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Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients With Diabetes Mellitus
Open accessAbstract
BACKGROUD Evidence is limited regarding the impact of healthy lifestyle practices on the risk of subsequent cardiovascular events among patients with diabetes. OBJECTIVES To examine the associations of an overall healthy lifestyle, defined by eating a high-quality diet (top two fifths of Alternative Healthy Eating Index), non-smoking, engaging in moderate- to vigorous-intensity physical activity (≥150 min/week), and drinking alcohol in moderation (5–15 g/day for women and 5–30 g/day for men), with the risk of developing cardiovascular disease (CVD) and CVD mortality among adults with type 2 diabetes (T2D). METHODS This prospective analysis included 11,527 participants with T2D diagnosed during follow-up (8,970 women from the Nurses’ Health Study and 2,557 men from the Health Professionals Follow-Up Study), who were free of CVD and cancer at the time of diabetes diagnosis. Diet and lifestyle factors before and after T2D diagnosis were repeatedly assessed every 2–4 years. RESULTS There were 2,311 incident CVD cases and 858 CVD deaths during an average of 13.3 years of follow-up. After multivariate adjustment of covariates, the low-risk lifestyle factors after diabetes diagnosis were each associated with a lower risk of CVD incidence and CVD mortality. The multivariate-adjusted hazard ratios (95% confidence intervals [CIs]) for participants with three or more low-risk lifestyle factors compared with zero was 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, 0.33 (0.21–0.51) for stroke incidence, and 0.32 (0.22–0.47) for CVD mortality (all P trend<0.001). The population-attributable-risk for poor adherence to the overall healthy lifestyle (<3 low-risk factors) was 40.9% (95% CI, 28.5%–52.0%) for CVD mortality. In addition, greater improvements in healthy lifestyle factors from pre- to post-diabetes diagnosis were also significantly associated with a lower risk of CVD incidence and CVD mortality. For each number increment in low-risk lifestyle factors, there were a 14% lower risk of incident total CVD, a 12% lower risk of CHD, a 21% lower risk of stroke, and a 27% lower risk of CVD mortality (all P <0.001). Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis. CONCLUSIONS Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality among adults with T2D. These findings further support the tremendous benefits of adopting a healthy lifestyle in reducing the subsequent burden of cardiovascular complications in patients with T2D.
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TL;DR
In two large U.S. prospective cohorts of adults with incident type 2 diabetes, greater adherence to an overall healthy lifestyle after diagnosis was associated with substantially lower risk of incident cardiovascular disease and cardiovascular mortality. Improvements in lifestyle from before to after diabetes diagnosis were also associated with lower subsequent CVD risk.
Key findings
- Among 11,527 participants with incident T2D, 2,311 incident CVD cases and 858 CVD deaths occurred over an average 13.3 years of follow-up.
- Comparing ≥3 versus 0 low-risk lifestyle factors after diabetes diagnosis, multivariate-adjusted HRs (95% CIs) were 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, 0.33 (0.21–0.51) for stroke incidence, and 0.32 (0.22–0.47) for CVD mortality (all P trend <0.001).
- The population-attributable-risk for poor adherence to the overall healthy lifestyle (<3 low-risk factors) was 40.9% (95% CI, 28.5%–52.0%) for CVD mortality.
- Each increment in low-risk lifestyle factors was associated with 14% lower risk of total CVD, 12% lower CHD, 21% lower stroke, and 27% lower CVD mortality (all P<0.001); improvements from pre- to post-diabetes diagnosis were also associated with lower CVD incidence and mortality.
Methods
- Prospective analysis pooled 8,970 women from the Nurses’ Health Study and 2,557 men from the Health Professionals Follow-Up Study with incident T2D diagnosed during follow-up, free of CVD and cancer at diabetes diagnosis.
- Diet and lifestyle factors were repeatedly assessed every 2–4 years; low-risk factors were high-quality diet (top two fifths of AHEI), non-smoking, moderate- to vigorous-intensity physical activity ≥150 min/week, and moderate alcohol intake (5–15 g/day women; 5–30 g/day men).
- Cox proportional hazards models with time-varying exposures and covariates estimated HRs and 95% CIs for total CVD, CHD, stroke incidence, and CVD mortality; analyses also modeled changes in lifestyle score from pre- to post-diabetes diagnosis and calculated PAR.
Limitations
- The paper states participants were all health professionals and mostly Caucasian, limiting generalizability; diabetes diagnoses spanned an extended period since the 1980s; self-reported diet/lifestyle had inevitable measurement error; there were no direct measurements of glycemic control or diabetes severity; PAR assumed causality; and residual confounding or chance could not be excluded.
- The paper also notes the low-risk lifestyle factors considered may not represent all healthy behaviors.
- Evident from the text: this is an observational cohort study, so the reported associations cannot establish causality, and the authors explicitly caution that the PAR calculation depends on a causal assumption.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Comparing participants with zero low-risk lifestyle factor, the participants with three or more low-risk lifestyle factors had HRs (95% CIs) of 0.48 (0.40–0.59) for total CVD incidence, 0.53 (0.42–0.66) for CHD incidence, and 0.33 (0.21–0.51) for stroke incidence (all P trend<0.001).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
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In the paper
“Comparing participants who adhered to ≥3 low-risk lifestyle factors with those who adhered to none, the HR (95% CI) was 0.32 (0.22–0.47) for CVD mortality (P trend<0.001).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Greater adherence to an overall healthy lifestyle is associated with a substantially lower risk of CVD incidence and CVD mortality among adults with T2D.”
- Also stated in: § Discussion · plain
“we found that an overall healthy lifestyle after diabetes diagnosis, defined as eating a high quality diet, non-smoking, engaging in moderate- to vigorous-intensity physical activity, and drinking alcohol in moderation, was significantly associated with a lower risk of CVD incidence and CVD mortality.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Abstract > CONCLUSIONS
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Discussion · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“When we only considered diet and alcohol consumption in the healthy lifestyle score, comparing ≥1 with 0 low-risk lifestyle factors, the HRs (95% CIs) were 0.91 (0.84, 1.00) for CVD incidence and 0.81 (0.71, 0.94) for CVD mortality.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“When moderate physical activity was further included in the score, comparing ≥2 with 0 low-risk factors, the HRs (95% CIs) were 0.85 (0.75, 0.96) for CVD incidence and 0.53 (0.42, 0.66) for CVD mortality.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Similar results were observed when analyses were stratified by diabetes duration, sex/cohort, body mass index at diabetes diagnosis, smoking status, and lifestyle factors before diabetes diagnosis.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Abstract > RESULTS
Strength:plain· not yet calibratedn = 2,311Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“When moderate physical activity was further included in the score, comparing ≥2 with 0 low-risk factors, the HRs (95% CIs) were 0.85 (0.75, 0.96) for CVD incidence and 0.53 (0.42, 0.66) for CVD mortality.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For each number increment in low-risk lifestyle factors, there was a 14% lower risk of total CVD incidence, a 12% lower risk of CHD incidence, a 21% lower risk of stroke incidence, and a 27% lower risk of CVD mortality (all P <0.001) (Table 4).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
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- It may state two separate claims as one. 9
- Probably not a substantial claim. 7
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In the paper
“However, the results remained similar when we further adjusted for duration of diabetes, use of insulin and hypoglycemic medications, and self-reported HbA1c levels, suggesting that our findings are unlikely explained by confounding due to the severity of diabetes.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“The results remained similar when analyses were stratified before/after 1998, when complete data were used, or when deaths occurred within 4 years of diabetes diagnosis were excluded.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Results
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In the paper
“The follow-up rate for death in the NHS and HPFS was over 98%.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Assessment of CVD and mortality
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“Prospective observational studies among diabetic patients thus far largely focused on associations between healthy lifestyle practices and total mortality (13–15), but data specific for CVD risk are lacking.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Introduction
What the sources say
- Not checked yetcites [13] Lin, 2012, Impact of lifestyle-related factors on all-cause and cause-specific mortality in patients with type 2 diabetes: the Taichung Diabetes Study, Diabetes Care source
- Not checked yetcites [14] Patel, 2018, Adherence to healthy lifestyle factors and risk of death in men with diabetes mellitus: The Physicians' Health Study, Clin Nutr source
- Not checked yetcites [15] Nöthlings, 2010, Lifestyle factors and mortality among adults with diabetes: findings from the European Prospective Investigation into Cancer and Nutrition–Potsdam study, J Diabetes
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None of the sources cited for this claim have been checked yet.
In the paper
“In our validation studies, 98% (61/62 cases) of diabetes cases confirmed by the supplementary questionnaire were re-confirmed by medical record review in the NHS, and 97% (57/59 cases) were re-confirmed in the HPFS (28,29).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Ascertainment of T2D
What the sources say
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In the paper
“Second, the diabetic patients in our study were diagnosed during an extended period of time since 1980s.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
None of the sources cited for this claim have been checked yet.
In the paper
“Several trials that examined the efficacy of multi-component lifestyle interventions have demonstrated tremendous benefits on reducing T2D risk and improving cardiovascular health among high-risk individuals (7–12), although the long-term benefits on reducing CVD events among diabetic patients were less established (6).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Introduction
What the sources say
- Not checked yetcites [7] Knowler, 2009, 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study, Lancet source
- Not checked yetcites [8] Lindstrom, 2006, Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study, Lancet source
- Not checked yetcites [9] Li, 2008, The long-term effect of lifestyle interventions to prevent diabetes in the China Da Qing Diabetes Prevention Study: a 20-year follow-up study, Lancet source
- Not checked yetcites [10] Li, 2014, Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study, Lancet Diabetes Endocrinol source
- Not checked yetcites [11] Estruch, 2013, Primary prevention of cardiovascular disease with a Mediterranean diet, N Engl J Med source
- Not checked yetcites [12] 2015, Long-term effects of lifestyle intervention or metformin on diabetes development and microvascular complications over 15-year follow-up: the Diabetes Prevention Program Outcomes Study, Lancet Diabetes Endocrinol source
- Not checked yetcites [6] Schellenberg, 2013, Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis, Ann Intern Med source
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In the paper
“In addition, such measurement errors were likely to be non-differential in this prospective study and thus would be more likely to bias the associations toward the null.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“In particular, we could not exclude the role of confounding by genetic susceptibility, medication use, or psychosocial stress, residual confounding due to measurement errors of covariates, or chance in the current study.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“The cumulative response rate was over 90% for both cohorts.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Study population
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In the paper
“To increase statistical power, we pooled the participants from the two cohorts in the absence of heterogeneity of results.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Study population
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In the paper
“The risk profile of diabetic patients might significantly change over time due to better control of blood lipids and other risk factors in recent years, although similar results were found in analyses stratified before/after 1998.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“Given that weight change is one of the typical symptoms of diabetes, and treatment could result in weight change after diagnosis as well, BMI may no longer serve as a valid measure of adiposity and thus was not included in the lifestyle score to minimize reverse causation bias (21).”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Definition of low-risk lifestyle factors
What the sources say
- Not checked yetcites [21] Tobias, 2014, Body-mass index and mortality among adults with incident type 2 diabetes, N Engl J Med source
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
- Rests on an assumption: Weight change is a typical symptom of diabetes, and treatment can result in weight change after diagnosis.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Lastly, the low-risk lifestyle factors considered in the current analysis may not necessarily represent all healthy behaviors.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“First, the study participants were all health professionals, and most were Caucasians.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Discussion > Strengths and limitations
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In the paper
“Physicians blinded to the participant questionnaire data reviewed all medical records.”
§ Influence of Lifestyle on Incident Cardiovascular Disease and Mortality in Patients with Diabetes Mellitus > Methods > Assessment of CVD and mortality
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
The authors state this as an assumption.
The population-attributable risk calculation assumes a causal relationship between the low-risk lifestyle factors and cardiovascular disease risk.
“Fifth, the PAR calculation was based on the assumption of a causal relationship between the low-risk lifestyle factors and CVD risk, which may not hold true in observational studies.”
The paper relies on this without support.
Little is known regarding whether improvements in lifestyle from pre- to post-diabetes diagnosis may yield cardiovascular benefits.
“Importantly, little is known regarding whether improvements in lifestyle from pre- to post-diabetes diagnosis may yield cardiovascular benefits.”
The paper relies on this without support.
Weight change is a typical symptom of diabetes, and treatment can result in weight change after diagnosis.
“Given that weight change is one of the typical symptoms of diabetes, and treatment could result in weight change after diagnosis as well, BMI may no longer serve as a valid measure of adiposity and thus was not included in the lifestyle score to minimize reverse causation bias (21).”
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“The magnitude of this association was generally larger than that previously reported by studies using self-reported MVPA data.38,39”
Citations
Cites
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Metadata
- Authors
- Liu, G., Li, Y., Hu, Y., Zong, G., Li, S., Rimm, E. B., Hu, F. B., Manson, J. E., Rexrode, K. M., Shin, H. J., & Sun, Q.
- Affiliations
- Harvard University (US)
- Chinese Academy of Sciences (CN)
- Boston University (US)
- Brigham and Women's Hospital (US)
- Corresponding author
- Sun, Qi
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2018-06
- Volume
- 71
- Issue
- 25
- Pages
- 2867-2876
- ISSN
- 0735-1097 (ISSN-L)
- PMC
- PMC6052788
- OpenAlex
- W2807965683
- Semantic Scholar
- 6317bba6e88e84f03622e634f93a9b1eb3725492
- Cited by
- 221
- References
- 47
- Citations by year
- 2026: 18 · 2025: 33 · 2024: 35 · 2023: 30 · 2022: 33 · 2021: 26 · 2020: 19 · 2019: 22 · 2018: 5
- FWCI
- 14.31
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R01HL035464, R01HL034594, R01HL088521)
- National Cancer Institute (UM1CA176726, UM1CA186107, UM1CA167552, U01CA176726, U01CA167552)
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK058845, R01DK082486)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Health and Risk Factors
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
- Keywords
- healthy lifestyle, type 2 diabetes, cardiovascular disease incidence, cardiovascular mortality, Alternative Healthy Eating Index, diet quality, physical activity, alcohol consumption, smoking, coronary artery disease, stroke, prediabetes, lifestyle adherence, population attributable risk, Nurses' Health Study, Health Professionals Follow-up Study, cardiovascular risk reduction
- MeSH terms
- Aged, Cardiovascular Diseases, Diabetes Mellitus, Type 2, Female, Humans, Life Style, Male, Middle Aged, Prospective Studies, United States, Incidence
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