Rothman, 1971
fumaratec
100 mg, twice daily, with meals, sustained release
24
26
12.4
11.4
1.0
Svanberg et al., 1976
100 mg, twice daily, sustained release
16
16
12.7
11.0
1.7
Puolakka et al., 1980
65 mg (+ 350 µg of folate)
21
24
12.7
11.0
1.6
Taylor et al., 1982
200 mg/day
22
23
12.6
11.3
1.3
Romslo et al., 1983
105 mg, sustained release, at breakfast
21
23
12.6
12.2
0.4
Wallenburg and van Eijk, 1984
65 mg as part of multivitamin-mineral supplement after meals
16
13
12.4
11.4
1.0
Dawson and McGanity, 1987
a Ferrous sulfate, unless otherwise stated.
b All differences were statistically significant except for Wallenburg and van Eijk (1984).
c Doses of 60 and 120 mg did not result in higher hemoglobin values.
SOURCE: From IOM (1990b).
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Iron Needs of Infants
Among infants, iron needs are primarily for growth. A high hemoglobin concentration at birth and abundant neonatal iron stores protect most term infants against iron deficiency until 4 months of age (Dallman, 1988). Indeed, total body iron scarcely changes during this period because of the physiologic decline in hemoglobin concentration; iron stores also diminish by 4 months of age (Figure B-7). Term infants are at the greatest risk of developing iron deficiency between 4 and 12 months of age and subsequently, when the iron needs for rapid growth must be supplied by the diet. At 1 year of age, for example, iron absorption is about four times greater than excretion, the difference being used for growth (Figure B-8). The risk of developing iron deficiency anemia during this period depends largely on the diet (Penrod et al., 1990; Pizarro et al., 1991; Tunnessen and Oski, 1987). Although iron deficiency anemia is rare in infants receiving iron-fortified formula, it is common in those fed unfortified formula or cow's milk (Figure B-9). Cow's milk not only has an extremely low concentration of iron but it also results in increased fecal blood loss (Ziegler et al., 1990) (Figure B-10). Furthermore, the higher calcium content of cow's milk compared with that of breast milk contributes to poor iron absorption (Hallberg et al., 1992). Exclusively breastfed infants may also develop iron deficiency, but only after about 6 months of age (Calvo et al., 1992; Duncan et al., 1985; Pizarro et al., 1991; Siimes et al., 1984), if they are not given an iron supplement (Figure B-9).
Figure B-7
Changes in body iron during infancy. There is little change in total body iron between birth and 4 months of age. In contrast, total body iron increases markedly during later infancy. The high iron needs from 4 to 12 months of age help to explain why the risk of iron deficiency is greatest during this period.
Source: Dallman (1988).
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Figure B-8
Iron metabolism in the 1-year-old infant. Iron absorption must exceed iron loss to allow growth; however, daily iron absorption and loss, even in infancy, are normally a minute percentage of total body iron. MB + ENZ = myoglobin and enzyme iron.
Source: Reproduced with minor modifications from Dallman (1988), with permission from Hanley & Belfus.
In the United States, there has recently been a marked decline in the prevalence of iron deficiency anemia among infants and young children (Yip et al., 1987a,b). This improvement is attributable to concurrent changes in infant feeding practices that would be expected to improve iron nutrition, including less use of cow's milk in the first year of life, more use of iron-fortified formulas, and less use of low-iron formulas (Fomon, 1987). Iron absorption studies suggest (Fomon et al., 1989) and clinical trials indicate (Walter et al., 1993) that iron-fortified infant cereals also play a significant role in preventing iron deficiency anemia.
Low-birth-weight infants may become iron deficient after 2 months of age and possibly earlier unless they are given an iron supplement (Lundström et al., 1977; Siimes et al., 1984) (Figure B-11). Their iron needs are greater because of their lower neonatal stores, a more rapid relative growth rate, and often, blood loss resulting from the increased number of laboratory studies that their early care may require. For low-birth-weight infants fed human milk, supplemental iron is recommended to start at about 2 weeks of age at a dose of 2 to 3 mg of elemental iron per kg/day (AAP, CON, 1985). Infants fed iron-fortified formula usually obtain sufficient amounts of iron to make an additional supplement unnecessary.
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Figure B-9
Iron deficiency anemia among 9-month-old children who have been fed different diets.
Source: From Pizzaro et al. (1991).
Figure B-10
The fecal hemoglobin concentrations of infants fed formula (•) and infants fed cow's milk (o) after 168 days of age. Early feeding of cow's milk to infants results in increased fecal blood loss. Bars indicate standard errors.
Source: Adapted from Ziegler et al. (1990).
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Figure B-11
Iron deficiency anemia among low-birth-weight infants. Low-birth -weight infants weighing 1,000 to 2,000 g are likely to develop iron deficiency anemia after 2 months of age if not given iron supplements (o). The supplemented infants (•) received a total of 2 mg of iron/kg/day as ferrous sulfate starting at 2 weeks of age.
Source: From Lundström et al. (1977).
Childhood and Adolescence
After infancy, iron deficiency becomes less common (Yip et al., 1987a,b) as the rate of growth decreases and the diet becomes more diversified. During adolescence, however, the prevalence of iron deficiency rises again (LSRO, 1984) because iron needs increase with the adolescent growth spun (Dallman, 1992) (Figure B-12). Presumably, iron deficiency is even more common among pregnant adolescents, in whom the iron needs for pregnancy follow closely after the increased needs for growth. However, no iron deficiency prevalence data for pregnant adolescents in the general population are available.
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trimester and less than 10.5 g/dl in the second trimester. The routine use of ferrous iron at a dose of about 30 rag/day was recommended for nonanemic women starting at 12 weeks of gestation.1
Anemia before conception or during pregnancy should be treated with 60 to 120 mg of ferrous iron per day, no more than about 60 mg per dose. A vitamin-mineral supplement containing 15 mg of zinc and 2 mg of copper was recommended to be taken at a different time of the day.2 The hemoglobin should be checked for improvement after about 1 month, and the dose should be lowered to 30 mg/day if the anemia has resolved. The possibility of side effects was mentioned, including the likelihood that nausea, cramps, constipation, or diarrhea, should they develop, often persist for no longer than 3 to 5 days. Liquid and chewable preparations were offered as alternatives for women who have trouble swallowing pills or capsules. The relevant information provided about iron supplements is summarized in Table B-13.
Life Research Office: Guidelines For The Assessment And Management Of Iron Deficiency In Women Of Childbearing Age
This report (LSRO, 1991) focused primarily on the problem of iron deficiency in nonpregnant women. The recommendations for pregnant women were essentially the same as those of the Institute of Medicine (IOM, 1990a, 1992).
The prevalence of iron deficiency in the total population was considered to be sufficiently low to preclude recommending an increase in current levels of iron fortification in standardized food.
The prevalence of iron deficiency in nonpregnant women of childbearing age was too low to justify supplementing all women. Women with iron deficiency anemia should therefore be detected by laboratory screening, and intervention with iron supplements should be recommended for women with iron deficiency anemia.
Nonpregnant women should be screened for anemia (hemoglobin concentration, <12.0 g/dl, or hematocrit, <36 percent, with corrections for altitude and smoking [Table B-11]). For mild anemia (a hemoglobin concentration of between 10.0 and 12.0 g/all), a therapeutic dose of iron, 60 mg twice a day, should be given for 6 weeks. Check for a change in hemoglobin concentration and continue for a total of 6 months, and then lower the dose to 30 mg/day and monitor iron status. For severe anemia (a hemoglobin concentration of <10.0 g/dl), investigate further for the cause of anemia (note that such low values are very rare). To make an etiologic diagnosis of anemia, serum ferritin concentra
1
Note that recent developments argue for earlier initiation of iron or iron and folate: Studies indicate an association of anemia (Kim et al., 1992) or iron deficiency anemia (Scholl et al., 1992) early in pregnancy with low-birth-weight (IOM, 1992) and the CDC recommendations that all women of childbearing potential consume 0.4 nag of folate per day (CDC, 1992; IOM, 1992).
2
The necessity for this recommendation might be reevaluated in light of evidence for decreased compliance when medication is recommended at intervals more frequent than once a day (IOM, 1992).
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TABLE B-13 Information About Iron Supplements
Types of iron preparations
Well-absorbed iron compounds include ferrous sulfate, exsiccated ferrous sulfate, ferrous gluconate, and ferrous fumarate.
Slow-release iron compounds are available if there are side effects, but these are more expensive and are not as well absorbed.
Liquid and chewable preparations are available for those who have trouble swallowing tablets.
Iron compounds can be given alone, in combination with folate, or as part of a multivitamin-mineral combination, according to the clinical circumstances.
Drug Facts and Comparisons (Kastrup, 1992) is a useful, frequently updated reference for contents and costs of currently marketed iron products. It is available in many pharmacies and medical libraries.
Iron doses can be expressed in terms of elemental iron, as here, or in terms of the iron compound:
30 mg of elemental iron is equivalent to: 150 mg of ferrous sulfate about 95 mg of exsiccated ferrous sulfate 90 mg of ferrous fumarate 250 mg of ferrous gluconate
60 mg of elemental iron is equivalent to: 300 mg of ferrous sulfate about 190 mg of exsiccated ferrous sulfate 180 mg of ferrous fumarate 500 mg of ferrous gluconate
What to tell the patient to improve compliance and safety
Taking iron to prevent or treat iron deficiency anemia helps to reduce fatigue and increase your ability to adapt to delivery.
Let me give you the name of a liquid or chewable preparation if you have difficulty swallowing tablets.
Iron-containing supplements are best taken between meals or at bedtime with water or juice, not tea, coffee, or milk (once-a-day regimens favor compliance).
You may notice a darkening in the color of your stools, which normally results from taking iron tablets. Higher doses of iron sometimes cause stomach discomfort, constipation, or less often, diarrhea, but these problems often persist for no longer than the first 3 to 5 days after you start taking iron. If problems persist, we can lower the dose or recommend a different (slow-release) preparation that can be taken with meals.
Use safety caps (let me show you how), and keep supplements out of the reach of children because iron is a very common cause of poisoning (Litovitz et al., 1992).
SOURCE: IOM (1992).
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tion determination is the preferred test. A value of less than 12 µg/liter by itself indicates iron deficiency. A value of less than 15 µg/liter in an anemic individual indicates iron deficiency anemia.
Therapeutic doses of iron for anemia should be given under medical supervision. The total daily dose can be between 60 and 180 mg/day but should not be more than about 60 mg per dose. Take iron alone with water or fruit juice, not with milk, tea, or coffee.
A maintenance dose of iron is 30 mg/day (range, 15 to 60 mg) when taken as prescribed (see discussion of RDAs below).
Advise on diet.
For follow-up, on a 6-week revisit, modify the dose according to the change in the hemoglobin concentration and compliance. Consider other causes of anemia if there has been no response.
Pregnant women should routinely take a maintenance dose of iron in the second and third trimesters even if they are not anemic. If anemic, they should receive a therapeutic dose of iron as described below. New CDC criteria for anemia during pregnancy should be used (Table B-11) (CDC, 1989).
Recommended Dietary Allowances, 10th Edition
For nonpregnant women, 15 mg of iron per day was considered to provide a sufficient margin of safety for essentially all adult women in the United States except for those with the most extreme menstrual losses, given usual dietary patterns (NRC, 1989). This is a reduction from 18 mg/day in the 1980 RDAs.
For pregnant women, a daily increment of 15 mg/day (or a total of 30 mg/day) is recommended; this value is averaged over the entire pregnancy (NRC, 1989). Since the increased requirements of iron during pregnancy cannot be met by the iron content of the habitual diet of most Americans or the iron stores of at least some women, daily iron supplements are usually recommended.
Editorial Discussions
There is a widely held view in Britain (Hibbard, 1988) and elsewhere (Hemminki and Starfield, 1978) that no medication (including iron supplements) should be given to pregnant women in the absence of proven need. The view of Hemminki and coworkers (1989) was based on an earlier meta-analysis indicating no proven benefits of using vitamin or mineral supplements (Hemminki and Starfield, 1978). Hibbard (1988) proposed screening pregnant women and treating those in low-risk categories with iron only if they have a low serum ferritin concentration or anemia, but Horn (1988), in the same issue of the British Medical Journal as the article by Hibbard (1988), recommended
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routine iron supplementation as practical and cost-effective. Hibbard (1988) also recommended routine iron administration if concomitant folic acid treatment was used. Thus, the recent recommendation to use folate before conception and early in pregnancy would also include the use of iron if iron and folate combinations are prescribed, as is commonly the case.
International Recommendations Directed Primarily to Developing Countries
These recommendations are intended primarily for pregnant women in developing countries, where surveys have shown a prevalence of iron deficiency anemia often in excess of 50 percent (DeMaeyer et al., 1985). The recommendations have involved the routine use of relatively high doses of iron and folate. Poor distribution of tablets and poor compliance have been recognized as major problems. Various strategies for fortifying food with iron have been studied, but there has been little progress in implementing them on a broad scale.
Fao/Who (1988)
Requirements for absorbed iron were calculated for various age, sex, and pregnancy categories. Recommendations for dietary iron intakes are based on the estimated bioavailability of iron from the customary diet. The assumed percentage of iron absorbed primarily from cereal and legume diets, which have poor iron bioavailability, are 5 percent; that absorbed from diets with intermediate bioavailability, 10 percent; and that absorbed from diets with high bioavailability (meat and ascorbic acid-rich diets, as is usual in the United States), 15 percent.
World Health Organization
The document Preventing and Controlling Iron Deficiency Anemia Through Primary Health Care (DeMaeyer, 1989) noted the need for supplementation in situations such as pregnancy, in which rapid improvement in iron status is important. It recognized the problem of compliance, especially when there may be side effects and no perception of ill health. It also stressed the need for communication and the importance of motivation skills for health workers. For pregnant women, the recommendation was to take tablets containing 60 mg of iron and 250 lag of folate twice a day. A diet rich in heme iron and ascorbic acid was advocated. The desirability of iron fortification of a staple food and the control of infection were discussed.
International Nutritional Anemia Consultative Group
Tablets containing 60 mg of iron and 250 µg of folate twice a day without food were recommended for pregnant women. If there were side effects, the tablets were to be taken after meals or at a lower dose for 1 week before resuming a full dose. Diet modification and fortification were mentioned (INACG, 1989).
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