RM Pulsford et al 2015 Sitting and Mortality Risk

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Title:

Associations of sitting behaviours with all-cause mortality over a 16-year follow up:

the Whitehall II study Authors (in order) and affiliations Richard M Pulsford PhD.*1, Emmanuel Stamatakis PhD.2,3,4
, Annie R Britton PhD.5, Eric J Brunner PhD.5, Melvyn Hillsdon PhD.1 Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, Exeter, Devon, United Kingdom Charles Perkins Centre, University of Sydney, Australia Exercise and Sport Sciences, Faculty of Health Sciences, University of Sydney, Australia Physical Activity Research Group (UCL-PARG), Department of Epidemiology and Public Health, University College London, London, United Kingdom Department of Epidemiology and Public Health, University College London, London, United Kingdom Correspondence:

Richard Pulsford, Sport and Health Sciences, College of Life and Environmental Sciences, St Lukes Campus, University of Exeter, EX12LU, tel:

+4
4
1392 722861, fax:

+4
4
1392 724
726, email:

HYPERLINK "mailto:

r.pulsford@exeter.ac.uk" r.pulsford@exeter.ac.uk Word count (text only) ࡱ 3000 Abstract word count - 24
5 Pages - 24
(including references and tables), Tables - MeSH:

Mortality, Sedentary lifestyle, Sedentary lifestyle/epidemiology, Television Conflict of interest statement Richard Pulsford:

PhD studentship sponsored by the University of Exeter Science Strategy No conflict of interests to declare Emmanuel Stamatakis:

No conflict of interests to declare Annie Britton:

Funded by the European Research Council No conflict of interests to declare Eric Brunner:

Funded by HEFCE and BHF No conflicts of interest to declare Melvyn Hillsdon:

Funded by HEFCE No conflict of interests to declare No financial disclosures were reported by the authors of this paper Key messages Five different indicators of sitting time were not associated with mortality risk over 16 years of follow-up This may be due in part to a protective effect of higher than average daily activity in this cohort Previously reported relationships between sitting time and health outcomes may be due in part to low total daily energy expenditure Policy makers should be cautious about recommending reductions in sitting time as a stand-alone public health intervention Future studies should examine the links between sitting and mortality risk using objective methods that quantify postural allocation Background:

Sitting behaviours have been linked with increased risk of all-cause mortality independent of moderate to vigorous physical activity (MVPA) Previous studies have tended to examine single indicators of sitting or all sitting behaviours combined This study aims to enhance the evidence base by examining the type-specific prospective associations of five different sitting behaviours as well as total sitting with the risk of all-cause mortality Methods:

Participants (3720 men and 14
12 women) from the Whitehall II cohort study who were free from cardiovascular disease provided information on weekly sitting time (sitting; at work, during leisure time, while watching TV, 4
during leisure time excluding TV, and at work and during leisure time combined) and covariates in 1997-99 Cox proportional hazards models were used to investigate prospective associations between sitting time (hrs/wk) and mortality risk Follow up was from date of measurement until (the earliest of) death, date of censor, or July 31st 2014
Results:

Over 81373 person-years of follow up (mean follow-up time 15.7 ࡱ 2.2yrs) a total of 4
50 deaths were recorded No associations were observed between any of the five sitting indicators and mortality risk either in unadjusted models or models adjusted for covariates including MVPA Conclusions:

Sitting time was not associated with all-cause mortality risk The results of this study suggest that policy makers and clinicians should be cautious about placing emphasis on sitting behaviour as a risk factor for mortality that is distinct from the effect of physical activity The health benefits of moderate to vigorous intensity physical activity (MVPA) are compelling ADDIN EN.CITE Lollgen2009582(1)58258217Lollgen, H.Bockenhoff, A.Knapp, G.Department of Medicine, Ruhr-Universtity, Remscheid, Germany loellgen@dgsp.deInt J Sports MedInt J Sports Med213-243032009/02/10AdultAgedAged, 80 and overCohort StudiesFemaleHumansLeisure ActivitiesMaleMiddle Aged*MortalityMotor Activity/*physiologyMultivariate AnalysisPhysical Fitness/*physiologyQuestionnairesRiskRisk Reduction BehaviorSex FactorsYoung Adult2009Mar1439-3964 (Electronic)0172-4622 (Linking)19199202http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1919920210.1055/s0028-1128150eng( HYPERLINK \l "_ENREF_1" \o "Lollgen, 2009 #582" 1) with inactivity estimated to cause 9% of premature mortality worldwide ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_2" \o "Lee, 2012 #928" 2) HYPERLINK \l "_ENREF_1" \o "Lollgen, 2009 #582" Despite this, modern lifestyles are characterised by both low levels of MVPA and high levels of sedentary behaviour ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_3" \o "Bauman, 2011 #606" 3) i.e sitting activities, which involve energy expenditure at resting levels (1-1.5 metabolic equivalents [METs]), ADDIN EN.CITE Pate200859(4)595917Pate, R R.O'Neill, J R.Lobelo, F.Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA rpate@maibox.sc.eduExerc Sport Sci RevExerc Sport Sci Rev17383642008/09/26AdultFemale*Health BehaviorHealth StatusHumansLeisure Activities*Life StyleMale*Motor Activity*Terminology as Topic2008Oct1538-3008 (Electronic)0091-6331 (Linking)18815485http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1881548510.1097/JE S.0b013e3181877d1a00003677-200810000-00002 [pii]eng( HYPERLINK \l "_ENREF_4
" \o "Pate, 2008 #59" 4
) HYPERLINK \l "_ENREF_2" \o "Owen, 2000 #67" Separate sitting behaviours, as well as total daily sitting time, have been linked with increased risk of all-cause ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_5" \o "Pavey, 2012 #601" 5-13) and cause specific ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_6" \o "Katzmarzyk, 2009 #8" 6, HYPERLINK \l "_ENREF_10" \o "Chau, 2013 #610" 10, HYPERLINK \l "_ENREF_14
" \o "Matthews, 2012 #580" 14
-16) mortality, cardiovascular disease (CVD) ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_17" \o "Stamatakis, 2011 #121" 17, HYPERLINK \l "_ENREF_18" \o "Wijndaele, 2011 #178" 18) and metabolic conditions ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_19" \o "Ford, 2010 #181" 19-22) independent of MVPA, indicating that sedentary behaviour is not simply the absence of physical activity but a distinct class of behaviour with its own health risks Previous studies have tended to focus either on selected single indicators of self-reported sitting, such as TV viewing ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_12" \o "Basterra-Gortari, 2014
#916" 12, HYPERLINK \l "_ENREF_14
" \o "Matthews, 2012 #580" 14
, HYPERLINK \l "_ENREF_16" \o "Warren, 2010 #20" 16, HYPERLINK \l "_ENREF_23" \o "Dunstan, 2010 #2" 23, HYPERLINK \l "_ENREF_24
" \o "Wijndaele, 2011 #179" 24
), screen time ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_17" \o "Stamatakis, 2011 #121" 17) or travelling in a car, ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_9" \o "van der Ploeg, 2012 #578" 9, HYPERLINK \l "_ENREF_12" \o "BasterraGortari, 2014
#916" 12, HYPERLINK \l "_ENREF_16" \o "Warren, 2010 #20" 16) or have only examined total sitting combined, ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_7" \o "Manns, 2012 #577" 7, HYPERLINK \l "_ENREF_9" \o "van der Ploeg, 2012 #578" 9, HYPERLINK \l "_ENREF_13" \o "Inoue, 2008 #7" 13, HYPERLINK \l "_ENREF_15" \o "Patel, 2010 #3" 15, HYPERLINK \l "_ENREF_25" \o "Petersen, 2014
#921" 25) and have observed differential associations with mortality ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_11" \o "Kim, 2013 #915" 11, HYPERLINK \l "_ENREF_12" \o "Basterra-Gortari, 2014
#916" 12, HYPERLINK \l "_ENREF_14
" \o "Matthews, 2012 #580" 14
, HYPERLINK \l "_ENREF_16" \o "Warren, 2010 #20" 16) Therefore this study aims to enhance the evidence base by examining the type-specific associations of five different sitting behaviours as well as total sitting with the risk of allcause mortality in a large cohort of UK adults with 16 years of follow up and a wide range of covariates Methods The Whitehall II study is a longitudinal study of London-based employees of the British Civil Service At the study ࡱ s inception in 1985, all civil servants (aged 35-55) from clerical and office support, middle-ranking executive, and senior administrative grades were invited to participate and 73% consented ADDIN EN.CITE Sabia2011573(26)57357317Sabia, S.Dugravot, A.Kivimaki, M.Brunner, E.Shipley, M J.Singh-Manoux, A.Centre for Research in Epidemiology & Population Health, INSERM, Villejuif, France Severine.Sabia@inserm.frAm J Public HealthAm J Public Health69870410242011/09/24AdultAgedCause of DeathCohort StudiesExercise/*physiologyFemaleFollow-Up StudiesHumansLondon/epidemiologyLongitudinal StudiesMaleMiddle AgedMortality/*trendsProspective StudiesQuestionnaires2011Apr15410048 (Electronic)0090-0036 (Linking)21940933http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=21940933AJPH.2011 300257 [pii]10.2105/AJPH.2011.300257eng( HYPERLINK \l "_ENREF_26" \o "Sabia, 2011 #573" 26) (original sample 10308) Baseline examination comprised a self-administered questionnaire and a clinical examination with subsequent measurement phases alternating between a postal questionnaire alone and a postal questionnaire accompanied by a clinical examination Approval for the study was given by the University College London research ethics committee and written consent was obtained from all participants As sitting behaviour measures were included for the first time at Phase (1997-99), this represents the baseline for the present analysis The Phase questionnaire included items on occupational and leisure-time sitting behaviours Participants reported on average how many hours per week they spent:

sitting at work, driving or commuting? and sitting at home e.g., watching TV, sewing, working at a desk? by selecting from eight response categories (none, 1hr, 2-5, 6-10, 11-20, 2130, 31-4
0, e"4
0 hrs) For sitting at home participants were given an open text response to specify two sitting behaviours and then selected a time category for each Using the midpoint of these time categories ( more than 4
0 hrs was represented as exactly 4
0 hrs) five different sitting indicators were computed:

1) work sitting (including commuting); 2) TV viewing time; 3) Non-TV leisure time sitting; 4
) total leisure time sitting (the sum of and above); and 5) total sitting time (sum of 1-3 above) While there is no objective criterion measure of context specific sitting, the questionnaire items used to construct the sitting exposures have demonstrated concurrent validity with past-week recalls (Pearson ࡱ s r= 0.4
4
), activity diaries (Pearson ࡱ s r= 0.4
1) ADDIN EN.CITE Wolf1994298(27)29829817Wolf, A M.Hunter, D J.Colditz, G A.Manson, J E.Stampfer, M J.Corsano, K A.Rosner, B.Kriska, A.Willett, W C.Channing Laboratory, Department of Medicine, Harvard Medical School, Boston, MA 02115.Int J EpidemiolInt J Epidemiol991- 92351994/10/01Adult*Epidemiologic Methods*ExerciseFemaleHumans*QuestionnairesRandom AllocationReproducibility of Results19940300-5771 (Print)0300-5771 (Linking)7860180http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7860180eng( HYPER LINK \l "_ENREF_27" \o "Wolf, 1994
#298" 27) and have also been used in a number of previous studies where associations between sitting time and health outcomes have been observed ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_12" \o "Basterra-Gortari, 2014
#916" 12, HYPERLINK \l "_ENREF_20" \o "Hu, 2001 #101" 20, HYPERLINK \l "_ENREF_21" \o "Hu, 2003 #4
4
" 21, HYPERLINK \l "_ENREF_28" \o "Pulsford, 2013 #574
" 28) Mortality was established through the national mortality register kept by the National Health Service (NHS) Central Registry Sociodemographic covariates were age, gender, ethnicity and employment grade at phase Employment grade (3 levels:

clerical and support, professional and executive, senior administrative grades) in the Whitehall II Study is a comprehensive marker of socioeconomic circumstance relating to social status, salary and level of responsibility ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_29" \o "Marmot, 1991 #270" 29) For retired participants, their last reported employment grade was considered Health related covariates included self-rated health (reported as; excellent, very good, good, fair, or poor), smoking status (current, previous, or never a smoker), alcohol consumption, diet quality, body mass index (BMI) and physical functioning Participants reported the number of ࡱ measures ࡱ of spirits, ࡱ glasses ࡱ of wine, and ࡱ pints ࡱ of beer consumed in the previous seven days, and this was then converted to units (1 unit=8g) of alcohol Diet quality was represented by frequency of fruit and vegetable consumption and was assessed using an eight point scale from:

1) ࡱ seldom or never ࡱ, to 8) ࡱ e"2 portions per day Height (m) and weight (kg) were recorded during clinical examination and BMI calculated using a standard formula To assess perceptions of physical functioning the SF-36 questionnaire was used and scored with the Medical Outcomes Study scoring system ADDIN EN.CITE Ware1993297(30)2972976Ware, J E., Jr.Snow, K.K.,Kosinski, M1993BostonNew England Medical Center( HYPERLINK \l "_ENREF_30" \o "Ware, 1993 #297" 30) The SF-36 assesses the extent to which participants ࡱ health limits their ability to perform physical activities, ranging in intensity from vigorous (sporting and volitional exercise activities) to light (day-to-day tasks) using the responses ࡱ a lot ࡱ, ࡱ a little ࡱ, and ࡱ not at all ࡱ Responses were scored, summed and transformed to scale from (limited a lot in performing all types of physical activities) to 100 (able to perform all types of physical activity without limitation) This scale has been demonstrated to have high internal consistency ADDIN EN.CITE McHorney1993296(31)29629617McHorney, C A.Ware, J E., Jr.Raczek, A E.Health Institute, New England Medical Center, Boston, MA 02111.Med CareMed Care247-633131993/03/01Activities of Daily LivingAdultAgedData Collection/methodsFactor Analysis, StatisticalFemale*Health SurveysHumansMale*Mental HealthMiddle AgedOutcome Assessment (Health Care)*Psychiatric Status Rating ScalesPsychometricsQuality of LifeQuestionnairesReproducibility of ResultsSampling StudiesStatistics as Topic19930025-7079 (Print)00257079 (Linking)8450681http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8450681eng( HYPER LINK \l "_ENREF_31" \o "McHorney, 1993 #296" 31) Physical activity covariates included daily walking time (minutes/day), and weekly MVPA (hrs/wk) Physical activity was assessed using a modified version of the Minnesota leisure-time physical activity questionnaire which assesses both occupational and leisure-time activities, and which has been validated previously ADDIN EN.CITE Taylor1978585(32)58558517Taylor, H L.Jacobs, D R., Jr.Schucker, B.Knudsen, J.Leon, A S.Debacker, G.J Chronic DisJ Chronic Dis741-5531121978/01/01*Health SurveysHumans*Leisure Activities*Physical ExertionPhysical Fitness*QuestionnairesSports19780021-9681 (Print)0021-9681 (Linking)748370http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=748370eng( HYPERLI NK \l "_ENREF_32" \o "Taylor, 1978 #585" 32) Twenty items (including open-text responses) assessed time spent engaged in walking, sports and games, gardening, housework and do-it-yourself building/maintenance projects, in hours over the previous four week period Each activity was subsequently assigned an energy expenditure value in METs (where MET is equal to energy expenditure at rest) using a compendium of activity energy expenditures ADDIN EN.CITE Ainsworth2011597(33)59759717Ainsworth, B E.Haskell, W L.Herrmann, S D.Meckes, N.Bassett, D R., Jr.Tudor-Locke, C.Greer, J L.Vezina, J.WhittGlover, M C.Leon, A S.Exercise and Wellness Program, School of Nutrition and Health Promotion, Arizona State University, Phoenix, AZ 85004, USA Barbara.Ainsworth@asu.eduMed Sci Sports ExercMed Sci Sports Exerc1575-814382011/06/18Activities of Daily Living/classificationAdult*Clinical CodingData Collection/classificationEnergy MetabolismFemaleHumansMaleMiddle Aged*Motor ActivityYoung Adult2011Aug1530-0315 (Electronic)0195-9131 (Linking)21681120http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=2168112010.1249/M SS.0b013e31821ece12eng( HYPERLINK \l "_ENREF_33" \o "Ainsworth, 2011 #597" 33) Moderate intensity activities were those eliciting an energy expenditure of 3-5.9 METs and vigorous intensity activities e"6 METs The energy expenditure of walking is dependent on walking pace and could not be determined from the Phase questionnaire Therefore while some walking may have met the required energy expenditure, for the purposes of the present analyses walking did not contribute to MVPA, but daily walking time was included as a separate covariate Due to low numbers in the original eight response categories for sitting time, these were collapsed into four categories of as near equal numbers as the data would allow Exact quartiles were not possible due to the non-normal distribution of the data To examine mortality risk from all causes across categories of the five sitting indicators, Cox proportional hazards models were fitted ADDIN EN.CITE Cox1972588(34)58858817Cox, D.R.J R Stat Soc BJ R Stat Soc B187-2203421972( HYPERLINK \l "_ENREF_34
" \o "Cox, 1972 #588" 34
) Survival time was measured from the date of measurement at Phase to death or censor (the earliest of the date of withdrawal from the study or 31st July 2014
) Hazard ratios and 95% confidence intervals were estimated for each sitting category with the shortest duration as the reference category Proportional hazards assumptions were checked using Schoenfeld residuals and Nelson-Aelen cumulative hazards plots for analyses of associations between five sitting indicators and mortality Schoenfeld residuals did not suggest evidence for any deviations from proportionality in any of the Cox models and this was consistent with observations from the Nelson-Aelen plots Cox models were adjusted for age, gender, employment grade and ethnicity (model 1) and subsequently for smoking status, alcohol consumption, fruit and vegetable consumption, BMI, walking time and MVPA (model 2) Wald chi-square tests were used to test for linear relationships in individual parameters and likelihood-ratio chi-square tests for non-linear relationships Analyses were limited to those free from CVD at Phase To examine whether the associations between sitting and mortality differed between a priori defined subgroups, interaction terms were fitted for each sitting indicator with gender, age (in ten year age groups), BMI (in categories according to WHO classifications of underweight, normal weight, overweight and obese), ADDIN EN.CITE World Health Organisation2000272(35)27227227World Health Organisation,WHO Technical Report Series8942000GenevaWorld Health Organisation( HYPERLINK \l "_ENREF_35" \o "World Health Organisation, 2000 #272" 35) and physical activity (according to adherence to the Department of Health guidelines for MVPA) ADDIN EN.CITE Department of Health2010205(36)20520527Department of Health, 1-872010May 2010Department of Health( HYPERLINK \l "_ENREF_36" \o "Department of Health, 2010 #205" 36) Likelihood-ratio tests were used to determine whether each interaction term improved the model fit To minimise potential confounding effects of occult disease at baseline, analyses were repeated after excluding those who died prior to Phase (2001:

15278 person years of follow up excluded), and then Phase (2003-04
:

27808 person years of follow up excluded) In order to examine the possibility of bias due to differential loss from the original 1985 cohort, baseline age, gender, employment grade, alcohol consumption and the likelihood of being obese and of being a current smoker were compared between those who did and those who did not respond to questionnaire items relating to occupational and leisure time sitting behaviour Analyses were conducted in 2014
using STATA version 13.2 Results The final sample consisted of 5132 participants who had complete data for sitting time and covariates Sample characteristics are described in table Compared to those in the sample, those lost to follow-up between the study ࡱ s inception in 1985 and Phase were slightly older at date of screening (0.4
2 yrs; 95%CI 0.17, 0.67:

p=0.001), consumed slightly less alcohol (1.19 units/wk; 95%CI 0.64
, 1.73:

p��8hrs per day) is comparable ADDIN EN.CITE van der Ploeg2012578(9)57857817van der Ploeg, H P.Chey, T.Korda, R J.Banks, E.Bauman, A.Sydney School of Public Health, University of Sydney, Sydney, NSW 2006, Australia hidde.vanderploeg@sydney.edu.auArch Intern MedArch Intern Med494-50017262012/03/28AgedCause of DeathFemaleHumansMaleMiddle Aged*MortalityNew South Wales/epidemiologyProspective StudiesRisk Factors*Sedentary LifestyleTime Factors2012Mar 261538-3679 (Electronic)0003-9926 (Linking)22450936http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=22450936172/6/494 [pii]10.1001/archinternmed.2011.2174eng( HYPERLINK \l "_ENREF_9" \o "van der Ploeg, 2012 #578" 9) or higher ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_5" \o "Pavey, 2012 #601" 5, HYPERLINK \l "_ENREF_13" \o "Inoue, 2008 #7" 13, HYPERLINK \l "_ENREF_14
" \o "Matthews, 2012 #580" 14
) than in previous studies where associations between sitting and mortality have been observed Another possible explanation is that the absence of any associations between sitting and mortality is attributable to a protective effect of the high volumes of daily walking reported in the Whitehall cohort The public transport infrastructure in London is such that London-based employees are far likelier to stand (on buses and trains) or walk during their commute to work than those residing in other areas of the country ADDIN EN.CITE Department for Transport2011339(39)33933927 Department for Transport, 2011Department for Transport( HYPERLINK \l "_ENREF_39" \o "Department for Transport, 2011 #339" 39) This is reflected in the mean reported daily walking time for the current sample (4
2.68 ࡱ 22.60 mins) which is over double the reported UK average (measured in the latter using an activity diary rather than a self-report questionnaire) ADDIN EN.CITE Office for National Statistics2006292(40)29229227Office for National Statistics,Lader, DShort, SGershuny, JCrown652006Office for National Statistics( HYPERLINK \l "_ENREF_4
0" \o "Office for National Statistics, 2006 #292" 4
0) A number of prospective cohort studies, have demonstrated that both habitual active transport, ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_4
1" \o "Matthews, 2007 #592" 4
1) and daily walking are ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_4
2" \o "Hakim, 1998 #593" 4
2-4
4
) inversely associated with risk for mortality Reported MVPA in the present sample is also very high, which is consistent with previous evidence that London based Civil Servants on average are more active than the age-matched wider ş?Ohࡱࡱ+'ࡱ?4
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