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Exercise and Hypertension

Author: Stan Reents, PharmD
Original Posting: 05/06/2007 12:37 PM
Last Revision: 01/15/2016 08:00 AM

According to 2013 stats from the American Heart Association, approximately 77.9 million individuals 18 yrs or older in the US currently have hypertension (high blood pressure). Stated another way, hypertension affects about 33% of adults in the US!

But wait, it gets even worse:

The Framingham Heart Study analyzed the risk of developing hypertension in roughly 1300 subjects ages 55-65 years old who did not currently have high blood pressure. In this study, more than half of the 55-year-olds and about two-thirds of the 65-year-olds developed hypertension within the ensuing 10 years (Vasan RS, et al. 2002). The authors concluded that "the residual lifetime risk for hypertension for middle-aged and elderly individuals is 90%....". Yes, that's right: NINETY PERCENT!

This is absolutely staggering. What this says is that, once you reach retirement age, you almost certainly will develop hypertension later in your life. And hypertension, in turn, increases the risk for other major medical conditions such as kidney failure, stroke, and heart disease.


Why is this "epidemic" of hypertension happening? Should we blame ourselves, or, has our medical community let us down? Clearly, health care professionals are screening for it: the results of a survey in 2000 showed that hypertension was the most common primary diagnosis in the US with 35 million office visits (Cherry DK, et al. 2002).

But when it comes to exercise counseling, physicians aren't doing as much as they should. Despite the fact that the nurse takes your blood pressure at every single office visit, how often has your own personal physician actually discussed the benefits of exercise with you? Not just in general terms, but I mean sitting down and having an honest face-to-face discussion that goes something like: "Dan, you need to exercise more. What I want you to do is walk 30-45 minutes per day five days per week, and I want you to start today."

The sad fact is that most physicians don't have these discussions with their patients (Ma J, et al. 2004). Managed care limits the amount of time physicians spend with each patient and, often, it's just easier to write a prescription and toss the patient a handout.

To be painfully honest, we should really blame ourselves. We simply don't take care of our health like we should. We don't exercise enough, and we eat salty, high-fat foods. Two-thirds of Americans are overweight. Eating a healthy diet, losing weight, and, especially, exercising regularly not only lowers blood pressure, but, quite possibly, could prevent hypertension from ever developing.

So, with that in mind, let’s review how exercise affects blood pressure.


What is normal blood pressure? Actually, it’s better to ask, what is the "optimum" or "desired" BP? For some people, their "normal" blood pressure (ie., their typical day-to-day BP) may actually be too high.

For many years, desirable blood pressure was considered to be 120/80 and treatment was instituted when BP was 140/90 or higher. However, as BP increases from 115/75 (ie., systolic/diastolic) to 185/115 mm Hg, each 20/10 BP increment doubles the risk of cardiovascular events like heart attack (myocardial infarction), heart failure, stroke and kidney disease (JAMA May 21, 2003).

Blood pressure cut-offs listed below are from the JNC-7, published in 2003 (Chobanian AV, et al. 2003):

Normal < 120 < 80
Prehypertension 120-139 80-89
Hypertension - Stage 1 140-159 90-99
Hypertension - Stage 2 160 and above 100 and above

On the other hand, elite athletes and aerobically-fit individuals may demonstrate a resting BP much lower than others. This is not harmful, nor unusual. In an aerobically-trained athlete, the heart is more efficient: it pumps more blood per stroke. The circulatory system overall improves as fitness improves: more oxygen is extracted from the blood with each heart beat. Oxygen uptake is higher in an athlete than in a sedentary person. In an athlete, the heart is stronger, and the heart rate is slower. Both contribute to a lower resting blood pressure. (see additional articles in the LIBRARY for separate discussions on these topics).

EFFECTS OF EXERCISE ON BLOOD PRESSURE: Immediate Effects vs. Long-Term Effects

Studies of the effects of exercise on hypertension have been conducted since the 1970s and several reviews of these studies have been published. But first, let's make a distinction between the immediate effects of a single exercise session on blood pressure vs. the long-term effects of regular exercise on hypertension.

Immediate Effects of Exercise on Blood Pressure

Blood pressure can fluctuate across a wide range depending on the activity at the time. During extreme effort, BP in some athletes can briefly rise to astronomical readings. For example, pressures as high as 480/350 have been documented in the brachial artery of a body-builder during a leg-press exercise (MacDougall, et al. 1985).

Long-Term Effects of Exercise on Blood Pressure

The research on the long-term effects of exercise on blood pressure will be grouped as either aerobic exercise or resistance exercise. Examples of aerobic exercise include walking, running, biking, swimming, playing tennis, etc....anything that gets the arms and legs moving and gets the heart rate up for a sustained period of time.

In 2002, an extensive review of the medical literature showed that aerobic exercise lowered BP not only in hypertensive patients, but also in normotensive patients, overweight subjects, and normal weight subjects. The average drop in blood pressure was 3.9/2.6 (systolic/diastolic) points. When only hypertensive patients were analyzed, the average drop was 4.9/3.7 (Whelton SP, et al. 2002). A Japanese study was even more impressive: aerobic exercise lowered BP by as much as 20/10 (systolic/diastolic) after 20 weeks (Kiyonaga A, et al. 1985).

Here are some specifics:


Running 2 miles/day every day for 3 months lowered blood pressure in 101 out of 105 patients with hypertension (Cade R, et al. 1984). In another study, jogging 60 minutes per day (target HR was 60-70% of age-adjusted maximum), twice weekly for 3 years, produced a satisfactory BP-lowering response (Ketelhut RG, et al. 2004).


In the HERITAGE Family study, subjects rode an exercise bike 3 days per week for 20 weeks. The intensity started at "moderate" exercise (55% VO2max) for 30 minutes and increased to "vigorous" exercise (75% VO2max) for 50 minutes during the study. At the conclusion, blood pressure wasn't reduced very much (the drop was less than 1 point for both systolic and diastolic). However, this doesn't suggest that cycling is ineffective for lowering blood pressure. In this study, the initial BP of the subjects was not substantially elevated and this was felt to be the explanation for the relatively minor response (Wilmore JH, et al. 2001).


Fewer studies have documented the long-term effects of swimming on hypertension, however, that does not mean that it should be ignored. On the contrary, swimming is an ideal cardiovascular exercise for people with knee pain or hip problems, or others that have trouble with walking or jogging.


In one study, overweight, sedentary subjects underwent 45 minutes of aerobic exercise at 70-85% of their personal heart rate reserve. The aerobic activity was either biking, jogging, or walking, and this was performed 3-4 times per week for 6 months. At the end of the study, this aerobic exercise program lowered both systolic and diastolic BP by 6 points (Georgiades A, et al. 2000).

This is an impressive response, but exercising at 70-85% of heart rate reserve is pretty tough for many people. How effective is less vigorous exercise?

It turns out that plain old walking can lower blood pressure. In one study of post-menopausal women, walking 3-km/day for 24 weeks lowered systolic BP by 6 points (Moreau KL, et al. 2001). A review of 16 other studies showed that walking produced an average drop in blood pressure of 3/2 (systolic/diastolic) points after 25 weeks (Kelley GA, et al. 2001).


During aerobic exercise, heart rate increases dramatically, while blood pressure increases only slightly. The opposite is true for resistance exercise: blood pressure increases to astronomical readings, but heart rate increases only slightly. As mentioned above, blood pressures as high as 480/350 have been documented during weight-lifting. So, does this mean that weight-lifting is bad for people with hypertension?

An increase in either measurement (ie., blood pressure, or, heart rate) will increase demand on the heart. To compare the impact of each form of exercise on the heart, something called the "rate-pressure product" [ie., (heart rate) x (blood pressure)] is calculated. This value can often be higher for aerobic exercise than for resistance exercise. This means that the demands on the heart can be greater for aerobic exercise than for resistance exercise (Stewart KJ. 2000).

In people with hypertension, resistance exercise does not have to be avoided. The American Heart Association recommends resistance exercise in the range of 30-60% of maximum effort in patients with hypertension. The American College of Sports Medicine also recommends resistance exercise for people with hypertension. However, aerobic exercise is preferred and should be the type of activity that you do if you choose to do only one type of exercise.

At least 11 studies have evaluated the effectiveness of resistance exercise on hypertension (Pescatello LS, et al. 2004). These studies are not consistent in their findings. In 2000, a review of this literature showed that resistance exercise was effective: at rest, both systolic and diastolic BP decreased by an average of 3 points (Kelley GA, et al. 2000).

Resistance exercise is mostly thought of as weight-lifting, but push-ups, sit-ups, pull-ups, squats, etc. also qualify as resistance exercise.


Vascular compliance is an assessment of not only how "flexible" your blood vessels are, but, also, how readily they can expand and contract on demand. Vascular compliance gets worse (decreases) with aging. This is not good.

It turns out that weight-lifting can worsen vascular compliance, whereas aerobic exercise can improve it.


An extensive review of the literature (54 studies) published in 2002, suggested that all forms of exercise can be beneficial in hypertension (Whelton SP, et al. 2002). Aerobic exercise should be emphasized, with some resistance exercise included. A combination of aerobic exercise (eg., 45 minutes of treadmill, stationary cycling, or stair-stepper exercise) with 7 different weight-lifting exercises 3 days per week was evaluated in elderly subjects (ages 55-75 yrs). This regimen produced a modest (2.2 mmHg) drop in diastolic BP after 6 months (Stewart KJ, et al. 2005). This drop in BP may not seem like much. However, combining resistance exercise with aerobic exercise will provide health benefits beyond simply lowering blood pressure. For example, weight-lifting will increase bone density and may help with posture and activities of daily living.

The idea of "prescribing" exercise as a treatment for some health conditions has gained attention. However, until very recently, there really wasn't a consensus on what worked best for hypertension. In 2002, the National High Blood Pressure Education Program (Whelton PK, et al. 2002) recommended:

"regular aerobic physical activity such as brisk walking at least 30 min/day on most days of the week".

In March 2004, the American College of Sports Medicine, one of the leading research organizations regarding the physiologic effects of exercise, published their latest recommendations regarding exercise and hypertension (Pescatello LS, et al. 2004). Here they are:

The "prescription" for exercise consists of 4 elements, represented by the acronym "FITT": frequency, intensity, time, and type.

  • Frequency: exercise should occur on most, preferably all, days of the week.
  • Intensity: exercise intensity should be moderate (ie., 40-60% of VO2max).
  • Time: duration of exercise should be at least 30 minutes per day; this can be achieved in one continuous session, or, a sum total of smaller periods of exercise throughout the day.
  • Type: endurance (aerobic) exercise is preferred, but resistance exercise should not be ignored.

If we reduced all this technical language down to more simple terms, it might be something like this:

walk briskly for 30-45 minutes per day, 5-7 days per week.


A lot of information has been summarized so far. So, what type of exercise is best for people with hypertension?

The short answer is: any type of "aerobic" exercise.

Aerobic exercise is generally defined as anything that requires you to move your arms and/or legs and gets your heart rate up and keeps it up for a while. Examples are numerous. It could be walking, jogging, biking, swimming, line-dancing, Zumba, etc. Basketball, soccer, volleyball, and all forms of racquet sports also qualify, though these sports entail periods of no activity.

Resistance exercise (eg., weight-lifting, exercises using your body weight like push-ups and pull-ups, working out with stretch bands) is also helpful, but, some research shows that when people perform resistance exercise for a long time without any accompanying aerobic exercise, the compliance of their blood vessels gets worse. So, if you like resistance exercise, make sure to also perform some type of aerobic exercise regularly, too.


First, no one should begin a new exercise program without first checking with your personal physician. This is especially important if you have any form of cardiovascular disease.

Further, if you have already seen your physician and you are currently taking medication to lower your blood pressure, generally, you still should not engage in strenuous exercise until the drug therapy has brought your blood pressure into a more normal range. This is very important, especially if you are older, or, if your blood pressure is very high.

Specifically, do not exercise if:

• Your resting BP is > 200/110

• During exercise, your BP increases higher than 220/115

• If you develop chest pain during exercise, stop immediately!


At the beginning of this discussion, I mentioned the extremely discouraging statistic that suggests the risk of developing hypertension as you get older is 90%. The immediate next question is: is there any evidence that regular exercise will, in fact, prevent hypertension? And the answer is yes!

Paffenbarger et al. studied Harvard alumni and found that those who did not engage in "vigorous sports activity" were at a 35% greater risk of hypertension than those who did. In this study, they defined "vigorous" activity as running, swimming, handball, tennis, cross-country skiing, etc. (Paffenbarger R, et al. 1983).

This 1983 Harvard alumni study found that vigorous exercise, but not light exercise, helped to reduce the risk of developing hypertension in later life. However, another study, in Japanese men, showed that walking for only 20 min/day successfully lowered the long-term risk of developing hypertension (Hayashi T, et al. 1999).


First, if you are taking medications for hypertension, do NOT begin a new exercise program without discussing your plans with your physician. However, having said that, many physicians are not well-versed on the issues that may arise regarding exercising while taking blood pressure medication. One reason is that issues that may arise when exercising while taking drug therapy are not widely known.

The topic of exercising while taking drug therapy for hypertension is too complex to review here. Keep in mind that there are over 200 unique prescription drugs for the treatment of hypertension on the US market. Even reviewing them categorically (eg., diuretics, beta-blockers, ACE inhibitors, calcium-channel blockers, etc.) would be a lengthy discussion. One issue worth noting, however is that beta-blockers are often not a good choice for exercisers due to their ability to interfere with energy utilization and limit exercise heart rate (Reents S, 2000). Some clinicians feel that beta-blockers should be the last choice for patients who wish to exercise (Houston MC. 1992).

(My text -- Sport and Exercise Pharmacology -- is the only book ever published describing what happens when people exercise while still taking prescription drugs. Generally, this book is intended for academics, graduate students in exercise physiology, and health care professionals. Editor.)

Regular Exercise Reduces the Need For BP Medications

Some studies have shown that regular exercise can reduce or even eliminate the need for antihypertensive medications (Ketelhut RG, et al. 2004). For example:

Running: In a study of patients with various degrees of hypertension conducted at the University of Florida, a daily running program made it possible for 24 out of 105 patients to discontinue their need for BP medications (Cade R, et al. 1984).

Stationary Cycling: An exercise program was evaluated in hemodialysis patients. Patients rode a stationary bike during dialysis. Initially, the average length of an exercise session was 17 minutes, but, gradually, these patients worked up to 45-minutes per session. After 6-months, half of the patients were able to reduce their need for BP medications. The researchers determined an overall reduction of 36% in the use of medications for high blood pressure which yielded a drug therapy costs savings of $885/year per patient (Miller BW, et al. 2002). This is impressive because it is often difficult to control blood pressure in patients with kidney disease.

Walking: An evaluation of walking revealed that as the distance and intensity of a walking session increased, the need for BP drugs decreased (Williams PT. 2008).

These studies are summarized in the table below:

• Running 2 miles/day
for 3 months
24 of 105 patients
were able to
d/c all BP drugs
(cost savings
not assessed)
Cade R, 1984
• Riding a stationary bike
during dialysis for 6 months
54% of patients
were able to
reduce their drug therapy
per patient
Miller BW, 2002
• Walking longer exercise sessions
more intense exercise
led to a reduction
in BP meds
(cost savings
not assessed)
Williams PT. 2008


Q: Dietary changes vs. exercise: which is more effective for lowering blood pressure in hypertension?

ANSWER: Diet and exercise are often lumped together by the medical community. But, which is more effective for hypertension? First, let's make a distinction between "diet modification" and "dieting". "Diet modification" is represented by changes to the diet (such as restricting sodium) without trying to lose weight. "Dieting", of course, means reducing calorie intake in order to achieve weight loss.

Dietary Modification: For years, physicians have instructed their patients with hypertension to limit their intake of salt/salty foods. The latest recommendations in the Dietary Guidelines for Americans, 2005 state: "not more than 2300 mg/day in healthy adults; not more than 1500 mg/day in patients with hypertension".

It turns out that this strategy doesn't lower BP very much. In one study, the drop in BP (systolic/diastolic) was only 1.7/0.9 (JAMA 1992), and in a review of 13 other studies, the average drop was only 3.6/2.0 (Grobbee DE, et al. 1986). However, even small drops in systolic BP are still significant because the risk of stroke and heart disease are reduced when large populations are studied. Also, black patients with hypertension should limit their intake of sodium as they seem to be more sensitive to its effects.

So, the answer is, yes, it is wise to reduce salt intake when managing hypertension. Restricting sodium is almost always a good health choice. One exception is the case of endurance exercise. For example, if you decide you want to walk or jog a marathon as your form of exercise, or, go on a 100-mile bike ride, or, do anything that causes you to perspire heavily over several hours, then, you need to make sure you take-in enough sodium. This is an entirely different topic and is discussed in "Why Sports Nutrition Is Different".

Dieting (ie., weight loss): Simply losing weight helps to lower BP in many patients with hypertension. Weight loss has been shown to be more effective in lowering blood pressure than a variety of dietary modifications (JAMA 1992). In fact, some researchers believe that controlling obesity might alleviate as much as 48% of the hypertension in whites and 28% of the hypertension in blacks (El-Atat F, et al. 2003).

So, when comparing diet vs. exercise for the management of hypertension, the best approach is a combination of: (a) proper diet (salt and calorie restriction), (b) weight loss, and (c) regular exercise. Dieting is beneficial if weight is lost, since, treating obesity helps to lower blood pressure. However, dieting does not strengthen the heart, lungs, muscles, and bones; only exercise can do this.


To have a beneficial effect on lowering your blood pressure, you don't have to endure punishing amounts of exercise. It turns out that plain old walking is good enough to attain a blood-pressure-lowering effect. Even cutting the grass, if you use a push mower, qualifies.

Keep these points in mind:

• First, if you have high blood pressure, or any form of cardiovascular disease, do NOT engage in strenuous exercise without being evaluated by your physician.

• If you are overweight or obese, lose that weight.

• Emphasize aerobic exercise, though, once your blood pressure is under control, don't ignore resistance exercise.

Hypertension is a disease that generally persists for life. But, evidence shows that regular exercise, combined with weight loss (if you are overweight), and limiting your intake of salty foods can help to lower an elevated blood pressure. Further, exercise improves other cardiovascular problems, too (Stewart KJ. 2002). More importantly, these lifestyle elements may actually prevent hypertension from ever developing in the first place. So, get out there!


Web Sites:

American Heart Association This site contains good information on hypertension and other cardiovascular diseases.

Centers for Disease Control and Prevention (CDC) There is a ton of useful public health information on this site.

National Heart, Lung, and Blood Institute The National Heart, Lung, and Blood Institute is a division of Health and Human Services. This site contains a lot of useful information on hypertension. The NHLBI also coordinates the National High Blood Pressure Education Program, which originated in 1972.


The American College of Sports Medicine has published Complete Guide to Fitness & Health. Chapter 15 covers High Blood Pressure.

Readers may also be interested in these reviews:


Stan Reents, PharmD, is available to speak on this and many other exercise-related topics. (Here is a downloadable recording of one of his Health Talks.) He also provides a one-on-one Health Coaching Service. Contact him through the Contact Us page.


Cade R, Mars D, Wagemaker H, et al. Effect of aerobic exercise training on patients with systemic arterial hypertension. Am J Med 1984;77:785-790.  Abstract

Cherry DI, Woodwell DA. National Ambulatory Medical Care Survey: 2000 summary. Advance Data 2002;328:1-32.  Abstract

Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. The JNC 7 report. JAMA 2003;289:2560-2572.  Abstract

El-Atat F, Aneja A, Mcfarlane S, et al. Obesity and hypertension. Endocrinol Metab Clin North Am 2003;32:823-854.  Abstract

Georgiades A, Sherwood A, Gullette EC, et al. Effects of exercise and weight loss on mental stress-induced cardiovascular responses in individuals with high blood pressure. Hypertension 2000;36:171-176.  Abstract

Grobbee DE, Hofman A. Does sodium restriction lower blood pressure? Br Med J 1986;293:27-29.  Abstract

Hayashi T, Tsumura K, Suematsu C, et al. Walking to work and the risk for hypertension in men: the Osaka Health Survey. Ann Intern Med 1999;130:21-26.  Abstract

Houston MC. Exercise and hypertension: maximizing the benefits in patients receiving drug therapy. Postgrad Med 1992;92:139-150.  Abstract

Kelley GA, Kelley KS. Progressive resistance exercise and resting blood pressure: a meta-analysis of randomized controlled trials. Hypertens 2000;35:838-843.  Abstract

Kelley GA, Kelley KS, Tran ZV. Walking and resting blood pressure in adults: a meta-analysis. Prev Med 2001;33(2 pt 1):120-127.  Abstract

Ketelhut RG, Franz IW, Scholze J. Regular exercise as an effective approach in antihypertensive therapy. Med Sci Sports Exerc 2004;36:4-8.  Abstract

Kiyonaga A, Arakawa K, Tanaka H, et al. Blood pressure and hormonal responses to aerobic exercise. Hypertension 1985;7:125-131.  Abstract

Klag MJ, Whelton PK, Randall BL, et al. Blood pressure and end-stage renal disease in men. N Engl J Med 1996;334:13-18.  Abstract

Ma J, Urizar GG, Alehegn T, et al. Diet and physical activity counseling during ambulatory care visits in the United States. Prev Med 2004;39:815-822.  Abstract

MacDougall JD, Tuxen D, Sale DG, et al. Arterial blood pressure response to heavy resistance exercise. J Appl Physiol 1985;58:785-790.  Abstract

Miller BW, Cress CL, Johnson ME, et al. Exercise during hemodialysis decreases the use of antihypertensive medications. Am J Kid Dis 2002;39:828-833. Abstract

Moreau KL, Degarmo R, Langley J, et al. Increasing daily walking lowers blood pressure in postmenopausal women. Med Sci Sports Exerc 2001;33:1825-1831.  Abstract

Paffenbarger R, Wing AL, Hyde RT, et al. Physical activity and incidence of hypertension in college alumni. Am J Epidemiol 1983;117:245-257.  Abstract

Pescatello LS, Franklin BA, Fagard R, et al. Exercise and hypertension. Med Sci Sports Exerc 2004;36;533-553.  Abstract

Prospective Studies Collaboration. Cholesterol, diastolic blood pressure, and stroke. Lancet 1995;346:1647-1653.  Abstract

Reents S. Sport and Exercise Pharmacology 2000, Human Kinetics, Champaign, IL.  Abstract

Stewart KJ. Exercise guidance in hypertension. Phys Sportsmed 2000;28:81-82.  (no abstract)

Stewart KJ. Exercise training and the cardiovascular consequences of type 2 diabetes and hypertension. JAMA 2002;288:1622-1631.  Abstract

Stewart KJ, Bacher AC, Turner KL, et al. Effect of exercise on blood pressure in older persons. Arch Intern Med 2005;165:756-762.  Abstract

Trials of Hypertension Prevention Collaborative Research Group. The effects of nonpharmacologic interventions on blood pressure of persons with high normal levels. JAMA 1992;267:1213-1220.  Abstract

Vasan RS, Beiser A, Seshadri S, et al. Residual lifetime risk for developing hypertension in middle-aged women and men. JAMA 2002;287:1003-1010.  Abstract

Whelton PK, He J, Appel LJ, et al. Primary prevention of hypertension. Clinical and public health advisory from the National High Blood Pressure Education Program. JAMA 2002;288:1882-1888.  Abstract

Whelton SP, Chin A, Xin X, et al. Effect of aerobic exercise on blood pressure: a meta-analysis of randomized, controlled trials. Ann Intern Med 2002;136:493-503.  Abstract

Williams PT. Relationship of distance run per week to coronary heart disease risk factors in 8283 male runners. The National Runners' Health Study. Arch Intern Med 1997;157:191-198. Abstract

Williams PT. Reduced diabetic, hypertensive, and cholesterol medication use with walking. Med Sci Sports Exerc 2008;40:433-443. Abstract

Williams PT, Franklin B. Vigorous exercise and diabetic, hypertensive, and hypercholesterolemia medication use. Med Sci Sports Exerc 2007;39:1933-1941. Abstract

Wilmore JK, Stanforth PR, Gagnon J, et al. Heart rate and blood pressure changes with endurance training: The HERITAGE Family Study. Med Sci Sports Exerc 2001;33:107-116.  Abstract


Stan Reents, PharmD, is a former healthcare professional. He is a member of the American College of Sports Medicine (ACSM) and holds current certifications from ACSM (Health & Fitness Specialist), ACE (Health Coach) and has been certified as a tennis coach by USTA. He is the author of Sport and Exercise Pharmacology (published by Human Kinetics) and has written for Runner's World magazine, Training and Conditioning, Club Solutions, and other fitness publications.

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