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Defining the Problem and Its Effects on Recruitment, Retention, Resilience, and Readiness

The first session of the workshop, moderated by Esther Myers, chief executive officer of EF Myers Consulting, Inc., examined the methods used for measuring obesity and overweight in the armed forces and discussed how these conditions affect recruitment, retention, resilience, and readiness.

THE BASIS OF CURRENT U.S. DEPARTMENT OF DEFENSE BODY FAT STANDARDS

Karl Friedl, senior research scientist in physiology at the U.S. Army Research Institute of Environmental Medicine, set the stage with a presentation on the rationale and methods for measuring body fatness among service members. He argued for the importance of defining the problem because of the many “misconceptions about why we have the composition standards that we try to enforce in the DoD [U.S. Department of Defense].” Body composition standards exist to sustain and support military performance, he explained, because it is imperative to ensure consistent readiness to perform missions that often require intense physical effort in harsh environments.

The development of enforced standards for fitness and body fat began in 1980, Friedl recounted, sparked when national news cameras panned down the “relatively wide gut line” of an Honor Guard in Washington, DC. Each service was represented, he noted, and “the national commentary was, ‘Do these guys look like they are fit to defend you?’” As a result, President Carter asked DoD to convene a panel of experts to develop an approach for instituting enforceable fitness standards. According to Friedl, the expert panel’s recommendations led to a DoD directive for all the services to adopt enforceable body fat standards based on abdominal circumference, not just body weight, which would make it possible to distinguish individuals who may be overweight but not overfat. The Marines had already adopted a

circumference-based standard, he noted, and now the other services would follow.

Abdominal circumference (and not just body weight) is key to three important outcomes related to the standards: military appearance, combat readiness, and health, Friedl elaborated. He added that the expert panel recognized that standards based on military appearance would be most stringent, while those based on health would be least stringent (see Figure 2-1). He also noted that the health-based standards would have to apply to all adult males and females, regardless of age, and have upper limits more appropriate for older than for younger adults, who are likely to gain weight as they age. According to Friedl, the panel realized that it would need to “meet in the middle” to account for all three outcomes.

Friedl explained that the panel considered the average body fat of a fit, young man or woman (15 percent and 25 percent, respectively), then allowed for a small statistical window and set a reasonable upper limit that would be consistent with maintaining fitness and also help drive healthy eating and physical activity habits to prevent excess weight gain. The panel’s recommended upper body fat limit was 20 percent for men and 30 percent for women, he reported. He noted that an explanation of sex-specific dif-

ferences in body composition was important to help DoD understand that the higher upper limit for women was appropriate, and that assigning them the same upper limit as men could push them to anorexic levels.

Next, continued Friedl, the services were told to develop a circumference standard, and each service had a different proposal. He explained that the services ultimately converged on the best standard, which was developed by the Naval Health Research Center. He described the resulting standard as focused on key sites reflecting chronic underexercise and over-nutrition habits: abdominal (navel) circumference for males, and abdominal (waist) and hip circumference in females. Measurements for both sexes are corrected for neck circumference and for stature, he added. Friedl argued that, while this is not necessarily a method that one would use in a research study requiring a precise measure of percent body fat, it is “a very practical and pragmatic method.”

Friedl then showed a nomogram to illustrate how the equation works (see Figure 2-2). The figure compares the difference between abdominal circumference and neck circumference plotted against stature, demonstrating the difference in body fat computation for a 69-inch-tall male with either

a small or large waist. For females, hip circumference would be added to abdominal circumference, Friedl noted.

Friedl clarified that using a body composition assessment method such as dual-energy X-ray absorptiometry (DEXA) or underwater weighing does not accord with the intent of this regulation, which is to enforce an abdominal circumference standard that is then corrected for height and other relevant variables. Measuring total body fat, he explained, begins to pick up ethnic differences and considers fat in other body regions where it is less responsive to changes in energy input and expenditure.

To summarize, Friedl showed a comparison of the standards of the Army and DoD (see Figure 2-3). In the Army, he observed, acceptable measures range from an ideal of 15 percent to up to 26 percent for men, and from an ideal of 25 percent to up to 36 percent for women. He further explained that the upper limits for young men and women are 20 and 30 percent, respectively, with a graduated adjustment to the upper limits as one ages. This adjustment, he elaborated, accounts for age-related changes in body composition, as well as the tendency of senior service members to have desk-bound jobs. By comparison, in DoD, the standards are 18 to 26 percent for men and 26 to 36 percent for women.

Friedl went on to describe the kind of aerobic and strength performance that the standards are intended to ensure. “Neither a sumo wrestler nor a marathoner is an ideal soldier,” he maintained, suggesting that for DoD, the ideal is probably between these two, incorporating an agility component. In discussing efforts to validate the standards against the type of aerobic and strength performance they are intended to enforce, Friedl said that in the future, the current standards could give way to an assessment based on

a combination of body mass index (BMI) and fitness testing. He noted that the Army may approve a new fitness test that could be used as part of such a combination assessment.

Turning to the changes in soldiers’ body composition over time, Friedl pointed to data on average height, weight, and circumference (chest, waist, and hips) collected in 1864 from nearly 1 million soldiers in Union camps, which could be used to estimate body fat. When compared with data from the year 2000, those early data show a 30-pound increase in lean mass and little change in body fat or adiposity for young men accepted into the military (Friedl, 2004). Friedl noted further that in the middle of the 20th century, there were many young men in the general population who were underweight, and now “we have a lot of young men [who are overweight] that we are turning away at the gate.”

Finally, Friedl claimed that the standards were successful in their intent to modify behavior, as they were correlated with an end to big lunches and an increase in individuals’ physical activity. He also mentioned three large trials that attempted to examine weight management approaches in the Army but were complicated by job-related migration. “We cannot give up,” he said in conclusion. “But it shows you that these are the realities of working with the military population.”

RECRUITMENT

Tracey Smith, a nutrition scientist at the U.S. Army Research Institute of Environmental Medicine, opened her presentation on recruitment by reporting that in 2007, the armed services spent about $1.5 billion for obesity-related health care expenses and the costs of replacing unfit military personnel (Voss et al., 2018). Moreover, she added, this number may underestimate the true figure, as it does not include long-term disability costs. She noted that obesity also leads to lost work days, degraded readiness and resilience, and higher need for aeromedical evacuation.

About one-third of U.S. adults are overweight and almost 40 percent have obesity, Smith continued, figures she said are relevant to DoD because it recruits its members from the general population. Indeed, she observed, according to DoD’s analysis of national height and weight data collected in 2014, approximately one-third of Americans aged 17 to 24 do not qualify for military service because of their weight (based on a BMI ≥27.5, the military’s upper limit for most age and sex groups). When this statistic is combined with other disqualifying factors, including criminal history and lack of adequate education, 71 percent of 17- to 24-year-olds are ineligible for military service, she reported (Council for a Strong America, 2018). She pointed out that these figures are based on height and weight data only, whereas assessing eligibility also requires circumference measurement to

determine whether an individual meets the military’s body fat standards (see the summary of Friedl’s presentation above).

Smith went on to discuss the proportion of military-age American civilians who, based on 2008 data, exceed service-specific standards for both body fat and weight-for-height. The figures range from 5 to 12 percent for men and 13 to 35 percent for women, she reported, depending on each service’s enlistment age requirements and standards (see Figure 2-4).

Moving on to examine statistics for individuals who apply for military service, Smith referred to 2014 data on applicants who underwent a physical at a military entrance processing station. Among first-time applicants for active component enlisted military service, approximately 9 percent were medically disqualified because of obesity based on International Classification of Diseases, Ninth Revision (ICD-9) coding.¹ Smith reported that this figure represented a decrease from 13 percent for the prior 5-year period. She added that, based on other medical failure codes provided by the U.S.

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¹ For the ICD-9 codes used to classify clinical diagnoses of obesity, see https://www.health.mil/Reference-Center/Publications/2016/10/01/Overweight-Obesity (accessed August 23, 2018).

Military Entrance Processing Command, about 16 percent of applicants in 2014 were disqualified because of weight and body build (Accession Medical Standards Analysis and Research Activity, 2015). For all the services, the average rate of disqualification due to weight and body build had decreased by 3 percent in 2014 compared with the prior 5-year period. Smith noted that weight status is a temporary disqualifying condition that can be remediated by an applicant without the need for an accession (initial military entry) medical waiver.

According to a 2013 technical report from the Defense Health Board, Smith continued, existing recruitment and accession standards are not posing challenges for recruitment goals (Defense Health Board, 2013).² For context, she noted that recruitment targets have decreased since 2007 because of the drawdown of troops, and recruiters are reporting that it has become easier to recruit healthy individuals.

Smith then turned to demographic characteristics associated with obesity and overweight at the time of accession into the Army. Overall, she reported, the prevalence of exceeding the Army’s screening table weights increased from 1989 to 2012, from a low of 5.7 percent to 25 percent, and peaking at 31 percent in 2006 and 2007. From 2008 to 2012, she added, women were less likely than men to exceed the guidelines, and women below age 20 were less likely to do so than women aged 20–29 and 30–39. The odds of exceeding the screening table weights showed no consistent trends with respect to educational attainment, marital status, or geography (Hruby et al., 2015).

Next, Smith shared data indicating the long-term impact of excess weight at accession on lower-extremity musculoskeletal injury and disorders and cardiometabolic risk factors. Relative to soldiers with normal BMI at accession, she said, those who were underweight, overweight, or had obesity had a 7, 11, and 33 percent, respectively, higher risk of injury (after adjusting for a number of sociodemographic factors). The risk of injury was lowest in soldiers with a BMI of 21–23 km/m² at accession, she pointed out (Hruby et al., 2016), adding that studies with shorter follow-up periods have yielded similar results. “Taken together,” Smith stated, “BMI at accession certainly has important implications for injury risk and does support the importance of upper limits of BMI at accession.”

Furthermore, Smith continued, relative to soldiers with normal BMI at accession, those who were overweight or had obesity had a higher risk for developing each of the following cardiometabolic risk factors: meta-

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² The recruitment targets presented at the workshop are recommendations from the 2013 Defense Health Board report Implications of Trends in Obesity and Overweight for the Department of Defense, published November 22, 2013. See http://www.dtic.mil/dtic/tr/fulltext/u2/1027323.pdf (accessed August 22, 2018).

bolic syndrome, glucose/insulin disorder, hypertension, and dyslipidemia. Soldiers with obesity at accession, for example, had three times the risk of hypertension relative to those with normal weight (Hruby et al., 2017). These elevated risks, she noted, were detected despite a generally low incidence of these risk factors in this young population, as well as a relatively brief (3.2 years) follow-up time.

Smith closed by citing four practical ways in which the information on national trends in overweight and obesity and implications for military personnel provided in the Defense Health Board’s 2013 report can be applied to advance efforts to recruit and retain fit armed forces:

• The report indicates that existing recruitment and accession standards are appropriate, although the indication that the standards are not posing challenges to recruitment goals could change should recruitment demands increase. As noted in the report, this issue should be revisited periodically.
• Recruitment centers should collect data on the number of people that are turned away from recruitment stations, given that some prospective applicants do not undergo an initial medical exam and thus cannot be factored into calculations of actual recruitment losses related to classification as overweight or obese.
• DoD should assess the feasibility of training recruiters to calculate BMI and collect circumference measurements to identify applicants who may not meet the weight standards but may meet the body fat standards.
• Current accession standards for weight-for-height and body fat should be maintained as minimal requirements for all military personnel to ensure an agile and responsive fighting force, with stricter standards for certain military occupational specialties, such as Special Forces.

RETENTION

Jay Heaney, deputy for the Warfighter Performance Department at the Naval Health Research Center, began by observing that the military’s Body Composition Assessment (BCA), performed on service members twice per year, influences retention and separation from service. The Navy follows the DoD’s upper limits for body fat of 26 percent for males and 36 percent for females, he said, reiterating Friedl’s explanation of the graduated adjustment to the upper limit with increasing age—as members become more senior in service, they “are probably not on the front line doing the physical labor that [they] used to do.”

Heaney shared the Navy’s BCA scorecard for 2017, which detailed the

pass/fail rate for male and female enlisted members and officers in three areas: height and weight (upper limit = BMI of approximately 27 kg/m²), abdominal circumference (upper limits = 39 inches for males, 35.5 inches for females), and age-adjusted body fat percentage by circumference. The pass rate for the BCA was 99.2 percent that year, although, he pointed out, that rate still left nearly 2,500 service members failing in both assessment cycles. He added that the pass rate for the Physical Readiness Test (PRT), which includes a 1.5-mile run and other components, was just under 99 percent. Thus, he observed, the average pass rate for the total Physical Fitness Assessment (PFA) process in the Army that year was slightly below 99 percent; the pass rate for height and weight was approximately 97.7 percent and for physical fitness was about 97.5 percent. To summarize, Heaney stated that most active duty service members pass their PFA, which puts them in good standing for advancement and retention.

Heaney went on to present data representing the number of enlisted sailors who separated because of PFA failure from 2013 through 2017 (see Figure 2-5). He explained that the majority of the Navy’s separations due to PFA failure occur among early-career sailors: “We are losing our service members in their first tour. We are not holding on to them.”

Heaney pointed out that for 2013 and 2014, the administrative policy

was that failing in three out of four PFA cycles led to separation. In 2016, he explained, the administrative policy changed, resulting in a “reset period,” and in 2017, a new policy was enacted that required separation after two out of three failed PFA cycles.

Another change in policy went into effect on January 1, 2018, Heaney continued. The Navy is currently short 8,000 shipboard sailors, he explained, and rather than changing physical readiness standards, it changed its physical readiness separation policy. The new policy, he elaborated, is more flexible, allowing sailors who fail two or more consecutive PFAs to serve until the end of their obligated term (enlisted) or projected rotation date (officer), during which time they have an opportunity to resume good standing by passing a PFA. However, he noted, individuals are not eligible for promotion or reenlistment during that time.

Heaney illustrated the new policy with the theoretical example of an officer who fails two consecutive PFAs but has 2 years remaining before his or her projected rotation date. The officer would be allowed to continue serving and would have four more cycles (two per year) to pass a PFA. For service members who want to remain in the Navy, Heaney elaborated, the policy gives them the time to change their behaviors and fitness levels to resume good standing. He added that sailors with nuclear training and those with a medical specialty or other special training may be granted an exception from the new policy. “We seem to find a way to give an exemption to keep that highly trained person in the service,” he remarked.

Heaney went on to report that sailors who exceed age-adjusted body fat standards are enrolled in the Fitness Enhancement Program. This program mandates nutritional counseling and 3 days per week of physical fitness training, and includes routine weight and body composition monitoring and other supportive resources. Sailors’ participation in the program continues for a minimum of 6 months until they pass the next PFA or BCA. The Army has a similar program, Heaney noted. He elaborated briefly on the other services’ separation policies related to BCA, which are fairly similar to that of the Navy and have their own nuances.

Heaney closed by emphasizing the critical role of the standards in ensuring military performance and execution of job responsibilities, asserting that “we cannot be … relaxing standards because our civilian population that we are recruiting from is coming in heavy.” He noted that while service members’ health is a concern, in the military, “it is really about being able to perform your job.”

RESILIENCE, READINESS, AND DEPLOYMENT

Bruce Jones, chief of the Injury Prevention Division at the U.S. Army Public Health Center, discussed resilience, readiness, and deployment

through the lens of the complex interrelationships among BMI, percent body fat, physical fitness, and injury risk.³

BMI, Physical Fitness, and Injury Risk Among Army Recruits

Jones began by reporting that among males and females in the Army’s basic combat training, the risk of injury is slightly higher at both extremes of the BMI quintiles and lowest in the average BMI group (middle quintile) (Jones et al., 2017). He went on to cite a consistent finding since the 1980s of the association for both men and women between decreasing aerobic endurance (based on 2-mile run time) and increasing injury risk. Risk increases steadily from the fastest to the slowest run times, he said, from about 10 to 24 percent for men and from about 27 to 56 percent for women (Jones et al., 2017). Taking BMI into consideration as well, he continued, the highest risk of injury occurs among the leanest individuals with the slowest run times, and “oddly enough,” the lowest risk is seen among those with the highest BMIs who also run the fastest. Across all fitness levels, he summarized, the highest injury risk occurs among those with the lowest BMIs (Jones et al., 2017) (see Figure 2-6).

BMI, Physical Fitness, and Age of Soldiers in Operational Units

Next, Jones shared data on soldiers in operational units, where he said age becomes a factor, as compared with basic training, where all trainees are relatively young. Presenting data for men, he pointed out a progressive increase in both BMI and 2-mile run time with age, adding that the data also show a progressive increase in BMI with increasing 2-mile run times. When age groups are stratified by BMI, he noted, the groups with the highest risk for injuries are those with the highest BMIs in the older age groups (25+ years) and those in the oldest age group (35+ years). When run times are stratified by BMI, the groups with the highest injury risk are those with the lowest and highest BMIs and the slowest run times (Rappole et al., 2017).

Correlations of BMI and Height with Physical Fitness and Military Performance

Moving on to BMI, height, physical fitness, and military performance, Jones observed that as BMI increases, aerobic fitness (as measured by 2-mile

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³ The views expressed in this presentation are those of the speaker and do not necessarily reflect the official policy of DoD, the Department of the Army, the U.S. Army Medical Department, or the United States.

run time) decreases for both men and women. On the other hand, increasing BMI is associated with increasing upper-body muscle endurance for men, and with increasing lower-body muscle endurance as well as increasing upper- and lower-body strength for both men and women. He added, however, that according to the data, overall combat fitness (as measured by time to complete a warrior task and battle drill obstacle course with a fighting load) does not change with increasing BMI for either men or women. There are no apparent differences across levels of BMI, he continued, suggesting that completing the obstacle course requires a combination of muscle strength, muscle endurance, and aerobic endurance. The picture is a little different with height, he said, displaying data indicating that the tallest men and women completed the obstacle course more quickly relative to those of shorter stature. Height made a bigger difference for women, he noted, with an improvement of several minutes for the tallest compared with the shortest women, versus an improvement of about 1 minute for the tallest men (Pierce et al., 2017).

Effects of Deployment on Body Composition and Physical Fitness

Jones then presented data on two groups of male soldiers, one on a 9-month deployment to Afghanistan and the other on a 13-month deployment to Iraq. In both cohorts, postdeployment body weight and BMI had increased, and in the 13-month group, body fat was measured and had also increased. Physical fitness had not changed in the 9-month group (Knapik et al., 2008), but several other fitness measures indicating muscle strength and power had increased in the 13-month group (Lester et al., 2010).

Closing Remarks

Jones closed by asserting that taken together, these findings suggest it may be misleading to think that increased BMI is associated with decreased military readiness, because soldiers with higher BMIs and higher fitness have shown greater musculoskeletal resilience in terms of being less injury-prone. Injuries are the leading cause of medical nonreadiness, he informed the audience. “If the Army desires the most physically ready soldiers,” he argued, “they may need standards that take into consideration both physical fitness and body composition simultaneously.”

FAMILIES AND COMMUNITIES

Obesity and overweight affect children and families throughout the military community said Karen Hawkins, a registered dietitian in the Office of Military Family Readiness Policy. In the Military Health System, she

said, 13 percent of children aged 6 to 17 are overweight, and another 17 percent are at risk for becoming overweight (Bencio et al., 2004). Many military children will wish to join the military once they grow up, she said, and DoD is trying to address the finding that as many as 30 percent of military children may not be eligible to do so because of weight.

Hawkins reported that a DoD Childhood Obesity Working Group appointed in 2012 had developed an educational campaign encouraging families to lead healthy lifestyles. She described the 5-2-1-0 Healthy Military Children Campaign, a partnership with the U.S. Department of Agriculture (USDA) and universities. The numbers in the campaign’s title refer to recommended healthy food and beverage consumption, hours of screen time, and physical activity: 5 or more daily servings of fruits and vegetables, no more than 2 hours of daily screen time, at least 1 hour of daily physical activity, and 0 sweetened beverages per day. While the concept may appear simple, said Hawkins, data support its effectiveness throughout the population and the public health community, both within and outside DoD. She described the campaign materials, which include a website, a newsletter, and toolkits for both civilian and military communities. The toolkits explain how to work with various facilities on a military installation, such as the commissary and child development centers, to support the campaign. She highlighted a recent example from April 2018 in which students on military installations created artwork illustrating the 5-2-1-0 message and how they use it in their daily lives.

Next, Hawkins touched on her work with the Military Family Learning Network, which provides research and continuing education for military family service providers and educators to enhance their professional growth and impact. She works with the network’s Nutrition and Wellness concentration area, determining the continuing education and resources needed for dietitians and other service providers to address nutrition needs in the military community successfully. The network develops and conducts about 10 educational webinars per year, she reported, with an average of 200–400 participants on a monthly basis.

Finally, Hawkins mentioned Military OneSource, a free resource available 24 hours per day, 7 days per week to connect service members and their families with a wide range of individualized consultations, coaching, and counseling for many aspects of military life. She highlighted in particular Military OneSource’s health and wellness coaching opportunity.

DISCUSSION

During a discussion period following the five presentations summarized above, speakers addressed questions from the audience on topics including

fitness measures, recruitment quotas, risk of injury among women, and use of the standards to maintain the appearance of military readiness.

Fitness Measures

Responding to a question on the practicality of measures to predict fitness, performance, and injury, Jones emphasized that BMI is a very good preliminary screening tool. However, he maintained, a combination of both fitness and body composition is needed, given that high and low BMI values are associated with different kinds of fitness. Friedl added that while BMI could play a role, a good fitness test should perhaps be the ultimate determinant of whether a person can do the job. He predicted that a new approach to fitness may be on the horizon, with a different test that is more job related. Jones concurred that fitness “may trump body composition if you are looking for soldiers that can do their job.”

The discussion then shifted to fitness tests for high school students and whether one standard could be used for that age group as well as in the armed forces. Jones argued that the military’s tests should not only measure military fitness but also encourage individuals to improve their own physical fitness, and should consist of simple, practical activities that can be done in normal, everyday settings. “If we come up with a good test, it could be something that high school kids could do too,” he suggested. Heaney added that the test should assess how well a person is able to carry his or her body weight to execute a job. Friedl mentioned that the Army has developed basic tests with components that assess one’s capacity to perform different jobs in the Army, which are in turn used to classify people for different demands in various jobs.

Recruitment Quotas

Referring to Smith’s report that recruitment commands are meeting their numbers, a participant asked whether there could be a point at which a surge in recruitment needs would require recruiting unfit individuals. Smith responded that specific numbers of recruitment needs have not been calculated, but the situation should be reassessed every 3 years based on the Defense Health Board’s 2013 report. In terms of how better to prepare society to help the military meet a possible surge in recruitment needs, Friedl mentioned a potential initiative in Switzerland to provide a fitness tracking system to all prospective male recruits of high school age to provide guidance during the year before they would enter basic training.

Citing the high percentage of age-eligible individuals who do not meet military recruitment standards, another participant argued that the military should advocate for society’s shared responsibility for raising awareness

of the importance of and cultivating a healthy population, starting during pregnancy and infancy. Jones emphasized that the problem is a readiness issue, which he said adds an incentive for the public to take more interest in the health and physical fitness of young people.

Risk of Injury Among Women

A participant noted that Jones’s data indicate that regardless of BMI, women’s risk of injury is almost three-fold higher than men’s. Jones responded that this is a consistent finding in basic training, where everyone is doing the same thing on a daily basis. The relationship is not observed in operational units, he continued, explaining that when one controls for physical fitness in basic training, the relative risk “goes from 2.5 to 3 times higher to almost 1 to 1 … maybe 1.2 or 1.3. Our suspicion is that it is mostly related to physical fitness.” Asked about the nature of the injuries observed in basic training, Jones responded that 70 to 80 percent are lower-extremity injuries, due mostly to overuse. Friedl added that the first women who complete rigorous training successfully are those who appear to have higher bone density, which he said appears to protect against stress fractures. Jones also noted that soldiers with the lowest BMIs are at the highest risk for stress fractures, and that overweight individuals appear to be protected against this type of injury.

Use of the Standards to Maintain the Appearance of Military Readiness

Participants briefly discussed how the perception of military members’ appearance can serve as a deterrent to conflict. If service members look flabby and out of shape, said Friedl, it is “not much of a threat to anybody.” Heaney added that in some services with a greater reliance on unmanned vehicles, “the appearance factor is not quite what it was for the infantry of old.” But even cyber warriors need daily physical activity for optimal brain function, Friedl argued, and chronic diseases affect cognition and mental health. Heaney agreed that appearance is still a relevant standard, but may not be as important as it was in earlier times.

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