Foundational Factors for Cardiovascular Disease: Behavior Change as a First-Line Preventive StrategyDisclosure: None of the authors have any conflicts to disclose
Pub Date: Wednesday, Nov. 27, 2013
Author: Barry A. Franklin, PhD; Jenna Brinks, MS; Harold Friedman, MD
Affiliation: Barry A. Franklin, Ph.D., Director, Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, Professor of Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, Michigan.
Jenna Brinks, M.S., Manager, Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, Michigan.
Harold Friedman, M.D., Medical Director, Preventive Cardiology and Cardiac Rehabilitation, William Beaumont Hospital, Royal Oak, Michigan.
CitationCitation: Spring B, Ockene JK, Gidding SS, Mozaffarian D, Moore S, Rosal MC, Brown MD, Vafiadis D, Cohen DL, Burke LE, Lloyd-Jones D; on behalf of the American Heart Association Behavior Change Committee of the Council on Epidemiology and Prevention, Council on Lifestyle and Cardiometabolic Health, Council for High Blood Pressure Research, and Council on Cardiovascular and Stroke Nursing. Better population health through behavior change in adults: a call to action. Circulation. 2013: published online before print October 7, 2013, 10.1161/01.cir.0000435173.25936.e1.
The just-published American Heart Association (AHA) Science Advisory by Spring et al.1 highlights the rationale for and important role of behavior change in achieving AHA’s 2020 goals, “to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases (CVD) and stroke by 20%.” Key strategies involve progressing from poor to intermediate and from intermediate to ideal healthy lifestyle behaviors and cardiovascular biomarkers at the individual, population, and health care system level. This commentary builds on the themes detailed herein, with specific reference to behavior-related antecedents of CVD, unhealthy lifestyle habits and population health, current (suboptimal) provider counseling practices, assessing patients’ readiness to change, and research-based interventions to improve patients’ behaviors (e.g., the 5 A’s, motivational interviewing, overcoming inertia with downscaled goals).
ACUTE CARDIOVASCULAR EVENTS: TRIGGERING MECHANISMS
Numerous studies have now shown that acute myocardial infarctions (AMI) often evolve from mild-to-moderate coronary artery stenosis.2,3 Rupture of a vulnerable atherosclerotic plaque with thrombus formation is believed to represent the triggering mechanism.3 Fortunately, the plaque components responsible for vulnerability are amenable to intervention via intensive coronary risk factor modification. This may occur by defusing triggers of arterial inflammation and improving endothelial function, or both, in the absence of overt anatomic plaque regression.4
Accordingly, the soft lipid-rich component appears to be more tractable, with greater potential to regress under intensive risk factor modification than the more voluminous calcium-collagenous component of atherosclerotic plaque. Because the anti-inflammatory and/or endothelial function benefits of intensive risk factor modification may occur soon after the intervention, these mechanisms may account for the early reduction in clinical cardiac events observed in contemporary cholesterol lowering trials.5
Regardless of the precise mechanisms, it appears that intensive risk factor modification may stabilize plaques, leaving them less likely to rupture. Collectively, these findings suggest a new paradigm for preventing and managing coronary heart disease (CHD).6
Unhealthy Habits, Population Health, and Mortality: The Cardiovascular Disease Pyramid
Population health is influenced by modulators in five domains – genetic predisposition, social circumstances, environmental exposures, behavioral patterns, and access to quality health care.7 When it comes to reducing early deaths, medical care has a relatively minor role, potentially preventing 1 in 10 premature deaths. Rather, the single greatest opportunity to improve health and reduce premature death lies in favorably modifying unhealthy behaviors, which account for approximately 40% of all deaths in the United States (U.S.). The top two behavioral causes of premature death, obesity/physical inactivity and cigarette smoking, are a result of unhealthy dietary and lifestyle choices (Figure 1).8 These adverse health behaviors are most prevalent among the less fortunate, that is, those with low socioeconomic status, less education, and limited access to health care. Because patients with chronic disease typically spend approximately 5000 hours each year independent of medical providers, it is critical to connect them with health-promoting resources in their immediate environment.9 Support can take the form of helping patients find and utilize school/university-based healthy lifestyle options, worksite wellness initiatives,10 community resources (e.g., park district or community center programs, healthy fast food restaurant options, walking paths, biking trails, recreation centers, farmers’ markets)11 and prevention-focused health care systems.12
Preventing or favorably modifying traditional and nontraditional (emerging) risk factors through a combination of lifestyle interventions and pharmacological therapy, complemented by public policy to enhance health outcomes, is now widely recognized as the cornerstone of initiatives aimed at the primordial, primary, and secondary prevention of CHD.13,14 Although patients, and the medical community, often focus on medications as a first-line strategy to stabilize or favorably modify traditional risk factors (e.g., obesity, hypertension, dyslipidemia, diabetes), these drugs do not address the root causes—that is, the most proximal risk factors for CHD, including poor dietary habits, physical inactivity, and cigarette smoking (Figure 2).13,14 Notably, these unhealthy lifestyle practices strongly influence not only blood pressure, lipid/lipoprotein levels, triglycerides, and glucose-insulin homeostasis, but also nontraditional risk factors such as endothelial function, oxidative stress, inflammation (e.g., C-reactive protein), thrombosis/coagulation, and other intermediary pathways (e.g., psychosocial stressors).13 Accordingly, as the importance of favorably modifying unhealthy behaviors becomes increasingly apparent,15-17 it’s time to change our emphasis from sick care to health care12 with a focus on prevention and the foundational causes of CVD.
Poor Dietary Habits. The AHA’s Diet and Lifestyle Recommendations for CVD Risk Reduction suggest balancing energy intake and energy expenditure to achieve or maintain a healthy weight and selecting a diet that is rich in fish, vegetables and fruits, whole-grain, high-fiber food, and foods with reduced amounts of saturated fat, cholesterol, sugar, and salt.18 These recommendations were echoed in a recent report intended to provide a useful framework for health practitioners and policy makers to understand contemporary issues related to the effects of dietary habits on CVD.19
Another systematic review found strong evidence of a causal relationship for cardioprotective dietary practices, including vegetables, nuts, and “Mediterranean” eating patterns, and adverse effects of trans-fatty acids and foods with a high glycemic index.20 In a recent multicenter trial in Spain, participants who were at high cardiovascular risk and randomly assigned to a Mediterranean diet supplemented with extra-virgin olive oil or nuts demonstrated a reduced incidence (approximately 31%) of major cardiovascular events as compared with their control diet counterparts (advice to reduce dietary fat).21 Other recent studies have shown that decreasing red meat consumption or the adoption of a vegetarian diet are associated with a lower mortality risk.22,23 Contemporary analyses have also shown that even modest reductions in dietary salt can substantially decrease future cardiovascular events and associated medical costs.24 Although epidemiological studies, controlled interventional trials, and systematic reviews have demonstrated the cardioprotective effects of omega-3 fatty acid consumption, either from marine sources or via supplements,25-28 other recent analyses have reported no additional cardioprotective benefit from omega-3 fatty acid supplementation.29,30 Collectively, these findings and other recent reports31 suggest that favorably modifying unhealthy dietary practices can result in a substantial reduction in initial or recurrent cardiovascular events.
Physical Inactivity/Low Fitness. A widely cited systematic review and meta-analysis of 33 physical activity studies (n = 883,372 participants) reported risk reductions of 30% to 50% for cardiovascular mortality and of 20% to 50% for all-cause mortality.32 Numerous studies also suggest that increasing the level of cardiorespiratory fitness, expressed as metabolic equivalents (1 MET = 3.5 mL O2/kg/min), significantly reduces the risk of CVD and dramatically improves prognosis.33 In fact, the reductions in risk parallel those observed with increasing physical activity, but are essentially twice as great for aerobic capacity (cardiorespiratory fitness).34 Among men and women with and without CHD, each 1 MET increase in exercise capacity is associated with an approximately 15% reduction in cardiovascular mortality, which compares favorably with the survival benefit conferred by low-dose aspirin, statins, β-blockers, and angiotensin-converting enzyme inhibitors after AMI.35,36 Indeed, a recent meta-analysis comparing the effectiveness of exercise treatment versus drug interventions on mortality outcomes in the secondary prevention of CHD reported similar benefits.37
Numerous studies and pooled analyses, in persons with and without CHD, have shown that walking speed and distance are powerful predictors of mortality in middle-aged and older adults.38-40 Data from the Concord Health and Ageing in Men Project, a cohort study of 1705 healthy men aged 70 and over living in several inner city suburbs in Sydney, Australia, was used to clarify the walking pace that may be associated with a heightened mortality. At baseline, walking speed was carefully measured at the usual pace, documenting the fastest time from two trials. A natural walking speed of 2 miles per hour (mph) was most predictive of early mortality, while older men who walked at speeds greater than this were less likely to die during the 6-year follow up. In fact, no men who initially walked at speeds ≥ 3 mph were among the 266 deaths reported.41 These findings support the hypothesis that faster walking speeds are associated with increased survival, as has been previously reported in coronary patients.42 The modest difference in walking speed associated with increased mortality and increased survival supports the notion that the primary beneficiaries of an exercise program are those at the bottom of the fitness/activity continuum.
To answer the question, “Should we be advising our patients to walk or run?,” researchers used a meta-analysis to evaluate the effect of physical activity at progressive intensities on all-cause mortality.43 The results showed a dose-response curve from sedentary subjects to those with low-to-moderate exercise intensities, with an only minor additional risk reduction with vigorous physical activity. Collectively, these data suggest that habitually sedentary patients should be counseled to become more physically active and/or fit by starting an exercise program, increasing lifestyle activity, or both, so as to move them out of the least fit, least active, “high-risk” cohort (bottom 20%).44 Advocating regular brisk walking, before gradually advising the additional benefits of jogging or running, would be an appropriate approach for most inactive patients.45
Cigarette Smoking. A landmark study of British physicians found that, on average, cigarette smokers die approximately 10 years earlier than nonsmokers. For someone who has smoked since adulthood, cessation at age 50 decreased their risk by one-half. Those who quit by age 30 had the same level of risk as a nonsmoker.46 Among post-MI patients with left ventricular dysfunction, smoking cessation is associated with a 40% lower all-cause mortality rate as compared with persistent smokers over an average follow-up of 42 months.47 Moreover, a recent report showed that weight gain following smoking cessation was not associated with a reduction in the benefits of quitting smoking on CVD outcomes.48
Unquestionably, cigarette smoking remains the most common cause of preventable death and disability in the U.S. Although important strides have been made in tobacco control, the self-reported smoking rate varies considerably among population subsets, from 1% among U.S. physicians to > 30% in some blue collar workers. The smoking prevalence among U.S. adults (≥ 18 years of age) now hovers at 20%, more than 8 million people are sick or disabled as a result of tobacco use, and smoking kills an estimated 450,000 Americans each year.49 Even brief periods of passive smoke exposure can lead to acute vascular injury characterized by mobilization of dysfunctional endothelial progenitor cells with blocked nitric oxide production.50 Secondhand smoke was responsible for an estimated 603,000 deaths worldwide in 2004, and approximately 63% of those deaths were due to ischemic heart disease.51 One provocative report found that never-smokers increased their risk of CHD by 30% if they lived with a smoker.52 Reductions in acute cardiovascular event rates have also been reported in several large U.S. cities and countries that have banned smoking in public places.53,54 By assuming that the tobacco war has been won, we risk consigning millions of Americans to premature death.
Risk Factors as Harbingers of Cardiovascular Disease: Debunking the 50% Misconception
A widely-cited review concluded that 75% to 90% of CHD incidence is explained by traditional risk factors.55 Moreover, Framingham Heart Study participants with optimal levels of cardiovascular risk factors and lifestyle behaviors at 50 years of age were at very low risk of ever developing CVD, 5% and 8% for men and women, respectively.56 Collectively, these data and other recent reports57,58 discount the longstanding claim that only 50% of the incidence of CHD in the population is attributable to traditional risk factors, and suggest that a more rigorous focus on these and the unhealthy behaviors that promote them has great potential to reduce the burden of atherosclerotic CHD (Figure 2).55,59 Although physicians have been increasingly urged to amplify efforts to favorably modify traditional risk factors in their patients,59 a large, international contemporary database reported that conventional cardiovascular risk factors are consistent, common, and remain largely undertreated and under-controlled in many regions of the world, including the U.S.60 Achieving increased CVD risk reduction and decreased mortality rates will, no doubt, involve embracing the research-based behavior change interventions outlined by Spring et al,1 as well as heightened ‘employee-responsibility’ via worksite wellness initiatives (e.g., participation in health screenings, ‘know your numbers’, desirable health metrics),10 and efforts to improve cardiovascular health at the community level.11
Advising Patients Regarding Behavior Change: Are We Doing Enough?
The Behavioral Risk Factor Surveillance System reported in 2000 that only 3% of 153,805 adults surveyed in the U.S. adhere to 4 of 4 healthy lifestyle characteristics, including not smoking cigarettes, maintaining a normal body mass index (18.5 to 24.9 kg/m2), consuming ≥ 5 servings of fruits and vegetables per day, and regular physical activity. The adherence rate was lower in blacks than in whites at 1.4% and 3.3%, respectively.61 These healthy lifestyle percentages were even lower (0.5% of blacks and 2.1% of whites) in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort, a national cohort of blacks and whites recruited between 2003 and 2007.62 According to a more recent report, a substantial percentage of patients receiving elective percutaneous coronary intervention for stable angina do not achieve lifestyle and risk factor goals and therefore remain at increased risk for recurrent cardiac events.63 Among a large sample of 7519 patients with a previous self-reported cardiac or stroke event from countries with varying income levels, 18.5% continued to smoke, only 35.1% undertook high levels of occupational or leisure-time physical activity (> 3000 MET-min/wk), and 39.0% were eating a healthy diet. Thus, the prevalence of healthy lifestyle behaviors was low, but more so in poorer countries.64
Although physicians and allied health professionals have regular opportunities to counsel patients regarding their lifestyle habits and risk factors, many have little or no training in the specific skills sets required for health promotion, especially application of behavior change interventions.65 Moreover, most physician practices are already overstretched, reimbursement for patient counseling and education remains suboptimal, and use of the electronic medical record may further decrease face-to-face dialogue with patients. Despite the well-established benefits of regular physical activity, weight reduction, and smoking cessation, less than half of all patients report being counseled about one or more of these risk-reduction strategies during their most recent physician office visit.66-70 Collectively, these and other relevant reports71 suggest that physicians and/or their support staff often miss opportunities to counsel patients regarding the need for substantive lifestyle modification. Yet, numerous studies have now shown that brief (e.g., 3-5 minutes) physician intervention during an office visit can play a critical role in patient implementation and outcomes.72
Assessing Patients’ Readiness to Change Behaviors
Facilitating lifestyle changes requires patient participation, knowledge, education, attitude, and motivation; however, tailoring messages on lifestyle counseling to patients’ individual readiness to change increases the likelihood of success. The Transtheoretical Stages of Change Model includes 6 stages of any behavioral intervention process: precontemplation (patient is not thinking about making lifestyle changes); contemplation (patient is considering but is not yet ready to change); determination (patient has taken some behavioral steps and intends to take action in the next 30 days); action (patient begins to consistently demonstrate the new behavior for < 6 months); maintenance (patient has been in action for ≥ 6 months); and, relapse (patient returns to former [unhealthy] lifestyle habits).73 Patients should be evaluated for their stage of readiness before being counseled to change a specific behavior. For example, physicians and other healthcare professionals should consider the issues outlined in Table 1 when assessing a patient’s readiness to embark on a weight loss intervention.74
Facilitating Behavior Change
The likelihood that patients will or will not engage in a particular lifestyle behavior is governed by a myriad of socioeconomic, attitudinal, and cultural factors, including their expectations of the benefits, costs, and consequences of that behavior.65 Lack of or a suboptimal social support system, social isolation, or financial difficulties are often cited as common barriers to achieving successful lifestyle behavior changes.75,76 Strategizing with the patient to identify realistic options to overcome these barriers, real or perceived, is integral to changing unhealthy behaviors. Practitioners should anticipate patients declaring that they are too busy to make certain lifestyle changes (e.g., a structured exercise program). Moreover, failure to address underlying psychosocial factors such as depression, anger, denial, chronic life stress, and personality traits – factors commonly clustered in patients with CVD – can be obstacles to a healthy lifestyle and directly promote CHD.75,76
More than 80% of adults currently have an established source of health care services, and this percentage is expected to appreciably increase with implementation of the Affordable Care Act. This shift will enable vulnerable subsets of the population who are more often plagued by unhealthy lifestyle practices to seek medical evaluation and care, empowering providers with heightened opportunities to facilitate improvements in population health over time.1 The 5 A’s approach has been reported to produce significant improvements in a variety of health behaviors, including smoking cessation, dietary choices, and physical activity (Figure 3).77,78 Fortunately, progress has been made in that more providers now perform the first 2 A’s, that is, assess the risk behavior and advise behavior change. On the other hand, it is the less frequently performed A’s (agree, assist, arrange), which require more time to implement and specific counseling skill sets to facilitate, that have the greatest impact on healthful behavior change.79,80 The core of effective counseling is a patient-centered approach, whereby providers work with patients, helping them to create and implement an ‘action plan’ to reach their self-stated goals, resulting from carefully crafted questions posed by the provider.81 Although most people believe that a single behavior change is preferred at any given time, embracing the notion that sequential changes can build on success, multiple simultaneous changes may be easier to adopt because they quickly yield perceptible benefits.82
Motivational Interviewing. Spring et al.1 highlight the important role of motivational interviewing as a form of talk therapy used by the health care provider during patient encounters to help encourage a behavioral transformation.83,84 To accomplish this, the clinician must convey understanding, acceptance, and interest in the patient as an individual. The first step is to identify the patient’s readiness to change their behavior by using empathy to identify suboptimal lifestyle practices. Getting patients to consciously recognize the circumstances or scenarios that contribute to these behaviors is critical. The next step is getting the individual to understand and accept the need for change. This may entail altering longstanding unhealthy behaviors that may be linked to stressful situations, psychosocial variables, work and/or home environments, inadequate education, economic factors, or combinations thereof. Confrontations and arguments must be avoided at this time, and interviewers should strive to encourage the patient to hear themselves express why they want to (or should) change.85 This is most effective using specific questions directed at the patient about why they need to change this behavior. More important, the patient needs to be allowed to speak and the provider should actively listen. The next step is to help the patient overcome inertia and become independent and self-motivating, emphasizing that time is an ally to successful lifestyle modification. Finally, patients should be counseled on handling resistance and dealing with recidivism.
Overcoming Inertia with Downscaled Goals. For many patients, setting initial goals for risk factors or lifestyle habits (e.g., body weight reduction, increasing physical activity) may be unrealistic and discouraging, especially if contemporary guideline recommendations are literally embraced. For example, the patient whose height is 172.9 cm and weighs 137.3 kg might be advised to reduce his body weight to a “normal” range (i.e., 75.6 kg), since this represents a body mass index corresponding to 25 kg/m2. A preferred approach may be to ask this patient for a realistic initial weight goal, and the associated timeline for its attainment. Regardless of response, if it is less than his/her current weight, the provider would agree with and support the patient’s objective. Similarly, rather than counseling the habitually sedentary patient to exercise for ≥ 30 minutes/day on most days of the week, as current guidelines suggest, consider recommending 10-minute exercise bouts, 3 times per week, over the initial month of physical conditioning. By overcoming inertia, many patients subsequently find themselves exceeding these modest goals.
The treatment of CHD has evolved from simple lifestyle modification in the mid-to-late 1960s, largely focused on early ambulation, exercise training, and a prudent diet, to an array of costly and palliative coronary revascularization procedures that fail to address the underlying causes: poor dietary habits, physical inactivity, and cigarette smoking. However, contemporary studies now suggest that behavior change and multifactorial risk factor modification – especially smoking cessation and more intensive measures to control hyperlipidemia with diet, drugs, and exercise – may slow, halt, or even reverse (albeit modestly) the otherwise inexorable progression of atherosclerotic CHD.86,87 Other studies have now shown that combining dietary therapy with drug treatment is more effective than drug treatment alone in improving brachial artery flow-mediated vasodilation,88 in correcting dyslipidemia,89,90 in reducing ambulatory blood pressure,91 and in reducing the risk of acute coronary syndromes.92
Chiuve et al.15,16 demonstrated that a healthy lifestyle plays an important role in the primary prevention of CHD and risk of sudden cardiac death in middle-aged and older men and women, respectively, even among those taking medications for hypertension or hypercholesterolemia. Moreover, systematic reviews now show that the mortality risk reductions associated with lifestyle changes in patients with CHD are similar to those reported for cardioprotective medications after AMI.37,93 Collectively, these findings and other recent data suggest that the effects of lifestyle change and combination drug therapy on cardiovascular risk reduction appear to be independent and additive.94-96
As cardiovascular health care providers, we need to become champions of achieving healthy lifestyle overhauls in our patients to prevent the development and progression of CVD. Our younger patients should be regularly counseled to favorably modify unhealthy lifestyle habits, including poor dietary practices, physical inactivity, and cigarette smoking. For patients aged 40 to 50 years, who already have ≥ 2 major risk factors, the elevated lifetime risks of developing CVD (69% for men and 50% for women) mandate adoption of adjunctive preventive therapies, including cardioprotective medications.56 Accordingly, patients should be directed to comprehensive programs designed to prevent or change unhealthy behaviors and facilitate cardiovascular risk reduction, including individually tailored interventions to circumvent or attenuate barriers to participation and adherence. Achieving these goals will, no doubt, involve embracing the research-based behavior change interventions and health care system improvements outlined by Spring et al.1.
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Figure 2. The evolutionary CVD pyramid. Unhealthy lifestyle practices lead to risk factors, the progression of CVD, and, ultimately, adverse outcomes or clinical endpoints. Prevention can be divided into 3 types: primordial (prevention of risk factors); primary (treatment of risk factors); and secondary (prevention of recurrent cardiovascular events), which can be modulated by environmental (e.g., air pollution) and psychosocial stressors, lifestyle change, and cardioprotective medications, if appropriate. The first-line strategy to prevent initial or recurrent cardiac events is to favorably modify unhealthy lifestyle habits or practices, including poor dietary habits, physical inactivity, and cigarette smoking. CVD signifies cardiovascular disease; MI indicates myocardial infarction; CHF, congestive heart failure; and PAD, peripheral arterial disease. Sources: Mozaffarian et al and Franklin et al.13,14
Figure 3. The 5 A’s to facilitate effective health behavior change counseling during a medical visit. Although more providers now perform the first 2 A’s, that is, assess the risk behavior and advise behavior change, it is the latter, less frequently performed 3 A’s (shaded) that have the greatest impact on healthful behavior change. Effective clinician behavior change strategies include using motivational interviewing along with rewards or incentives, asking patients to self-monitor behaviors, enhancing patients’ self-efficacy (confidence), accessing social support from family and friends, and scheduling regular follow-up communications/meetings to assess progress. Sources: Chase et al and Alexander et al.77,78.
|Table 1. Brief Behavior Assessment of a Patient’s Weight Loss Initiative|
Has patient sought weight loss on his/her own initiative?
|Before initiating treatment, professionals must determine if patient recognizes the need for and benefits of weight loss and wants to lose weight.|
What events have led patient to seek weight loss now?
|Weight loss motivation and goals are evident by responses to this question.|
What is patient’s level of stress or depression?
|Patients who report higher-than-usual stress levels or depression may be unable to focus on weight management.|
To increase the likelihood of weight-loss success, counseling may need to be initiated.
Does patient have an eating disorder?
|Approximately 20% to 30% of obese patients who seek weight reduction (at university clinics) indulge in binge eating.|
Binge eaters are typically distressed by their chaotic eating patterns; the greater the person’s distress or depression, the greater the need for additional forms of counseling (psychologic or nutritional).
Does patient understand the treatment requirements and believe that they can be met?
|Health care professional and patient should select a course of treatment requirements together.|
Treatment activities should include those that are a high priority for the patient and those that the patient believes can be achieved.
How much weight does the patient expect to lose?
|Professionals must assist patients in understanding that slow, modest weight loss can improve health.|
What other benefits does the patient anticipate?
|In addition to weight loss, progress should be assessed by achievement of selected health improvement metrics, including increased physical activity or fitness.|
Source: National Institutes of Health; National Heart, Lung, and Blood Institute, NHLBI Obesity Education Initiative, North American Association for the Study of Obesity, 2000.74