Document 6425164

/AA762214
NAVAL SUBMARINE MEDICAL RESEARCH LAS GROTON CT
CARDIOVASCULAR RISK FACTORS IN SUBMARINERS,(U)
0 V TAPPAN I L W MOONEY ,M J JACEY
1979
'
B
A
L
NSMR
7 llff
UNCLASSIFIED
FIG 14/5
4
NL
L
NAT)O~. W.M
OF STNDS
,*
Oct
~
1
Cardiovascular risk factors in subm rn
D. V.JPPAN, L. W. ?fINDNEY. M. I. AACEV.6W LI)jEYDER/
U
Tappa. D V .L W Monne. M4J kacr". sod E H"dgw 5979 Carthovraaculer nsk Woctn is
subtnesVo
hoonowie s Sub. S"Op 3301- S215. - A utembk 0 - of WaohAMLi
hemabsoiogK ad ph) aaoq vun*4es Owa%aidlcatly dhch prpom for thsmaue of am.
necaall he cova
heart hsase.(CHDI.-. m uleed w 1017 witenmrw. Shiofold ikset
hto .aasbhas dtewsaed
&u
to be Nows the. wemost otWee ptapsome.
W
of unlar op. theI
total level of
fat was wihthe ramnp of MOt sarselt) Serm chtolesterol levels. doWtk
wookw4.mkowt e.
sd iwod pinsure appeed to be the ftcton mo dhww*l inposele
for ftheiars; of cardoacua nih in th. wap of subsse Thao
sat s~ee- a ap
dwecs ielaboobi between lcobol comsewpoa r cafefm dra acardovetsertish. tesm
were stnw*cos-etatwms noeed These fctr. combmed wih .w
chobsusol lei cont
smoieg. newd multae wyt. dew o' coadiunoa as pouesudly awoilabe 0(I) nek
LJC*ren.
caa*osscuhe nok 11scuor
serm cholesterol
mhtmy pereomsie
mmhuf
Alcoho Conumtion
bWWo
prssst
In etrare sludie fte arnosant of lowe seI on activee submatine duty was shown to have
tevre bechnwa
t~wnesinNaval personnel (Tappan. )amy. Heyder. Ad TauseY 1975.
Tappan. Jacey. Heydet. and Harvey 19NO -The prncpsl biochemscal ~~cs of subsuiter We
on vounwew bmahnrn we". trends toward incielased meum cholesterol concentratioas and
Owmad
re ofwilitston gflucose ofer a loaingtl test. 3Bt of these chin wer WW-
eMmlitelted directy to yea of submariswm evic sice they occawud in addlit to the
chavpe in these seum comilet atruftablet to op ace umm cholesero is a Iro
I
member of a powq of %clms asweoc ld wth "t~ of cardiorvascular dis
(Lev
Un iEnw
197); blooe 1973) OWl an exagersled asel response to a CMbh*u load my pmW
the eelopment of detest mel IuII ofma-- 1%4). addtonal InVesttlo Of *ANs An
related factors seemed warranted for the sum hethy subminer population.
79 l0smil18
U)44
~
/
S202
TAIVAN. UMNEY. JACEY. AND HEYDER
In this paper. we bave examined the relationship in 1017 submariners of several
hemtatoloW~. biochemical, and physigi vanables that have significance for the prognosis.
pevvention. or treatment of disease of apng, with particular reference to factors associated
with a rskof coronary hen disease.
Though the study was dened to evaluate the effects of submanne duty through a series of
re-exammations of the indiviul subjects. this report is concerned with comparisons of the
data obtained at the initial examinations of the subjects. We present evidence that there is a
measurable risk 01 cariovascul., disease rmiaed to length of submarin duty in addition to the
risk attributable to icreasing age. Several factors. including coffee and alcohol consumption
and ctgaret smoking. appear to contribute to this risk.
METHODS &%D MATERIALS
The gmup of 1017 active-duty submariners participating in this study and the extensive
series of medical and laboratory, eumanations, perforned on these subjects were described
previously (Sawyer with Baker 19r.. Tansey 1974. Tappan et al. 1975, 19M9. The examination
program was iitiated to provide backgroud data on the health staws of Mhe geeral ribiirerpopulation and to provide preliminary indications of the effects of livmng withim the
closed environments of modern submarines, Of the subjects voluneering for the 00ud. 64 W%
were members of the crews of 23 operational submarines, the other ubjects came bo. nam
short-based rotation awsstments. All were qualified submariners. Li 7W were enhesed personnet and 14.3% were officers. For our comparative studies, data perthnent to cornay heun
disease tCHD) and related risks ware obtained ftm the medical and smhrupom potins,
of the two-day serie of tests lpven to each subject and from the biochemical and heasololc
segmets of this multiphauic study. The data for time on nuclear patrol were avedable I r-1)
from the health records of the men since it is hmnndatory that record he kept at Maie of
potential exposure to radiation aboard muclenr submarnes
For an estimation of the CI4D risk among the ubjects eumied. the I-l
t
e w n~b
ode
of Truett. Cornfield, and Kan-es 11907) based on discsminam Mcto anr
alyst of 12-year
follow-up data from the Framiunha study of cardiovascular dignme
"niec
rn wased To
calculate the level of cardovascula risk for all of out subjects less than 40 years of #V. a
have used the contants in the risk-estimating equation derived by Halerin. Black aeldef. and
Vetter (197 1)for thewr lowest age gup ("0-39 yr) Their values for the 461-4 ap 0 f
utilized for our subjects agled 40 and above. Included in our risk calculatons am data fr smum
cholesterol iingd), systolic blood pressure imaks). relative wet IwinW/edan we*W
perhbeightpop x 100.ciprette smoking; 0 - none. I - < 1. 2- I. )3. > I picks'dy).
ECO (l - normal. 2 - abnormal. hem-olbin (ill)s. and al (Halpeuieo a l. 1971).
We present in Table I the frequecy istt*tlo . means, and
btnaddsaosfr
a
pmip of Wacors asociated directly or "niectlywith cadiovnla risk and fr wo Overal
tl. and hemoglobIn weed is the calculations Veoe here ewe NImled is a pisvis
pubit in 4Tappmat
e al. IM.9
To provide 11 qency data so that the rsade an wae Iherw adcatulom opoultl
statistics, the distiutions an shownm
in tabular rtete than Igall' hrm The No anid law
S203
CARDIOVASCULAR RISK FACTORS
TABUK I
FeQtENV DiST11VTIONS Of
Lowb
Ref
%Fat
Abdomen
Ht Wt
Skinfold
Rel Wt
Smokin
Systolic
Diastobtc
Rate
coffee
Alcohol
Risk
Rtsk>28
High
Ref
3
32.
70
1111
11.2
14.0
12
34
0.7"2
1.44
0
4
148
100
48
96
40
106
0
14
0
64
0.1
6.5
0.1
6.5
POTENTIAL CoaoNARY HXAxT
SL 3M ARUIERS
2
3
4
>8
Mean
4897 135 210 1"9170 73 23 7
76 144 233 231 148 104 "4 17 10
49 99 191 236 227 124 57 13 6
9 66 137 150 140 101 67 26 8 9
6 44 16267 248 1473823815
3
330 1.06123 1"9103 66 37 14 40
6
39 149 276 307 159 53 18 7 3
9
9 11 214 285 267 119 21
3 4
4
7 54 10295241 163 4919
3
M469145 110114 55 96120 400
97 421 2L'100 7231 20 301024
349 415 103 47 30 19 8 1 11 27
27
41 197 944 29 135311
19.5
90.1
12.6
40.6
1.01
0.39
113.9
70.2
73.3
<-I
1
31
9
9
5
6
Diusu RisK FACroas
7
8
is
SD
5.3
10.4
0.6
16.0
0.14
0.90
8.7
3.2
9.9
4.3
4.3
14.4
1.12
2.14
17.6
3.60
5.09
VaINeS WO mOO1 so
Fat - pe ce bodyr Wa.Abdoment - aiemutal cicunirece. cmn.
HtW1 - IPoAd- almis. heVIMh(acwtis
lght
i ms.
Shaibi - samiof inacapalar aid tricels
sbjefold thickness. ev. Re1 VA - elave melt. iei weWbt? ht V rsq Soks" - W
cqretes. picks day. Sysaobc - systok blood pinnat. eaft. iatlc - diastoic pin@to. mtaft.
Raw. - pube. biaftituna. Coffe - total coffee. cup~dea' Alcohol - totdaloaho. dilaks/week. Risk
- calcuated ignt5 121
yew . @am populbos Malurwa et al, 1971). Ritk>211 calculated %ess 12
yeam. miin 23 year ofa se lderii
4
reference data values for each of the rows are presented in the fi two data columns of the
table. The data runge between each panr of reference values is divided into eight equa intervals, with the population count faling %"thineach interval showo in columns I to S. 11e
number of suboecs having values belo% and above the reference values are Indiated in
columns -c - I and > 3. Fiure I provides an illustration of the data. showing praphcally the
distribution of the calculated risk of CHD among the subjects over a 12-year perlid.
The blood pressur dama in Table I represent the means of 4 masuremenits each for systlic
and diastolic pressures. 2 in the sittg and 2 in the supine position. Pulse rate isa mean value
from 2 dretninatoas made at rest in the sialin position. Since total smoking, alcohol intake.
and coffee drinking data were recorded for the date of the test and for each peedn
O 5-year
interval. the WWd fbr these varabls um caclae by: current value * I Ifth of vilue 5
years s * 1l10t of value 10 years qo (Sawyer with Baker 1972). and so fort. Soch a
calculation isbased on the work of Coruleld and Mitchell(1909. who con clu dtat touoa
the inca- risk of cardiovascular disease associated with smokin disappears raply with
tome after smoking is stopped, the risk does not disappear compltely for at least a decadet.
Though we named residual elbcis similar to smoking slbta-t for alcohol and -Ne consumption, we found concurrin results when carryover was not included insthe data. To
icueciparee smoking in the calculation of CUD risk. only th mu of soking at the11
tim of the eamaed lon was, used to coafor to the ,1sk-eeton p redtue emp1flod
(Trueft at al. 1967; Halperin st Wi.1971).
-414.
520
TAPPAN. MOONEY. JACIEY. AND HEYDER
400
a
iL 200
0
z
<.I
Ft. I Pfrmfty
.9
I~s
2.5
4.1
5. 7
% RISK OF CMO INCIDENT
Pawu
psm
W
Akhbouo sock of th mamm of gmWa body
of the 00mu of my advidua. ths urn soaa
ofm
C D laddar .l"
>6.5
12ym W 1017
Mom gives a wmewhas dilii
W
wm e &=M
mom 6 vadami estima.
The comkosm coofficam of omii" woi~k. which boned in the calcidm of risk. aphat
the otha estima of body bulk or himwem
&s097
(mi pueu 60. 0i.= (vs. abdoin
cIc - dkmncs. -09M (vs. puismI ludeM. aid OJI? (vs. mm of Wmtlia). Al vordMlulm
um s- Mplat p < 0.001 (Seoor gd Cochim 1967).
Trake2 howi -orvubdomofdthe kmad poe rb& hc od of smmmdwishd
apmat qp. sat iIm ial
Urn. m vie Urns, ad Urn exposed to dnsd wbsmme
e'mosus.Correlula -eopm smuhd ioav~wso
I ---*- tis. pum pw.
adid
rscetimecud-for apeftd.
Ecep fbr he amsip~ca
aur
doh- wtW
slbfr
BCE abwrwldsa ad I7m
Mood p.m
iuhlho
cmosore
okalid
tWel u-
thaim
tCARDIOVASCULAR
S203
RISK FACTORS
TAUS 2
Cottwttviof's or Pbrp~rimt CowwASY HEART DS&Aw Rm FACTORS WIne1 AGE.
St.1MAR11111 QLAAIPICAIIO Tim. ANiD Marw~nv SEUVCs Timc iN Suussarn~Es
Age
4i21
Factor
Age
Subm
Nuke
Serv
43)
(4)
(5)
0.951'
-
-
0a.166t
0.099
191e
0co.
0.07e
0.I g
02
0.199
0 01t0.0
F10
cgwowhmo0.1481
017
e
0.00 cv 0on5
o uban qaldkto
Systlic
Distlc.24
R14.2
0346t
05635f
-
R13.20
0.3to
0.
0
r9htw
Ak-th old
1eut1,ph0.
0eccy.
and 001
. Sb0
0antt
1 0-ose fct
patrol After
0ac01a
th2t0e.ssaict
-
0.02,0.2
bath4
00
f
0.111fo theefec14
coeer05."
R13.2
at
0P2
0.ahye
co2el4e 0.061cn~
s0b0rin
0. 1'son
0.07
se.0d
tao.SOOc
w
I
ecrrekatioors. Totd evyFhroriskcount we&n avalemotese
th
e standea . d
mrm Co -n
eutropiA
lymphocawes gNueallydecws a
relave wenww
relati-eelymphocyte cMmwemug, Swhite cefi counts.ldrmwrbe noted thattcmimplatio.swill
I d o sows compa3reid or s2nt
bctrende tofmbe nepti
ams the3. -s
p 2* poqpualifiato ofcoe datmcole positi evelwithe effcts
o'ure.
th mst
andlrs
ai.eesterol tbodroten.ol.
of stp (Mdepoar andi glcose1967)a icholegeo
cob omm two Varilmbit
levelohed eambe correao apingivel ith the mOuthn apin
pice. ursbmaad aa.
Ot her nsocw hadogahb old coelte countot serv
sId
wmit
phehame tend cemintr ceariak
Tahkl
toeidirtes coreionse'O
awlcted ulis
fptnilak.rale
isoe
nTk2
atilcnltmcluain
nuA w'
riskthe
br
pwerel
efe-sofi*a
corctO
actua
ai1967
andortedsa
ale dimsth
and 46.llii thm ee swlutl at P < 0se05eamSodoe
e i
fl.-rw tmw iutbetw onl
lash mabier well
it mappdaen wtheda om seud erimyted pulishe sties Ind
nii
toa
etohs
nlwivctsorltdiiiatywt
-ccis
woo
S20
CARDIOVASCULAR RISK FACTORS
TANA I
of PoTWNT1AI CoaoNmav HaAny Dis&ASE RIS FAcToRs Wit" Aot.
SvemAeuir QvtivavArTom Time, AN4D MILITARY Seavica Timt tIN SIJRMARINE
Cowwt.ATtois
Fa rAgV
1I
21
Subs,
Nuke
Serv
411
t44
451
Systohe
Hb
Rel wt
FCG
Risk
Dowstob
Rate
coffee
0.148f
0.417t
-0015
-0.0'"0
0 221#
-0.0A.,
0.4.%t
0-274
0VR
0993
0.5"'1
ous
0-166t
0.2w9
0.000
0.043
0.203'
-002.6
0 424t
0.231t
038
0.4901
o*f
4
0063*
0 199f
0.055
-0029
0-127t
-0.013
0.304*
0.1811
0.032
0.31.1'
Alcohol
0 106$
0 122f
0.013
A..e
Smoking
(liof
-
R13,20
o.sIt
0.191 t
0.0731
0.301t
0.0659
00i11
0.023
-0.029
-0.002
0.237f
0.044
-0.043
0.032
0.445'
0.U$
0.284t
0.01M
0. IOP -0.027
0..544
0.053
0. 120' 0.061
It14.2
1115.2
--
0.021
0.033
0.0751
-0.002
0.007
0.013
0.07311
0.043
-0.026
0.023
-0.0541
0. 14t
0.029
0-061$
O.060
0.009
0.021
0O0l
0.078#
0.04
0. 130
0.0759
'dabae we covewte
me lwfkwts *Fw nsk Owton. weeTakl I kxoews. Aw - yeen. Sub.
yta %vin
e uobumawnuabton. Nub. - yea om acb -1u--- rn%Choi - chole~eni. wod
masr
wtm er'%- wan' 4 nmbtwy senice. lNb - hemogkwts. '4l. FC - elcrcru
msktae. *mi': - coneitwiba of variable
0001U).
tr 001. If 005
a
couina I ad wbowmO
01e ato -soe
for ap (2).
apM-At rue 4f 'ubMOMI qaaltkatWG Or tne OIL Racetr Petro. OfWerMIOV1l Of the tifOct
of age lSnecfcor andl Cochran 1967i. cholesterol levels. ECG aboonnallbes. OWd total risk
levtls had a hoome correlation agamst vabtmarine time than amafht the oduer two variables.
Other rik faWons ha a hbghe coffebtion afamst total service tise
Tattle ) ondmcates coftelatgoms of the h-9 Lokgy and chemstry variables masured aginst
the seleced hst of poseiwin risk vanables preented in Table 2. Partia correlation callations
iSneilecar and Cochran 1907) were used to correct for the effects of both RV wtu so' nai v
servocc tuwn these data, only those corvelatioes that were signifiant at P < 005 we shown.
It vs apparent from the dfta that the "ruwcyle elements. hmOcw and hemoglobla. as well
ss the total leucocytes. meutrophils. and lymphocytes correlated sigilcanly with seveia of
the potefflsi mk factor. Totld erythrocyte Counts wer no avalble anwim thewe data Since
ielatisw or percen lymphocytes, generally decrease as neutumphis increase in standard Nfem Inwtal
u e cell counts. dtshould be noted that correlatimonsorelative lymphocyte cout
spnt the rtsk acosnded tobhe neptive data noshwul compaedto the slcam
postewcorrlions recovded for calculaedtotalacllmasher (Table31.
For the most part. 2-h postprundial glucose data cornelatd positively wAt risk factors
Fasting and postprandia ghcase as wrel as urk said. cholestrol totl proen
I
lh@I, a. and
two oftheeatymes correlaI neptivey withthe mnt o of-fee GoompuOn". Variations
oftuc acid. cows.
hesoglobia. tow Ilucy"e Count. setuspho' hate
e~ort
I
wam. lowa potts. an allsk phI Incnetwt
hs tede to oIu
si
cacldriak.
Table 4 shos One memos kw woud rik aad actual or posile rbsk famr foth
*a
ect in
Av*-yin qp pump between ao13 led
0;prbn
, WAO4M*0
wit
a
seven
1 Tbea
esioudy pubishe
IsIuItIm
m-
tde" inskMA sreu
'uate
Am
a,
MIX6
TAPPAN. MOONEY. JACEY. AND HEYDER
TAMLE3
Coanio or HaMAIoWOG AN'D SERVM CONSTITVEITS WiT14 POTENTIA1. COWoe&XV
HEART DISASE RIsK FAcTooR OIcTaD mwi Aoa AND SvMauiNS QtJALJCAIIOI TowE
HCT
smoking
alcohol
systolic
diastolic
211??
coffee
0,137t
0.0116t
0.06119
0.171$t
01811p
0. 129f
0.1W~
0.129$
rate
chol
rel W1
risk
systolic
diastolic
rate
chol
rel %V
CA
alcohol
smoking
diastoki
0.0811
systolic
0. 116t
rate
chol
rei art
0.1w9
0.107t
0. 49
diastoki
rate
Chi
P110
risk
0.0371:
Cofse
alcolhol
systolic
role
smok.ing
0.2)9
0.019
0.110
lt
0.0744
0.221t
TLMp
smoking
0. 179t
Coffee
0.004t
0.0744
0.08S
0.IlI,
0.132t
0.076#
0. 141t
0.
tos"
coffee
0182f
alcohol
0.071II
chot
0.1Is"
risk
0,254$
DUN
smoking -0.110
alcobol -0.014
dm1l
0.0964
risk
0.121f
UA
Coffe
-0.1lot
dial
06$
ref wt
0.079
risk
0.2Wt
CHOL
coffee
-0.196t
0.295t
0.126'
0.0739
0-197f
0.0159
0.077f
GLUC
diastolic
rat
rel wo
utah
-0-0119
caffe
diffstolic 0.0699
iPI
smoking -0-116t
coffee
-0.0711
&[Cohol
0.01
systolic
0.069
diastolic
0.132t
0.136t
0.262f
0.091t
rate
chol
coffee
HS
WICS
smokmn
cog"e
alcohol
rue
C101
tt~h
NEUT
smoking
0. 1l4
0.0799
0. 109$
0.0731
0.0769
0.122,
ris
ALON
smokig -00110
systolic
0.0726
diastolic 0. 113t
rat
-0.0460
GLOB
smoking -0.01
Coffee
0.10111
alcohol
0.097S
diastolic 0.0731
rat
0. 1731P
Choi
0.149t
rU art
W
0.074
AIO
smoking 0.01
TBIL
smoking 0.337t
CO&e
0.0799
LDH
saiokaq
alcohol
rate
rel wt
0.0731
0.01)9
0.11 5t
0.172t
SGO
coffee
akbo
diastoli
-0.0739
0.135t
0.101$i
0.195'
0.149'
0.194t
rate
chol
rel wt
SpOGR
alcohol, -0. 1034
AK
coffee
-0.0711
rat
00
C1101
ref art
0.343t
0.0111
0.089*
0.085:1
0. 156't
0.436t
%fohat,
O iye
gM.
Pa rf hF of
T"i I am 2 #894um: Ila bte ";iU
US - hasglbla; WKC - whilee il l. NIUT - muecpbb: TUWF - fina Wo
eborya
OLIJC - belg #=ss.m* -hW
CA - amlom; PROS fterpmc pbw
phemvs: SUN - orea Walrps; UA a rkc odd; CHOL * chalesterel TPR *W pmeW.s
ALON - athomtia; GLOB - globelia; AIO - aftemialgh~bea ratio; TOIL I oWah~iulb;
ALKF - aloln
(M-
pbempliese;. LON
in
*ol heir
ov'pui: 110OT
u*~
mn~m; SIP
_viy
wdl_
tr
-
0.01.
p 4
"L p -
&a
S207
CARDIOVASCULAR RISK FACTORS
ConNAav
W&ART
tau"m
DIusKAS
RiSK AND
TABUK 4
RiSK F~cToas Pta AOL CArwOms~t
a Sew
111
%Oaka
us"
*8
VA
i- t
39.41
4)
39
41
5
29
1
104
99is
004
0 e
44
'U0
so
04
lik.1I
%%wm
Cowl
1., 62
9,
M54
104
1b
909?
1'
2:.,'
&l
9
Toe
299:104
'44'
HiO
w SvuAiraw~a
S)V1i,
19 199
19
16
il q
Em
0X
11V0
OW
ft''
am
*1
0 a4111
discussed with respect to subjects ag. T7hough the small number of sub*ect inthe oldest age
group appeared in some cases to disrupt the agerclated trends. vanous generalizatlion. may be
made concerning the changing levels of the nsk factors as the population aged. Cholesterol
coficentrations and relative weight that appear in the nisk-estsmating equation (Halpern et al.
1971) showed unustakable tendencies to increase with aW. and they thereby increased the
overall calculated levels of risk. Amouint Of cigarette smoking increased among the younger
subjts for the first 15 t 5yewrs of service. and then began to decrease among the older
subject. On the other hand. hemogk'bsn concentrations. systolic blood guessures. and ECG
abnormalities twhich ame actually non-numenc in nature) were not age-dependent, according
to this evaluation. Both total alcohol consumnpto and coffee drinking dlearly incileased with
subariners' age.
Several aspects of the data for these one thousand appandy healthy amn aged 16-8 are
worthy of wrous conlsideration. Fromt the pilefims investigatio of bwochemical fladig im
these subjects. it was concluded thlet most of the dota fell within rmap comsidered morseel
(Tappan et al.- 1973). aned it is ano strprisin dthat with reme exceptions, the samte obsoedoatio
cmn be madek concerning the factors analyzed inm repoi . It is importaint. however. to PO
out tat staitcally, oL, rarges for biochemical or physiologic variables for populations in
thes country do not necessarily speif the conditions conducive to optimal healt, antd that
mndrvdtals areavarying degre of risk for serious healt problems that requmw dentificataon
anld amelioration. An evaluation of the extaet of existing risks prsdes a loped foundation for
insttuting programt desiped to pirevent or bas such risks.
The reltive weipt or ftness, of the sulject this study was evaluated no only because of
the agkace of the reave wuighit ofan individual! to CHD risk (Tmein let d. 1967. Ha0psim
tA
W. 197 1. Kann1. Caaue. McNamem McKee. aned Peinluib 1972). but dalobecmaeoftOw
ineloruanc to the submarin Navry ofe answer to the querstion of oWtsh habits land tie
that deop aboardm
sb -' inrnedring patrolledto weight
to perational per nl
Accate kdorionm re g the degre of lha nes
to the su-e is als i imPort11nto
relation- to the geea level of decondtioaeft of physical fitness experlenced by saubiera
dwrin deplo) we t is ala of con id IrIagle
s 0nce is detm1ning whethe the Woo of
Use spent on1
nemega p agl ismalcrtcal to the accondi of occupedwtllo
f In
this uniqe voctin the
t1esa
elaio o umr 1aiduty. The mods at Vvin
aboard 11~ e tho mend. to paomote minimal phyical activity end the coeamptieni of
-
I
S2OS
TAPPAN, MOONEY. JACEY. AND HEYDER
generous diets, either of which promotes weight increases. may serve as models for the study
of the effects of living habits that predominate in the American population.
Since there is ite controversy over the fact that' the real culprit to good health ii. not lota
body weingh. but relative or percent fat" Wnght and Wilmore 19741. many mthodsi have
been proposed to estimaite the degree of fatness or obesty in human subjets The indirect
estimate of percent body fat calculated from our data by the procedure of Wright and Wilmore
11974) yieledt.mean value of 19. 5 .8%~ (sw) (at for the submariners. We chose the simpler
of the methods described by these authors. which employ% weight and abdominal circumference and correlates highly (P - 0.99) with measured data *tied by underwater weighing
methods, to, avoid error in the use of their alternate procedure using skinfold data because of
differences in the calipers used. Results for a similar population indicated 16.5 -6. 2' body
fat for .197 randoimly selected marine%with an average age of 28,7 years (Wright and Wilmore
1974). A survey also showed 14 3.14.6.15.). 15.5. and 18.7% fat for civilian males. 23.1%~ for
an Air Forve population, and 12 5, 17.4. and V0 5'* in Army personnel, all forages in the range
of the men in our study iWright and Wilmnore 1974). Though the spread of available data
indicates the possibility of considerable experimental error, we concluded that the relative
faitsii of the submariners tended toward high normal ranges but did nam greatly exceed that of
may similar groups of healthy young men.
Among the other indexes of gieneral body conformation, the sum of skinfold measurements
from the upper arm 4tricpsL) and subicapular onfrascapularl re~pon% indied a considerabl
excess of skinfold thickness in the subjects of this study compared to other population groups.
While the overall mean for this group of submariners was 4.0 t 16 cm. a Aimilar mean for a
probability sample of men aped IS- 79. representing the non-istotutionalired population of the
United States tSioudt. Damon. McFarland. and Robert%1973). has been reported tobhe 18cm.
with means of 2.4to )-0cm for the age categories between 18 and.44 years. All groups to men.
including foreign and domestic populations. Army personnel. and former Naval aviators.
whose data are summarized in the Nattial Center for Health Statistics (NCHSi Report
iStouditetal 1973) have considerably smaller %kinfold measurements than the subjets of the
current study. Means or median values rane from 1.1o3.4 cm for the various groups.
Researchers involved in makig skinfold measurements emlplasize that differences nvariably arise from varoiats in the technique of different investigators and the use of different
calipers iMeyer 1973. Stoud et A. 1973v A comparion of skinfold data for 46 men masured
by three different types of caliper showed mean values, of 1.69. 1.84. and 2.19 cm for mnfa
scapular skinfolds, and 1.07. 1.13. and 1.27 cm for triceps skinfolds using the Harpenden.
Iang. and Minnesota calipers, respectively (Soude et al. 1973). This V4* variability among
istruinents does no seemi sufficient to ezplai the discrepancy between the data of the
porsent study and those reported earlier. especially since we employed L.ange calipers. which
prod-ce mid-rage values. From such consideration, we concluded that submariners fre-
quently have skafold thicknesses in excess of those of men of comparable groups.
In a fu~he comiparison of the skinfold data reported for the NCHS survey (Stoui et al.
".7)with similar amow rouin frm our study, our means went 1.90 ± 0.512and 2.16 ± 0.9"
cm for triceps and sulscapulor skinfolds. respectively, while mneans for the HCHS survey
were 1.1 andl 1.4 cm. Hencs the two measuremens sem to account about equally for the
increae in the sum of sifold thickness reporte for these sub*t.
In cftrenrace among; our sabjects equal to 90.1 :z 10.4 cma and
With the mavi n
the m valae for the me of the NCN3 varvey 815.9 cm. with m0of the population falliag
bete 72.1 and 10.0cinfSkmiltet al. 1973h. theis no remn o conclude that there was a
sigalkcant dillbeenc betwee subiarinen and American - for this measur of body sia.
CARDIOVASCULAR RISK FACTORS
S20
The ponderal index establishes a leanness-stockiness scale and is considered by some
investigators to be the singlle best measure of body build (Meyer 1973; Stoudt el al. 1973). The
mean index value for men of the United States in 1960- 3962 was 12.40. ra.tq from 12.67 for
men Ill-24 years to 12.32 for 35-44 yeams (Staudt el al. 1973). In the present study the mean of
12.6 2 0.6 indicated no remarkable difference, according to this criterion. between submariners and other American men. Since the values for this index fall within a very narrow rage.
the mean value of 12.73 2 0.63 found for U.-S.- Army men (Staudt et al. 3973) may indicate a
slightly pster degree of leanness in Army subjects compared to submariners. (Note that the
index increases as relative fatness decrease.)
To consider the contributions of the various factors to the risk 01 cardiovascular disease an
assumption was mae concerning the applicability of the analysis of risk to our subjects
according to the multivariate logistic procedure. The orignal model of Truett et al. (1967).
based on data for seven parameters measured for the subjects 01 the Framingham study, was
later modified by Cornfield and Mitchell (3969) to include only five variables.- The procedure
was further refined by Halperin et al. (1971). who used a maximum likelihood method for
arriving at parameter constants and again used seven variables to define risk. The generality of
the latter approach was verified by Brand. Rosenman. Scholti. and Friedman (1976) for
application to cardiovascular disease incidence data collected over Sit years in dhe Western
Collaborative Group Study In that study, correlation coefficients of0012-0.19 were found
betueen predicted and actual occurrence 01 cardiovascular disease. Though high correlations
ir w 0,9411 were obtained for our data between the five-variable and the seven-variable
analyses, the maximumi likelihood constants of Halperin et al. (1971 I were used to obtain the
nisk estiates reported here because of the confirmation (Brand et al.- 19761 of the validity of
this approach. The 'alue of the procedure used here was emphasized by Gordon and Kennel
119711 and by Kennel 1197,6 who considered this the method that practicing physicians shoul
use to evaluate risk levels in their patients realistically.
One rather profound alteration in the design of the mutivarsate analysis of risk was required
to accommodate part of the data front our study. Since the risk of cardiovascular incident was
collected fro the Framinomn subjects for population Voups agled 30-39.40-49. and older.
it was necessy to use the values for the lowest age group (30-39) to evaluate our subjects
aged 19- 30 and 30- 39. The equation coefficients for ales 40-49 were used for calculations
made for subjects over 40. Since the mean age for the subjects was 29.4 year. an overappeoximaition of risk seems to have been made for about half of the subject. When calculationswr
performedforthe olderhalf01thesubjecs 2.0 yea or above, for w ond constants apply
with reasonabl accuracy, the meom risk was 2.14 1 5.09 per 100 owv 32 years compared to an
approximat risk of11.12 * 3.4Gfortheploupaaa whole. It may be eenflomthdateaflble
4dspie
tu aproaleoveremationmof riskfor theyoungermeamr ode pp a steady
increase in risk occurrd for the subjects during thlr caeer of submar-eduty. Wth our
present level of infbomation, we can only determine within a wide mearnof uncertainty
whether die me experlenced a cardovascular risk dilhret lhum doot 0 cmrble poultines, in other occupations. Lmrg standard deviatons in all of the etimaes po ted here
idicate hirty serious risks for a few Indvidual, which by this model may minich 15-30
chances per 100 over the 32year risk period. Despte ewpao1s1- oveemo
a
end my
psycholoocad amqe thmightbe ihed.dOa poe"a formodlylag risk (Gordoinsand
Kassed 1971; Proelchr and Lancaster I97)-. Kamd.l INJOrtboi. and Cu"t IM74)
n
examinations and risk eWiate (smc a aioe perfbrmed he) po ely Vurc
b a
populaton a you" and vilorou, as -ubArwinesevi meers.
S210
TAPPAN. MOONEY. JACEY. AND HEYDER
The data preented in Table 2, which relate known and possible risk lactors to length of time
since qualiiation for subaine service. number of Year aboard nuclear submarines, and
total time of military service. lfumsh partial answers to the question of whethe duty done
sWet in the Closed eaviroameat of modern submarines is primarily responsible for amy
health-relaed effects among the subjects. The data for lengh of exposure to closed submarine
environments are only pertanem to time spent aboar nuclear submarines, since similar infortation concerning time spent on diesel submarines Was not available Also diesel submaries
operate by periodically adding fresh air to the submarine enviaronment and arm almost obsolete
in the U S. Navy.Table .1indicates that for most of the known or possible cardiovascular risk factors. theme is
a higher Correlation With total military serice time than with tume since Qualification for
submarine serice. In general, the correlation for tume spent on submerged Patrols was lower.
The strong, correlations of the risk factors with age, however. suses the imnportance of
examining correlations that have been corrected for age (Siiwecor and Cochran 19C7). With a
few, notabl exceptions, such data, presented in the last three columns of Table 2. indicate that
the risk factors have the highest correlatioris with total militar) service time. Submerged patrol
tame had the lowest correlations, with relationship to submiarine time generally intermediate.
The exceptions to these generalizationsneed special consideration.
Particularly prominent among the age-correctedl correlations of the risk factors is the apparenty Significant (P < 0-051 correlation of cholesterol level with time sice qualification for
submarine service, This relationship, reported earlier (Tppan et al. 1979). appemn stronger
than that to military servce time, and the increased association cannot be directly related to
time spent on submerged patrols. Total calculated risk. party but niot entirely because of its
dependence on cholesterol level, also seems to correlste most highly with length of submarine
service. If these relationships to subarine time are irerdled by other studies, various stressons in the Wie of submariners, such as the abteation in routine between on-boad submarine
duty and ashore *recovcry' periods or the unique workrest schedules on patrol, arid the
specific diet and activity patterns. may be shown to a, S P t these effects sauiflcandly.
Despite the sonificant correlatons of serum cholesterol levels and risk against submn
time demonstrated hbae and in our other paper (this Supplemienti (Tappan et a&.19IM. we wish
to sound a note of cautio in interpreting the data because of the method used to choose
subects for the study (Sawyer with Baker 1972; Tansey 1974). Although the subjects included
submariners of various s. lengths of service. and occupational specialties, it was so
proved that these men represent an unbiased cross-secton of submarine service peron.
A split-samiple correlation analysis performed as a check on the sipilcuue of the incrent
in age-correed cardiovascular risk with length of submarin sevice however, helped confirm the reliability of the data. For the verdication tem. t population was divided accordingl
to a random selection procedure a complete set of correlation analyse was peeforad for
each of the two subgroups. The correlation agast submarmn timie, afte correcton for the
influence of age. for the two subpopulation containin 49.7 and 50.3% of the avalable subjects were 0.2192 mad 0.222. respectively. The sipioficancer ratio of 0.412 clearly ikndiae tha
the to gmpscasinosbe consideredto have bendran f op
seart poptilaiotm(Snsdewo
mod Cochra 1967).
The dea ilhaewnsed in Table 3 weww derived to deternm whether my insopt might be
gamsed an* the etilgy of caudlovasadar risk born the commonly wmmeed serm chemistry
or hematrolg walabies. Puial corarLn Orcion for de comI Ionm of alp and subamin service we reeome for die dea t 10 cownerebhtOnshis betwee the ris ONe,
ad laboratorv
#I fmigh be independent of te expwelmesl sitio. Tbq
W
CARDIOVASCULAR RISK FACTORS
S211
correlat,ons, with possible statistical sgnificance are shown in the table, Only the most outstanding will be discussed. Others that seem unimportant now may eventually become imparThe positive correlations of the risk factors with hemoglobin and hemnatocnt levels apparenitly derived in I&W pan from the fact that ciarette smoking increases hemnatocrit or hemoglobin levels through the relative anoxia produced by carbon monoxide and other noxious
agents iFroelicher and Lancaster 1973). The cattioxyhemoglotmn levels in submariners and the
relative concentration of this hemoglobin derivative in smokers and non-smoker mna closed
submarine environment have recently been described b) Bonds. Very. and Schaefer 41978)
From a nationial survey in~.olving 29.000 Mood donors living in urban. suburbian. and rural
communities of the United States, a strong correlation has been reported bertween blood levels
of catoyhemoglobin and total blood hemoglobin concentrationst Tobacco smoking was the
tingle most important factor for increased cartioxyhemoglobii saturations observed iStuart.
Baretta, Platte. Stuart. Kaibfeisch. Vain Yserloo, and Rimm 1974)11Th correlation datm
presented in Table 3 also suuest that leucocytei and neutropluls ma) tie related to CHD risk
through extent of cigarette smoking. T'he possibility of inhibition of chemoictaxis of leucoc)tes
by the components of cigartt smoke- particularti by the various aldehydes. has been
suggested by Eichel and Shahock 419691 and by Bridges. Kraal. Huang. and Chancellor 1977a;
Bridge%. Kraal. Huang. and Chancellor 197"b It should also be noted that each of the seum
proteins measured correlated negatinely with the extent of cigarette smoking In addition to its
close relationiship to cholesterol level, total risk also correlated highl in the submariners with
,.arious chemical components of the serum, including inorganic phosphate, urea nitrogen. uric
acid, and alkaline phosphatase
Among other relationships show&n in Table I that should be considered ame the sigificant
correlaions of blood presure, pulse rate. cholesterol, and relative weight with hemoglobin
aid hematocni levels These correlations add confirmatory evidence that justifies the inclu%ionof hemoglobin in the calculation of CHD risk fTruelt ei al 1967. Halperin et al. 1971).
Similarly, the positive association of blood pressure. palse rate, cholesterol, and relative
weigh: with postprandial glucose levels supports the established associaiti of diabetes with
CHDnrik iGordon andKannet 1971.Kanneet aI 1974). Though none of the subjects of this
vtud . to our know ledge, was diabetic, a measuii'l prediabetic symptomnatology was detected in the data iTappan et al 19179. this Supplement).
In most cases where risk was apparetly associated with serum chemistry variables, i.e..
with inorganic phosphate. urea nitrogen, uric acid, or alkaline phosphatase. the cholesterol
level appeared to be the most closely related of the established risk fators. At this point.
however, there s%
no reason to think that changes in cholesterol level arm responsible for the
fluctuatioins of other serum components, Blood pressure and heart rate. according to these
data, are associated positively with serum protein levels. particularly total prtin and globulin These indicators of increased work load on the circulatory system, including the slgh
relative hemoconceitration. apparently reflect as well as contribute to the long-term accumulation of CHD risk in the wb~cts of this study, The negative correlaion of urinary specdlc
gravity with alcohol consuimption may imply a siht real dysfianction or perhaps A Icreme
in thu-st as a delayed aftereffect leading to increased water loading and excretion.
Though it is obvmos that the variables used to estimate risk should correlat highl with
risk. calculatioas were mae to evaluat the relatve contrliatlon of the individual thectorii to
overall cardwoveacular disese risk in submarines. Conuaousan for these and other variables
against ris we: smokting 0.272: alcoho corautpim 0.003t. coffee 0.266. I
@II
0.2)6';puls rat 0. l064. rbl
PIc
0.037: systolk blood ptessur 0.09St; diasto pMe
4
S2l2
TAPPAN. MOONEY, JACEY. AND HEYDER
weight 0.253f. and cholesterol 0.5' 0' - P <0.001. S - P -. 0.0i1. These data leave little
doutab that cigarette smoking, blood pressure. relative weight, and serum cholesterol levels
make estremel) important contributions to the risk of cardiovascular disease in soubmanners.
as is true for the population an general (tidam 1969; Kannel and Dawber 1972).
The above correlations and those shown in Table 4 wmnest that total alcohol consumption is
somewhat less closely associated with factort directly of indirectly related to CHD risk than is
total coffee consumption. Because of alcohol's potential for damage to the liver and other
orgas however. it is expected that alcottol intake will be at least weakly associated with
serum levels of SGOT and LDH uI).mm and King 1965, bieber 19751 and possibly with
erythroc~yte counts and serum protein levels
Despite a significant association between coffee consumption andl CHD risk, the relationship beWeen the two %anablsappears to be complex. Although faiting and postprandial
glucose, uric acid, cholesterol, and total protein, as well as the enzyaws ALKP a&d SOOT.
exhibit negative correlations with coffee intake, these factors generally correlate positively
with total risk levels.
It appears possible that two different physsoocal effects of coffee consumption may be
reflected hy the data, First, the diuretic effect of large amounts of the beverage may exert at
least a small influence on various serum components because of increae excretion rates.
Second. the stimulant Mfect on the central nr o'us and cardiovascular s)ystems of the alkaloid
components of coffee is probably even more intimately associated with CHO ris in these
personnel. Either because persons who are emotionally more tense tend to drink morm coffee
or because coffee consumption leads to increaseid tension, coffee drinking may be associated
with CHI) risk in the petuliar occupatiorial circumstanices of the subjects in this study. The
susceptijbilty it, CHD of inlivduals who are emotionally stresserd, who feel a strong sense of
urgency. or who arm hahtuall) over-conipetitive or hostile isfairlyi well estaklished 4Friedman
1969. Rosenmnan. Brand. Jenkins. Friedman. Straus. and Wurm 197!i. Jenkins. Zyzanski. and
Itoseaman 1976. Glass 19711 The term type A pemrsoaitty has been used by Friedman and
Roseniman i l"9. 19741 to descrtbe such indivdua- Though st to not within the scope of this
report to consider the psychological makeup of these -ubjeci.s. there is considerable evidence
to indicate that highly moiated pernel .olunteer for submarine duty iWeybrvw 19,71)
Several of out sutjecs may therefore he predicted to fall into the type A category.
Aucording to Table 4. the level of alcohol use increases hy a factor o about 1.5between the
,ourqiest and the oldest groups of suAetis, while cigarette smoking is heavier for men between the agsn of .8 and V8 than for younger subjects and decreases again after aboust the age
of 40 M~ean coffee consumption increases four. or fivefold for subjects between their 19th and
48th years Although the data are not adequate to establish a causative relationtship between
either alcobol or coffee consuaption and risk of cardiovascular disease, theme is an association
with these habis that cam only be attributed partly to their comrlations with age. Table .1
indics sigimflcant correlations of these habits with length of service even after the partial
correlation effects of age have been eliminated- Regular alcohol consumption, even in what
may be considered moderate amounts. has been extensively documented as a potential contribuwo to heart disease i~ing. Tillmans. and Ideka 1975. Guninar. Demakis. Rahimtooia.
Sinno. and Tabin 1975. Regan. Ettinger. Oldwiiel. and Haider 1975. Talbot 1975).
No absolute evaluasion of the comparative nisk for CHID in these subjects can be mde with
other groups because of the methodologtc differences discussed earlier, the relatively small
number of subjecs in the older age groups, and die variey of methods used by various authors
for reporting incidence of disease. Nevertheless. it is instruactive to compete the apparent
risks, as shownt in Table 4. with the frequency of cardkvascular dissaseis) observed in othe
Studies
CARDIOVASCUL AR RISK FACTORSS23
From the tab"e of pretbctive n~k% denved from data of the Framngham stud) 4kannel
11,141. it nu) he deterined that for pcr'on' Aliho% chleiterol valuc% are 210 mgdl. vhmfte
%s%lobi bloodl prc%'urE ame 1.0 mmHg. aho %amoke. and Oho eithibit neither giucosir intoler
Ance nor left heArt %cntncIeclctrocardifgrAm ahuotralatit. the e~pected prxuhahulittKe of
de~IopunS hean diheaa within 11)car% air 0 9 I) at ageW
l.1 S 100lat 40. and 4 K 1010
for
Dowt~rie
fw he re aerw odeinte nd%utpA:ed oronar%hearl disae chi men i
)Car%, 2 M Alt)IS- 49 %cam~2 01M at 40-44 )Cam~ and to 101)at 41-49 )Cot% of Age
i~ordlon and (,armt 190P~
In the %%ctcrnCollabor-ati~c (iroup Stud). NWz)ear occurtence late%of CHD. including
Angina pecitonm. mso.srdal infarction, and acute mn)ocartbal infarcito. uere 6 4 100 oer"I
for wujeit%agled 140 wean ill 4 1010
f#w type A iubtectt. 4 2 100 fr nontIpe A or ty-pe ft
%Uh)jrctti (RtiCnMan ei l 1 97441
the predicted 12)ecar occurvrnct ratv- lor the wumer of our mtud). 21 1010
at 11- U
)eau%. I ' It00 at "1-44 yearm and 10 4 101) at 41-49 sean. teem %ef3 cortipaui to the data
fro'm the u'ther -Alute when %.ortected it) the tame timne %pan%The apparent frequenc) of
:ufrcnth. detectat'k (HI) in the tut'tect' of the NCllS etamination weit%t(.or'do aOd (iarm
1961) uould. in fact. indicate uowne'hat higher ratet of ,wurtvnc in the %ubjecta of that
trie% ompaired to the o1ther %tudhei Sidant diffctvn4ct in approach, hotwe~cr. must not
he oterho-ed
Though according it) the cmntra uted the men oft the mihnne te
%cew do not teem to he
more %
ulncrable to, ..oronar) heart dijeate than male%of ther United Statct populatxmni. the)
neecrthelet appear to he at leatt m~ wwtepteble as other populatiobn Vp,
Since these mn
helong to a phs wialkt tomiethat telet Wtpptioin and mutt remnaen rcammuNl. health) to
.continue in the tubmnn terice. it is apparent that to fulfill the health potential of this grop
~.omplce% . there it xwicerahk rown for improtement in hahut%. enwourriental comrponentt. and! ther factors that contnhute to health Fix"i the etadence presented in Table 4 that
indicate' that the total amoiunt of cigarette tntokang among men of the highest ager groupa
eem%to hue decreatung omewbat comrpared to the )oungpctrimen. it is possible to derive %one
encouragemaent fini the fact that there am) he changet in living tyles that will lead erventuall)
ito, a lo-Acrng of CHD risk Irosement in this and other modifiable farom% at youniger sot
couldl etentuall lead to a helter progntsrt for the cardsosasc~ular health of thi%popullation.
W*
mv wok!d to aumi~
'enfwe
Tmmwi l~rdi mu to Ow mdiano
wi pulxwqWa On. dw3 Tlw
at
a"s
,
a Pl 10VNavel Makeal ftaWaft WellDtapoW('1mm
g~
Wout 1101MM~ I L Of4M wft"v mw~
P",.r-0 06. p of*" Wie, mm,s
otnd
4mos 1978
~Ie
tap~iaa s'IWmom'a.
L w)
hi I 1a8"j. aOW
E 14,1*1 I"7 Fmem de nsqiac aovaecodwor ches 1.011,m -smnow tViirwo 111'
Ret Su' SNWp S201-&215 -Flasmm
%rua4t%htorhamqwee h*nmtkVpqwes. ts ptychohkitpies. tignikaave por le petamimtic des
mahde' deps1ieutvn 01 "W10111
,sm I" Imublif
maiuwu. wall iwet dw 1.017 umsnawunmn t ph cutaat em pis ipaa cfit ont eajits q chit b ~t des hon. Wm AV
conme
Le wost adt~it tatal te tuv dame In If ie do Pin . ILAAMoitmll li. In
Cittiit. kSpoid% irht. et bs timeffifief "m lie haimi 440clie
rmpiaminkt d
neqi, cadrwafcuhin &i cc gmpmigwoi
u
s. simu-minieum w i b ia piu phsexpaoe a
u,,*m cardwmaocubtirw qm drtrwsu Awmmm.
aim%aom oburti qm It
0* MMe
deb4.La fm wn.sioaetu t4mir
l. s
s afiile &mq ft
ats
a
1 me.d
fileUs
erditsoubmqwm
afflabm ONto Q84p~n a n Pt Oficm
4 Opp-
d
S214
TAPPAN. WVONlEY. JACEY. AND HEYDIE3
dare, cm It naqase caidaoaamu
ei Is cnsimi~mmmIs deiFalool oudua
Cde. des c&srretawua uymwaoaults ONt w bowse Ces ladoalt. avftla chiiieterlemae. lW%
Coftltet. Cl kePSo% felatd. doa%eal tCU, -onaadee COWin det fa-CetUSS 11110fial)les Chtae
nm
prouver us rqmp.2
btar
de n~qaw cuaotasculium
perummal mabztaut
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dt I AkOal
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Moorc. F
lHRAl
Rega. T
S215
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Ee.Wnason D C
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leveh m Amencan Wood downv )AMA L19 1187- 11"
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aubmanne ofuan
%au,) daysa
ore
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Mst