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Body Mass Index, Waist Circumference, and Health Risk
Evidence in Support of Current National Institutes of Health Guidelines
Ian Janssen, PhD;
Peter T. Katzmarzyk, PhD;
Robert Ross, PhD
Arch Intern Med. 2002;162:2074-2079.
ABSTRACT
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Background No evidence supports the waist circumference (WC) cutoff points recommended
by the National Institutes of Health to identify subjects at increased health
risk within the various body mass index (BMI; calculated as weight in kilograms
divided by the square of height in meters) categories.
Objective To examine whether the prevalence of hypertension, type 2 diabetes mellitus,
dyslipidemia, and the metabolic syndrome is greater in individuals with high
compared with normal WC values within the same BMI category.
Methods The subjects consisted of 14 924 adult participants of the Third
National Health and Nutrition Examination Survey, which is a nationally representative
cross-sectional survey. Subjects were grouped by BMI and WC in accordance
with the National Institutes of Health cutoff points. Within the normal-weight
(18.5-24.9), overweight (25.0-29.9), and class I obese (30.0-34.9) BMI categories,
we computed odds ratios for hypertension, diabetes, dyslipidemia, and the
metabolic syndrome and compared subjects in the high-risk (men, >102 cm; women,
>88 cm) and normal-risk (men,  102 cm; women, 88 cm) WC categories.
Results With few exceptions, within the 3 BMI categories, those with high WC
values were increasingly likely to have hypertension, diabetes, dyslipidemia,
and the metabolic syndrome compared with those with normal WC values. Many
of these associations remained significant after adjusting for the confounding
variables (age, race, poverty-income ratio, physical activity, smoking, and
alcohol intake) in normal-weight, overweight, and class I obese women and
overweight men.
Conclusions The National Institutes of Health cutoff points for WC help to identify
those at increased health risk within the normal-weight, overweight, and class
I obese BMI categories.
INTRODUCTION
IN 1998, the National Heart, Lung, and Blood Institute of the National
Institutes of Health (NIH) published evidence-based clinical guidelines on
the identification, evaluation, and treatment of overweight and obesity in
adults.1 These guidelines included a classification
system for assessing health risk based on the body mass index (BMI; calculated
as weight in kilograms divided by the square of height in meters) and waist
circumference (WC). In this classification system, a patient is placed in
1 of 6 BMI categories (underweight, normal-weight, overweight, or class I,
II, or III obese) and 1 of 2 WC categories (normal or high). The relative
health risk is then graded on the basis of the combined BMI and WC. The health
risk increases in a graded fashion when moving from the normal-weight through
class III obese BMI categories,2-3 and
it is assumed that within the normal-weight, overweight, and class I obese
BMI categories, patients with high WC values have a greater health risk than
patients with normal WC values. This classification system was developed on
the basis of the knowledge that an increase in BMI is associated with an increase
in health risk, that abdominal or android obesity is a greater risk factor
than lower-body or gynoid obesity, and that the WC is an index of abdominal
fat content.1
The sex-specific WC cutoff points used in the NIH guidelines were originally
developed by Lean and colleagues,4 who compared
the WC and the BMI in a large and heterogeneous sample of white men and women.
In that sample, a WC of 102 cm in men and 88 cm in women corresponded to a
BMI of 30.0. Although subsequent studies have shown that men and women with
WC values above 102 and 88 cm, respectively, are at increased health risk
compared with men and women with WC values below these cutoff points,5-10 these
studies did not control for the effects of BMI when examining the differences
in disease between individuals with high and low WC values. Thus, no evidence
confirms that the NIH WC cutoff points predict health risk beyond that already
predicted by the BMI.
The purpose of this investigation was to determine whether the prevalence
of hypertension, type 2 diabetes mellitus, dyslipidemia, and a clustering
of metabolic risk factors is greater in individuals with high WC values compared
with individuals with normal WC values within the same BMI category. We used
metabolic and anthropometric data from the Third National Health and Nutrition
Examination Survey (NHANES III), which is a large cohort representative of
the US population.
SUBJECTS AND METHODS
STUDY POPULATION
The NHANES III was conducted by the National Center for Health Statistics,
Hyattsville, Md, and the Centers for Disease Control and Prevention, Atlanta,
Ga, to estimate the prevalence of major diseases, nutritional disorders, and
potential risk factors for these diseases. The NHANES III was a nationally
representative, 2-phase, 6-year, cross-sectional survey conducted from 1988
through 1994. The complex sampling plan used a stratified, multistage, probability-cluster
design. The total sample included 33 199 persons. Full details of the
study design, recruitment, and procedures are available from the US Department
of Health and Human Services.11-12 Of
the total sample, 14 924 subjects were 17 years or older in whom measures
of the WC, height, weight, and metabolic variables were obtained and who fit
the BMI categories examined. Informed consent was obtained from all participants,
and the protocol was approved by the National Center for Health Statistics.
SURVEY METHODS
BMI and WC
Body weight and height were measured to the nearest 0.1 kg and 0.1 cm,
respectively, using standardized equipment and procedures.11-13 The
BMI was subsequently determined from these measures. The WC measurement was
made at minimal inspiration to the nearest 0.1 cm, midway between the last
rib and the iliac crest.11-13
Metabolic Variables
Three blood pressure measurements were obtained at 60-second intervals
with the subject in a seated position using a standard manual mercury sphygmomanometer.11-12 We used the average of the 3 readings
for this analysis. Blood samples were obtained after a minimum 6-hour fast
for the measurement of serum cholesterol, triglyceride, lipoprotein, and glucose
levels as described in detail elsewhere.11-12,14 Briefly,
cholesterol and triglyceride levels were measured enzymatically in a series
of coupled reactions hydrolyzing cholesterol ester and triglyceride to cholesterol
and glycerol, respectively. Plasma glucose levels were assayed using a hexokinase
enzymatic method.11-12,15
Confounding Variables
On the basis of self-report, we assessed the confounding variables,
including age, race, health behaviors (alcohol intake, smoking, and physical
activity), and the poverty-income ratio. Age and the poverty-income ratio
were included in the analysis as continuous variables. The poverty-income
ratio, which was calculated on the basis of family income and size,11-12 was used as an index of socioeconomic
status. Race was coded as 0 for non-Hispanic white, 1 for non-Hispanic black,
and 2 for Hispanic subjects and as 3 for subjects of other races. Alcohol
consumption was graded as none (0 drinks/mo), moderate (1-15 drinks/mo), or
heavy (>15 drinks/mo). Subjects were considered current smokers if they smoked
at the time of the interview, previous smokers if they were not current smokers
but had smoked 100 cigarettes, 20 cigars, or 20 pipefuls of tobacco in their
entire life, and nonsmokers if they smoked less than these amounts. Leisure-time
physical activity was graded as none (<4 times/mo), low (4-10 times/mo),
moderate (11-19 times/mo), or high (>19 times/mo).
DEFINITION OF GROUPS AND TERMS
Subjects were divided into 2 groups for the WC and 3 groups for the
BMI according to the NIH cutoff points.1 Men
and women with WC values of no greater than 102 and 88 cm, respectively, were
considered to have a normal WC, whereas men and women with WC values of greater
than 102 and 88 cm, respectively, were considered to have a high WC. On the
basis of their BMI, subjects were classified as normal weight (18.5-24.9),
overweight (25.0-29.9), or class I obese (30.0-34.9). Because all subjects
who were underweight (BMI<18.5) had normal WC values and all subjects with
class II and III obesity (BMI 35.0) had high WC values, they were excluded
from the data analysis.
Hypertension and type 2 diabetes were defined according to the guidelines
of the Joint National Committee on Detection, Evaluation, and Treatment of
High Blood Pressure16 and the American Diabetes
Association,17 respectively. Dyslipidemia and
the metabolic syndrome were defined according to the latest National Cholesterol
Education Program guidelines.18 The metabolic
syndrome, which is also known as syndrome X and the insulin resistance syndrome,
represents a clustering of plasma lipid and glucose and blood pressure risk
factors. Hypertension was defined as systolic blood pressure of at least 140
mm Hg, diastolic blood pressure of at least 90 mm Hg, or the use of antihypertensives.
Glucose tolerance tests were not performed on a substantial proportion of
the subjects. Therefore, we considered subjects to have type 2 diabetes if
they reported that their physician had ever told them they had diabetes (only
if diabetes was diagnosed after age 25 years and occurred outside of pregnancy),
if they reported using insulin or a hypoglycemic agent, or if they had a fasting
glucose level of greater than125 mg/dL (>6.9 mmol/L). Dyslipidemia was defined
as hypercholesterolemia (total cholesterol level, 240 mg/dL [6.2 mmol/L]),
high low-density lipoprotein (LDL) cholesterol level (160 mg/dL [4.1
mmol/L]), low high-density lipoprotein (HDL) cholesterol level (<40 mg/dL
[<1.0 mmol/L]), or hypertriglyceridemia (serum triglyceride level, 200
mg/dL [2.3 mmol/L]). Metabolic syndrome was defined as 3 or 4 of the following:
triglyceride level of at least 150 mg/dL (1.7 mmol/L), HDL cholesterol
level of less than 40 mg/dL (<1.0 mmol/L) in men or less than 50 mg/dL
(<1.3 mmol/L) in women, blood pressure of at least 130/85 mm Hg, or fasting
glucose level of at least 110 mg/dL (6.1 mmol/L).
STATISTICAL ANALYSIS
The Intercooled Stata 7 program19 was
used to properly weight the sample to be representative of the population
and to take into account the complex sampling strategy of the NHANES III design.
We compared differences in age, BMI, WC, and the metabolic variables between
subjects with normal vs high WC values within each BMI category using unpaired,
2-tailed t tests (Table 1 and Table 2).
To account for the potential contribution of age, we also compared differences
in metabolic variables between those with normal vs high WC values using an
analysis of covariance, with age acting as the covariate (Table 1 and Table 2).
We compared prevalences of hypertension, type 2 diabetes, dyslipidemia, and
the metabolic syndrome in those with normal vs high WC values within each
BMI category using  2 statistics (Table 1 and Table 2). We used logistic regression analysis to examine the associations between WC
classification and metabolic risk within the normal-weight, overweight, and
class I obese BMI categories (Table 3).
Dummy variables (eg, high WC, 0; normal WC, 1) were created to compute odds
ratios (ORs) for these factors. A normal WC was used as the reference category
(OR, 1.00). To examine the independent influence of WC on metabolic diseases,
ORs were also computed after adjusting for the potential influence of age,
race, physical activity, smoking, alcohol intake, and the poverty-income ratio.
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Table 1. Comparison of Anthropometric and Metabolic Variables and Disease
Prevalence in Men With Normal vs High WC Values Within Different BMI Categories*
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Table 2. Comparison of Anthropometric and Metabolic Variables and Disease
Prevalence in Women With Normal vs High WC Values Within Different BMI Categories*
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Table 3. Odds Ratios for Metabolic Diseases Comparing High vs Normal
WC Within Different BMI Categories*
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RESULTS
The subject characteristics, categorized according to BMI and WC categories,
are shown in Table 1 (men) and Table 2 (women). In the normal-weight BMI
category, 1.0% of the men and 13.7% of the women had WC values within the
high range. In the overweight BMI category, 27.6% of the men and 71.6% of
the women had WC values within the high range. In the class I obese BMI category,
84.8% of the men and 97.5% of the women had WC values within the high range.
Independent of sex and within each of the 3 BMI categories, subjects with
normal WC values were younger and tended to have a more favorable metabolic
profile (eg, lower mean blood pressure and glucose and cholesterol values)
compared with subjects with high WC values (Table 1 and Table 2).
In addition, in both sexes and in all BMI categories, the prevalence of hypertension,
type 2 diabetes, dyslipidemia (hypercholesterolemia, high LDL cholesterol
or low HDL cholesterol level, or hypertriglyceridemia), and the metabolic
syndrome tended to be higher in subjects with high WC values compared with
those with normal WC values (Table 1 and Table 2).
Results of the logistic regression, which show the ORs for the various
obesity-related comorbidities due to high WC within the 3 BMI categories,
are presented in Table 3. In the
normal-weight BMI category in men, the odds of hypertension and type 2 diabetes
were increased (P<.05) for those with high WC
values compared with those with normal WC values. In the normal-weight BMI
category in women, the odds for all of the comorbidities were increased (P<.05) for those with high WC values. With the exception
of hypertension in men and high LDL cholesterol level and type 2 diabetes
in women, these observations remained significant (P<.05)
after adjustment for the potential contributions of age, race, health behaviors
(eg, physical activity, smoking, and alcohol intake), and the poverty-income
ratio.
In the overweight BMI category, the ORs for all comorbidities were increased
(P<.05) in the men and women with high WC values
compared with the men and women with normal WC values (Table 3). Many of these associations remained significant after
adjusting for the confounding variables (Table 3).
In the class I obese BMI category, the odds of hypertension and the
metabolic syndrome were increased (P<.05) in men
with high WC values. In women, the odds of hypertension, type 2 diabetes,
high LDL cholesterol level, and the metabolic syndrome were increased (P<.05) for subjects with high WC values. With the exception
of hypertension in men, the associations between a high WC value and these
comorbidities in the class I obese subjects remained significant after adjusting
for the confounding variables (P<.05; Table 3).
COMMENT
The results of this study indicate that the health risk is greater in
normal-weight, overweight, and class I obese women with high WC values compared
with normal-weight, overweight, and class I obese women with normal WC values,
respectively. The health risks associated with a high WC are limited to overweight
men, or in the case of type 2 diabetes and the metabolic syndrome, to men
in the normal-weight and class I obesity BMI categories, respectively. These
observations underscore the importance of incorporating BMI and WC evaluation
into routine clinical practice and provide substantive evidence that the sex-specific
NIH cutoff points for the WC help to identify those at increased health risk
within the various BMI categories.
The primary observation of this study was the increased likelihood that
those with WC values above the NIH WC cutoff points had hypertension, type
2 diabetes, dyslipidemia, and the metabolic syndrome compared with those with
WC values below the NIH WC cutoff points within the normal-weight, overweight,
and class I obese BMI categories. This finding has important clinical implications,
given the widespread use of the NIH classification system, given that most
(approximately 90%) Americans fit within the normal-weight, overweight, or
class I obese BMI categories,20 and given that
a mixture of subjects with normal and high WC values was found within these
3 BMI categories (particularly the overweight category). Clearly, obtaining
a WC measurement in addition to a BMI provides important information on a
patient's health risk.
The additional health risk explained by the WC likely reflects its ability
to act as a surrogate for abdominal, and in particular, visceral fat. Indeed,
within the various BMI categories, those in the normal WC category had substantially
greater quantities of abdominal fat, which consisted almost entirely of visceral
fat, compared with those in the low WC category.21 Moreover,
because WC is only a modest predictor of abdominal subcutaneous and nonabdominal
(eg, subcutaneous fat in the periphery) fat after controlling for the BMI,
abdominal subcutaneous and nonabdominal fat might not be the primary vehicles
by which the WC explains health risk beyond that predicted by the BMI.21
The additional health risk explained by WC also reflects that those
with high WC values were older than those with normal WC values independent
of sex and BMI category (Table 1 and Table 2). Indeed, adjusting for age diminished
the strength of the associations between high WC values and hypertension,
diabetes, dyslipidemia, and the metabolic syndrome. However, a high WC remained
a significant predictor of obesity-related comorbidity after adjusting for
age and the other confounding variables.
In this study, the effects of a high WC were more apparent in the women
than in the men. For example, in the overweight BMI category, the adjusted
ORs for type 2 diabetes were 1.99 in the men with a high WC and 4.07 in the
women with a high WC, compared with the men and women, respectively, with
a normal WC. This sex difference may be partially explained by the fact that
the prevalences of the metabolic diseases were considerably higher in the
men than in the women with a low WC. In reference to the example used above,
2.7% of the overweight men with a normal WC had type 2 diabetes, whereas only
1.6% of the overweight women with a normal WC had type 2 diabetes. However,
the prevalence of type 2 diabetes was similar in the overweight men (10.6%)
and women (10.0%) with a high WC. Thus, because the ORs were determined within
each sex by comparing the subjects with a high WC with the subjects with a
normal WC, the higher ORs observed in the women with a high WC may be explained
by the lower prevalences of the metabolic diseases in the women with a normal
WC.
The finding that subjects with high WC values had a greater health risk
compared with those with low WC values within the same BMI category does not
imply that WC values of 102 cm in men and 88 cm in women are the ideal threshold
values to denote increased health risk. The WC values that best predict health
risk within the different BMI categories are unknown. Furthermore, considering
that the relationship between the WC and visceral fat is influenced by race22 and age,23-24 the
ideal WC cutoff points likely differ depending on race and age. Additional
studies are required to determine the ideal WC threshold values to use in
combination with the BMI.
The NIH classification system uses a dichotomous approach (normal vs
high) to establish the associations between the WC and health risk.1 However, the WC is related to health risk in a linear
fashion.5, 25-26 Thus,
some authors have suggested using a graded system for assessment of health
risk based on WC,4-5,8, 27 which
is similar to the method currently advocated for the BMI by the NIH. For example,
Lean and colleagues4 proposed that WC values
of less than 94 cm in men and of less than 80 cm in women denote a low health
risk; those ranging from 94 to 102 cm in men and 80 to 88 cm in women, a moderately
increased health risk; and those greater than 102 cm in men and greater than
88 cm in women, a substantially increased health risk. When we subdivided
the subjects in the normal-weight and overweight BMI categories into the 3
WC categories proposed by Lean and colleagues,4 we
observed that disease risk was lower in those with low WC values (men, <94
cm; women, <80 cm) compared with those with moderately elevated WC values
(men, 94-102 cm; women, 80-88 cm); subjects with moderately elevated WC values
in turn had a lower disease risk compared with those with high WC values (men,
>102 cm; women, >88 cm) (data not shown). The clinical implication is that
individuals with WC values moderately below the NIH cutoff points (eg, men,
94-102 cm; women, 80-88 cm) are at increased health risk compared with those
within the same BMI category who have WC values considerably below the NIH
cutoff points (eg, men, <94 cm; women <80 cm). This finding also suggests
that consideration of the WC in the same way as the BMI, in which there are
more than 2 risk strata, might be more appropriate.
Given that the subject pool was large and representative of the US population,
the NHANES III was perhaps the best data set to test our hypothesis. Nonetheless,
our study has 2 limitations that should be recognized. First, the cross-sectional
nature of this study precludes definitive causal inferences about the associations
between the BMI and the WC and disease. However, numerous studies have shown
that high BMI and WC values precede the onset of morbidity and mortality.28-31 Second,
there was a potential bias due to survey nonresponse and missing values for
some of the metabolic and confounding variables. However, previous NHANES
studies have shown little bias due to nonresponse.32
CONCLUSIONS
We have shown that the health risk is greater in individuals with high
WC values in the normal-weight, overweight, and class I obese BMI categories
compared with those with normal WC values. Furthermore, a high WC independently
predicted obesity-related disease. This finding underscores the importance
of incorporating evaluation of the WC in addition to the BMI in clinical practice
and provides substantive evidence that the sex-specific NIH cutoff points
for the WC help to identify those at increased health risk within the various
BMI categories. Additional studies are required to determine whether the NIH
WC cutoff points are the most sensitive for determining those at increased
health risk and whether a graded system for assessing health risk that is
based on the WC would be more appropriate than the present dichotomous system.
AUTHOR INFORMATION
Accepted for publication February 27, 2002.
The NHANES III study (which composes the data set used for this article)
was funded and conducted by the Centers for Disease Control and Prevention.
Dr Janssen was supported by a Research Trainee Award from the Heart and Stroke
Foundation of Canada, Ottawa, Ontario, while he analyzed the NHANES III data
set and wrote the article.
Corresponding author and reprints: Robert Ross, PhD, School of Physical
and Health Education, Queen's University, Kingston, Ontario, Canada K7L 3N6
(e-mail: rossr{at}post.queensu.ca).
From the School of Physical and Health Education (Drs Janssen, Katzmarzyk,
and Ross) and the Department of Medicine, Division of Endocrinology and Metabolism
(Dr Ross), Queen's University, Kingston, Ontario.
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Abdominal Obesity and the Risk of All-Cause, Cardiovascular, and Cancer Mortality: Sixteen Years of Follow-Up in US Women
Zhang et al.
Circulation 2008;117:1658-1667.
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Complete health checkup for adults: Update on the Preventive Care Checklist Form(C)
Iglar et al.
cfp 2008;54:84-88.
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Obesity in asylum seekers' children in The Netherlands the use of national reference charts
Stellinga-Boelen et al.
Eur J Public Health 2007;17:555-559.
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Nutrition Assessment of Patients With Inflammatory Bowel Disease
Vagianos et al.
JPEN J Parenter Enteral Nutr 2007;31:311-319.
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Gestational Diabetes After Delivery: Short-term management and long-term risks
Kitzmiller et al.
Diabetes Care 2007;30:S225-S235.
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Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia
Barnett et al.
J Psychopharmacol 2007;21:357-373.
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Effects of Different Doses of Physical Activity on Cardiorespiratory Fitness Among Sedentary, Overweight or Obese Postmenopausal Women With Elevated Blood Pressure: A Randomized Controlled Trial
Church et al.
JAMA 2007;297:2081-2091.
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Physical Activity in Young Adults and Incident Hypertension Over 15 Years of Follow-Up: The CARDIA Study
Parker et al.
Am. J. Public Health 2007;97:703-709.
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Dietary Patterns in Adolescence Are Related to Adiposity in Young Adulthood in Black and White Females
Ritchie et al.
J. Nutr. 2007;137:399-406.
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Dietary Fat and Risk of Postmenopausal Breast Cancer in a 20-year Follow-up
Kim et al.
Am J Epidemiol 2006;164:990-997.
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What aspects of body fat are particularly hazardous and how do we measure them?
Snijder et al.
Int J Epidemiol 2006;35:83-92.
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Body mass index and waist circumference both contribute to differences in insulin-mediated glucose disposal in nondiabetic adults
Farin et al.
Am. J. Clin. Nutr. 2006;83:47-51.
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Metabolic Syndrome: Risk factor distribution and 18-year mortality in the Multiple Risk Factor Intervention Trial
Eberly et al.
Diabetes Care 2006;29:123-130.
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Are waist circumference and body mass index independently associated with cardiovascular disease risk in Chinese adults?
Wildman et al.
Am. J. Clin. Nutr. 2005;82:1195-1202.
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Activation of the Peripheral Endocannabinoid System in Human Obesity
Engeli et al.
Diabetes 2005;54:2838-2843.
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Which anthropometric measurements is most closely related to elevated blood pressure?
Yalcin et al.
Fam Pract 2005;22:541-547.
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