BMI and mortality

The Body Mass Index (BMI) is one way of assessing weight categories. According to a study published online by the medical journal Lancet, high and Low BMIs were associated with increased mortality risk.

This large research examined data from 57 prospective studies with 894,576 participants, mostly in western Europe and North America. Mortality was lowest among those associated with BMIs in the range of 22.5 to 25 kg/m2. Above 25, every 5-unit increase in BMI translated to a serious 40% higher risk for death from ischemic heart disease or stroke and 10% increased risk for cancer-related deaths.

The authors commented "Although other anthropometric measures (eg, waist circumference, waist-to-hip ratio) could well add extra information to BMI, and BMI to them, BMI is in itself a strong predictor of overall mortality both above and below the apparent optimum of about 22.5—25 kg/m2."

Even though the "normal" BMI range is usually quoted to start from BMI of 18.5, the study showed that adults whose BMI was below 22.5 were also at higher risk for death. However, such a higher mortality was mainly, but not entirely, due to smoking-related lung diseases and cancer.

This important study was funded by UK Medical Research Council, British Heart Foundation, Cancer Research UK, EU BIOMED programme, US National Institute on Aging, and Clinical Trial Service Unit (Oxford, UK).

Reference article:
Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Prospective Studies Collaboration. Lancet. 2009 Mar 28;373:1083-1096.
(Abstract)
doi:10.1016/S0140-6736(09)60318-4
(How to use the doi system?)

High Intake of Red and Processed Meats Increases Mortality Risk

A recent research supported by the National Institutes of Health, published in the Archives of Internal Medicine has shown that daily intake of red and processed meats (examples: beef and pork) is associated with increased risk for death in older adults, while white meat (examples: chicken, turkey and fish) may have a small protective effect. This is the largest study ever, including more than a half million adults aged 50 to 71, who were followed for 10 years. After adjustment for BMI and smoking, those who had the highest red meat intake had significantly higher risk of dying overall, and of dying from cancer and cardiovascular disease. Same applied to processed meat (examples: sausage, cold cuts or hot dogs). As the authors pointed out in the discussion of the article, meat is a source of several carcinogens (substances that can cause cancer) which are formed during high-temperature cooking of meat. Iron in red meat may increase oxidative damage increasing the formation of N-nitroso compounds. While red meat is a major source of saturated fat (not good), fish is rich in omega-3 fatty acids (good). In 2004, the FDA Announced a Qualified Health Claim supporting that consumption of omega-3 fatty acids reduces the risk of heart disease (coronary artery disease).

Reference article:

Meat intake and mortality: a prospective study of over half a million people. Sinha R, Cross AJ, Graubard BI, Leitzmann MF, Schatzkin A. Arch Intern Med. 2009 Mar 23;169(6):562-71. [PMID: 19307518] (Free Full Article)

Washington Post coverage

First Heart Attack - How Young?

A study from Michigan gave an answer to a question: Can obesity make someone suffer a heart attack at a younger age? The authors examined the data of 111,847 patients who suffered from a type of heart attacks called "non-ST-segment elevation myocardial infarction (NSTEMI)." They found that the leanest individuals whose BMI was 18.5 kg/m(2) or less, developed that type of heart attacks at an average age of 74.6 years, compared to those with BMI of 40 or above, whose average age for the first heart attack was only 58.7 years.

Notice that a BMI of less than 18.5 is considered, by definition, underweight (see the Bariatric Surgery Glossary), which is abnormal and not healthy. Remember, the benefits of a healthy heart can only be realized in an overall healthy body. Having said so, the contribution of obesity to the premature occurrence of a heart attack cannot be ignored. We should do everything possible to treat and prevent obesity when as young as possible, to help preventing life-threatening complications.

Reference:

Madala MC, Franklin BA, Chen AY, Berman AD, Roe MT, Peterson ED, Ohman EM, Smith SC Jr, Gibler WB, McCullough PA; CRUSADE Investigators. Obesity and age of first non-ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2008 Sep 16;52(12):979-85. [PMID: 18786477] (Abstract)

At what age do we stop being so active?

I wondered, at what point in our lives have we shifted from running to walking? From moving a lot to moving only if we need to? Basically, when does our moderate-to-vigorous activity level shift from the tireless running allover the place to the more adult-like style of moving when we need to? A very interesting study, published in the July 16, 2008 issue of JAMA gave some insight. The authors analyzed the data of more than 1000 children, almost half of them were boys and the other half were girls. The researchers followed their patterns of moderate-to-vigorous physical activity from age 9 to age 15. They found that at 9, the average child engaged in good 3 hours of moderate-to-vigorous physical activity, which is well more than the recommended minimum of 60 minutes per day. By age 15 years, adolescents were active at that level for only 49 minutes per weekday and 35 minutes per weekend day. Boys were more active than girls. It is well-known that decreased physical activity is an important factor in childhood obesity.

I am not sure what exactly happens. Why at some point in our lives we start walking if we don't have to run, and sit if we don't have to walk? At any rate, knowing that the transition takes place between the ages of 9 and 15, we can target that time interval and aim at keeping children engaged in organized moderate-to-vigorous activities during that period, hoping that the habit continues with them for so many more years of their lives.

Reference:

Nader PR, Bradley RH, Houts RM, McRitchie SL, O’Brien M.
Moderate-to-Vigorous Physical Activity From Ages 9 to 15 Years.
JAMA. 2008;300(3):295-305. (Abstract)

Affiliations of the authors of the reference article: Department of Pediatrics, University of California San Diego, La Jolla; Center for Applied Studies in Education, University of Arkansas, Little Rock; Statistics and Epidemiology, RTI International, Research Triangle Park, North Carolina; and Department of Human Development and Family Studies, University of North Carolina, Greensboro.

Economy of Health and Obesity

You probably heard about this study that was recently reported in the media. The title is: "Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure". The study indicates that it costs more if people live longer, than if they die at an earlier age from obesity. Using a mathematical simulation model, the study concluded that total lifetime health spending was greatest for the healthy-living people, lowest for the smokers, and intermediate for the obese people.

Notice that previous studies have consistently calculated the health expenditure savings resulting from reducing the financial burden caused by treating comorbidities related to obesity. Those studies did not enter in the calculations, the life prolonging effects of treating obesity, and the costs of living longer. Pieter van Baal and colleagues conclude, based on their simulation model, that obesity prevention leads to a decrease in costs of obesity-related diseases, but this is offset by cost increases from diseases unrelated to obesity in life-years gained.

I do not know how to use this information. The study that came from the Netherlands is very objective, and proposes no policy recommendations based on the findings. As a matter of fact, the authors stated that it does not imply that preventing obesity is not worthwhile, since the associated health gain is valuable in itself, for society and the individuals concerned. Furthermore, the article commented that Bonneux et al. (from the Netherlands, as well) made it very clear: “The aim of health care is not to save money but to save people from preventable suffering and death. Any potential savings on health care costs would be icing on the cake.”

I cannot imagine anyone finding it morally attractive or ethical to not prevent or treat obesity and smoking, because of the above findings. Those two particular health problems are not the only ones that can potentially affect the life span. How about stopping being aggressive in preventing or treating heart disease, diabetes, etc. Wouldn't that save dollars, too? Living better, healthier, and hopefully longer, is priceless. Stay Healthy!

The study in focus:

van Baal PHM, Polder JJ, de Wit GA, Hoogenveen RT, Feenstra TL, et al. (2008) Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure. PLoS Med 5(2): e29 doi:10.1371/journal.pmed.0050029 (Full Text)

PLoS Med is the Public Library of Science Medicine

Reference:

Bonneux L, Barendregt JJ, Nusselder WJ, der Maas PJ. 1998. Preventing fatal diseases increases healthcare costs: cause elimination life table approach. BMJ. 316:26–29. (Full Text)

Roundup - What's the Problem?

"... as an adult, we understand even if you ruin an appetite, there's another appetite coming right behind it. There's no danger in running out of appetites. I've got millions of them." --Jerry Seinfeld. The "Heart Attack" episode.


Fact: When food is in short supply, obesity as a public health problem does not exist. As a matter of fact, being obese under those circumstances signifies being wealthy or of higher economic status than the average population. Look at countries where some are living in poverty, and others are more affluent. Which segment of that society has a problem with obesity?

Fact: When food is made available and affordable, in the presence of abundance, the average person will eat more. Much more. Bigger portions. It is surprising to see people who immigrated as adults from less affluent countries continuing to eat the portions and at the times that they were used to, and stay slim. They have already developed the habits and controls and they stay satisfied with the portions and types of food that they used to consume. Their first generation kids, however, who were not raised in such a controlled environment, may become overweight or obese.

Fact: When food is not only made available in abundance 24 hours a day, but is also advertised all day long, people tend to consume even more. And branding does affect their choices.

Fact: Social networks can strongly enhance the spread of obesity.

One conclusion I can draw here is that: External influences tend to have a stronger effect on controlling how much we eat than spontaneous internal influences, in the average person. It takes a conscious effort and proper habit building and modifications to overcome those external influences. That we are victims of an environment and a culture that facilitates (or may even encourage) habits that will make us unhealthy, the only true refuge is our own ability to change habits and behaviors that developed under those circumstances. Although I stress on over-eating as a deadly habit, it is important to notice that serious under-eating as in anorexia nervosa is at least as deadly, if not more.

Remember, weight control is achieved through three elements:

1. Diet (portion acontrol and quality control)

2. Exercise or physical activity

3. Behavioral change towards healthy habits

Everything else (a diet program, a trainer, a pill, a surgical operation) is a tool that helps you control your energy storage (and, consequently, the weight of fat) through one or more of the above mechanisms.

Stay healthy! Happy Holidays!

Childhood and Adolescent Obesity - A Real Concern

Well, this is another blog entry that is not a bariatric surgery issue, but a real public health and epidemiology concern. The New England Journal of Medicine issue of December 6, 2007, has three excellent articles:

1. Childhood Obesity — The Shape of Things to Come by Dr. D.S. Ludwig (Link) from Harvard Medicalo School
2. Childhood Body-Mass Index and the Risk of Coronary Heart Disease in Adulthood by Dr. J.L. Baker and others (Link) from Copenhagen, Denmark
3. Adolescent Overweight and Future Adult Coronary Heart Disease by Dr. K. Bibbins-Domingo and Others (Link) from the University of California, San Francisco

The Journal is making the full text of those articles (not just the abstracts) available for free.

In the perspective article "Childhood Obesity — The Shape of Things to Come", Dr. David Ludwig (Director of the Optimal Weight for Life Program, Children's Hospital Boston, Harvard Medical School) views the obesity epidemic as consisting of four phases. The first phase (began in the early 1970s) witnessed a progressive increase of the average weight among children from all socioeconomic levels and geographic areas in the United States.

The second phase, which we are now entering, is characterized by the emergence of serious weight-related problems in adolescents, including type 2 diabetes, fatty liver, orthopedic problems, sleep apnea, social isolation, anxiety, and depression.

Phase 3 will signal opening the doors for the medical complications of obesity to lead to life-threatening or limb-threatening disease. There will be an increased risk of coronary heart disease in adulthood, a high risk for limb amputation, kidney failure requiring dialysis, and premature death. The article quotes that the risk of dying by middle age is already two to three times as high among obese adolescent girls as it is among those of normal weight. Dr. Ludwig has predicted that pediatric obesity may shorten life expectancy in the United States by 2 to 5 years by midcentury, which would be equal to that of all cancers combined.

Phase 4 of the epidemic, if allowed to take place, will lead to even higher obesity rates because of transgenerational mechanisms.

Those articles are a highly recommended reading for anyone who feels that childhood obesity is hitting home.

CDC: Adult Obesity Prevalence - No Significant Increase

The Centers for Disease Control and Prevention (CDC) has announced the new obesity prevalence statistics in a report titled, "Obesity Among Adults in the United States -- No Change Since 2003-2004". There was no "significant" change in obesity prevalence between 2003-2004 and 2005-2006 for either men or women. I would consider this "encouraging", but far from being exactly "good" news.

Some have declared that the media headlines should, at the very least, be shouting: “Obesity Epidemic Over!” (1). In literal terms, and based only on this piece of information, an obesity epidemic may, indeed, be over. After all, the definition of "epidemic", according to Webster's New World Medical Dictionary is "The occurrence of more cases of a disease than would be expected in a community or region during a given time period." Well, so what? Should we be proud of the current number of 34% being obese, knowing of the adverse health effects of obesity? According to the news release, more than one-third of U.S. adults -– over 72 million people -- were obese in 2005-2006. This includes 33.3 percent of men and 35.3 percent of women. The reality is that the lack of statistically significant increase in prevalence does not mean at all that we are OK. At the very best, we are just maintaining a peak high prevalence of obesity. Actually, the 2007 report of the Trust of America's Health (posted in the Bariatrics Lounge blog), using a different methodology, concluded that adult obesity rates showed an increase in 31 states last year. So, where is the truth. I would say, at the very best, and if we take only the CDC report, we are maintaining a dangerously high prevalence of obesity. And that all is about obesity in adults. Folks, we are not even talking about childhood obesity. Epidemic or not, it is already pretty bad.

(1) Please note: This blog does not endorse the Junkfood Science blog, which is mentioned here purely as a reference to an article that indicated one point of view.

Obesity Among Friends, Spouses, Siblings and Neighbors

Obesity has become an epidemic. Right? We hear this all the time. Well, isn't the term "epidemic" used often for diseases that are spread from a person to a person, like infectious diseases? Could the phenomenon of the prevalence of obesity be actually behaving as an infectious process? Could the benefits of obesity control, likewise, spread in an epidemic (good) way? Should the treatment of obesity be considered not only a form of individual therapy, but also, and probably more importantly, a treatment of public health proportions and general community benefits?

A very important article appeared in the July 26, 2007 issue of the New England Journal of Medicine "The Spread of Obesity in a Large Social Network over 32 Years" by Drs. Nicholas A. Christakis and James H. Fowler from Harvard Medical School, Boston and University of California, San Diego, San Diego. The researchers analyzed the nature and extent of the person-to-person spread of obesity as a possible factor contributing to the obesity epidemic. To do so, they evaluated a social network of 12,067 people assessed repeatedly from 1971 to 2003 as part of the Framingham Heart Study.(1) They examined whether weight gain in one person was associated with weight gain in his or her friends, siblings, spouse, and neighbors.

What they found? A person's chances of becoming obese increased by 57% if he or she had a friend who became obese. The type of friendship appeared to be important. Between mutual friends, a person's risk of obesity increased by 171% if the other became obese. In contrast, the influence did not appear to be statistically significant when one person, but not the other, defined the relationship as a friendship. The sex also appeared to be important. When analysis singled out same-sex friendships, the probability of obesity in a person increased by 71% if the friend became obese. For friends of the opposite sex, however, the probablity of obesity did not increase significantly. Among friends of the same sex, a man had a 100% increase in the chance of becoming obese if his male friend became obese, whereas the female-to-female spread of obesity was not as significant.

How about siblings? If one sibling became obese, the other's chance of becoming obese increased by 40%. As for married couples, if one spouse became obese, the likelihood that the other spouse would become obese increased by 37%. By the way, those effects were not seen among neighbors.

If social networks are so influential in the spread of obesity, then this may actually explain another well-known observation. Individuals in weight loss programs or after weight loss (bariatric) surgery, who attend regular support group activities, that modify the person's social network, are more successful than those that do not.

This is a great study that will certainly be quoted over and over in the future.

(1) The Framingham Heart Study is an ambitious project that was initiated in 1948, when 5209 people were enrolled in the original cohort. The Framingham Offspring Study began in 1971, when most of the children of members of the original cohort and their spouses were enrolled in the offspring cohort. In 2002, the third-generation cohort, consisting of 4095 children of the offspring cohort, was initiated. All participants undergo physical examinations (including measurements of height and weight) and complete written questionnaires at regular intervals.


Source:

Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007 Jul 26;357(4):370-9. [PMID: 17652652]

Excess Fat, Red Meat, Alcohol, and Cancer

"Food, Nutrition and the Prevention of Cancer: a global perspective", a report produced by the World Cancer Research Fund together with the American Institute for Cancer Research , has been the most authoritative source on food, nutrition, and cancer prevention for 10 years. In October 2007, the updated Report was released in Washington, DC. The Report is the result of a five-year process that included examination of the world's literature by a panel of the world's leading scientists, supported by observers from United Nations and other international organisations

The Report found out that carrying excess body fat increases the risk for cancer of the colon, kidney, esophagus, pancreas, and endometrium, as well as breast cancer in post-menopausal women. Their first recommendation is: Be as lean as possible within the normal range of body weight.

The Report also indicated that there is convincing evidence linking consumption of red meats like beef, pork and lamb to colorectal cancer. The recommendation is: Limit intake of red meat and avoid processed meat. People who eat red meat to consume less than 500 g (18 oz) a week, very little if any to be processed. ‘Red meat’ refers to beef, pork, lamb, and goat from domesticated animals including that contained in processed foods. "Processed meat" refers to meat preserved by smoking, curing or salting, oraddition of chemical preservatives, including that contained in processed foods.

Another recommendation: Limit alcoholic drinks. The evidence on cancer justified a recommendation not to drink alcoholic drinks. The report specified that, based solely on the evidence on cancer, even small amounts of alcoholic drinks should be avoided. But, because other evidence shows that modest amounts of alcoholic drinks are likely to reduce the risk of coronary heart disease, the Report recommended limiting rather than avoiding, alcohol consumption.

The strongest evidence on methods of food preservation, processing, and preparation showed that salt and salt-preserved foods are probably a cause of stomach cancer.

The World Cancer Research Fund global network consists of the following charitable organisations: The American Institute for Cancer Research (AICR); World Cancer Research Fund (WCRF UK); Wereld Kanker Onderzoek Fonds (WCRF NL); World Cancer Research Fund Hong Kong (WCRF HK);Fonds Mondial de Recherche contre le Cancer (FMRC FR) and the umbrella association, World Cancer Research Fund International (WCRF International)
The World Cancer Research Fund global network funds research on the relationship of nutrition, physical activity and weight management to cancer risk, interprets the accumulated scientific literature in the field, and educates people about choices they can make to reduce their chances of developing cancer.

Source:
An abbreviated version of the full Report http://www.dietandcancerreport.org/downloads/summary/english.pdf

For a summary of the recommendations:
http://www.wcrf.org/home/recommendations.lasso

The Paradox

Restaurant (A) presents food items that are advertised as being healthy choices, and has even caused some people to lose serious weight. Restaurant (B) was the topic of an entire movie (Supersize Me) which focused on unhealthy eating. Could someone possibly think that eating huge portions at restaurant (A), and picking up choices that were not advertised in their health menu, would still be healthier than eating anything at Restaurant B? Aha, it is the branding thing, again. You remember, we touched on that once before. And here is a very elegant study, actually four studies in one report, that is an eye opener. The article title is “The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions”, that appeared in the October issue of the Journal of Consumer Research.

Study 1: “Calorie Estimations by Subway and McDonald’s Diners” concluded that branding Subway as the healthier choice leads people to believe that Subway meals contain 21.3% fewer calories than same-calorie McDonald’s meals.

Study 2: found that even consumers who are "familiar" with both restaurants estimate that Subway sandwiches contain much less calories than McDonald’s sandwiches containing the “same” number of calories.

Study 3 is the real kicker. Participants were given Subway sandwiches that contained 50% “more” calories than the “unhealthy” Big Mac. In addition to a serious underestimate of the calories in the Subway sandwich, participants who ate the Subway sandwiches ended up ordering higher-calorie drinks and cookies. It is as if those who thought that they ate healthier main-dishes, tended to reward themselves by eating higher calorie side-dishes or drinking more calorie-rich drinks. As you can imagine, they consumed many more calories because of the double mistake (underestimating the main meal calories, and taking richer side orders)

Study 4 actually proved the influence of marketing and branding. When consumers were presented with arguments contradicting the health claims, the “halo effects” mentioned above tended to disappear.

What a fascinating research, and no doubt one that will become a classic. The series of studies were designed to help finding an answer to a question, as stated by the authors: Why is America a land of low-calorie food claims, yet high-calorie food intake?

Source:

Chandon P, Wansink P. The Biasing Health Halos of Fast-Food Restaurant Health Claims: Lower Calorie Estimates and Higher Side-Dish Consumption Intentions. Journal of Consumer Research. Vol. 34 · October 2007

Pierre Chandon, Ph.D. is Associate Professor of marketing at INSEAD, France. Brian Wansink, Ph.D. is the Chair of Marketing and of Nutritional Science in the Applied Economics and Management Department, Cornell University, NY. The data in these studies were collected at the expense of the authors, and the studies were not sponsored by any outside source.

Life Expectancy - again

A very good article reporting and commenting on the 2 studies from the August 23 issue of the New England Journal of Medicine (NEJM), appeared in the Independant Weekly of Lafayette, Louisiana. It is titled "Life Expectancy - New studies show bariatric surgery patients are living longer." By following this Link, you can access the article. This "Bariatrics Lounge" blog reported on the NEJM article on August 22, so our readers were among the first to be informed. You can go back to that blog entry by clicking this Link.

Obesity Rates - still on the rise :(

I thought the obesity epidemic is plateauing. Well, News Flash! Obesity and overweight rates continue to rise. A new report by Trust for America's Health (TFAH) showed that in 31 states, obesity rates got worse in the past year. State of Washington is actually one of them. Moreover, all states fail to meet the national goal of reducing adult obesity levels to 15 percent by the year 2010. The adult obesity rate of the State of Washington is 22.4 percent, ranking it the 31st heaviest in the nation, according to TFAH's report titled "F as in Fat". Mississippi is top of the list. Colorado continues to be the leanest.

The report noticed that 16 states and Washington, D.C. have passed taxes on junk food or sodas, including Arkansas, California, D.C., Illinois, Indiana, Kentucky, Maine, Minnesota, Missouri, New Jersey, New York, North Dakota, Rhode Island, Tennessee, Texas, Virginia, Washington, and West Virginia.

The full report with complete state rankings in all categories is available on TFAH's Web site at http://www.healthyamericans.org/. The report was supported by a grant from the Robert Wood Johnson Foundation.

Bariatric Surgery Lowers Long-Term Mortality

More data to support that bariatric surgery may improve mortality. Two new studies are published in the August 23, 2007 issue of the New England Journal of Medicine, indicating that bariatric surgery resulted in decreased overall mortality, in addition to the known effective long-term weight loss. One study came from Utah (Adams et al.). The other came from Sweden (Sjöström, et al). In an Editorial in the Journal, Dr. George A. Bray of the Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, commented that those articles "may provide the missing link between intentional weight loss and lives saved for obese patients"

The Utah study is a retrospective study that aimed at determining the long-term mortality among more than 9000 patients who had undergone gastric bypass and a comparable number of severely obese persons who applied for driver's licenses. During follow-up averaging 7 years, mortality in the surgery group decreased by 56% for coronary artery disease, by 92% for diabetes, and by 60% for cancer. On the other hand, mortality from accidents and suicide, was 58% higher in the surgery group than in the control group. All in all, there was a survival benefit from bariatric surgery.

The other article titled "Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects" reports a prospective, controlled Swedish Obese Subjects study involving more than 4000 obese subjects. The study reports on the overall mortality during an average of 10.9 years of follow-up with an impressive follow-up rate of 99.9%. The study concluded that bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality.

References:

Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, Lamonte MJ, Stroup AM, Hunt SC.Long-term mortality after gastric bypass surgery.N Engl J Med. 2007 Aug 23;357(8):753-61. PMID: 17715409 (Full Text)

Sjöström L, Narbro K, Sjöström CD, Karason K, Larsson B, Wedel H, Lystig T, Sullivan M, Bouchard C, Carlsson B, Bengtsson C, Dahlgren S, Gummesson A, Jacobson P, Karlsson J, Lindroos AK, Lönroth H, Näslund I, Olbers T, Stenlöf K, Torgerson J, Agren G, Carlsson LM; Swedish Obese Subjects Study.Effects of bariatric surgery on mortality in Swedish obese subjects.N Engl J Med. 2007 Aug 23;357(8):741-52. PMID: 17715408 (Full Text)