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Shangguan S, Mozaffarian D, Sy S, Lee Y, Liu J, Wilde PE, Sharkey AL, Dowling EA, Marklund M, Abrahams-Gessel S, Gaziano TA, Micha R. Health Impact and Cost-Effectiveness of Achieving the National Salt and Sugar Reduction Initiative Voluntary Sugar Reduction Targets in the United States: A Microsimulation Study. Circulation 2021; 144:1362-1376. [PMID: 34445886 PMCID: PMC8555680 DOI: 10.1161/circulationaha.121.053678] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND High intake of added sugar is linked to weight gain and cardiometabolic risk. In 2018, the US National Salt and Sugar Reduction Initiative proposed government-supported voluntary national sugar reduction targets. This intervention's potential effects and cost-effectiveness are unclear. METHODS A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), coded in C++, was used to estimate incremental changes in type 2 diabetes, cardiovascular disease (CVD), quality-adjusted life-years (QALYs), costs, and cost-effectiveness of the US National Salt and Sugar Reduction Initiative policy. The model was run at the individual level, incorporating the annual probability of each person's transition between health statuses on the basis of risk factors. The model incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey across 3 cycles (2011 through 2016), added sugar-related diseases from meta-analyses, and policy costs and health-related costs from established sources. A simulated nationally representative US population was created and followed until age 100 years or death, with 2019 as the year of intervention start. Findings were evaluated over 10 years and a lifetime from health care and societal perspectives. Uncertainty was evaluated in a 1-way analysis by assuming 50% industry compliance and probabilistic sensitivity analyses through a second-order Monte Carlo approach. Model outputs included averted diabetes cases, CVD events and CVD deaths, QALYs gained, and formal health care cost savings, stratified by age, race, income, and education. RESULTS Achieving the US National Salt and Sugar Reduction Initiative sugar reduction targets could prevent 2.48 million CVD events, 0.49 million CVD deaths, and 0.75 million diabetes cases; gain 6.67 million QALYs; and save $160.88 billion net costs from a societal perspective over a lifetime. The policy became cost-effective (<150 000/QALYs) at 6 years, highly cost-effective (<50 000/QALYs) at 7 years, and cost-saving at 9 years. Results were robust from a health care perspective, with lower (50%) industry compliance, and in probabilistic sensitivity analyses. The policy could also reduce disparities, with greatest estimated health gains per million adults among Black or Hispanic individuals, lower income, and less educated Americans. CONCLUSIONS Implementing and achieving the US National Salt and Sugar Reduction Initiative sugar reformation targets could generate substantial health gains, equity gains, and cost savings.
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Affiliation(s)
- Siyi Shangguan
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- Massachussets General Hospital, Boston, MA 02114 USA
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Stephen Sy
- Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Yujin Lee
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- Myongji University, Yongin, Gyeonggi-Do 17058 South Korea
| | - Junxiu Liu
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Parke E. Wilde
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Andrea L. Sharkey
- New York City Department of Health and Mental Hygiene, Long Island City, NY 11101 USA
| | - Erin A. Dowling
- New York City Department of Health and Mental Hygiene, Long Island City, NY 11101 USA
| | - Matti Marklund
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- The George Institute for Global Health, Sydney, NSW 2050 Australia
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205 USA
| | | | - Thomas A. Gaziano
- Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
- Brigham & Women’s Hospital, Boston, MA 02115 USA
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- Department of Food Science and Human Nutrition, University of Thessaly, Volos, Thessaly 38221 Greece
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Ajeigbe OF, Oboh G, Ademosun AO, Oyagbemi AA. Ficus asperifolia Miq
‐enriched biscuit diet protects against
L
‐NAME induced hyperlipidemia and hypertension in rats. FOOD FRONTIERS 2021. [DOI: 10.1002/fft2.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Olufunke Florence Ajeigbe
- Functional Foods and Nutraceutical Unit Department of Biochemistry Federal University of Technology Akure Ondo P.M.B 704, 340001 Nigeria
- Department of Physical and Chemical Sciences Elizade University Ilara‐Mokin Ondo State P.M.B, 002, 340271 Nigeria
| | - Ganiyu Oboh
- Functional Foods and Nutraceutical Unit Department of Biochemistry Federal University of Technology Akure Ondo P.M.B 704, 340001 Nigeria
| | - Ayokunle Olubode Ademosun
- Functional Foods and Nutraceutical Unit Department of Biochemistry Federal University of Technology Akure Ondo P.M.B 704, 340001 Nigeria
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Lee Y, Mozaffarian D, Sy S, Liu J, Wilde PE, Marklund M, Abrahams-Gessel S, Gaziano TA, Micha R. Health Impact and Cost-Effectiveness of Volume, Tiered, and Absolute Sugar Content Sugar-Sweetened Beverage Tax Policies in the United States: A Microsimulation Study. Circulation 2020; 142:523-534. [PMID: 32564614 PMCID: PMC7423682 DOI: 10.1161/circulationaha.119.042956] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sugar-sweetened beverage taxes are a rapidly growing policy tool and can be based on absolute volume, sugar content tiers, or absolute sugar content. Yet, their comparative health and economic impacts have not been quantified, in particular, tiered or sugar content taxes that provide industry incentives for sugar reduction. METHODS We estimated incremental changes in diabetes mellitus and cardiovascular disease, quality-adjusted life-years, costs, and cost-effectiveness of 3 sugar-sweetened beverage tax designs in the United States, on the basis of (1) volume ($0.01/oz), (2) tiers (<5 g of added sugar/8 oz: no tax; 5-20 g/8 oz: $0.01/oz; and >20 g/8 oz: $0.02/oz), and (3) absolute sugar content ($0.01 per teaspoon added sugar), each compared with a base case of modest ongoing voluntary industry reformulation. A validated microsimulation model, CVD-PREDICT (Cardiovascular Disease Policy Model for Risk, Events, Detection, Interventions, Costs, and Trends), incorporated national demographic and dietary data from the National Health and Nutrition Examination Survey, policy effects and sugar-sweetened beverage-related diseases from meta-analyses, and industry reformulation and health-related costs from established sources. RESULTS Over a lifetime, the volume, tiered, and absolute sugar content taxes would generate $80.4 billion, $142 billion, and $41.7 billion in tax revenue, respectively. From a healthcare perspective, the volume tax would prevent 850 000 cardiovascular disease (95% CI, 836 000-864 000) and 269 000 diabetes mellitus (265 000-274 000) cases, gain 2.44 million quality-adjusted life-years (2.40-2.48), and save $53.2 billion net costs (52.3-54.1). Health gains and savings were approximately doubled for the tiered and absolute sugar content taxes. Results were robust for societal and government perspectives, at 10 years follow-up, and with lower (50%) tax pass-through. Health gains were largest in young adults, blacks and Hispanics, and lower-income Americans. CONCLUSIONS All sugar-sweetened beverage tax designs would generate substantial health gains and savings. Tiered and absolute sugar content taxes should be considered and evaluated for maximal potential gains.
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Affiliation(s)
- Yujin Lee
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Dariush Mozaffarian
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Stephen Sy
- Brigham & Women’s Hospital, Boston, MA 02115 USA
| | - Junxiu Liu
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Parke E. Wilde
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
| | - Matti Marklund
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, PO Box M201, Missenden Rd, NSW 2050, Australia
| | | | - Thomas A. Gaziano
- Brigham & Women’s Hospital, Boston, MA 02115 USA
- Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA
| | - Renata Micha
- Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111 USA
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Cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid: A microsimulation study. PLoS Med 2019; 16:e1002761. [PMID: 30889188 PMCID: PMC6424388 DOI: 10.1371/journal.pmed.1002761] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/11/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Economic incentives through health insurance may promote healthier behaviors. Little is known about health and economic impacts of incentivizing diet, a leading risk factor for diabetes and cardiovascular disease (CVD), through Medicare and Medicaid. METHODS AND FINDINGS A validated microsimulation model (CVD-PREDICT) estimated CVD and diabetes cases prevented, quality-adjusted life years (QALYs), health-related costs (formal healthcare, informal healthcare, and lost-productivity costs), and incremental cost-effectiveness ratios (ICERs) of two policy scenarios for adults within Medicare and Medicaid, compared to a base case of no new intervention: (1) 30% subsidy on fruits and vegetables ("F&V incentive") and (2) 30% subsidy on broader healthful foods including F&V, whole grains, nuts/seeds, seafood, and plant oils ("healthy food incentive"). Inputs included national demographic and dietary data from the National Health and Nutrition Examination Survey (NHANES) 2009-2014, policy effects and diet-disease effects from meta-analyses, and policy and health-related costs from established sources. Overall, 82 million adults (35-80 years old) were on Medicare and/or Medicaid. The mean (SD) age was 68.1 (11.4) years, 56.2% were female, and 25.5% were non-whites. Health and cost impacts were simulated over the lifetime of current Medicare and Medicaid participants (average simulated years = 18.3 years). The F&V incentive was estimated to prevent 1.93 million CVD events, gain 4.64 million QALYs, and save $39.7 billion in formal healthcare costs. For the healthy food incentive, corresponding gains were 3.28 million CVD and 0.12 million diabetes cases prevented, 8.40 million QALYs gained, and $100.2 billion in formal healthcare costs saved, respectively. From a healthcare perspective, both scenarios were cost-effective at 5 years and beyond, with lifetime ICERs of $18,184/QALY (F&V incentive) and $13,194/QALY (healthy food incentive). From a societal perspective including informal healthcare costs and lost productivity, respective ICERs were $14,576/QALY and $9,497/QALY. Results were robust in probabilistic sensitivity analyses and a range of one-way sensitivity and subgroup analyses, including by different durations of the intervention (5, 10, and 20 years and lifetime), food subsidy levels (20%, 50%), insurance groups (Medicare, Medicaid, and dual-eligible), and beneficiary characteristics within each insurance group (age, race/ethnicity, education, income, and Supplemental Nutrition Assistant Program [SNAP] status). Simulation studies such as this one provide quantitative estimates of benefits and uncertainty but cannot directly prove health and economic impacts. CONCLUSIONS Economic incentives for healthier foods through Medicare and Medicaid could generate substantial health gains and be highly cost-effective.
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Aluko EO, Omobowale TO, Oyagbemi AA, Adejumobi OA, Ajibade TO, Fasanmade AA. Reduction in nitric oxide bioavailability shifts serum lipid content towards atherogenic lipoprotein in rats. Biomed Pharmacother 2018. [PMID: 29525675 DOI: 10.1016/j.biopha.2018.03.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Nitric oxide (NO) is major endothelial relaxing factor and reduction in its bioavailabilty has been linked to hypertension. Furthermore, high lipid content is a strong risk factor predisposing to cardiovascular diseases. The principal focus of this study was to investigate the effect of blockade of nitric oxide synthase (NOS) on serum lipid content in rats. Male Wistar rats (150-170 g, n = 15) were randomly divided into two groups designated control (n = 5), and L-Name group (n = 10) and were gavage with distilled water and 60 mg/kg of L-NAME respectively daily for three weeks. After 3 weeks, the L-NAME group was sub-divided into two sub-groups (n = 5 each): L-NAME (60 mg/kg of L-NAME), and L-NAME plus ramipril (LR) (60 mg/kg of L-NAME plus 20 mg/kg of ramipril) and were treated daily for another three weeks. The blood pressure (BP) of the conscious rats was measured by tail-cuff method at the onset, at the third and at the sixth weeks of the experiment; while serum lipid contents and NO were measured at the third and sixth weeks. At the end of the experiment blood sample was drawn by ocular puncture for evaluation of lipid profile and NO, and the animals were later euthanized by overdose of anaesthesia. Data were analyzed using ANOVA at p < 0.05. There was a significant increase in BP, triglyceride, total cholesterol, low density lipoprotein-cholesterol, and atherogenic indices in L-NAME group compared to the control and LR group (p < 0.05); NO and high density lipoprotein-cholesterol was significant lower in the L-NAME group compared to control and LR (p < 0.05). In conclusion, reduction in NO bioavailability alters lipid metabolism, which was rectified by ramipril.
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Affiliation(s)
- Esther Oluwasola Aluko
- Department of Physiology, Faculty of Basic Medical Sciences, University of Uyo, Uyo, Akwa-Ibom State, Nigeria.
| | | | - Ademola Adetokunbo Oyagbemi
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
| | | | - Temitayo Olabisi Ajibade
- Department of Veterinary Physiology, Biochemistry and Pharmacology, Faculty of Veterinary Medicine, University of Ibadan, Nigeria
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Pandya A, Sy S, Cho S, Alam S, Weinstein MC, Gaziano TA. Validation of a Cardiovascular Disease Policy Microsimulation Model Using Both Survival and Receiver Operating Characteristic Curves. Med Decis Making 2017; 37:802-814. [PMID: 28490271 DOI: 10.1177/0272989x17706081] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite some advances, cardiovascular disease (CVD) remains the leading cause of death and healthcare costs in the United States. We therefore developed a comprehensive CVD policy simulation model that identifies cost-effective approaches for reducing CVD burden. This paper aims to: 1) describe our model in detail; and 2) perform model validation analyses. METHODS The model simulates 1,000,000 adults (ages 35 to 80 years) using a variety of CVD-related epidemiological data, including previously calibrated Framingham-based risk scores for coronary heart disease and stroke. We validated our microsimulation model using recent National Health and Nutrition Examination Survey (NHANES) data, with baseline values collected in 1999-2000 and cause-specific mortality follow-up through 2011. Model-based (simulated) results were compared to observed all-cause and CVD-specific mortality data (from NHANES) for the same starting population using survival curves and, in a method not typically used for disease model validation, receiver operating characteristic (ROC) curves. RESULTS Observed 10-year all-cause mortality in NHANES v. the simulation model was 11.2% (95% CI, 10.3% to 12.2%) v. 10.9%; corresponding results for CVD mortality were 2.2% (1.8% to 2.7%) v. 2.6%. Areas under the ROC curves for model-predicted 10-year all-cause and CVD mortality risks were 0.83 (0.81 to 0.85) and 0.84 (0.81 to 0.88), respectively; corresponding results for 5-year risks were 0.80 (0.77 to 0.83) and 0.81 (0.75 to 0.87), respectively. LIMITATIONS The model is limited by the uncertainties in the data used to estimate its input parameters. Additionally, our validation analyses did not include non-fatal CVD outcomes due to NHANES data limitations. CONCLUSIONS The simulation model performed well in matching to observed nationally representative longitudinal mortality data. ROC curve analysis, which has been traditionally used for risk prediction models, can also be used to assess discrimination for disease simulation models.
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Affiliation(s)
- Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Stephen Sy
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Sylvia Cho
- Department of Biomedical Informatics, Columbia University, New York, NY, USA (SC)
| | - Sartaj Alam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Milton C Weinstein
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG)
| | - Thomas A Gaziano
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA (AP, SS, SA, MCW, TAG).,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA (TAG)
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Markov Decision Processes for Screening and Treatment of Chronic Diseases. INTERNATIONAL SERIES IN OPERATIONS RESEARCH & MANAGEMENT SCIENCE 2017. [DOI: 10.1007/978-3-319-47766-4_6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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Francis DO. Bench to trench: how evidence and guidelines shape health care policy and practice. Otolaryngol Head Neck Surg 2013; 149:356-9. [PMID: 23715682 DOI: 10.1177/0194599813491228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Clinical practice guidelines and performance measures are becoming increasingly pervasive. They epitomize the evidence-based movement, which recognizes that mere "clinical judgment" is often inadequate to synthesize all the important data to determine the best management for a particular patient. This movement has at its core the fundamental expectation that medical decisions be based on sound data rather than anecdote. Unfortunately, this concept rarely manifests in daily practices where significant variations in care still exist. Guidelines were designed to improve patient care, reduce unnecessary variation, and reduce attributed costs. Therefore, it is not surprising that associated recommendations are now being incorporated into health care legislation as part of the Patient Protection and Affordable Care Act. In this environment, there is growing urgency for otolaryngologists to participate in rigorous comparative effectiveness research that will direct our Academy's guideline developers and policy makers to make recommendations that optimize care for all our patients.
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Affiliation(s)
- David O Francis
- Vanderbilt Voice Center, Vanderbilt University Medical Center, Nashville, Tennessee 37232-8783, USA.
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Rodríguez Poncelas A, Alemán Sánchez J, Álvarez Cosmea A, Serrano Cumplido A, Torres Baile J. Documento de consenso de la Red de Grupos de Estudio de la Diabetes en Atención Primaria de la Salud) sobre el tratamiento de la dislipidemia en la diabetes tipo 2 en prevención primaria. HIPERTENSION Y RIESGO VASCULAR 2013. [DOI: 10.1016/j.hipert.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Dowdy D, Bishai D, Chen AH. Setting clinical priorities: a framework for incorporating individual patient preferences. PATIENT EDUCATION AND COUNSELING 2013; 90:141-143. [PMID: 23073315 DOI: 10.1016/j.pec.2012.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/17/2012] [Accepted: 09/22/2012] [Indexed: 06/01/2023]
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Kirsh SR, Aron DC. Choosing targets for glycaemia, blood pressure and low-density lipoprotein cholesterol in elderly individuals with diabetes mellitus. Drugs Aging 2012; 28:945-60. [PMID: 22117094 DOI: 10.2165/11594750-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Diabetes mellitus in the 'elderly' poses unique management challenges that contribute to conflicting priorities. Individualized management requires taking into account each patient's medical history, functional ability, home care situation, life expectancy and his/her health beliefs; individuals value trade-offs (e.g. quantity versus quality of life, and side effects as well as risks versus long-term benefits) differently. Moreover, this decision making relies on imperfect evidence. Target goals for three intermediate outcomes - glycaemic control (glycosylated haemoglobin [HbA(1c)]), blood pressure control and lipid control (low-density lipoprotein cholesterol [LDL-C]) - help keep management on track. Of these, glycaemic control is usually the most complex. Glycaemic control alleviates symptoms of hyperglycaemia and can improve micro- and macrovascular outcomes. Tight glycaemic control (HbA(1c) <7%) clearly improves microvascular outcomes. However, hypoglycaemia and polypharmacy are the main drawbacks of tight control. Factors that influence the benefits and drawbacks include age, longevity and co-morbidities, including the geriatric 'syndromes' of frailty and falls. We favour the explicit risk-stratified approach of the Department of Veterans Affairs/Department of Defense (VA/DoD) guidelines, which set HbA(1c) target ranges based on physiological age or the presence/severity of major co-morbidities and microvascular complications. There are clear benefits of blood pressure and cholesterol control (primarily reduction of macrovascular events, but also microvascular events), and their overall cost effectiveness exceeds that of glycaemic control. Issues with treatment for hypertension include potential side effects of drugs, a potential increased risk of falls and risks of polypharmacy. Nevertheless, the evidence for a blood pressure target of <140/80 mmHg is reasonably strong if it can be achieved safely. In general, we recommend use of an HMG-CoA reductase inhibitor (statin) and an LDL-C target of <100 mg/dL, especially if an individual cannot tolerate a moderate dose of a statin.
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Affiliation(s)
- Susan R Kirsh
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, OH, USA
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