Author + information
- Received May 21, 2014
- Revision received December 12, 2014
- Accepted December 17, 2014
- Published online March 17, 2015.
- Yufang Bi, MD, PhD∗,
- Yong Jiang, PhD†,
- Jiang He, MD, PhD‡,
- Yu Xu, PhD∗,‡,
- Limin Wang, PhD†,
- Min Xu, PhD∗,
- Mei Zhang, MS†,
- Yichong Li, MS†,
- Tiange Wang, PhD∗,
- Meng Dai, BS∗,
- Jieli Lu, MD, PhD∗,
- Mian Li, PhD∗,
- Chung-Shiuan Chen, MS‡,
- Shenghan Lai, MD, MPH§,
- Weiqing Wang, MD, PhD∗∗∗∗ (, )
- Linhong Wang, PhD†∗∗ (, )
- Guang Ning, MD, PhD∗∗ (, )
- 2010 China Noncommunicable Disease Surveillance Group
- ∗State Key Laboratory of Medical Genomics, Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, National Clinical Research Center for Metabolic Diseases, Collaborative Innovation Center of Systems Biomedicine and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
- †National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
- ‡Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
- §Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- ↵∗Reprint requests and correspondence:
Dr. Guang Ning, Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, 197 Rui-Jin 2nd Road, Shanghai 200025, China.
- ↵∗∗Dr. Linhong Wang, National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, 27 Nan Wei Road, Beijing 100050, China.
- ↵∗∗∗Dr. Weiqing Wang, Key Laboratory for Endocrine and Metabolic Diseases of Ministry of Health, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, 197 Rui-Jin 2nd Road, Shanghai 200025, China.
Background Cardiovascular disease has become the leading cause of death in China.
Objectives The goal of this study was to evaluate the current status of cardiovascular health in Chinese adults.
Methods Cardiovascular health data were collected from a nationally representative sample of 96,121 Chinese adults age ≥20 years in 2010. Ideal cardiovascular health was defined according to the American Heart Association’s 2020 Strategic Impact Goals as follows: the simultaneous presence of 4 favorable health behaviors (ideal smoking status, ideal body mass index, physical activity at goal, and healthy dietary habits) and 4 favorable health factors (ideal smoking status, untreated total cholesterol <200 mg/dl, untreated blood pressure <120/<80 mm Hg, and untreated fasting plasma glucose <100 mg/dl) in the absence of a history of cardiovascular disease.
Results The estimated percentage of ideal cardiovascular health was 0.2% in the general adult population in China (0.1% in men and 0.4% in women). An estimated 0.7% (0.4% in men and 1.0% in women) of Chinese adults had all 4 ideal health behaviors, and 13.5% (5.0% in men and 22.3% in women) had all 4 ideal health factors. Men most frequently had 3 to 4 ideal components, and women most commonly had 4 to 5 ideal components of the 7 cardiovascular health metrics. Ideal diet (1.6%) was the least common among all cardiovascular health metrics. Female sex and younger age were the 2 most common protective factors for cardiovascular health in Chinese adults.
Conclusions The percentage of ideal cardiovascular health in Chinese adults is extremely low. Both population-wide and high-risk strategies should be implemented with great effort to promote cardiovascular health in China.
To further perpetuate the downward trend of cardiovascular disease, the American Heart Association (AHA) recently set new national goals (i.e., the AHA 2020 Impact Goals) for cardiovascular health promotion for the next decade: “by 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%” (1). To quantify the impact, the AHA introduced 7 cardiovascular health metrics: smoking, body mass index (BMI), physical activity, healthy diet score, total cholesterol, blood pressure, and fasting plasma glucose. These 7 metrics were grouped into cardiovascular health behaviors and cardiovascular health factors. By introducing the new concept of “cardiovascular health” and including health behaviors in the construct of the goals, the AHA emphasized health promotion by prevention of risk factors, a policy that is known as primordial prevention (2).
Cardiovascular disease and stroke mortality have declined due to downward shifts in population levels of cholesterol, blood pressure, and smoking in high-income countries (3–6). Cardiovascular disease mortality declined by 31.0% from 2000 to 2010 in the United States (7). Stroke mortality declined by almost 3% annually from 1980 to 2005 in European countries, including the United Kingdom, Norway, and Finland (8). Secular trends of cardiovascular risk factors in low- and middle-income countries are varied but have increased in many regions. The prevalence of diabetes in China more than doubled during the past decade (9,10), and the prevalence of hypertension and dyslipidemia has increased dramatically as well (11–14). Smoking remains highly prevalent in Chinese men, making China the largest consumer of tobacco in the world (15). Cardiovascular mortality in China increased from 223.5 per 100,000 persons to 239.5 per 100,000 persons from 2004 to 2010 (16).
China is the most populous country in the world, and changes in disease prevalence in the Chinese population will significantly affect the global burden of disease. In the context of the present epidemic of cardiovascular risk factors, it is crucial for China to obtain national data on cardiovascular health, as well as to monitor its trends over time with nationwide surveillance. By adopting the concept and definition of cardiovascular health from the AHA, we used data from a nationally representative sample of 98,658 adults to evaluate the current status of cardiovascular health in the general population of China.
China Noncommunicable Disease Surveillance 2010 included all 162 study sites from the Chinese Center for Disease Control and Prevention (CDC) National Disease Surveillance Point System. This system was designed to select a nationally representative sample of the general population, covering the major geographic areas of all 31 provinces, autonomous regions, and municipalities in mainland China (10,17).
At each site, a complex, multistage, probability sampling design was used to select participants who were representative of civilian, noninstitutionalized Chinese adults. Only persons who had been living in their current residence for ≥6 months were eligible to participate. In the first stage, 4 subdistricts in urban areas or townships in rural areas were selected from each site with probability proportional to size. In the second stage, 3 neighborhood communities or administrative villages were selected with probability proportional to size. In the third stage, households within each neighborhood community or administrative village were listed, and 50 households were randomly selected. In the final stage, 1 person age ≥18 years was randomly selected from each household by using a Kish selection table (18). When the selected individual refused or was unavailable, a replacement household was selected from all households of similar composition in the same neighborhood or village after excluding the already selected households by using the simple random sampling method. If the second household did not participate, a third household was selected. All replacements were successfully recruited by the third sampling. If no available replacement was found in the same neighborhood or village, the nearest neighborhood or village was used. A total of 109,023 subjects were selected, and 98,658 participated in the survey, with an overall response rate of 90.5%. For the present report, 96,121 participants age ≥20 years were included (1).
The ethical review committee of the China CDC and other participating institutes approved the study’s protocol. Written informed consent was obtained from all study participants.
Data collection was conducted in examination centers at local health stations or community clinics in the participants’ residential area by trained staff according to a standard protocol. A questionnaire comprising information on demographic characteristics, lifestyle factors (including smoking and dietary habits), history of chronic diseases, and use of medications was administered by trained interviewers. The Global Physical Activity Questionnaire was used to assess physical activity, which included household and work-related activities, as well as activities during transportation and at leisure time (19). A food frequency questionnaire was used to collect habitual dietary intake in study participants by asking the frequency of consumption and portion size of typical food items over the previous 12 months. Weight and height were measured according to a standard protocol, and BMI was calculated as weight in kilograms divided by height in meters squared.
Trained observers obtained 3 blood pressure measurements from the nondominant arm of each participant by using a calibrated automatic electronic device (OMRON model HEM-7071, Omron Co., Kyoto, Japan) in a separate examination room after at least a 5-min sitting rest. Participants were advised to avoid alcohol, coffee, tea, smoking, and exercise at least 30 min before the blood pressure measurement. The average of 3 readings was used for analysis.
Blood samples were collected in all participants after an overnight fast of at least 10 h. Serum samples were aliquoted and frozen at –80°C within 2 h of collection and shipped by air in dry ice to a central laboratory, which was accredited by the College of American Pathologists. Serum total cholesterol was measured by using an autoanalyzer (ARCHITECT ci16200, Abbott Laboratories, Abbott Park, Illinois). Plasma glucose was measured by using glucose oxidase or hexokinase methods within 24 h.
A stringent quality assurance and quality control program was implemented to ensure the validity and reliability of the study data. All investigators and research staff underwent a week-long training session on the use of standardized protocols and instruments for data collection. Only certified staff was allowed to collect data. All laboratory equipment was calibrated, and blinded duplicate samples were used. All data were double-entered into a database and then compared and corrected for errors.
AHA’s cardiovascular health and cardiovascular health metrics
According to the AHA (1), ideal cardiovascular health is defined as the simultaneous presence of 4 favorable health behaviors (ideal smoking status, ideal BMI, physical activity at goal, and healthy dietary habits) and 4 favorable health factors (ideal smoking status, untreated total cholesterol <200 mg/dl, untreated blood pressure <120/<80 mm Hg, and untreated fasting plasma glucose <100 mg/dl) in the absence of cardiovascular disease history. Smoking appears on both lists of health behaviors and health factors due to its importance for health promotion.
Each of the 7 metrics was categorized as ideal, intermediate, or poor (Online eTable 1). We used the food frequency questionnaire of the previous 12 months to characterize dietary metrics and replaced whole grains with bean consumption (soy protein ≥25 g/day) as one of the components, because data on whole grain intake were not collected and bean consumption has been shown to promote cardiovascular health (20,21). The intake of soy protein was estimated by collecting information on the frequency and quantity of soy food consumption, most typically tofu in Chinese adults. The average amount of soy intake per day was then calculated, which was translated into soy protein intake for analysis. Sodium intake was estimated by collecting information on household consumption of dietary salt per month and average numbers of family members eating breakfast, lunch, and dinner at home. Different weights were applied to each of the 3 meals, and the average intake of sodium per person in the family per day was used.
Ideal cardiovascular health was therefore defined by the presence of all 7 ideal metrics among subjects with no history of cardiovascular disease. Intermediate cardiovascular health was defined by the presence of ≥1 metric at the “intermediate” level and none at the “poor” level among subjects with no cardiovascular disease history or by the presence of all 7 ideal metrics among subjects with a history of cardiovascular disease. Poor cardiovascular health was defined by the presence of ≥1 metric at the “poor” level among subjects with no history of cardiovascular disease or by the presence of ≥1 metric at the “intermediate” or “poor” level among subjects with a history of cardiovascular disease.
Proportions and SEs for each of the 3 levels of the 7 metrics were estimated in the total population and in subgroups of sex, age, urbanization (urban/rural), stages of economic development, major ethnic groups, and geographic regions (northern and southern China). Proportions and SEs of numbers of ideal cardiovascular health metrics from 0 through 7, numbers of ideal health behaviors from 0 through 4, and numbers of ideal health factors from 0 through 4 were also calculated in the total population as well as in subgroups. Cross-tabulation was used to calculate proportions of Chinese adults at different numbers of ideal health behaviors versus ideal health factors. Proportions of different numbers of ideal metrics were also assessed according to age, urbanization, and economic development in Chinese men and women separately, as well as the overall cardiovascular health at ideal, intermediate, and poor levels. A multivariable multinomial logistic regression analysis was used to identify demographic characteristics associated with cardiovascular health in Chinese adults.
All calculations, except for the number of participants, were weighted to represent the overall Chinese adult population age ≥20 years. Each study site was categorized as an underdeveloped, intermediately developed, or developed region according to the tertiles of their gross domestic product per capita in 2009. Study sites with gross domestic product per capita in 2009 <¥14,397 were categorized as underdeveloped; those between ¥14,397 and ¥27,107 were categorized as intermediately developed; and those >¥27,107 were categorized as developed.
Data were analyzed by using SAS version 9.3 (SAS Institute, Inc., Cary, North Carolina) and SUDAAN version 10.0 (Research Triangle Institute, Research Triangle Park, North Carolina). All statistical tests were 2-sided, and a p value <0.05 was considered statistically significant.
The distribution of 3 levels of all 7 cardiovascular health metrics in the overall Chinese population and in subgroups is presented in Table 1 and Online eTable 2. Approximately 70% of Chinese adults reported that they never smoked or had quit smoking for >12 months (43.4% in men and 97.3% in women). Two-thirds (66.2%) of Chinese adults had ideal BMI levels (65.6% in men and 66.7% in women). Subjects with ideal BMI were more common in rural and underdeveloped regions. The majority of men (80.0%) and women (85.0%) reported ideal physical activity. Less than 2% of Chinese adults achieved 4 to 5 component goals of healthy diet. The proportion of subjects who achieved the goal of each dietary component was 53.8% for fruit and vegetables, 27.2% for fish, 8.0% for sodium, 93.4% for sugar-sweetened beverage, and 0.3% for soy protein. Most Chinese adults (83.9%) had ideal total cholesterol levels, but only 26.1% had ideal blood pressure levels. In addition, 60.4% of Chinese adults had ideal fasting glucose levels. A significantly higher proportion of women had ideal blood pressure and glucose levels compared with men. Proportions of ideal cholesterol, blood pressure, and fasting glucose decreased with age as well as economic development.
Only 0.2% of the entire Chinese adult population had all 7 ideal cardiovascular health metrics (Table 2 and Online eTable 3). The majority of Chinese adults had 3, 4, or 5 ideal metrics, which accounted for 76.8% of the population collectively. Men most frequently had 3 to 4 ideal components, whereas women most commonly had 4 to 5 ideal components. When the numbers of ideal health behaviors and ideal health factors were examined separately, only 0.7% of adults had all 4 ideal behaviors and 13.5% had all 4 ideal factors. The numbers of ideal cardiovascular health metrics, ideal health behaviors, and ideal health factors were higher in younger age groups. Subjects living in urban and developed regions generally had higher numbers of ideal health behaviors, but slightly lower numbers of ideal health factors, compared with rural or less developed regions. The proportions of Chinese adults with different numbers of ideal health behaviors versus ideal health factors are shown in Figure 1.
Proportions of Chinese men and women with various numbers of ideal cardiovascular health metrics according to age, urbanization, and economic development are presented in Figure 2. In general, younger age groups had higher numbers of ideal cardiovascular health metrics in both men and women. In addition, those living in rural areas had higher numbers of ideal health metrics compared with their urban counterparts. Similarly, persons living in underdeveloped or intermediately developed regions had higher numbers of ideal cardiovascular health metrics compared with those living in developed regions.
The proportions of ideal, intermediate, and poor cardiovascular health according to age, urbanization, and economic development are shown in Figure 3 and Online Figure 1. Almost no Chinese men attained ideal cardiovascular health, and the proportion of poor cardiovascular health was >80% in every male subgroup. Although overall cardiovascular health was better in women, the proportion of poor cardiovascular health was >50% in all subgroups. Cardiovascular health decreased with age, and 92.4% of men and 89.9% of women age ≥65 years had poor cardiovascular health.
The proportion of each individual cardiovascular health metric, the proportion of numbers of ideal cardiovascular health metrics, and the proportion of overall cardiovascular health status according to ethnic groups and geographic regions are presented in Table 3, Table 4, and Figure 4, respectively.
Demographic characteristics associated with cardiovascular health among Chinese adults are presented in Table 5. Among all the demographic variables, female sex was the strongest protector. Women were 3.52-, 7.75-, and 35.76-fold more likely to have 2 to 3, 4 to 5, and 6 to 7 ideal metrics, respectively, than having only 0 to 1 ideal metric, compared with men. Younger age was another important protective factor of cardiovascular health, especially for ideal health factors. Adults age 20 to 44 years and 45 to 64 years were 4.43- and 1.20-fold more likely to have 3 to 4 ideal health factors, respectively, than having only 0 to 1 ideal health factor, compared with subjects age ≥65 years. Being economically less developed and having more education were also associated with greater numbers of ideal cardiovascular health metrics.
By adopting the AHA’s concept and definition of 7 health metrics, cardiovascular health was evaluated in a large, nationally representative sample of the general Chinese population. The estimated percentage of ideal cardiovascular health among Chinese adults age ≥20 years was 0.2% (0.1% in men and 0.4% in women) in 2010 (Central Illustration). The estimated percentage of intermediate cardiovascular health was 24.8% (13.6% in men and 36.3% in women), and that of poor cardiovascular health was 74.9% (86.3% in men and 63.3% in women). The majority of Chinese adults had 3 to 5 ideal cardiovascular health metrics. The proportions of adults with optimal levels of all 4 health behaviors and all 4 health factors were estimated to be 0.7% (0.4% in men and 1.0% in women) and 13.5% (5.0% in men and 22.3% in women), respectively. These data indicate that the majority of the Chinese adult population did not meet optimal levels of cardiovascular health. Without effective intervention, cardiovascular disease will become epidemic in the near future in China.
Our findings add to previous reports of extremely low proportions of ideal cardiovascular health in the general population in various countries. Results from the National Health and Nutrition Examination Survey showed that <1% of U.S. adults exhibit ideal cardiovascular health for all 7 metrics (22). Data from a nationwide population-based study in Spain revealed that only 0.2% of Spanish adults attained ideal cardiovascular health status (23). After standardization to the 2010 World Population (24), the age-standardized prevalence estimate was 0.28% in the Spanish population compared with 0.24% in the Chinese population in our study. The proportion of those obtaining all 7 ideal metrics was 0.67% in middle-aged Korean men (25). In addition, our findings are consistent with previous reports on cardiovascular risk factor clustering among Chinese adults. More than a decade ago, InterASIA (the International Collaborative Study of Cardiovascular Disease in Asia) reported that 80.5% of Chinese adults age 35 to 74 years had ≥1 modifiable cardiovascular risk factor, including dyslipidemia, hypertension, diabetes, cigarette smoking, and overweight (26). Results from the 2007 to 2008 China National Diabetes and Metabolic Disorders Study reported an 86.5% national prevalence of having at least 1 risk factor (e.g., smoking, overweight or obesity, hypertension, dyslipidemia, hyperglycemia) among Chinese adults (27).
To include health behaviors in the definition of overall cardiovascular health represents a critical step toward implementation of primordial prevention. It emphasizes prevention of adverse levels of risk factors, rather than prevention of clinical events among individuals at risk (i.e., primary prevention). Primordial prevention is of particular importance for cardiovascular disease prevention, because persons with controlled risk factors are still at increased risk of developing unfavorable cardiovascular outcomes compared with persons with no risk factors in the first place (28). In addition, associations of cardiovascular disease with levels of risk factors are graded and often extend beyond the lower limit of the “normal” range (29). Among those heart-healthy behaviors defined by the AHA, ideal diet was the most difficult to achieve. Only 1.6% of the general adult population in China was eating a healthy diet. In the United States, the percentage was 0.6% for men and 1.4% for women (30). The low percentage of ideal diet was the major contributor to the extremely low percentage of overall ideal cardiovascular health.
Our findings have important public health and clinical implications. Cardiovascular disease remains the leading cause of death in China and worldwide (31,32). Previous large prospective cohort studies and clinical trials have documented that each health metric plays an etiological role in the risk of cardiovascular disease. Recently, overall ideal cardiovascular health and the increased numbers of ideal cardiovascular health metrics have been documented to predict lower risks of cardiovascular disease (33–35), cardiovascular mortality (35–37), all-cause mortality (36,37), and noncardiovascular diseases, such as cancer and end-stage renal disease (38,39). Promotion of cardiovascular health is particularly urgent for China because rapid economic growth, accelerated urbanization, and aging of the population have led to an epidemic of chronic diseases in the nation (10,12,14,40,41). According to national data, chronic diseases account for an estimated 80% of deaths and 70% of total disease burden in China (42). In addition, the World Health Organization estimated that the economic loss from heart disease, stroke, and diabetes in China could reach $558 billion between 2005 and 2015 (43). Our findings provide additional evidence for the national and regional health policy makers to promote cardiovascular health as a top public health priority in China.
Our study indicates that the majority (74.9%) of Chinese adults had poor cardiovascular health. Both a population-wide strategy and a high-risk strategy targeting subjects at high risk must be used to improve the overall cardiovascular health of the Chinese population. The promotion of healthy behaviors is more effective when implemented at the population level. Health education through mass media, public awareness campaigns on cardiovascular disease prevention, development of tobacco control laws and regulations, and promotion of food policies that restrict high-sodium and high-fat food consumption, as well as improvement of access to health facilities that support physical activity, could all be important in improving the population distribution of cardiovascular risk factors. In addition, the treatment and control of cardiovascular risk factors, including hypertension, hypercholesterolemia, and diabetes among high-risk subjects, have been shown to be effective in preventing clinical cardiovascular events. A large proportion of Chinese adults with cardiovascular risk factors were not adequately controlled (10,12,14).
First, ∼10% of selected subjects did not participate in the survey, which could potentially undermine the representativeness of the study samples. However, the replacements were used to maximize the national representativeness of the study samples regarding geographic distribution, economic development, and urbanization. Second, history of cardiovascular disease was self-reported and only included myocardial infarction and stroke during the previous year. Therefore, our study might have underestimated the cardiovascular disease history and overestimated the proportion of ideal cardiovascular health in Chinese adults. Third, a semiquantitative food frequency questionnaire was used to document participants’ dietary habits within the past 12 months. Although food frequency questionnaires have been widely used in epidemiological studies (especially in studies with large sample sizes), multiple 24-h dietary recalls may provide more accurate and precise estimates of absolute intake of foods. Dietary sodium intake from processed food or from eating outside was not recorded; thus, dietary sodium intake might have been underestimated. In addition, we used soybean in replacement of whole grains to approximate the AHA’s definition for healthy diet score. Bean consumption has been shown in a number of studies to promote cardiovascular health (20,21). Soybean protein supplementation reportedly reduced systolic and diastolic blood pressures in a randomized, double-blind, controlled trial in Chinese adults (20). A meta-analysis of 41 randomized controlled trials showed that soy protein intake was associated with a significant reduction in total cholesterol, low-density lipoprotein cholesterol, and triglycerides, and a significant increase in high-density lipoprotein cholesterol (21). Nevertheless, the substitution of whole grains with bean consumption in the dietary metric needs to be further validated. Furthermore, although age standardization could provide a more accurate comparison of ideal cardiovascular health among countries, we were unable to obtain age-standardized prevalence for U.S. adults and middle-aged Korean men because the age-specific data were not reported in these studies (22,25). Finally, follow-up for cardiovascular disease events and mortality is warranted in this nationally representative sample to illustrate the relation of ideal cardiovascular health metrics and important clinical outcomes in the general Chinese population.
Our study indicates that the percentage of ideal cardiovascular health in Chinese adults is extremely low. These data suggest that, without effective intervention, cardiovascular disease will become epidemic in the near future in China. Therefore, both population-wide and high-risk strategies should be implemented with great effort to promote cardiovascular health in China.
COMPETENCY IN SYSTEMS-BASED PRACTICE: Relatively few Chinese adults have ideal cardiovascular health, defined by both health factors and behaviors. Absent effective intervention, poor cardiovascular health threatens to bring about an epidemic of cardiovascular disease in China.
TRANSLATIONAL OUTLOOK: The development and implementation of efficient strategies to mitigate cardiovascular risk among the large population of China could yield enormous health benefits and greatly reduce the cost of care in the near future.
The authors thank the provincial and regional CDC staff for the collection of data, and study participants for their participation and contribution.
For a full list of investigators as well as supplemental tables and a figure, please see the online version of this article.
This work was supported by grants 2013BAI09B13 from the China National Clinical Research Center for Metabolic Diseases, 2015CB553600 from 973 Program, 2012AA02A509 from the National High Technology Research and Development Program of China (863 Program) and 81321001, 81390350, 81222008, and 81130016 from the National Natural Science Foundation of China. Dr. Y. Xu was supported by the Fogarty International Center of the National Institutes of Health under award number D43TW009107. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Bi, Jiang, He, and Y. Xu contributed equally to this work, and Drs. W. Wang, L. Wang, and G. Ning jointly directed this work.
- Abbreviations and Acronyms
- American Heart Association
- body mass index
- Center for Disease Control and Prevention
- Received May 21, 2014.
- Revision received December 12, 2014.
- Accepted December 17, 2014.
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