original article Growth reference for Saudi schoolage children and adolescents: LMS parameters and percentiles Mohammad El Mouzan, a Abdullah Al Salloum, a Ahmad Al Omer, a Mansour Alqurashi, a Abdullah Al Herbish b From the a Department of Pediatrics, King Saud University and b Department of Pediatrics, Sulaiman Al Habib Medical Center, Riyadh Saudi Arabia Correspondence: Dr. Mohammad El Mouzan Department of Pediatrics, King Saud University, PO Box 2925, Riyadh 46, Saudi Arabia +966467007, F: +9664679463 drmouzan@gmail.com ORCID: http://orcid.org/0000000699343 Ann Saudi Med 206; 36(4): 26526 DOI: 0.544/02564947.206.265 BACKGROUND: Information on LMS parameters and percentiles reference for Saudi children and adolescents is not available. OBJECTIVE: To report the L, M, and S parameters and percentile reference graphs for growth. DESIGN: Field survey of a populationbased sample of Saudi schoolage children and adolescents (5 years of age). SETTING: A stratified listing of the Saudi population. SUBJECTS AND METHODS: Data from the national study of healthy children were reanalyzed using the LambaMuSigma (LMS) methodology. The LMS parameters of percentiles for weight, height, and body mass index for age were calculated for children and adolescents from 5 to years of age. MAIN OUTCOME MEASURE: The main outcomes were the LMS parameters and percentiles of growth. RESULTS: There were 9 299 and 927 (50.9%) were boys. The data for weight, height, and BMI for age for boys and girls are reported for the 3rd, 5th, 0th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles including LMS parameters for each percentile and age. Figures corresponding to each table are color coded (blue for boys and pink for girls). CONCLUSIONS: This report provides a reference for growth and nutrition of Saudi schoolage children and adolescents. The detailed LMS and percentile tables and graphs provide essential information for clinical assessment of nutritional status and growth in various clinical conditions and for research. LIMITATIONS: This report does not reflect regional variations in growth. Growth charts have long been used worldwide to assess nutritional status. However, regular revisions were performed to account for secular changes in growth and to take advantage of modern statistical techniques. The American growth charts, including the previous 97 National Center for Health Statistics (NCHS) and the current revised National Center for Disease Control reference growth charts (CDC 2000), which reflect the growth of children of the United States, are commonly used. 2,3 However, in an attempt to provide growth charts more applicable to populations other than the United States, the World Health Organization (WHO) created the WHO Growth Reference Charts for Schoolage Children and Adolescents in 2007. 4 Despite the common use of the CDC 2000 and WHO growth reference charts in some countries, others developed local growth reference more suitable to their population. 5 In Saudi Arabia, growth charts from a representative sample of children have been published in the form of charts only. 9 Therefore, the objective of this article is to report detailed percentile values of commonly used growth parameters, including LMS values, in children and adolescents from 5 to years of age. SUBJECTS AND METHODS The methodology has been reported in a previous study. 9 In brief, multistage probability sampling was used to se Ann Saudi Med 206 JULYAUGUST www.annsaudimed.net 265
original article lms parameters for growth Figure. Weightforage percentiles for boys, 5 to years. lect a representative sample from each region of the country. Only healthy children were included. Weight is expressed in kilograms (kg) and length/height in centimeter (cm). As in previous analysis, the age was converted in Gregorian to facilitate comparison with growth charts of other populations. Statistical methods The L, M, and S method was used to synthesize the distribution of growth parameters as a function of age. The LMS parameters are the median (M), the generalized coefficient of variation (S), and the power in the BoxCox transformation (L). The method models the entire distribution taking into account degree of skewness (L), central tendency (M), and dispersion (S). The parameters L, M and S were calculated according to the method of maximum penalized likelihood. 0 Percentiles for all the anthropometric measures were calculated using the following formula. P= M [ + LSZ] /L, L 0 Where the L, M, and S are the values from the appropriate table corresponding to the age in years of the child. Z is the zscore that corresponds to the percentile. For this study, we have calculated the 3rd, 5th,0th, 25th, 50th, 75th, 90th, 95th and the 97th percentiles for weight, height, and added the 5th percentile for body mass index, commonly used to define overweight. The LMS Chart Maker Light 2. (Medical Research Council, London, UK) was used to process the data and Qtest was used to assess the goodness of fit of all L, M, and S models. 2 This analysis is based on data from health profile of Saudi children and adolescents study funded and approved by King Abdul Aziz City for Science and Technology, Riyadh, Saudi Arabia. Figure 2. Heightforage percentiles for boys, 5 to years. RESULTS The sample size consisted of 9 299 Saudi children and adolescents from 5 to year of age. All were Saudi nationals and 9 27 (50.9 %) were boys. For boys, the L, M, and S parameters and percentiles for weight for age, height for age, and BMI for age are presented in the Tables to 3, respectively, and the Figures to 3 represent plots corresponding to the tables. Similarly, Tables 4 to 6 show L, M, and S parameters and percentiles for girls, including weight for age, height for age, and BMI for age. Figures 4 to 6 are plots of the data in Tables 4 to 6. DISCUSSION Worldwide variations of human growth are well known, suggesting that the use of growth references from another population is potentially risky. 3 Previous studies from Saudi Arabia demonstrated marked differences in growth between Saudi children and their American counterparts. 46 More recently reported differences between Saudi and both CDC 2000 and WHO growth charts confirm previous studies. 7, The implication of these differences are considerable with the potential of overestimation of prevalence of short stature and malnutrition potentially resulting in unnecessary referrals and patient and parent anxiety. The percentile system is commonly used in clinics and hospitals for the assessment of growth and nutrition in clinical setting. 9 The percentile ranks of individuals define the nutritional and growth status in comparison with peers of the same age and gender. Children and adolescents are growing subjects and regular evaluation of their growth and nutritional sta 266 Ann Saudi Med 206 JULYAUGUST www.annsaudimed.net
lms parameters for growth original article Figure 3. Body mass indexforage percentiles for boys, 5 to year Figure 4. Weightforage percentiles for girls, 5 to years. Figure 5. Heightforage percentiles for girls, 5 to years. tus is mandatory. This is especially true for those affected by chronic medical conditions potentially affecting growth and nutrition. In addition, the LMS parameters and tables of percentiles allow the incorporation of growth charts in electronic hospital and clinic records. The L, M, and S parameters and growth percentile reference has recently been reported in Saudi preschool children. 20 However, to our knowledge, no reference has been reported for Saudi schoolage children and adolescents. In this report, growth indicators (weight for age, height for age, and BMI for age) are presented, allowing more accurate assessment of growth and nutritional status. Regular follow up of growth parameter percentiles at different ages helps detection and definition of malnutrition. For example, a flat growth line crossing more than one percentile curve in a weight for age or below the 3rd percentile define failure to Figure 6. Body mass indexforage percentiles for girls, 5 to years grow, also called failure to thrive. Similarly, height for age dropping below the 3rd percentile is a sign of short stature. In addition, the BMI is increasingly used to define thinness (BMI < 5th percentile), overweight (BMI > 5th percentile) and obesity (BMI > 95th percentile). 2 In conclusion, the availability of L, M, and S parameters, percentiles tables, and reference charts for height for age, BMI for age and to lesser extent weight for age for schoolage children and adolescents is important for research and health care. Acknowledgment The authors extend their appreciations to the Deanship of Scientific Research at King Saud University for funding this work through Research Group No. RGP436007. Ann Saudi Med 206 JULYAUGUST www.annsaudimed.net 267
original article REFERENCES. Cole TJ. The development of growth references and growth charts. Ann Hum Biol 202; 39: 32 94. 2. Hamill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center for Health Statistics percentiles. The Am J of Clin Nutr. 979; 32: 60729 3. Kuczmarski RJ, Ogden CL, Guo SS, GrummerStrawn LM, Flegal KM, Mei Z, et al. 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 2002; 246: 90. 4. De Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for schoolaged children and adolescents Bull World Health Organ 2007; 5:6607. 5. Bonthuis M, Van Stralen KJ, Verrina E, Edefonti A, Elena A. Molchanova EA, et al. Use of National and International Growth Charts for Studying Height in European Children: Development of UpToDate European HeightForAge Charts. PLOS One 202 Volume 7 Issue e42506. 6. Tinggaard J, Aksglaede L, Sørensen K, Mouritsen A, WohlfahrtVeje C, Hagen CP, et al. The 204 Danish references from birth to 20 years for height, weight and body mass index. Acta Pædiatrica 204; 03: 24 24. 7. Khadilkar V, Yadav S, Agrawal KK, Tamboli S, Banerjee M, Cherian A, et al. Revised IAP Growth Charts for Height, Weight and Body Mass Index for 5 to yearold Indian Children. Indian Pediatr 205; 52: 4755.. Zong XN, Li H. Construction of a New Growth References for China Based on Urban Chinese Children: Comparison with the WHO Growth Standards. PLOS ONE 203; Issue 3 e59569. 9. El Mouzan MI, AlHerbish AS, AlSalloum AA, Qurachi MM, AlOmar AA. Growth charts for Saudi children and adolescents. Saudi Med J 2007; 2: 5556. 0. Cole TJ, Green PJ. Smoothing reference percentile: The LMS method and penalized likelihhood. Stat Med 992; : 3059.. Cole T J, Freeman JV, Preece MA. British 990 growth reference centiles for weight, height, body mass index and head circumference fitted by maximum penalized likelihood. Stat Med 99; 7: 40729. 2. Pan H, Cole TJ. A comparison of goodness of fit tests for agerelated reference ranges. Statist. Med. 2004; 23: 749 65. 3. Natale V, Rajagopalan A. Worldwide variation in human growth and the World Health Organization growth standards: a systematic review. BMJ Open 204;4:e003735. 4. Al Sekait MA, Al Nasser AN, Bamgboye EA. The growth pattern of schoolchildren in Saudi Arabia. Saudi Med J 992; 3: 46. 5. AlNuaim AR, Bamgboye EA, AlHerbish A. The pattern of growth and obesity in Saudi Arabian male schoolchildren. Int J Obes lms parameters for growth Relat Metab Disord 996; 20: 0005. 6. AlMazrou YY, AlAmoud MM, ElGizouli SE, Khoja TA, AlTurki KA, Tantawi NE, et al. Comparison of the growth standards between Saudi and American children aged 05 years. Saudi Med J 2003; 24: 59602. 7. El Mouzan MI, AlHerbish AS, AlSalloum AA, Foster PJ, AlOmar AA. Qurachi MM, et al. Comparison of the 2005 growth charts for Saudi children and adolescents to the 2000 CDC growth charts. Ann Saudi Med 200; 2: 33440.. El Mouzan MI, Foster PJ, AlHerbish AS, AlSalloum AA,, AlOmar AA, Qurachi MM, et al. The implication of using the World Health Organization Child Growth Standards in Saudi Arabia. Nutrition Today 2009; 44: 6270. 9. World Health Organization Physical status: The use of and interpretation of anthropometry. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser 995; 54: 6 2. 20. El Mouzan M, Al Salloum A, Al Herbish A, Shaffi A. Growth Reference for Saudi Preschool Children: L M S Parameters and Percentiles. Ann Saudi Med 205: In Press. 2. Department of Health and Human Services, Centers for Disease Control and Preventions. Body Mass Index: Considerations for Practitioners. http://www.cdc.gov/obesity/ downloads/bmiforpactitioners (Accessed 5/2/205). 26 Ann Saudi Med 206 JULYAUGUST www.annsaudimed.net
Growth reference for Saudi schoolage children and adolescents: LMS parameters and percentiles (TABLES TO 6) El Mouzan M, Al Salloum A, Al Omer A, Alqurashi M, Al Herbish A. Growth reference for Saudi schoolage children and adolescents: LMS parameters and percentiles. Ann Saudi Med 206; 36(4): 26526. DOI: 0.544/02564947.206.265 Table. L, M, and S parameters and percentiles for weight for age: boys 5 to years. Age (y) L M S 3 rd 5 th 0 th 25 th 50 th 75 th 90 th 95 th 97 th 5.046774 6.65079 0.550993 2.9055 3.22 3.9993 5.07723 6.65079.6072 20.0742 22.40426 23.5309 6.032594.640 0.65233 4.704 4.6024 5.3396 6.7433.640 2.0366 23.004 25.3963 27.36547 7.0547 20.66037 0.9 5.4023 5.90975 6.7596.4042 20.66037 23.55329 26.9576 29.555 3.45556 0.9957 23.206 0.9562 6.9652 7.55.5555 20.504 23.206 26.7622 30.92749 34.4503 36.677 9 0.9524795 26.0635 0.200576.69 9.36 20.5556 22.47 26.0635 30.3009 35.4506 39.43634 42.52 0 0.9793 29.0466 0.22002 20.42467 2.22672 22.5539 25.26373 29.0466 34.0576 40.20527 44.99669 4.7324 0.29525 32.4206 0.230557 22.3467 23.349 24.94 2.00907 32.4206 3.2932 45.5062 5.6 55.49237 2 0.753365 36.42373 0.23563 24.7367 25.763 27.65393 3.2576 36.42373 43.245 5.5274 5.03479 63.02903 3 0.6774 40.5276 0.244675 27.3762 2.627 30.74394 34.9376 40.5276 4.666 5.2203 65.3676 70.9235 4 0.69575 45.73953 0.2479675 30.36456 3.79524 34.22245 39.003 45.73953 54.57247 65.6076 73.944 79.3055 5 0.569272 50.7593 0.24905 33.55655 35.64 37.363 43.2445 50.7593 60.509 72.275.0396 7.773 6 0.56256 55.37 0.245967 36.47562 3.22 4.7227 46.99 55.37 65.7262 7.45399.0029 95.23035 7 0.60233 5.5773 0.24792 3.906 40.74362 43.5572 49.9706 5.5773 69.4454 3.24 93.4520 0.64 0.64024 6.25766 0.245296 40.96 42.7943 46.00937 52.3479 6.25766 72.9552 6.9922 97.65765 05.7
Table 2. L, M, and S parameters and percentiles for height for age: boys 5 to years. Age (y) L M S 3 rd 5 th 0 th 25 th 50 th 75 th 90 th 95 th 97 th 5.44274 07.974 5.40E02 96.72755 9.727 00.37 04.0 07.974.757 5.3279 6.396 3.609 5.22E02 02.3724 03.794 05.97 09.5992 3.609 7.602 2.796 7 0.949675 9.93 5.06E02 07.47 09.2292.4093 5.057 9.93 23.9 26.54 0.94493 24.4657 4.94E02 2.9265 4.3706 6.5963 20.3204 24.4657 2.66 32.3627 9 0.9439 29.4396 4.9E02 7.5055.9993 2.304 25.53 29.4396 33.7335 37.604 0 0.6246465 33.9074 4.9E02 2.5972 23.7 25.4709 29.445 33.9074 3.4299 42.543 9.42E02 3.63 5.0E02 25.9425 27.475 29.6 33.9576 3.63 43.4659 47.9409 2 7.27E02 44.09 5.9E02 30.67 32.2703 34.774 39.077 44.09 49.572 53.9494 3 0.257995 49.6053 5.24E02 35.4007 37.24 39.7 44.39 49.6053 54.963 59.9034 4 0.932599 55.04 5.7E02 40.697 42.56 45.49 50.372 55.04 6.242 66.509 5.4325 6.436 4.97E02 45.703 47.7542 50.666 55.949 6.436 66.7743 7.4564 6 2.75764 65.562 4.69E02 49.296 5.4456 54.6555 59.7773 65.562 70.2502 74.623 7 3.433 67.4663 4.42E02 5.744 54.0466 57.2535 62.247 67.4663 72.27 76.365 3.9055 6.05 0.047342 53.64 55.03 5.9572 63.45 6.05 73.375 77.976 7.370 23.33 29.057 4 34.606 2 39.923 2 45.034 6 50.679 56.96 62.96 69.092 9 74.207 6 77.49 7.700 4 79.372 6.67 2 24.695 9 30.46 7 36.064 3 4.430 4 46.657 9 52.4 5.42 64.96 5 7.005 4 75.974 7.759 3 0.7 5 0.744
Table 3. L, M, and S parameters and percentiles for body mass index for age: boys 5 to years. Age (y) L M S 3 rd 5 th 0 th 25 th 50 th 75 th 5 th 90 th 95 th 97 th 5.546 4.425 0.75.539 2.253 2.5600 3.37456 4.4254 5.6727 6.4423 7.004 7.936.602 6.749 4.535 0.26.7474 2.0323 2.5079 3.3225 4.53462 5.9274 6.0206 7.45674.53642 9.3935 7.943 4.72 0.3997.70 2.0045 2.5047 3.4529 4.77 6.2675 7.25246.00262 9.25692 20.026.209 5.03 0.5.397 2.36 2.67425 3.70075 5.0292 6.65 7.943.0676 20.2745 2.3667 9.207 5.62 0.696 2.057 2.4047 2.9559 4.035 5.62799 7.57034.5257 9.459 2.55233 22.4696 0.72 6.265 0.7227 2.3624 2.7369 3.36675 4.566 6.26476.42953 9.743 2.00345 22.960 24.4662.235 6.946 0.63 2.6909 3.09729 3.709 5.006 6.94554 9.3322 20.9366 22.942 24.3563 26.07443 2.04 7.642 0.93 3.0272 3.4663 4.20533 5.64509 7.6423 20.2427 2.996 23.36342 25.7536 27.59449 3 0.9647.34 0.96 3.3455 3.0 4.6342 6.639.343 2.094 22.942 24.45 26.99756 2.9497 4 0.92.9 0.20253 3.6767 4.767 5.02697 6.643.9799 2.95556 23.9439 25.49473 2.759 30.292 5 0.47 9.666 0.2074 4.044 4.5797 5.4766 7.2334 9.66593 22.92 24.92463 26.56565 29.39 3.55593 6 0.65 20.334 0.20 4.4575 5.0265 5.9493 7.765 20.3342 23.66469 25.90323 27.6553 30.6956 33.02959 7 0.932 20.943 0.237 4.6774 5.4364 6.393.257 20.94259 24.4459 26.27 2.7096 32.093 34.5737 0.976 2.46 0.265 5.25003 5.2 6.07.7440 2.463 25.5499 27.6465 29.704 33.2966 36.24
Table 4. L, M, and S parameters and percentiles for weight for age: girls 5 to years. Age ( y) L M S 3 rd 5 th 0 th 25 th 50 th 75 th 90 th 95 th 97 th 5 0.9395 6.4299 0.6536 2.442 2.434 3.49605 4.7474 6.4299.5272 20.947 22.65023 23.93477 6 7 9 0 2 0.95705 0.9953 0.623634 0.322223 0.7994724 0.7663324 0.743344.45433 0.750 3.77099 4.227 4.99332 6.46255.45433 20.96522 23.5503 25.976 27.56234 20.6649 0.93735 5.6592 5.6974 6.536.302 20.6649 23.66574 27.62 29.7665 3.7543 23.7324 0.999672 6.7307 7.34735.336 20.3973 23.7324 26.74599 30.95694 34.7 36.543 25.972 0.209703.4657 9.773 20.370 22.72062 25.972 30.94 35.205 39 4.993 29.3699 0.2777 20.665 2.4435 22.400 25.5747 29.3699 34.35965 40.30696 44.2735 4.204 33.57265 0.22370 23.305 24.27543 25.905 29.0424 33.57265 39.432 46.46 5.735 55.042 3.3703 0.227055 26.459 27.60592 29.4953 33.20366 3.3703 45.6304 53.27594 59.4433 64.4745 3 0.73925 43.2264 0.2279 29.77024 3.033 33.706 37.36462 43.2264 50.56 60.0503 67.0092 72.3693 4 5 0.73354 0.7550535 47.25764 0.2272233 32.59572 33.97274 36.3024 40.70 47.25764 55.6043 65.59375 73.95 7.97207 50.024 0.22554 34.6629 36. 3.559 43.3654 50.024 5.6646 69.3974 77.395 3.5566 6 0.777939 52.04097 0.2236553 36.6599 37.6565 40.7663 45.2304 52.04097 6.09903 7.9759 0.2705 6.62072 7 0.0327 53.222 0.2273 37.3643 3.64573 4.974 46.2067 53.222 62.4223 73.50063.97466.4792 0.27 53.650 0.2202955 37.5966 39.0506 4.65562 46.66542 53.650 62.9094 74.042 2.5967 9.763
Table 5. L, M, and S parameters and percentiles for height for age: girls 5 to years. Age ( y) L M S 3 rd 5 th 0 th 25 th 50 th 75 th 90 th 95 th 97 th 5 0.9724 07.352 5.39E02 96.9977 9.2706 00.325 03.92 07.352.7599 5.2937 7.409.73 6.025 3.07 5.2E02 0.77 03.39 05.3575 0.972 3.07 7.0439 20.6655 22.3 24.232 7.0474.522 0.05654 06.979 0.4309 0.6634 4.392.522 22.6479 26.3557 2.5722 30.006.046376 23.42 5.05E02 2.0533 3.5352 5.53 9.6207 23.42 2.0569 3.449 34.094 35.579 9.0275 29.633 4.94E02 7.632.6694 20.92 24.65 29.633 33.4632 37.33 39.6463 4.49 0 0.95657 34.663 4.2E02 22.492 24.065 26.369 30.3064 34.663 39.0724 43.0252 45.393 46.937 0.06756 40.3 0.0475 27.9437 29.475 3.69 35.596 40.3 44.7774 4.22 5.2332 52.079 2 0.7635555 45.5699 4.60E02 33.45 34.6625 37.0543 4.0729 45.5699 50.0999 54.2049 56.674 5.226 3 0.574023 49.75 0.044907 37.392 3.9255 4.30 45.30 49.75 54.34 5.5453 6.057 62.694 4 0.2693 52.669 4.4E02 40.395 4.969 44.237 4.94 52.669 57.276 6.49 64.0497 65.7275 5 6 0.007422 0.5357 54.3053 4.37E02 42.66 43.647 45.93 49.333 54.3053 5.9247 63.227 65.397 67.5707 55.00 4.37E02 43.323 44.552 46.722 50.632 55.00 59.74 64.7 66.99 6.730 7.40942 55.5257 4.42E02 43.6594 45.04 47.224 5.0356 55.5257 60.37 64.976 67.7792 69.709.76596 55.763 4.49E02 44.07 45.47 47.5594 5.3422 55.763 60.07 65.633 6.7209 70.3
Table 6. L, M, and S parameters and percentiles for body mass index for age: girls 5 to years. Age (y) 5 6 7 9 0 2 3 4 5 6 7 L M S 3 rd 5 th 0 th 25 th 50 th 75 th 5 th 90 th 95 th 97 th.3297 4.3299 0.24472.63.95329 2.3976 3.2324 4.3299 5.66306 6.50564 7.392.902.95529.2939 4.402 0.33596.649.93405 2.4055 3.29727 4.402 5.9362 6.6706 7.57226.75246 9.62239.2723 4.7455 0.436224.6709.99053 2.4946 3.45457 4.7455 6.3473 7.366.09 9.52405 20.52522.24666 5.790 0.536925.564 2.45 2.7277 3.76909 5.790 6.9606.26 9.024 20.5645 2.7227.24775 5.69607 0.63453 2.0774 2.4306 3.0239 4.5329 5.69607 7.663.97423 9.96 2.73473 23.06392.7507 6.35505 0.724243 2.4257 2.0402 3.4304 4.66594 6.35505.53366 9.979 2.234 23.09243 24.6079.2933 7.790 0.0299 2.9472 3.30453 3.99292 5.33042 7.790 9.57733 2.63 22.44677 24.64075 26.32944.054.46 0.6309 3.4377 3.92795 4.6750 6.2963.46 20.7705 22.53679 23.92236 26.3327 2.20093.05025 9.2067 0.906 4.594 4.639 5.44607 7.0202 9.2067 22.0592 23.907 25.49064 2.256 30.5.0267 20.722 0.946503 4.7322 5.29402 6.5452 7.3455 20.722 23.2279 25.249 26.906 29.7392 3.9247.04 20.9756 0.974603 5.24643 5.7093 6.694.44307 20.9756 24.5 26.2365 27.99302 30.9236 33.29374.006032 2.50933 0.999027 5.6363 6.905 7.2522.95463 2.50933 24.63 27.353 2.92606 32.06425 34.49603.002935 2.9292 0.202254 5.7659 6.44464 7.4035 9.2292 2.9292 25.37526 27.72699 29.5424 32.4599 35.3799 0.9946 22.0539 0.204699 5.922 6.49753 7.4695 9.3764 22.0539 25.562 27.9535 29.696 33.23357 35.3947