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Abstract

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

Background Immigration to Italy has increased drastically, but there is a paucity of data on the health of these immigrant populations and the need to improve their health care. Therefore, we analyzed a multiethnic immigrant population in Bologna (northern Italy) to identify the risk factors for health. This anthropometric study was part of a multiregional project “Health Assistance and Monitoring for Indigent Italian Citizens and Immigrants” funded by the Italian Ministry of Health.

Methods The sample consisted of 401 adult immigrants from southeastern Europe (Kosovars, Gypsies, or Roma) and four extra European countries (Senegalese, Moroccans, Tunisians, and Pakistanis). Ethnic ancestry was self-reported. Anthropometric (height, weight, and waist circumference) and blood pressure data were collected during the survey.

Results The prevalence of overweight (and obesity) exceeded 50% in Moroccans and Kosovars of both sexes and in male Roma. The ethnic heterogeneity was associated with different patterns of obesity: the highest prevalence of abdominal obesity was in Moroccan and Kosovar women and in male Kosovars and Gypsies. The highest prevalence of hypertension (more than 20%) was in Senegalese, Kosovar, and Gypsy males.

Conclusions Some of the immigrant subsamples had a high prevalence of obesity, which is associated with morbidity. Our findings on the relationships between the anthropometric traits and the blood pressure suggest different cardiovascular disease risk profiles in the ethnic groups (higher for Kosovars and Roma) and an urgent need for preventive measures.

The generally good health status of immigrants rapidly declines after their arrival in the new country.1,2 Stress and factors linked to a new lifestyle can partly explain the poorer health status of the immigrant population. Recent studies on migrants to Europe from South Asia,3 the Middle East,4 and North Africa5 suggest a variable incidence of coronary heart disease (CHD) among ethnic groups in relation to a wide range of risk factors. Obesity is the fastest growing health problem worldwide and a strong risk factor for cardiovascular disease and other illnesses.6,7 Stress and rapid changes in lifestyle have often been associated with an increased incidence of obesity in immigrant populations.8–12

In addition to the general marker of obesity [body mass index (BMI)], waist circumference (WC) is considered the best marker of central adiposity, as it is a more suitable measure of metabolic and cardiovascular risks than waist-to-hip ratio.13–18

At the end of 2000, there were approximately 1.7 million immigrants in Italy; 55% of them were living in northern Italy19 because growth of manufacturing and agriculture has led to a greater need of low–medium-skilled workers. Most immigration has been illegal, although a series of regularizations has granted many immigrants legal status.20,21 In 2000, the Bologna area was ninth among Italian provinces for the number of foreign-born people (2.2% of the national presence); 22 the foreign-born component consists mainly of young African and Asian adults.23

According to an Italian study on differences in hospitalization between immigrants and the resident population in 2000, the low hospitalization rates for foreigners were not related to good health status but were partially due to administrative, linguistic, and cultural barriers.24 Cardiovascular diseases cause 36.6% of the deaths among immigrants;25 therefore, it is important to evaluate their health status and to monitor their use of health services. The present study is part of a multiregional project “Health Assistance and Monitoring for Indigent Italian Citizens and Immigrants” funded by the Italian Ministry of Health. The objectives of the present study were to analyze weight status, adiposity patterns, and hypertension in the immigrant population and to assess the susceptibility to disease, with particular reference to obesity and cardiovascular response in immigrants of different ethnic groups.

Methods and Subjects

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

The study was conducted in 2000–2002 in several health clinics in Bologna (northern Italy). Various meetings were held in immigrant centers to inform potential participants about the study. The number of foreign-born subjects examined during the project corresponded to about 6% of the total foreign population living in Bologna.26 The recruited subjects underwent a physical examination by physicians and an anthropometric survey by anthropometrists.

Among the immigrants living in the Bologna centers who were invited to take part in the study, 401 people aged 17 to 65 years agreed to participate (participation rate 67.3%). The subjects, helped by professional translators/interpreters, gave their informed written consent, which was approved by the Ministry of Health.

We used the native country of the subject to approximate ethnicity. Personal data, educational level, year of arrival in Italy, and information about ethnicity were recorded during a preliminary interview. The demographics are reported in Table 1. Several Roma (gypsies from the Balkan) and Kosovars had recently sought refuge in Italy. Kosovars were the least educated (closely followed by Gypsies) and the least employed. Pakistanis were the most recent immigrants and the most educated. The education level was similar in both sexes, but employment rate was about twice as high in Moroccan males than in females, higher in Kosovo females than males, and similar in male and female Roma. Unemployment generally decreased as the time since arrival in Italy increased. Hence, the lower rate of employment in Moroccan females than males with the same origin can be explained by their more recent immigration in addition to other cultural influences. Women had emigrated more recently than men, except for the Roma. Other questions concerned smoking habits and alcohol consumption. The lifestyle of the immigrants was characterized by a low smoking rate and low alcohol consumption. The proportion of current smokers was highest in male Roma (3.5%). The highest percentage of drinkers was also in the male Roma group (21.8%), followed by male Moroccans (11.2%). All women reported that they never smoked or drank alcohol.

Table 1.  Characteristics of migrant sample distributed by country of origin
CountryAge (y), mean (SD)Time from arrival in Italy (y), mean (SD)EducationEmployment status
None (%)Primary (%)Secondary (%)Higher (%)No (%)Yes (%)
Senegal
 Males (n = 44)34.7 (6.8)7.6 (4.7)10.035.052.52.510.090.0
Morocco
 Males (n = 139)42.4 (10.0)12.8 (5.2)20.829.245.05.07.392.7
 Females (n = 22)36.3 (9.1)8.1 (2.7)11.138.944.45.556.343.7
Tunisia
 Males (n = 18)39.1 (7.3)12.7 (3.1)35.364.77.192.9
Pakistan
 Males (n = 78)32.6 (8.5)2.9 (2.8)6.317.577.714.344.355.7
Kosovo (Serbia)
 Males (n = 11)33.2 (10.5)3.7 (4.5)57.128.614.385.714.3
 Females (n = 19)27.3 (10.5)5.1 (4.1)58.835.35.973.326.7
Balkans (Gypsies)
 Males (n = 32)37.3 (14.9)8.9 (3.4)36.032.032.045.854.2
 Females (n = 38)38.1 (14.4)7.9 (3.0)38.235.326.546.953.1

Height, weight, systolic blood pressure (SBP), and diastolic blood pressure (DBP) were also recorded in all the ethnic groups. Weight was measured while the subject was wearing light clothing. A stadiometer was used to measure height to the nearest 0.1 cm. WC was measured to the nearest 0.1 cm with a tape measure at the level of the minimum circumference of the torso of the standing subject at the end of a normal expiration. All the anthropometric traits were measured according to traditional methodology.27,28 Overweight was defined as BMI 25 to 29.9 kg/m2; obesity as BMI ≥ 30 kg/m2.23 Central adiposity (abdominal obesity) was defined using WC cutoff points of 88 cm for females and 102 for males.29 Blood pressure was measured (at least twice) to the nearest digit by a physician using a standard mercury sphygmomanometer. Measurements were taken in the morning with the subject seated. SBP was recorded as the first appearance of a pulse sound and DBP as the disappearance of a pulse sound.30

For comparison between immigrants and the host population, we also report data on a sample of native Italians with characteristics similar to each foreign-born group in terms of sample size (males, 104; females, 58) and age (males, 37.3 years; females, 36.3 years), whose anthropometric profiles have already been determined and published.31 Of the considered anthropometric traits, WCs were not collected in the Italians.

Descriptive statistics were calculated for quantitative variables (mean, SD, and range) and qualitative variables (relative frequencies). Bivariate Spearman correlations were performed to assess the relationships between blood pressure and somatometric traits. Student’s t-test was used to compare the differences in anthropometric characteristics between immigrants and native Italians. To evaluate the differences between the ethnic groups, we conducted one-way analysis of variance (ANOVA) on each sex separately, followed by the Tukey honestly significant difference (HSD) post hoc test. Chi-square tests were used to compare the frequencies of central obesity, hypertension, and cardiovascular diseases (CVD) risk among ethnic groups. Statistical significance was set at p ≤ 0.05. Data were analyzed using Statistica for Windows, version 5 (2000; StatSoft Italia srl, Vigonza, Padua, Italy).

Results

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

The characteristics of immigrants of different ethnic origin and the prevalence of general and central adiposity are summarized in Tables 2 to 4.

Table 2.  Somatometric characteristics of immigrants and gypsies of both sexes
Ethnic groupHeight (cm)Weight (kg)BMI (kg/m2)WC (cm)
MeanSDRangeMeanSDRangeMeanSDRangeMeanSDRange
  • p < 0.05 in Tukey tests in male subsamples: Senegalese versus Moroccans/Pakistanis/Roma in height; Pakistanis versus Roma in weight; and Roma versus Senegalese/Pakistanis in BMI. BMI = body mass index; WC = waist circumference.

  • *

    p < 0.05 between immigrants and native Italians.

Senegalese 
 Males178.57.0161.7–191.573.112.053.0–106.022.93.418.1–33.6
Moroccans 
 Males171.76.4154.0–186.773.011.351.0–105.524.83.516.5–35.190.610.268.9–113.3
 Females159.55.8149.0–169.969.911.847.0–91.027.64.817.2–34.387.511.463.0–100.0
Tunisians 
 Males172.74.8161.8–179.474.411.657.0–96.025.04.119.0–32.288.010.970.5–105.1
Pakistanis 
 Males170.77.1150.9–189.566.611.946.0–89.022.83.615.6–29.086.912.264.8–114.0
Kosovars 
 Males169.43.2166.2–176.777.521.848.0–116.026.17.416.4–39.688.320.063.8–118.4
 Females157.97.8143.0–169.667.39.448.0–79.027.44.619.4–34.294.57.587.2–106.2
Roma 
 Males167.15.0156.3–174.577.217.348.0–132.027.76.419.2–47.495.116.268.3–134.5
 Females155.25.7145.8–170.058.912.733.0–99.024.55.415.2–39.780.513.462.0–111.7
Total 
 Males172.27.0150.9–191.572.710.946.0–132.024.64.315.6–47.490.212.163.8–134.5
 Females156.16.4143.0–170.063.112.533.0–99.025.95.215.2–39.784.113.162.0–111.7
Italians 
 Males173.06.075.710.4*25.23.0
 Females159.15.4*60.69.223.93.4*
Table 3.  Blood pressure characteristics in immigrants and gypsies
Ethnic groupSBP (mm Hg)DBP (mm Hg)
MeanSDRangeMeanSDRange
  • Hypertension was defined as SBP > 140 mm Hg or DBP > 90 mm Hg; p < 0.05 in Tukey tests in male subsamples: Roma versus Pakistanis in SBP and p < 0.05 in Tukey tests in female subsamples: Roma versus Moroccans for SBP. SBP = systolic blood pressure; DBP = diastolic blood pressure.

  • *

    p < 0.05 between immigrants and native Italians.

Senegalese 
 Males122.611.3100–15081.08.960–100
Moroccans 
 Males122.412.5100–17077.79.150–100
 Females107.510.390–12569.47.360–85
Tunisians 
 Males126.112.2110–15079.411.060–100
Pakistanis 
 Males117.79.2100–14077.37.960–95
Kosovars 
 Males128.916.2110–16077.87.970–90
 Females113.47.5100–13074.48.360–95
Roma 
 Males129.018.3110–19083.38.670–110
 Females121.419.7100–18078.317.850–150
Total122.712.8100–19078.88.950–110
115.716.090–19074.913.950–150
Italians 
 Males129.67.4*81.24.4*
 Females121.712.9*77.78.6
Table 4.  Percent distribution of immigrants in underweight, overweight, and obese subjects and prevalence of central adiposity (WC: >102 in males and >88 in females) and of hypertension (SBP ≥ 140 or DBP ≥ 90)
Ethnic groupBMI < 18.5 (%)25.0 ≤ BMI ≤ 29.9 (%)BMI ≥ 30 (%)Central adiposity (%)Hypertensive subjects (%)
  1. BMI = body mass index; WC = waist circumference; SBP = systolic blood pressure; DBP = diastolic blood pressure.

Senegalese
 Males7.921.15.335.0
Moroccans
 Males1.644.17.115.018.2
 Females15.446.223.154.50.0
Tunisians
 Males033.313.314.322.2
Pakistanis
Males12.825.6013.915.4
Kosovars
 Males10.030.030.037.536.4
 Females033.340.083.35.3
Roma
 Males035.532.337.533.3
 Females15.433.312.832.123.5

48.4% of males and only 26.8% of females had a normal BMI (Tables 2 and 4). However, there was high variability among ethnic groups: normal weight ranged from 30% to 32% in male Kosovars and Gypsies (15.3% in female Moroccans) to 61.5% to 65.7% in male Pakistanis and Senegalese (38.5% in female Gypsies); 5.4% of males and 10.3% of females were classified as underweight, 31.6% of males and 37.6% of females as overweight, and 14.7% of males and 25.3% of females as obese. Obesity was completely absent in Pakistanis but reached 40% in female Kosovars. The male Kosovars, Moroccans, and Gypsies had a particularly high prevalence (≥60%) of overweight/obesity (BMI ≥ 25 kg/m2). On average, immigrants were significantly different in height (shorter in female immigrants), weight (lighter in male immigrants), and BMI (higher values in female immigrants) than native Italians.31 In particular, the mean BMI for each female ethnic group (Roma excepted) was significantly higher (p < 0.001) than that of native female Italians. Among males, only the Roma had a mean BMI value significantly greater than that of native Italians (p < 0.01); Pakistanis and Senegalese had significantly lower BMI values (p < 0.0001). Differences between Italian males and those of other ethnic groups did not reach statistical significance.

56.4% of females and 79.1% of males had a WC in the normal range (Tables 2 and 4). However, there were significant differences in the incidence of central obesity among ethnic groups, both in males (p < 0.05) and in females (p < 0.05). High percentages of subjects with central adiposity were found in male Gypsies (nearly 40%) and especially in female Moroccans and Kosovars (more than 50%).

Blood pressure values also differed according to ethnicity and gender (Table 3). The lowest mean SBP and DBP were in Pakistanis and the highest ones in Gypsies; 78% of males and 87% of females were normotensive (SBP < 140 and DBP < 90 mm Hg), while the other 22% and 13%, respectively, were hypertensive (SBP ≥ 140 or DBP ≥ 90 mm Hg). Among men, the highest prevalence of hypertension was in Kosovars, followed by Senegalese and Roma (Table 4). Among women, the Roma had the highest prevalence of hypertension. However, the differences in the prevalence of hypertension among ethnic groups were only significant (p < 0.05) in females. On average, immigrants had significantly lower SBP and DBP than native Italians. The native Italians had significantly higher values of SBP than Senegalese (p < 0.0001), Moroccans (males and females) (p < 0.0001), Pakistanis (p < 0.0001), and Kosovars (females) (p < 0.01). Likewise, the mean DBP value in Italians was significantly higher than in Moroccans (males and females) (p < 0.001), Pakistanis (p < 0.0001), and Kosovars (males) (p < 0.05). Although male and female Roma showed a trend toward higher values of DBP than native Italians, as well as similar SBP values, the differences did not reach statistical significance.

ANOVA revealed a significant effect of ethnic group for all the somatometric and physiometric traits in males (results of post hoc analyses are reported below the tables). This effect was significant in females only for weight, WC, and SBP.

To determine the independent effects of BMI and abdominal adiposity on blood pressure, we computed r correlations for the total sample of immigrants, separately for sex. SBP and DBP were significantly correlated with BMI only in males (M: r = 0.256, p < 0.001 for SBP and r = 0.239, p = 0.001 for DBP; F: r = 0.061, p = 0.679 for SBP and r = 0.234, p = 0.109 for DBP). In both sexes (DPB in females), the blood pressures were correlated with WC (M: r = 0.279, p < 0.001 for SBP and r = 0.279, p < 0.001 for DBP; F: r = 0.199, p = 0.237 for SBP and r = 0.452, p = 0.005 for DBP). Therefore, we computed the prevalence of an increased CVD risk in the presence of a hypertension factor in a different way for males and females: as hypertensive males according to BMI (≥25 kg/m2) and WC (>102 cm) contemporaneously (Senegalese excepted) and as hypertensive females according to WC (>88 cm) alone (Figure 1). There was a significantly high variability in the prevalence of CVD risk among ethnic groups only for males (p < 0.001). Among men, the highest prevalence of CVD risk associated with hypertension in overweight/obese subjects with high WC values (>102 cm) was found in Roma, followed by Kosovars. No subject with high disease risk was observed among Pakistanis. Among women, the highest prevalence of CVD risk associated with hypertension in subjects with WC >88 cm was found in Roma. No subject with high disease risk was observed among Moroccan women.

image

Figure 1. Prevalence of immigrants at high disease risk—hypertension plus overweight/obesity and waist circumference (WC) > 102 in males (hypertension plus overweight\obesity for Senegalese group) or hypertension plus WC > 88 in females.

Download figure to PowerPoint

Discussion

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

Given the tendency to obesity and hypertension in minority ethnic groups and immigrants,4,32,33 it is crucial to monitor their situation in Italy—a country with a high level of immigration—and to understand the influence of their nutritional status on blood pressure. Important links between obesity and central adiposity and numerous diseases have been described in many populations.34–39

A limitation of the present study might be the extension to different ethnic groups of the WC cutoff points associated with obesity in Caucasians. In fact, we decided to use the same methodology, without considering possible differences in relationships between WC and body fat among ethnic groups to simplify and standardize the procedures for comparative purposes. Therefore, in view of the reported higher disease risk in South Asians,39–41 the absence of subjects with WC greater than 102 cm among Pakistanis does not completely assure less disease risk in these immigrants. Moreover, even though the general adiposity index (BMI) did not indicate adiposity development that would explain the high incidence of hypertension in the Senegalese, the lack of WC measurements for this ethnic group prevents a complete interpretation of their data.

Significant differences emerged from the general comparison between immigrants and host Italian population for all the examined traits in relation to the different genetic and cultural characteristics of the groups. With respect to native Italians, only the Roma and Kosovars showed significantly higher values of BMI, with SBP and DBP values similar or slightly higher. Hence, we can reasonably assume that there is a trend in these immigrant groups toward presentation of the same diseases as in the native groups but with a tendency to rapid worsening.

Of the immigrants included in our sample, 11.7% (females, 16.7%; males, 10.3%) were obese (BMI ≥ 30) and 36.4% (females, 38.5%; males, 35.7%) were overweight (BMI 25.0–29.9). Hence, our data on immigrant groups living in Italy confirm the general problem of obesity in immigrants. Comparing these data with those for native Italians,42 we observe that the overall percentages of overweight/obesity are similar in males but higher in the immigrant females than in Italian females (43.2% vs 45.8% for males; 59.1% vs 33.6% for females). Nevertheless, the observed prevalence of obesity is generally higher than the values reported for the same ethnic groups in their countries of origin.

A survey43 in Morocco in 2000 indicated that 13.3% of adults aged 20 y or more were obese (males, 22%; females, 8%). In Morocco and Tunisia, overweight is on the rise in both sexes.44 However, the female prevalence of central obesity in Morocco was low (16.8%)45 compared to that of Moroccan women who had immigrated to Italy (more than 50%).

The high incidence (>30%) of central adiposity (in both males and females) and of obesity (in males) in the Roma confirms the literature data. In previous studies, a close association was observed between the greater dyslipidemia, obesity, and insulin resistance of Gypsies and their low educational level and lifestyle.46

A high prevalence of obesity was also reported for populations living in territories of the former Yugoslavia.47,48 However, the obesity rates of Kosovar immigrants were double those reported for the native population of Bosnia and Herzegovina (16% of men and 20% of women obese),47 even though the prevalence of hypertension was similar for men and lower for immigrant females.

Obesity is also increasing in Pakistan: a quarter of the population is overweight or obese.49 However, the reported prevalence (25.0%) is only apparently similar to our data on Pakistani immigrants because lower BMI cutoff values were used in the cited paper (BMI ≥ 23 kg/m2). This group of male immigrants also showed the highest incidence of BMI < 18.5.

A comparison of our Senegalese immigrants, with a low prevalence of overweight, with the native population of Senegal is difficult because literature data for males are lacking. Nevertheless, a sharp rise in the prevalence of obesity was recently reported in females because overweight body sizes are considered in a positive light.50

The ethnic groups examined in the present study had a high prevalence of obesity, which was always greater in Italy than in the countries of origin (data are lacking for the Senegalese).

Ethnic differences in the prevalence of overweight and hypertension could depend on differences in genetic susceptibility and health-related behaviors. A different etiology can be suggested for the high incidence of hypertension in the Senegalese group despite the low prevalence of overweight. Indeed, there are reports of weaker associations between obesity and hypertension, or at least a lesser impact of obesity and fat distribution on hypertension prevalence, in blacks (African Americans) than in whites.51,52 Moreover, the overall rate of mortality from CHD is higher in African Americans than in any other ethnic group in the United States, and this increased CHD mortality can be accounted for, at least in part, by the high prevalence of coronary risk factors.53 Other factors related to migration and to the new environment—racism, stress, lack of work, inadequate salary, inappropriate housing, lack of family support, and lack or reduction of physical activity20,54—may be factors contributing to the high prevalence of hypertension in Senegalese immigrants in contrast to the very low prevalence of certified hypertension in their native country (7.4%).55

The observed tendency to overweight and to associated health problems in some immigrant groups and in native Italians reflects the well-documented epidemic diffusion of obesity, a complex condition affecting different socioeconomic groups. General population comparisons suggest a decline of health in immigrants to Italy, and this decline can be attributed to the adoption of an unhealthy lifestyle after their arrival.1,56 In addition, discrimination and social and cultural barriers could be important factors in the decreased health status of immigrants.57 Therefore, it is necessary to analyze possible differences in the health status of various ethnic groups and to verify that immigrants and native Italians are equally likely to use health care facilities, even if the irregular conditions of many migrants in Italy make this process very difficult.58,59

Conclusions

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

Our survey revealed ethnic differences in weight status, adiposity pattern, and blood pressure, suggesting different cardiovascular disease risk profiles in the ethnic groups. Kosovars and Roma are heavier and have a higher prevalence of abdominal obesity and hypertension than the other groups. Therefore, they appear to be at increased risk of associated morbidity.

Our findings are only a stepping-stone toward additional clinical and nutritional examinations of the immigrant sample according to the general research project. It must be mentioned that as a consequence of the general project, there has been increasing attention to health care for immigrants and to their reception in Emilia-Romagna, with new training courses established to facilitate migrant interactions and to provide greater availability of cultural mediation services. In particular, after completing specific courses, female Roma have become cultural facilitators who can cooperate with their peers to promote the use of social and health services. Although appropriate care strategies and preventive measures must be adequately developed to offer the perspective of improved health in the immigrant population, it is fundamental from a social point of view that native Italians accept immigrants not only as laborers but also as citizens in the new multiethnic society.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

Grants and other financial support for this study were provided by the Italian Health Ministry (project: “Health Assistance and Monitoring for Indigent Italian Citizens and Immigrants”) and by the University of Ferrara and Bologna.

Declaration of Interests

  1. Top of page
  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References

The authors state that they have no conflicts of interest.

References

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  2. Abstract
  3. Methods and Subjects
  4. Results
  5. Discussion
  6. Conclusions
  7. Acknowledgments
  8. Declaration of Interests
  9. References
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