Adeline Bats
email: adeline.bats@gmail.com

Pierre Tallet

Juan Carlos

Moreno García

" Fonction

THE PRODUCTION OF BREAD IN CONICAL MOULDS AT THE BEGINNING OF THE EGYPTIAN MIDDLE KINGDOM THE CONTRIBUTION OF EXPERIMENTAL ARCHAEOLOGY

Keywords: bakery, ancient Egypt, bread moulds, experimental archaeology, emmer

Despite rich iconographic documentation, and the abundance of culinary ceramics discovered in archaeological sites, the process of bread production in moulds has intrigued Egyptologists for many years. Experiments presented in this article proposes a new chaîne opératoire for the production of bread in conical moulds dating from the early Middle Kingdom (2050( -1900 BCE) BCE), mainly based on results from the site of Ain Sukhna. Thanks to a new analysis of the iconography, a re-examination of the ceramics, and a close collaboration with a farmer-baker using flours made from "old wheat", experimentation produced perfectly baked breads that did not require breaking the ceramics to remove them from the moulds. The experiment also provides an explanation of the conical shape of the moulds, and the presence of several internal linings, as well as a better understanding of the role played by the use of low gluten flours, particularly starch-based flours, and the use of sourdough starter.

INTRODUCTION

Bread and beer were the base of the ancient Egyptians' daily food (SAMUEL 2000). The production of bread is well documented for Pharaonic Egypt, particularly through images of food processing that are part of the decoration of Old and Middle Kingdom elite tombs, and so-called bread moulds -ceramic cooking utensils found in large numbers in archaeological sites. Nevertheless, despite this rich documentation, the chaîne opératoire is not well known and understood.

Several reasons for our imprecise knowledge about this process can be advanced. First, Egyptian iconography is very standardized and the motifs chosen are combinations of several viewpoints 1 . The images do not work as naturalistic 2 representations, but rather the evocation of particular actions. Furthermore, to this day, no recipe for bread dough is known and the near-absence of laboratory analysis does not allow us to compensate for this lack of information. Thirdly, baking bread in ceramic moulds is an uncommon practice in other civilizations and researchers are still wondering about the role played by these utensils (BATS 2019, pp. 329-331, 405-4226). Finally, while in the Old Kingdom bread moulds were frustoconical shaped and flared walls with flat bottoms or with round and rough conical bases, from the beginning of the Middle Kingdom (around 2000 BCE), they changed their shape considerably to become conical (JACQUET-GORDON, 1981).

In response to these many questions about the representations of food processing, bread recipes and reasons for such a change in bread mould typology, several experimental archaeology projects have been set up in recent decades. All these reconstructions were undertaken in order to answer questions related to specific discoveries at archaeological sites. The baseline study was conducted by D. Samuel on the basis of material discovered at Tell el-Amarna (1333-1330 BCE) (SAMUEL, 1989). Further research was carried out at Giza based on bread moulds from the Old Kingdom (2750-2250 BCE) (LEHNER & HAWASS, 2017: pp. 376-377). To date, no comprehensive study was undertaken on material dating from the Middle Kingdom 2 , a pivotal period for understanding the baking and culinary practices of the Ancient Egyptians.

In 2017, as part of my PhD, an experimental archaeology project was set up with the aim of gaining a better understanding of the stages of bread production in conical moulds dating from the first part of the Middle Kingdom (2050( -1900 BCE) BCE) based on material discovered at Ain Sukhna -an Egyptian harbour and logistic hub for expeditions to South-Sinaï located on the northern end of the Golf of Suez -in the frame of the French-Egyptian Ain Sukhna Archaeological mission (Ifao-CNRS-Sorbonne University). A strict methodology (VERLY & LONGELIN, 2019) was put into place in order to explore the various questions raised by the iconographic and archaeological evidence. This scientific rigour was applied during the restitution 3 process, notably through the search for "old wheat" and collaboration with traditional artisan-bakers.

Material and method 1.Iconography

The iconography of the Old Kingdom (2750-2250 BCE), tomb scenes and limestone models, is probably the most instructive of all periods (FALTINGS, 1998: pp. 89-137;SAMUEL, 2000;VEREECKEN, 2013: p. 58-60). Three general stages are represented in the scenes:

-The heating of the moulds. The ceramics are stacked above a fire. The baker is represented in a sitting position, protecting his face from the heat with his hand. With the other hand, he holds a poker and maintains the hearth.

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-The removal of the moulds. A second person is represented removing the ceramics from the hearth, manipulating them with a poker and/or a ceramic potholder in order to stabilize the mould without getting burned. He stands next to the stack, both hands at the top of it.

-Filling the mould. The mould is positioned on the ground. The liquid dough is poured inside.

During the Middle Kingdom, several changes are apparent in the iconography. Firstly: the shape of the moulds became conical. There are fewer bakery scenes from the Middle Kingdom than from the previous period. According to the iconography of the Middle Kingdom, there are two stages:

-Heating of the moulds in a fireplace. -Filling the moulds outside the fireplace. The bread moulds are shown upright. The dough appears semi-solid.

The chaîne opératoire for baking bread in conical moulds has been discussed several times. The main difficulty with interpreting these images lies in the order of the steps, in particular, whether or not the empty moulds are pre-heated. H. Wild, considers that a preheating of the ceramics was a necessary step, both in the Old and Middle Kingdom (WILD, 1975: p. 595). Similarly, the firing process is also discussed: for H. Wild the depiction of the standing moulds corresponds to the position of the ceramics during the firing of the bread, while D. Samuel believes that the fireplace scenes may indicate either the preheating of the moulds, or the baking of the bread in the ceramics (SAMUEL, 1989: pp. 155-156).

Bread moulds

Bread moulds are very abundant type of pottery in Egyptian settlement sites throughout the Pharaonic period. There are several forms, the best documented being the "bedja mould" (bḏȝ) which evolved considerably between the end of the Old Kingdom and the end of the Middle Kingdom (between 2250 and 1700 BCE approximately) (JACQUET- GORDON, 1981)

[figs. 1 & 2]
. This utilitarian ceramic is generally produced in Nile C, a coarse silty clay "tempered" with gravel and plant chaff (ARNOLD & BOURRIAU, 1993 : pp. 173-174 ;SCHIESTL & SEILER, 2012 : pp. 750-757). L.A. Warden considers that despite their abundance and ubiquity, bread moulds are still not understood well (WARDEN, 2019: p. 2). The author notes that these ceramics are generally considered "throwaway", broken after firing in order to remove the loaf. However, the presence of a lining made of clay and sand inside, that was clearly renewed, seems to indicate that the moulds were used multiple times, and were discarded only after several uses (WARDEN, 2019: p. 7). This inner lining, sometimes consisting of multiple layers, has also been observed on many conical bread moulds in Ain Sukhna [Fig. 3].

Experimental method

The work presented here focuses on three aspects: the stages of the chaîne opératoire ("protocol"), the temperatures for heating the moulds and baking the bread, and finally the bread recipe.

The research into the stages of the bread production chain was essentially based on Egyptian iconography, the observation of bread moulds from the Middle Kingdom and archaeological data collected at the site of Ain Sukhna. Thanks to these studies, "experimental protocols" were then formulated and modified according to the results obtained during the restitutions. Three protocols were therefore developed during this research and which are successively presented in this article under the title "Experimentation Series 1, 2 and 3". It has been decided to heat and bake the bread in open fireplaces positioned in shallow pits, in accordance with the discoveries made at Ain Sukhna. Indeed, there are two types of fireplaces associated with bread baking at this site: simple fireplaces and "oven rooms" in which the fireplace fills all the available space (BATS, in preparation ). For all the experiments, several bread moulds were either produced in Aubechies (Belgium) or Ain Sukhna (Egypt), each time using local clay. Fresh donkey dung and gravel were used as temper. The ceramics were fired in open fireplaces at temperatures between 850°C and 950°C. All employed elements and the observation made will be published in detail in a forthcoming article (BATS, in preparation).

During the baking process, temperature measurements using a laser thermometer. The team recorded the temperatures of the fire and of the heated moulds at the time of the filling in of the dough, and then every 5 minutes during the baking of the bread in order to maintain consistency (fire, outside and top of the bread mould). Later, in the third series of experiments, a "sensor Type-K" thermocouple was used in order to be more precise in taking the temperature. All the old protocols were then re-tested while recording the temperatures using the more accurate equipment.

Bread is a fermented and baked preparation mainly based on flour and water. Nevertheless, many varieties of breads exist and have existed in the world. In the absence of a "recipe" known to date for ancient Egypt, our first difficulty was therefore to produce bread dough that could be baked in conical ceramics, in other words, bread dough requiring the use of a ceramic support. In general, the production of bread dough from the basic ingredients takes place in several necessary steps. Kneading is a fundamental step, since it is during this stage that the dough is homogenized, stretched and oxygenated. This mechanical action, causing the gluten proteins to unfold, creates a network of gluten chains that give the dough a plastic and elastic texture. Then, during the fermentation process, the sugars are transformed into carbon dioxide, which exerts pressure inside the dough and causes it to swell. The dough rise then creates the crumb, thanks to the distribution of gas bubbles within the network of gluten chains formed during kneading. The swelling of the dough therefore depends on two things: its plasticity (created during the kneading process to stretch the gluten) and its fermentation. They are therefore two distinct and complementary elements (CAPPERS et al., 2016(CAPPERS et al., : p. 1239;;PEIGNEY, 2010, p. 405;DUPAIGNE, 1999: p. 172). The iconography of the Middle Kingdom shows that Egyptian bread doughs associated with conical moulds are semi-solid and prepared in large ceramic vats, unlike other solid productions and kneaded on flat supports. This semi-solid consistency depends on the rate of hydration of the bread dough, the type of flour used, the kneading, but also on the fermentation process (fermentation time and types of ferments).

Botanical studies carried out on relevant material from Egyptian sites have shown that during the Pharaonic period, two cereals were cultivated: common barley (Hordeum vulgare) and emmer wheat (Triticum turgidum ssp. dicoccon), both hulled cereals (CAPPERS, 2012). It was essential to work with at least one of these plants, which are very rarely cultivated in the world today. So, I asked for R. Feuillas, a farmerbaker and specialist in "old wheat" varieties, to participate in this research project4 . R. Feuillas provided an organic "black emmer" flour. This cereal was used during all the experimentations5 . Emmer produces a tasty, low gluten and highly digestible flour (STEGASSY & BOLOGNINI, 2018: p. 138). Its low gluten content has therefore led us to work on different fermentations and degrees of humidity to obtain a semi-solid dough, in accordance with the iconographic data. In the absence of reliable data regarding the use of yeast and sourdough in association with the conical moulds of the Middle Kingdom, I opted to carry out several test, with sourdough starter of einkorn (Triticum monococcum) at our disposal6 , or long spontaneous fermentations. R. Feuillas and I have therefore worked with several recipes for doughs made from black emmer 100% bran7 , more or less hydrated (between 72 and 90% humidity) and with different degrees and times of fermentation (from 5h to 14h) [fig. 4]. The other emmer cultivars (red and white) and common barley have not been tested8 . Salt has sometimes been used to correct the acidity of bread9 .

Our objective was to produce a perfectly baked bread (with no trace of charring or a semi-baked mushy appearance) that would release itself perfectly from the ceramic without breaking it.

Restitutions

2.1.

Experimentation, Serie 1

In the first experiments, we followed the idea of Mark Lehner's team in Giza that the bread moulds function in considering that the bread mould functions as a "small oven" storing sufficient heat to bake the bread. Thus, the first protocol adopted the following sequence: Application of an internal lining to each mould used for a new baking attempt + Heating of the moulds + Filling the moulds outside the fireplace + EXTERNAL Cooking (outside the fireplace, the moulds are in a vertical position). Conical bread moulds were made in Aubechies (Belgium) with local clay and tempered with fresh donkey dung and gravel. The bread moulds were engobed inside with a very plastic grey clay by the potter of the city of Cucugnan (Aude Department, France). Eight restitutions of bread baking were thus carried out in Cucugnan in the bakery of R. Feuillas, using different mould heating temperatures in order to check whether the heat stored by the ceramics during this phase could diffuse and allow the bread to be baked outside the hearth.

The sequence of the first protocol was therefore carried out: 1. empty mould put in a fire10 (of ca. 600 or 700°C depending on the type of hearth); 2. empty mould is taken out of the fire when a certain temperature is reached. This first experimentation made it possible to clarify several points: -The management of temperatures of the moulds is essential for the incorporation of the bread dough. Above 400°C, the bread dough carbonises as soon as it comes into contact with the ceramic.

-Regardless of the heating temperature of the moulds, once out of the furnace, the ceramics quickly lose the stored heat. When the temperature drops below 100°C, the baking of the bread is stopped.

-A possible bias must also be taken into account: the moulds made in Aubechies could be too calcareous and therefore not refractory enough. Thus, they would lose the stored heat more quickly.

-The question of the heat input therefore arises. Thus, it is possible to wonder whether the cooking was not done -as for the heating -in a hearth.

2.2.

Experimentation, Serie 2

The experiment carried out in September 2017 at Cucugnan showed the need to work again on the temperatures of the moulds during the heating and on the form of the heat input. In order to correct a possible bias introduced by overly calcareous ceramics made from Belgian clay, new moulds were produced with clay collected in Ain Sukhna. On this site, in February 2018, three days were devoted to bread baking experiments. The dough was made from black emmer supplied by R. Feuillas (100% bran), salt (8g for 500g of flour) and a moisture content of 72%. The mixture fermented for 7 hours without the addition of yeast or sourdough starter. The internal lining of the bread moulds was made with local clay, water and sand from the erosion of the gebel.

Our first concern was to definitively invalidate the first protocol consisting of heating the moulds followed by baking the bread outside the hearth with ceramics made of local clay. With a furnace temperature between 650°C-700°C, the incorporation of the dough was carried out in moulds heated at approximately 450°C. The results obtained confirm the conclusions drawn from the first experiment carried out at Cucugnan, as the incorporation of the dough at too high a temperature causes carbonization of the crust, while the rapid drop in temperature did not allow the bread to be baked. In such circumstances, demoulding was difficult. Inside, the bread is not baked. The first protocol was therefore invalidated.

A second protocol was put in place in order to alleviate the problems previously encountered: Application of an internal lining to each mould used for a new baking attempt + Heating of the moulds + Filling the moulds outside the fireplace + INTERNAL Cooking (inside the fireplace, maintaining a constant heat input. The moulds are in a vertical position). Two hearth temperatures were tested: 750°C and 400 -450°C. At 750°C, several problems are to be noted. Firstly, to reach such a temperature, a lot of fuel is needed [fig. 7]. Secondly, there are handling difficulties, such as difficulty standing above the fireplace [fig. 8]. With the heat from the fire, air pockets form when the dough is incorporated into the ceramic. The bread dough therefore does not fall to the bottom of the mould and remains stuck to the walls of the ceramic. In addition, the ceramic moulds heated to over 400°C caused the bread to carbonize and prevented it from coming out of the mould [ A second heat source of 450°C-500°C was tested. The source of heat was a few embers, and many ashes produced by the combustion of shrubs and dry branches collected on site (primarily Tamarix nilotica). The moulds were preheated to around 200-250°C for 20-40 min depending on the moulds, lying in the fire after the incorporation of the lining [fig. 10]. The ceramics were left in the fireplace (at this temperature, the fire consists of ashes and embers) and then straightened up vertically, with their bottoms in the embers. The dough was incorporated from the top. It soon became apparent that a slow firing of at least 35 min gave much more satisfactory results than previous experiments, even though the top of the bread was still not baked. In spite of this improvement, we still noticed the presence of high humidity in the loaves and a base still slightly charred [ The experiments carried out in February 2018 at Ain Sukhna made it possible to test the two protocols with bread moulds made from local clay. Several additional conclusions can be reported: -Even with moulds produced with local clay the results do not change for protocol 1.

-It appeared that the bread had to be baked in relatively low heat, in fireplaces mixing ashes and charcoal and giving off less than 500°C.

-Leaving the mould inside the hearth allowed for a constant heat input and therefore a better baking.

-Nevertheless, despite these advances, the bread was not perfectly baked and a complete review of the historical documentation is necessary to draw up a new protocol.

In May 2018, both protocols were tested again at Aubechies (Belgium). The provision by G. Verly of "sensor Type-K" thermocouples made it possible to take heat measurements directly in the bread dough and thus monitor the baking process more precisely. The results of these restitutions proved to be quite similar to the previous tests: the bread dough inside the mould did not exceed 85°C and this temperature was only maintained for a very short time (less than 5 min).

2.3.

Experimentation, Serie 3: new analysis of archaeological evidence and new protocol

Thanks to the help of G. Verly, we had access to the collections of the Royal Museums of Art and History of Brussels, where bread moulds from the excavations of W.M.Fl. Petrie (PETRIE & BRUNTON, 1924) dating from the end of the Old Kingdom11 to the beginning of the Middle Kingdom12 are kept. Two observations could be made. While the late Old Kingdom mould can be placed on its base [Fig. 12], the other later moulds were not made to be placed like this [Fig. 13]. Indeed, when D. Samuel, and ourselves, needed to vertically fix the conical bread moulds outside the fireplace, small cavities had to be dug in the ground (SAMUEL, 1989: p. 271). In addition, G. Verly suggested that I observe and understand the traces of fire visible on the moulds, especially during secondary firings. For example, the mould dating from the end of the Old Kingdom shows a trace of localized heating at its base [Fig. 12], evidence of an ancient heat source limited to the lower part of the object. The Middle Kingdom mould show more diffuse heating traces at the base and also on the lower two-thirds of the mould [Fig. 13]. Similar traces could be observed on conical moulds in Ain Sukhna (BATS, in preparation).

So it seems that the change in the shape of the bread moulds called "bedja" (bḏȝ) at the end of the Old Kingdom is evidence of a new way of firing that does not require the ceramic to be kept standing. Indeed, carbon deposits at the base of the moulds and secondary traces are visible on the wall. As the moulds are reusable, the walls change from reducing to oxidising atmospheres during baking. The side surface is therefore the witness of these positioning changes, while presenting the state of the last firing.

The long carbonated traces on the wall is therefore the witness of the final baking of the bread by rolling the pan on a layer of ashes. Thus, the vertical position depicted in the tombs could be limited to the stage of filling in the dough. It was therefore assumed that after the application of the lining, the heating of the moulds and the filling in of the dough, the moulds had to be laid flat in the hearth. Re-examination of the iconography could confirm this hypothesis. In fact, the stela E30 from the Garstang Museum of Archaeology shows a staggered arrangement of the ceramics (KITCHEN, 1961), an arrangement facilitated by the conical shape of the bread moulds as from the First Intermediate Period (i.e. after the end of the Old Kingdom). Such a motif is also present in the tomb of Amenemhat at Beni Hassan (see above).

A new protocol has therefore been established: Application of an internal lining to each mould used for a new baking attempt + Heating of the moulds + Filling the moulds outside the fireplace + INTERNAL Cooking (inside the fireplace, maintaining a constant heat input. The moulds are in a horizontal position). In order to have a constant cooking, the moulds are rolled every 5mins with a poker13 .

Another test phase was therefore undertaken, once again in Cucugnan, in the bakery of R. Feuillas. In order to test the new protocol, we benefited from the help and expertise of Th. Authier and R. Cleguer, two bakers from the Maîtres de mon Moulin's team. A first batch was initiated from a bread dough made from a black emmer flour without bran (300g), with a moisture content of 80% and 5g of salt. We added 5g of sourdough starter (i.e. 1.6% of the preparation) in order to compensate for a fermentation that was too short (4 hours) 14 . For this experiment, we had only one "sensor Type-K" thermocouple. With such a configuration, three measurements were recorded for the whole batch: the temperature taken inside of the dough by the thermocouple "sensor Type-K", as well as of the fire and the outside of a empty mould (a control sample) with a laser thermometer. The moulds used for the restitution were produced in Aubechies (Belgium) with local clay. The internal lining was composed of clay and sand mixed with water. The fireplace is set on a flat floor and is made of ashes and embers in order to obtain a low temperature.

The temperature of the dough was around 100°C throughout the baking process and gradually increased to 120°C. The significant drop in the temperature of the hearth slightly influenced the temperature of the dough [Table 5]. The addition of embers made it possible to stop the drop in temperature, and to continue baking. After 1h05, the moulds were taken out of the fireplace and the breads were removed from the moulds. To reach 100°C in the bread dough (Sensor-K), the fire must generate approximately 400°C of heat. During this restitution, it has also become clear that the internal lining had to be well fixed in the mould before filling the dough. Otherwise, the lining remains stuck to the bread during baking and removal from the mould is difficult.

In spite of the good demoulding, and acceptable baking of the bread, the crumb was still not satisfactory: the bread dough was not fermented enough and the alveoli were not sufficiently formed, blocking the distribution of heat inside the mould. The solution would have been to repeat the same process with a longer fermentation, however this would have aggravated the problem of the acidity of the dough. In fact, since the beginning of the experiments, the bread systematically had a more or less acidic taste; much more acidic than the traditional sourdough bread that can be found in bakeries today. Thus, the poor distribution of heat and the very acidic taste of the bread due to the long spontaneous fermentation led us to add an additional ingredient: sourdough starter. 5. Temperatures recorded for the batch of 29/06/2018 at Cucugnan (tests no. 39-46), with a fire temperature around 300-400°C. In blue, temperature drop.

A second batch was thus prepared, using a bread dough composed of 1kg of 100% bran black emmer, 15g of salt, 170g of einkorn (Triticum monococcum) sourdough starter and 750g of water (i.e. 75% humidity). The protocol of the first batch was repeated identically [figs. 14 & 15]. Better fuel management made it possible to maintain constant temperatures throughout the baking of the bread, between 100°C and 110°C inside the moulds [Table 6]. After one hour of baking, the loaves were removed from the moulds: extraction of the bread was very easy [fig. 16]. The crust was judged "beautiful", although very lightly roasted at the base [fig. 17]. The sections made on several loaves show a perfectly baked and well honeycombed crumbly texture [fig. 18]. The action of the sourdough starter, combined with the salt, also helped to rectify the acidity and create the honeycombing necessary for a good distribution of heat during baking.

Fireplace

Sensor Type-K (inside the dough) Finally, this protocol was repeated a third time with the same conditions (same actions, same dough recipe, and same baking temperatures). However, the step of applying of the lining was omitted because the old layer had remained intact after the previous batch. It turned out that the loaves did not come out of the moulds because, during the baking process, the dough remained stuck in the ceramics. It therefore seems likely that a fresh lining is necessary, because even though the surface of the clay is dry and does not adhere to the dough when it is put into the oven, moisture is still present deep down. A circulation of hot air therefore seems to be created during the baking of the bread, between the wall of the ceramic and the dough, which in the long run makes it easier to remove the dough from the mould. The application of a layer of clay therefore seems necessary for each new batch15 .

Results

In this study, 54 loaves of bread were produced, to which were added the loaves made during the repetitions of the protocols (i.e. actions and steps) for which no measurements were recorded. For all these experiments, only 100% bran black emmer was tested. The use of grain from the correct species, produced organically, was critical to the experimentation.

After testing two protocols based on the classical interpretation of historical data (Experiments Series 1 and 2), it was necessary to review the archaeological and iconographic evidences.

A new chain of operations for baking bread for the early Middle Kingdom could be proposed:

-The inside of the conical bread moulds is covered with a layer of fine sandy clay for every re-use of the mould. -The moulds are then placed horizontally and without any particular

arrangement in an open fireplace made of many ashes and coals.

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-The temperature of this fire must not exceed 500°C.

-Once the moulds have been heated on all sides and the lining is well fixed, the moulds are straightened and the dough is filling in. The dough is shaped in advance into elongated dough pieces. -With the heat of the moulds and the semi-solid consistency of the bread dough, the dough quickly sets into the ceramic and it is possible to lay the moulds down immediately. -In accordance with certain iconographic representations, the moulds were staggered and rolled regularly (every 5 minutes in order to maintain a rhythm and to record temperatures), a positioning facilitated by the conical shape of the ceramics. -After 60 min of baking between 100°C and 120°C, the dough was completely baked. -During the firing process, it slightly detached from the ceramic and a crust formed on the outside. -On the inside, thanks to the presence of sourdough starter, a dense honeycomb formed, allowing a good distribution of hot air during baking.

Thus, despite the presence of sourdough starter, the bread dough did not rise much and did not create pressure inside the mould. The use of emmer -a cereal low in gluten -is therefore quite relevant in the context of bread production in a ceramic mould (see above for the distinction between the action of gluten and fermentation). Indeed, the dough rises little and does not exert pressure inside the mould. The bread can therefore be unmoulded perfectly, by inverting the ceramics. The bread moulds are not broken during the demoulding process. They can therefore be used again, as long as a new coating is applied before each batch. This lining insulates the bread dough from the porosity of the ceramic, but also acts as a moisture reserve that diffuses during the baking process and allows the bread to detach slightly from the ceramic. The other advantage of this baking technique is fuel economy. In fact, for a batch of eight loaves only a small quantity of coal and ashes is needed.

This experimental archaeology project proposes a new understanding of the bread production scenes in Middle Kingdom iconography. Thus, the scene in the tomb of Baqet III seems to be an illustration of a heating phase of the empty moulds. The ceramics are placed in a disorganized position in a fireplace and are removed by means of a poker slipped into the opening of the mould. The mould is held by the baker using a potholder. This removal of the moulds is called wp.t bḏȝ which should rather be translated as "distinguishing / separating the mould-bḏȝ". The scene in the tomb of Amenemhat at Beni Hassan shows the baking phase. The moulds are positioned in two rows in the hearth in a staggered pattern. Similarly, on the Liverpool Stele E31, the baker is shown handling the ceramics using two pokers to clamp the moulds filled with bread dough. These experiments also shed light on several technical elements of archaeological bread moulds: the conical shape allowing a flat staggered arrangement, the role of the coating often consisting of several layers, and traces of fire.

Far from being complete, this research nevertheless shows the importance of crosschecking data and comparing hypotheses with practice. These experiments should be replicated with other emmer cultivars (red and white), with common barley or with mixed flours. Further work, carried out jointly with ceramologists, archaeobotanists and archaeometers is also to be hoped for.

Conclusions

The currently prevalent understanding of the process of bread baking, that was developed based on iconographic data and widely disseminated in the Egyptological literature, has been tested in different contexts and according to different variables. Nevertheless, no bread could be baked correctly and several handling difficulties appeared. Thanks to the integration of these results, a close collaboration with a farmer-baker and a new analysis of the iconographic and archaeological documentation, a new chaîne opératoire can be proposed. Protocol 3 can therefore be considered viable as it allows for the production of perfectly baked bread and for keeping the bread moulds intact after each batch. This new framework highlights several elements of analysis of culinary ceramics and also allows us to deepen our research problems during the archaeological excavation of combustion structures and food processing areas. However, in addition to these results, these reconstructions are part of broader studies, notably on the understanding of the technical choices of the cereal sector -from the cultivation to the consumption of cereals -in Pharaonic Egypt. The production of bread in conical moulds is also part of a reflection on the storage of cereal products ("saving capacities") and on the use of these products in the monetary system (BATS, 2019).

Credits:

The experiments presented in this article were carried out as part of a doctoral dissertation defended at the Sorbonne University, Faculty of Arts and Humanities on 17 December 2019, under the direction of Pierre Tallet and Juan Carlos Moreno García. These experiments benefited from the financial support of the team Mondes Pharaoniques (CNRS, UMR 8167, Orient & Méditerranée), directed by Pierre Tallet, and the French-Egyptian archaeological mission of Ain Sukhna (Egypt) directed by Claire Somaglino (Sorbonne University) and Mahmoud Abd el-Raziq (University of the Suez Canal). The mission is supported by the French Institute of Archaeological Research in Cairo-Ifao, CNRS and Sorbonne University, and takes place thanks to the authorization of the Egyptian Ministry of Antiquities and help of the Inspectorate of Suez. The various restitutions were carried out on the archaeological site of Aubechies (Belgium), in the bakery of Cucugnan (France) and on the archaeological site of Ain Sukhna (Egypt). The experiments required the participation of many people, who were essential to the recording of data and handling, and with whom many exchanges took place: Georges Verly (Université Lettres Sorbonne -KU Leuven), Roland Feuillas (Les Maîtres de mon moulin), Claire Somaglino (Sorbonne University), Véronique Van der Stede (Musée du Cinquantenaire), Charlotte Doyen (EACOM), Julie Marchand (HISOMA), Théophile Authier (Les Maîtres de mon moulin), Raphaël Cleguer (Les Maîtres de mon moulin), Élodie Girard and Aliénor Roussel (students of the Sorbonne University), Xenia Blockerye, Meredith Borodine de Kirdetzoff, Axelle Debèque, Yorick Weenen and Aurélie Wery (students of the ULB), Taha Hussein Sayed and Ragab Nubi (workers of the archaeological team of Ain Sukhna).

I would like to thank Claire Malleson (American University of Beirut, archaeobotanist for Ain Sukhna mission) for her valuable suggestions and correction of my English, as well as the editors for inviting me to participate in the volume and their valuable remarks.

Fig. 1 .Fig. 2 .Fig. 3 .Fig. 4 .Fig. 5 .

 12345 Fig. 1. Bread mould dating from the Old Kingdom discovered at Ain Sukhna (n°323). [© Ihab MOHAMED / Ifao] Fig. 2. Conical bread mould dated to the beginning of the Middle Kingdom discovered at Ain Sukhna (n°3314). [© Ain Sukhna Archaeological Mission / Georges VERLY] Fig. 3. Inside of a bread mould, discovered in S6 south, US 400. [© Ain Sukhna Archaeological Mission / Georges VERLY] Fig. 4. Example of bread doughs before fermentation made at Cucugnan. [© Adeline BATS] Fig. 5. Longitudinal section of bread no. 4. [© Adeline BATS]

Fig. 6 .Fig. 7 .Fig. 8 .Fig. 9 .Fig. 10 .Fig. 11 .Fig. 12 .Fig. 13 .Fig. 14 .

 67891011121314 Fig. 6. Unmoulded piece of bread no. 8. [© Adeline BATS] Fig. 7. Heating the moulds. [© Ain Sukhna Archaeological Mission / Adeline BATS] Fig. 8. Difficulty incorporating bread into the moulds. [© Ain Sukhna Archaeological Mission / Aliénor ROUSSEL] Fig. 9. Bread n°13 [© Adeline BATS] Fig. 10. Baking in the fireplace at low temperature. [© Ain Sukhna Archaeological Mission / Aliénor ROUSSEL] Fig. 11. Breads n°25 and n°26. [© Adeline BATS] Fig. 12. Bread mould from Sedment, VI th Dynasty, Bruxelles RMAH E.5804/3. [© Musée d'Art et d'Histoire de Bruxelles / Georges VERLY] Fig. 13. Bread mould E.00969 dated to the First Intermediate Period (2250-2044 BC). [© Musée d'Art et d'Histoire de Bruxelles / Georges VERLY] Fig. 14. Heats empty moulds after application of the lining. [© Adeline BATS]

Fig. 15 .

 15 Fig. 15. Baking bread [© Adeline BATS] Fig. 16. Demoulding [© Théophile AUTHIER]

Fig. 17 .

 17 Fig. 17. Unmoulded bread [© Adeline BATS]

Fig. 18 .

 18 Fig. 18. Bread Section [© Adeline BATS]

Table 1 .

 1 Temperatures recorded for test no. 4 carried out on 7/09/2017 at Cucugnan, with a temperature in the fire of around 600°C. In red, temperatures below 100°C.

			Bottom (above the	Top (Opening)
			ashes)
	Mould	standing	300°C	250°C
	(empty)
	00:05		190°C	105°C
	00:10		140°C	75°C
	00:15		106°C	68°C
	00:20		81°C	60°C
			Bottom (above the	Top (Opening)
			ashes)
	Mould	standing 560°C	460°C

They are positioned vertically; 3. Measuring the temperatures at the bottom and the top directly after taking it out; 4. filling in of dough; 5. Baking process. Additional measurements every 5 mins. The first restitutions were aimed at testing two empty mould heating temperatures: 250-300°C [Table 1 & fig. 5] and more than 400°C [Table 2 & fig. 6].

Table 2 .

 2 Temperatures recorded for test n°8 carried out on 8/09/2017 at Cucugnan, with a temperature in the fire around 700°C. In red, temperatures below 100°C.

Table 3 & fig. 9].

 3

			Mould	Bottom (above the	Top (Opening)
				ashes)
	In the fireplace	488°C
	Mould	standing		412°C	166°C
	(empty)
	00 :05			369°C	121°C
	00 :10			276°C	113°C
	00 :15			260°C	111°C
	00 :20			240°C	115°C
	00 :25			224°C	116°C

Table 3 .

 3 Temperatures recorded for test n°13 carried out on 31/01/2018 in Ain Sukhna, with a temperature in the fire close to 750°C.

Table 4 & fig. 11].

 4

			Mould	Bottom (above the	Top (Opening)
				ashes)
	In the fireplace	230-250°C
	Mould	standing		260°C	100°C
	(empty)
	00 :05			170°C	60°C
	00 :10			170°C	70°C
	00 :15			120°C	85°C
	00 :20			160°C	72°C

Table 4 .

 4 Temperatures recorded for test n°25 carried out on 4/02/2018 at Ain Sukhna, with a fire temperature of around 500°C. Fresh embers were added at 00:20 min and 00:35 min. In red, temperatures below 100°C.

Table 6 .

 6 Temperatures recorded for the batch of 30/06/2018 at Cucugnan (tests no. 47-54), with a furnace temperature below 500°C.

	Top of the empty
	mould	(control

This name is used in traditional agriculture in contrast to "modern wheat" (or "industrial wheat") developed after the Second World War to meet the growing demand for food(STEGASSY & BOLOGNINI 2018, pp. 23-27). Today, all "old wheat" varieties are organic and are cultivated in keeping with biodiversity, but "industrial wheat" can also be organic. The difference therefore lies in the selection of the seeds and their DNA. To my knowledge, no emmer flour can be bought outside the group "old wheat" producers. Collaboration with R. Feuillas was suggested by Ph. Marinval, an archaeo-botanist and researcher at the CNRS.

STEGASSY& BOLOGNINI, 2018: pp. 138-141. Cultivars cannot be determined by marcoscopic observations and DNA analyses are required. Color differentiation comes from the straw and not from the seed. About black, red and white emmer in Egyptian texts, cf. BATS, 2019: p. 32.

For lack of time, I could not raise an emmer-based sourdough. The cultivation of the einkorn is not proven in Egypt during the Pharaonic period, but it was the only sourdough starter at our disposal. Also low in gluten, its properties are close to those of emmer.

The bran is the caryopsis of the cereal surrounding the almond. Bran is a fibrous layer that absorbs more of the water added to the dough. Therefore, the higher the bran content, the more hydrated the bread dough will need to be.

On bread doughs in ancient Egypt and the different recipes tested during the experiments cf. BATS, FEUILLAS in preparation.

Salt reduces the acidity of the bread, but does not slowing down the fermentation processes of the dough. On the presence and use of salt during the Pharaonic period, see the recent article DEVAUCHELLE, 2020.

In the hearth of the baker's wood-fired oven (tests n°1-4, see Table1), then in a coal-fired hearth in a 30 cm pit (tests 5-8, see Table2). Not all tests are presented in this article. Only one significant example is given for each set of experiments.

A similar mould is kept in the Petrie Museum (UC 17987, Sedment, tomb 415, 6th dynasty).

For other parallels, cf. SCHIESTL & SEILER 2012, p. 754-757.

This interval was chosen because the temperatures are taken every 5 minutes.

Spontaneous fermentation is a long process (several hours). When time is short, the bread dough can be inoculated with a few leaven in order to accelerate the development of lactic acid bacteria. The sourdough starter used here is natural, it's a living matter. Unlike chemical yeasts, a resting time is necessary for the reproduction of bacteria. But, with only 1.6% sourdough in the bread dough, this bread cannot be considered "sourdough bread".

On the role of moist clay in contact with high heat, cf. VERLY, 2017.


Vincent Chagué
email: im2s@orange.fr

Sous-dochead Les enseignements d'une crise sanitaire inédite Les établissements d'hébergement pour personnes âgées dépendantes à l'épreuve de la pandémie

Keywords: communication, Covid-19, établissement d'hébergement pour personnes âgées dépendantes, management

La pandémie a touché avec violence certains établissements pour personnes âgées dépendantes, mais tous ont dû se réorganiser. Leur fonctionnement ne sera plus jamais le même et la transparence vis-à-vis des salariés et des familles des résidents est devenue une obligation. La coopération avec les pharmaciens d'officine, qui peuvent être des relais d'information auprès des familles, doit s'intensifier.

Néanmoins, s'ils sont habitués à confiner les résidents pendant quelques jours ou quelques semaines, ils n'étaient pas préparés à un confinement aussi drastique et aussi long (77 jours), ni à une telle pression des autorités et des médias.

Entre le 1 er mars et le 2 juin 2020, 28 940 décès de patients atteints du Covid-19 ont été comptabilisés, dont 10 350 résidents en Ehpad et autres structures médico-sociales [2]. Dans ce contexte exceptionnel, les Ehpad ont su malgré tout continuer à prendre soin des personnes âgées.

Mais cette crise sans précédent a des conséquences sur le fonctionnement des établissements qui doivent intégrer de nouvelles manières de travailler, non seulement parce que la pandémie n'est pas terminée et peut connaître un nouveau pic, mais aussi parce que les attentes des différents acteurs ne sont plus tout à fait les mêmes qu'auparavant.

T1 Des équipes de direction plus réactives

TEG1 Les Ehpad ont été en première ligne dès le début de la crise du Covid-19. Alors que le confinement de la population n'a commencé que le 17 mars 2020, les visites extérieures ont été interdites dès le 11 mars. De nombreux établissements, en particulier dans le Grand Est, avaient déjà pris cette mesure et décidé, de la même manière, de confiner les résidents dans leur chambre.

TEG1 Leur principale difficulté a été d'évaluer la gravité de la situation, mais aussi d'anticiper ou d'appliquer les consignes sanitaires. Il a également fallu mettre en place des mesures barrières et faire appliquer par les professionnels des règles d'hygiène drastiques. Cela s'est avéré plus ou moins difficile en fonction de la stabilité des équipes.

TEG1 Les directions ont été amenées à instaurer une nouvelle organisation afin de permettre le confinement en chambre des résidents, le service des repas également en chambre et, éventuellement, une sectorisation. En effet, des zones Covid ont parfois été créées afin de limiter la propagation du virus. Les équipes de direction ont fait la preuve de leur capacité à s'adapter, à quelques exceptions près. Mais au-delà de la sécurité et du bien-être des résidents, qui ont constitué leurs priorités, elles ont dû renforcer le management des professionnels et apprendre à gérer différemment les familles. TEG1 La gestion des plannings, qui est un casse-tête permanent au sein des Ehpad, est devenue encore plus complexe, surtout dans les établissements dont les personnels étaient touchés par le Covid-19. Il a fallu remplacer des salariés alors qu'il est difficile d'en trouver, même en faisant appel à la réserve sanitaire.

T1 Des professionnels confrontés à des difficultés inédites TEG1 Les établissements n'ont pas tous abordé la crise du

TEG1 Les professionnels ont parfois fait face à des situations très difficiles à vivre, notamment quand les décès de résidents se succédaient. Un sentiment d'impuissance a pu les envahir, comme quand, au début de la pandémie, des médecins coordonnateurs arrivaient difficilement à faire hospitaliser des résidents dans un état grave.

TEG1 Ce contexte totalement hors norme a nécessité un renforcement du management de proximité, les équipes de direction ont intensifié leur présence auprès des équipes et ont veillé à améliorer leur communication interne.

TEG1 À l'issue du confinement, les établissements ont dû préparer la sortie de crise en prenant en compte deux risques majeurs :

• le désengagement des professionnels au moment où ils se retrouveraient dans une situation normale et retomberaient dans la routine ;

• l'affaiblissement des résidents, dû au confinement, au Covid-19 ou au syndrome de glissement, qui, par exemple, pouvait faire craindre les conséquences d'une canicule estivale.

T1 Des familles en demande d'informations

TEG1 Les familles ont fait face à un double confinement, celui de leur parent et le leur, sans avoir le temps de s'y préparer. Les premiers jours ont été d'autant plus difficiles qu'ils manquaient cruellement d'informations. Les structures tentaient de s'organiser et la communication avec l'extérieur n'était pas leur priorité.

TEG1 Rapidement, les outils numériques ont été utilisés pour permettre aux familles de rester en contact avec leur parent. Cela n'a souvent pas suffi, car elles étaient en quête d'une transparence totale sur ce qui se passait au sein de l'Ehpad.

TEG1 Quand un établissement a eu à déplorer des cas de Covid-19, voire des décès, la communication s'est avérée encore plus complexe. La direction a dû mettre en place une information quotidienne des familles concernées (appel journalier d'un infirmier diplômé d'État ou du médecin coordonnateur). La communication après des autres familles a été renforcée de manière à les informer en temps réel de l'évolution de l'épidémie in situ. Le mail a souvent été l'outil privilégié. Certains établissements ont fait le choix d'envoyer régulièrement une newsletter pour montrer que la vie continuait malgré le confinement et l'absence de moments de convivialité (animations, repas, coiffeur, etc.).

TEG1 Il a fallu ensuite organiser des visites en respectant des mesures barrières très strictes. À la fin du confinement de la population, les équipes ont expliqué que, début juin, les modalités des visites ne changeraient pas beaucoup, au grand regret de certaines familles qui espéraient un retour à la normale.

TEG1 Les établissements doivent aujourd'hui faire face à des injonctions paradoxales de familles qui veulent pouvoir accéder facilement aux Ehpad tout en exigeant que leurs parents soient totalement protégés du Covid-19 ; cela nécessite encore des efforts de communication de la part des directions.

TEG1 La transparence et la réactivité doivent être privilégiées de manière pérenne. Les Ehpad qui l'ont fait dès le début de la crise du Covid-19 ont eu des relations plus apaisées avec les familles.

T1 Conclusion

La crise liée à la pandémie a révélé des insuffisances des Ehpad en termes de communication. La transparence doit être de mise avec les familles d'abord, mais aussi avec les médias et les autorités, et s'avère tout aussi importante avec les salariés des établissements, qui se sont retrouvés en insécurité et dans l'incertitude vis-à-vis de l'évolution de la crise.

Les Ehpad n'avaient pas été suffisamment préparés à une crise d'une telle ampleur, n'ayant pas de moyens spécifiques dédiés à la communication. Il faudra donc rapidement repenser l'organisation des établissements pour améliorer l'information.

Les pharmaciens d'officine ont joué un rôle important auprès des familles qui sont souvent leurs patients pour lesquelles ils ont été des relais de proximité. Cette crise a montré à quel point le maillage territorial des pharmacies est un élément essentiel de la politique de santé de notre pays, car il représente aussi un formidable outil de communication. Il ne peut être que bénéfique de renforcer la coopération entre les Ehpad et les pharmaciens d'officine.

Points à retenir

• La pandémie a touché avec violence certains établissements d'hébergement pour personnes âgées dépendantes (Ehpad), mais tous ont dû se réorganiser.

• Les directions et les salariés ont su s'adapter rapidement à de nouvelles contraintes.

• Le renforcement du management de proximité est nécessaire en période de crise.

• La communication avec les familles des résidents doit s'intensifier de manière pérenne.

• La coopération entre les Ehpad et les pharmaciens d'officine doit être encouragée, car ces derniers peuvent être un relais de proximité auprès des familles.

Sur 1 colonne à droite après la puce de fin

Déclaration de liens d'intérêts

L'auteur déclare ne pas avoir de liens d'intérêts.

Références

  Covid-19 dans les mêmes conditions. Certains bénéficiaient d'équipes stables et motivées, d'autres d'équipes plus fragiles, avec un nombre de remplaçants plus ou moins élevé et des degrés d'engagement divers. Néanmoins, en quelques jours, tous ont été obligés de modifier leurs pratiques professionnelles. TEG1 La vie personnelle des salariés a été radicalement impactée par le confinement. Tout est devenu contrainte et a nécessité une phase d'adaptation, d'autant plus angoissante que l'échéance de cette crise était incertaine.

[ 1 ]

 1 Arrêté du 7 juillet 2005 fixant le cahier des charges du plan d'organisation à mettre en oeuvre en cas de crise sanitaire ou climatique et les conditions d'installation d'un système fixe de rafraîchissement de l'air ou de mise à disposition d'un local ou d'une pièce rafraîchis dans les établissements mentionnés à l'article L313-12 du Code de l'action sociale et des familles. www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000633683. [2] Santé publique France. COVID-19 : point épidémiologique du 25 juin 2020. 25 juin 2020. www.santepubliquefrance.fr/maladies-et-traumatismes/maladies-et-infectionsrespiratoires/infection-a-coronavirus/documents/bulletin-national/covid-19-point-epidemiologiquedu-25-juin-2020. Illustration Cha_illus1 © Reddragonfly/stock.adobe.com Si les établissements d'hébergement pour personnes âgées dépendantes sont habitués à isoler les résidents pendant quelques jours dans le cadre du plan Bleu, ils n'étaient pas préparés à un confinement aussi drastique et long. Sur 1 colonne en haut à droite en première page


Keywords: clinique, Covid-19, épidémiologie, SARS-CoV-2, transmission

Le Severe Acute Respiratory Syndrome Coronavirus 2, coronavirus à tropisme respiratoire responsable de la Covid-19, a été isolé pour la première fois en Chine fin 2019. Six mois après sa découverte et malgré sa diffusion pandémique, il reste de nombreuses zones d'ombre concernant la physiopathologie et le traitement de la Covid-19. Nous disposons en revanche de données solides concernant ses caractéristiques épidémiologiques et l'expression clinique de cette maladie est maintenant bien décrite.

Le Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) est un virus à acide ribonucléique (ARN) appartenant au genre des Betacoronavirus et génétiquement proche de virus zoonotiques. Six mois après son identification, il reste de nombreuses zones d'ombre concernant la physiopathologie et le traitement de la Covid-19, maladie dont il est responsable. Nous disposons en revanche de données épidémiologiques et cliniques de plus en plus solides.

T1 Évolution de l'épidémie

TEG1 Les premiers cas d'infection par le nouveau coronavirus à tropisme respiratoire, ultérieurement baptisé SARS-CoV-2, ont été identifiés à Wuhan en décembre 2019 [START_REF] Zhu | A novel coronavirus from patients with pneumonia in China, 2019[END_REF]. L'épidémie de Covid-19 s'est étendue en quelques semaines à l'ensemble de la Chine continentale, où elle semble avoir été rapidement maîtrisée grâce aux mesures de santé publique (figure 1).

TEG1 Des cas ont cependant été diagnostiqués sur tous les continents et, dès le 11 mars 2020, l'Organisation mondiale de la santé a reconnu le caractère pandémique de la Covid-19. À partir de fin février 2020, l'Europe de l'Ouest est devenue la région où l'épidémie se développait le plus rapidement. TEG1 Devant l'explosion du nombre de cas et la saturation des systèmes de santé dans certaines régions, des mesures de confinement (lockdown) ont progressivement été instituées dans la plupart des pays européens, permettant le contrôle de l'épidémie dont le pic a été atteint début avril. TEG1 Début mai 2020, le continent américain est devenu le nouvel épicentre de l'épidémie, alors qu'une montée inquiétante du nombre de contaminations était observée au Moyen-Orient, en Asie du Sud-Est et en Afrique.

T1 Caractéristiques épidémiologiques et transmission

TEG1 La transmission interhumaine du SARS-CoV-2 est avérée, avec un taux de reproduction de base (R0) compris entre 2 et 4 [START_REF] Liu | The reproductive number of COVID-19 is higher compared to SARS coronavirus[END_REF], ce qui signifie qu'un sujet infecté contamine en moyenne deux à quatre autres personnes. Le mode de transmission prépondérant impliquerait les gouttelettes de taille importante (> 5 µm) générées au cours de la parole, de la toux ou des éternuements, et ne se propageant pas à plus de deux mètres du sujet émetteur. Il existe des arguments solides en faveur de l'existence d'une transmission aérienne [START_REF] Gehanno | Arguments pour une possible transmission par voie aérienne du SARS-CoV-2 dans la crise COVID-19[END_REF], médiée par les aérosols (gouttelettes de taille ≤ 5 µm), mais cette voie est marginale, tout comme la transmission par contact avec des surfaces contaminées.

TEG1 La maladie est contagieuse avant même l'apparition des signes cliniques. Les patients infectés présenteraient une contagiosité maximale pendant les quatre jours entourant le début des symptômes. Mais d'authentiques infections secondaires ont été observées autour de sujets strictement asymptomatiques.

T1 Présentation clinique

TEG1 La présentation clinique de l'infection par le SARS-CoV-2 est très polymorphe. La proportion de formes asymptomatiques est encore débattue, elle se situe probablement autour de 15 % [START_REF] Byambasuren | Estimating the extent of asymptomatic COVID-19 and its potential for community transmission: systematic review and meta-analysis[END_REF]. Chez les patients symptomatiques, la période d'incubation suivant la contamination dure moins de quatorze jours (médiane cinq jours) [START_REF] He | Estimation of the basic reproduction number, average incubation time, asymptomatic infection rate, and case fatality rate for COVID-19: meta-analysis and sensitivity analysis[END_REF]. Il s'agit d'une durée comparable à celle retrouvée avec d'autres virus dits respiratoires où la porte d'entrée de l'agent infectieux et le site définitif de réplication virale sont similaires. Les périodes d'incubation des autres présentations, notamment cutanées, neurologiques et digestives, sont moins connues et pourraient être plus longues, car impliquant une étape virémique intermédiaire.

TEG1 Le tropisme du SARS-CoV-2 explique en grande partie les différentes manifestations rencontrées. Le récepteur viral est la protéine Angiotensin-Converting Enzyme 2 (ACE2), présente sur l'ensemble du tractus respiratoire, mais également sur les cellules du tractus gastro-intestinal et les cellules endothéliales. La réaction immunitaire en réponse à l'infection est un autre élément essentiel de la physiopathologie de la maladie. Elle peut aller d'une forme asymptomatique, avec une clairance virale associée à une production d'anticorps neutralisants, à une réponse inflammatoire disproportionnée et délétère pour l'organisme. TEG1 L'expression ACE2 tout comme l'état immunitaire diffèrent selon l'âge et certaines comorbidités. Cela explique probablement en partie les énormes différences d'expression clinique et de gravité observées entre des individus jeunes sans antécédent et des sujets âgés ou comorbides. Plus de 90 % des patients décédés de la Covid-19 ou de ses complications étaient âgés de 65 ans ou plus et la majorité présentait une comorbidité, en particulier une hypertension artérielle, un diabète ou une obésité. La situation des enfants est particulière, avec un taux d'hospitalisation inférieur à 1 %, mais quelques formes rares de myocardite.

TEG1 Les manifestations classiques de la maladie sont celles d'une virose respiratoire, allant d'une atteinte respiratoire haute bénigne à une pneumonie sévère. Les symptômes les plus fréquemment rapportés sont la toux (75 %), plutôt sèche, la fièvre (50 %) et la dyspnée (30 %) [START_REF] Pascarella | COVID-19 diagnosis and management: a comprehensive review[END_REF]. Des signes digestifs (diarrhées) et des céphalées peuvent les accompagner. La proportion exacte de chacune de ces manifestations dépend de la sévérité de la forme clinique. La pneumonie présente au scanner thoracique un aspect particulier en plages de verre dépoli périphériques. Enfin, un des signes les plus évocateurs est la survenue de troubles du goût (dysgueusie) et de l'odorat (anosmie, hyposmie), réversibles en quelques jours à quelques semaines. Ils pourraient être en lien avec une atteinte du rhinencéphale.

TEG1 Plus rares, mais maintenant bien décrites, les atteintes extrarespiratoires font toute la particularité de l'infection à SARS-CoV-2.

Les symptômes dermatologiques sont le reflet du tropisme du virus pour l'ACE2 exprimé à la surface des cellules endothéliales. Une réaction inflammatoire lymphocytaire cluster de différenciation 8 (CD8) périvasculaire est responsable de manifestations de type vascularite des petits vaisseaux [START_REF] Mahieu | No antibody response in acral cutaneous manifestations associated with COVID-19?[END_REF]. Les patients présentent alors des engelures, parfois caractérisées par des évolutions bulleuses, dont la guérison est la règle en quelques jours à quelques semaines.

Les atteintes digestives peuvent être présentes de manière isolée, notamment chez le sujet âgé ou le jeune enfant, ou associées à d'autres manifestations. Elles ne sont pas graves en soi, mais difficiles à repérer. De plus, elles complexifient la démarche diagnostique en augmentant de manière importante le nombre de cas suspects.

Plus rares, des manifestations neurologiques ont été décrites, prenant la forme d'encéphalites ou de polyradiculonévrite. Elles correspondent à une atteinte directe encéphalitique du virus ou à des symptômes inflammatoires postinfectieux aspécifiques [START_REF] Bridwell | Neurologic complications of COVID-19[END_REF].

Chez le sujet âgé, l'infection est fréquemment responsable de complications non spécifiques, tels un état confusionnel ou une chute. des signes pris isolément ou en association ne permet cependant de porter ou d'infirmer le diagnostic de Covid-19, ce qui impose la réalisation d'un test virologique (transcriptase inverse-réaction en chaîne par polymérase [RT-PCR]) chez tout patient suspect.

TEG1 Globalement, la mortalité associée au Covid-19 s'établirait, en France, à 0,7 % [START_REF] Salje | Estimating the burden of SARS-CoV-2 in France[END_REF]. Il est estimé que 80 % des sujets symptomatiques ne nécessiteront pas d'hospitalisation (figure 2). La soudaineté de l'expansion de ce virus explique l'impact majeur qu'il a eu sur les systèmes de santé, en saturant brutalement toute l'offre de soins, malgré un taux de létalité relativement bas.

T1 Facteurs influençant l'évolution de l'épidémie

TEG1 Parmi les facteurs influençant la vitesse de dissémination du SARS-CoV-2, outre les caractéristiques intrinsèques du virus, les facteurs climatiques, les comportements humains, les politiques de santé publique et l'état d'immunité de la population peuvent être mentionnés. Il a été observé que d'autres coronavirus sont responsables d'épidémies essentiellement hivernales [START_REF] Kissler | Projecting the transmission dynamics of SARS-CoV-2 through the postpandemic period[END_REF]. De plus, la persistance de ces virus sur les surfaces inertes raccourcit lorsque la température augmente [START_REF] Casanova | Effects of air temperature and relative humidity on coronavirus survival on surfaces[END_REF]. Il était donc envisageable que la transmission interhumaine du SARS-CoV-2 soit moins efficace en été. Cependant, l'épidémie se développe dans des pays à climat chaud, ce qui a très tôt suggéré que l'arrivée de l'été ne suffirait pas à faire disparaître le virus d'Europe. TEG1 L'efficacité du port du masque, des mesures d'hygiène et de la distanciation physique n'est plus à démontrer. Mais notre société maintiendra-t-elle un niveau suffisant d'utilisation de ces mesures sur le long terme [START_REF]Covid-19 : une enquête pour suivre l'évolution des comportements et de la santé mentale pendant l'épidémie. 22 juin 2020[END_REF] ? TEG1 Le confinement, mis en place dans de nombreux pays depuis le début de la pandémie, a été extrêmement efficace [START_REF] Salje | Estimating the burden of SARS-CoV-2 in France[END_REF], faisant chuter le R0 de 77 % en France, au prix de lourdes conséquences sociales et économiques.

TEG1 Depuis la levée du confinement, le contrôle de l'épidémie repose sur une politique de tests virologiques massifs, associée à l'isolement des sujets infectés (RT-PCR positive) et à l'identification précoce des sujets contacts à risque (contact tracing). Cette stratégie a fait la preuve de son efficacité, notamment en Chine [START_REF] Bi | Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study[END_REF] et en Corée du Sud [START_REF] Lu | Weathering COVID-19 storm: successful control measures of five asian countries[END_REF].

TEG1 Enfin, l'état d'immunité de la population est un élément déterminant de l'évolution d'une épidémie. Sur la base de modélisations prenant en compte le R0 de la maladie, il peut être estimé que l'épidémie s'arrêtera lorsque environ 70 % de la population seront immunisés [START_REF] Kwok | Herd immunity -estimating the level required to halt the COVID-19 epidemics in affected countries[END_REF]. Or, la séroprévalence de la Covid-19 en France à l'issue de la première vague reste faible, 4,4 % à la mi-mai 2020 [START_REF] Salje | Estimating the burden of SARS-CoV-2 in France[END_REF]. Il est toutefois possible qu'une partie de la population soit protégée vis-à-vis du SARS-CoV-2 en raison d'une immunité croisée avec d'autres coronavirus. Des anticorps reconnaissant ce virus sont en effet présents chez les patients ayant été infectés par le SARS-CoV [START_REF] Lv | Cross-reactive antibody response between SARS-CoV-2 and SARS-CoV infections[END_REF], mais ils ne sont probablement pas neutralisants. L'immunité antivirale cellulaire pourrait également conférer un certain degré de protection croisée [START_REF] Grifoni | Targets of T cell responses to SARS-CoV-2 coronavirus in humans with COVID-19 disease and unexposed individuals[END_REF].

T1 Conclusion

Les inconnues sont nombreuses. Il paraît difficile d'anticiper la survenue et l'ampleur d'une éventuelle deuxième vague. Une disparition rapide et définitive de la maladie est très peu probable au regard de sa diffusion mondiale.

Points à retenir

• Après avoir débuté en Chine, en décembre 2019, l'épidémie de Covid-19 a vu son épicentre se déplacer vers l'Europe, puis le continent américain.

• Le Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) se transmet essentiellement par les gouttelettes émises par les sujets infectés, même asymptomatiques.

• L'expression clinique de la Covid-19 est polymorphe, mais la forme la plus commune est l'infection des voies respiratoires hautes ou basses, pouvant aller jusqu'à la pneumonie gravissime.

• La mortalité globale de la Covid-19 en France est de 0,7 %, avec de grandes variations selon le terrain, l'âge supérieur à 65 ans étant le principal facteur de risque de forme grave.

• En l'absence d'un traitement efficace et d'un vaccin, l'hygiène et les politiques de santé publique, comprenant le dépistage massif et le confinement des sujets infectés, sont les principaux leviers pour lutter contre l'épidémie.

Sur 1 colonne à droite après la puce de fin

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Références

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  Figures

Figure 1 .Figure 2 .

 12 Figure 1. Nombre quotidien de nouveaux cas de Covid-19 par région de l'Organisation mondiale de la santé.


Jacques Blacher
email: jacques.blacher@aphp.fr

Virginie Femery

Florence Thorez

Philippe Sosner

Alain Dibie

Bruno Pavy

Philippe Beaunier

Jean-Michel Chabot

Mickaël Benzaqui

Robin Ohannessian

Marcel Garnier

Anne Dubois

Corinne Isnard-Bagnis

Isabelle Durand-Zaleski

A novel personalized approach to cardiovascular prevention: The VIVOPTIM programme

ont été assignés à l'un des trois niveaux de risque cardiovasculaire. VIVOPTIM comprend quatre volets : une évaluation du risque cardiovasculaire, une information sur les maladies et les facteurs de risque cardiovasculaires, un coaching personnalisé (séances téléphoniques, fixation des objectifs de santé individuels, surveillance des progrès et motivation des participants) et un suivi e-Santé.

Résultats. -Les données de 2240 participants ont été analysées. Des bénéfices significatifs ont été observés sur la pression artérielle (-3,4 mmHg), le poids (-1,5 kg), le tabagisme (-2,2 cigarettes par jour) et le nombre de pas (+1726 pas par jour (tout P < 0,0001), mais pas sur la durée hebdomadaire de l'exercice (-0,2 heure par semaine, P = 0,619).

Conclusion. -Grâce aux résultats positifs du programme pilote sur le poids, le tabagisme, la pression artérielle et l'activité physique, le programme VIVOPTIM, étendu à la France entière, a le potentiel d'avoir un fort impact sur les soins et sur l'organisation du système de santé.

KEYWORDS

Introduction

Cardiovascular diseases are the leading cause of mortality, worldwide and in France [START_REF] Gbd | Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015[END_REF]. However, a considerable number of such deaths are theoretically avoidable [START_REF] Cdc | Vital signs: avoidable deaths from heart disease, stroke, and hypertensive disease -United States, 2001-2010[END_REF]. Prevention strategies are known to exert beneficial effects -to varying degrees -on various major risk factors for cardiovascular mortality, i.e. hypertension, diabetes mellitus, smoking and atherogenic dyslipidaemia. In addition to these, other non-independent risk factors are also theoretically modifiable. This is the case for overweight and obesity, a sedentary lifestyle, a non-Mediterranean type diet, social deprivation and chronic stress [START_REF] Yusuf | Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study[END_REF]. Nevertheless, despite this widely acknowledged scientific evidence, the prevalence of these risk factors has not improved within the population, and overweight and obesity have increased [START_REF] Diouf | Evolution of obesity prevalence in France: an age-period-cohort analysis[END_REF].

The first step in cardiovascular prevention is patient education. Messages of prevention can be provided collectively, via prevention campaigns aimed at the public at large, and are generally initiated by national public services. They can also be individually targeted, in which case they are generally discussed during visits to a healthcare specialist. However, the cost-effectiveness of individualized programmes has been the subject of considerable debate. Targeting high-risk patients increases efficiency, but the benefit to healthcare systems as a whole is less notable than that of nontargeted nationwide interventions, such as campaigns to reduce dietary intake of trans fats or salt [START_REF] Aljutaili | Should health insurers target prevention of cardiovascular disease? A cost-effectiveness analysis of an individualised programme in Germany based on routine data[END_REF][START_REF] Barton | Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study[END_REF]. Nowadays, in addition to classic healthcare promotion campaigns, patients can also search for information themselves, either on the internet or via the different social networks, and both are endless sources of misleading or false information about cardiovascular prevention. Amongst others are the conspiracy theories, particularly regarding the purported adverse effects of cardiovascular agents used for prevention. The popularity of such stories has a particularly deleterious effect on treatment compliance and even on prescribing habits [START_REF] Lecoffre | LDL cholesterol in adults in metropolitan France: Mean concentration, awareness and treatment in 2015, and trends since 2006[END_REF]. This phenomenon came to light by comparing the results of the Esteban study [START_REF] Lecoffre | LDL cholesterol in adults in metropolitan France: Mean concentration, awareness and treatment in 2015, and trends since 2006[END_REF] with those of the Nutrition Health national survey between 2006 and 2015 particularly with regard to the prescription of statins. Despite the preventive measures put in place, there has been very little progress over recent decades with regard to the management of cardiovascular risk factors [START_REF] Perrine | Hypertension in France: Prevalence, treatment and management in 2015 and temporal trends since 2006[END_REF].

Patients who are given comprehensive information on measures for cardiovascular risk reduction often see the changes as a complete upheaval of their lifestyle, affecting diet, treatment compliance, physical activity and smoking, to name but a few. Many see these changes as such an intrusion into their personal life and freedom that they ultimately give up their good resolutions and lose all motivation. From a population perspective, the onset of a considerable number of cardiovascular events can be accounted for by modifiable risk factors [START_REF] Centers For Disease | Vital signs: avoidable deaths from heart disease, stroke, and hypertensive disease -United States, 2001-2010[END_REF][START_REF] Yusuf | Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study[END_REF], and therefore innovative motivational strategies have the potential to exert a significant impact on cardiovascular morbimortality.

Given the undeniable inefficacy of both collective and individual cardiovascular prevention strategies to date, the Mutuelle Générale de l'Education Nationale (MGEN; General Mutual of National Education) -a provider of private health insurance in France -has developed the VIVOPTIM programme. The primary objective is to provide a novel digital approach to individual wellbeing based on personalized, ranked management of cardiovascular risk factors by a multiprofessional team of healthcare providers. MGEN is a not-for-profit complementary health insurance that covers over four million individuals in France for healthcare costs not covered by the mandatory national health insurance.

This paper presents the details of this pilot project and the clinical results 24 months into the programme. Work is also underway on the medical and economic impact of this programme, and how it is likely to affect the organization of the healthcare system in France in terms of prevention. The results of that branch of our work will be the subject of a dedicated paper.

Patients and methods

Identification and recruitment of participants

Between November 2015 and June 2016, eligible individuals (age 30-70 years) from two regions of France -all of whom were covered by an MGEN complementary health insurance policy -were invited to take part in the study by mail, telephone or during promotional events. At inclusion, volunteers were asked to complete a questionnaire based on the Framingham Heart Study Risk Score for cardiovascular events [START_REF] Agostino | General cardiovascular risk profile for use in primary care: the Framingham Heart Study[END_REF] that included eight questions on individual cardiovascular risk factors.

The Framingham Heart Study Risk Score for cardiovascular events was chosen instead of the SCORE scale for several reasons, particularly the upper age limit (which is 74 in the Framingham Heart Study Risk Score versus 65 in SCORE). Global cardiovascular risk was calculated and participants were assigned to one of three risk levels (level 1, 10-year risk of a cardiovascular event < 10%; level 2, 10-20%; level 3, > 20% or previous history of cardiovascular events, diabetes mellitus, hypertension, renal failure or obesity).

General information about cardiovascular risk prevention was provided to level 1 participants.

Due to the lack of any likely substantial benefits, this group was not offered a personalized programme. Participants in levels 2 and 3 were asked to complete a more detailed questionnaire (60-80 questions) regarding their cardiovascular risk profile. Based on their answers, patients received suggestions for personalized objectives. There were three types of objectives: healthier diet, increased physical activity and improved personal care. The latter could take different forms, such as a more balanced diet, weight loss, stricter adherence to drug therapy, or reducing cigarette consumption.

These objectives were agreed upon during a first motivational telephone interview conducted by a trained nurse, thus concluding the recruitment process.

Data pertaining to participants with a cardiovascular risk level of 2 or 3 who finalized the recruitment process and provided their written consent to participate were included in the statistical analysis. Data pertaining to risk level 1 participants were not included as their exposure to the programme was limited to online information and quizzes on cardiovascular disease and risk factors.

Intervention

There were four components to the programme: cardiovascular risk assessment during the inclusion process, education to improve understanding of cardiovascular diseases and associated risk factors, personalized self-management support and follow-up, and e-Health monitoring. These were not intended to replace the patients' usual care provider and did not cover drug prescriptions or clinical management. As long as participants provided their written consent, individual health data (collected during the programme) were also made available to their general practitioners, who could request the data via a dedicated platform on the VIVOPTIM website. Individuals of all risk levels had access to a website providing information on cardiovascular diseases [START_REF] Vivoptim | Vos habitudes d'aujourd'hui font votre santé de demain[END_REF]. This included general data on cardiovascular risk factors (fact sheets, articles, quizzes, videos, personalized recipes, etc.), e-learning sessions, and online communities where participants could share information and provide mutual support.

Personalized self-management support was available for risk level 2 and 3 participants. It comprised up to six telephone coaching sessions conducted by a specially trained nurse or another healthcare professional (such as a dietician, a medical sports trainer, or a tobaccologist) over the course of a year. The designated referral nurse was in charge of providing information on risk factors and disease management, setting up individual health targets, monitoring progress and providing motivational support to help participants reach their individual objectives. Personal aptitude for change was assessed regularly [START_REF] Prochaska | Stages of change in the modification of problem behaviors[END_REF][START_REF] Amrhein | Client commitment language during motivational interviewing predicts drug use outcomes[END_REF] to help the healthcare professionals coach the participants. The content of the coaching could then be adjusted accordingly. A follow-up coaching session took place after an overall participation period of 18 months.

Participants in the risk level 3 group -particularly those with a history of cardiovascular events -were offered e-Health monitoring of weight and blood pressure, using connected scales and a home blood pressure measurement device.

Data collection and reporting

Demographic characteristics, baseline risk factors and disease history were documented in the inclusion questionnaire. Clinical measurements were collected from participants via the online questionnaires and during structured interviews with trained nurses. There were no predefined frequencies or mandatory measures. The frequency of coaching sessions was agreed upon between the referral nurse and the study participant. Clinical criteria included systolic blood pressure (SBP), body weight, cigarette use (defined as current smoking or stopped ≤ 2 years ago) and physical activity (calculated from reports of weekly duration of physical activity and daily steps).

As all health data were self-reported by the participants, in order to reduce bias, we implemental several procedures:

• All measurements for a participant were performed using the same device; the referring nurse ensured the proper use of devices

• Concerning blood pressure measurements, home blood pressure values were systematically preferred to measurements made by the attending physician or another healthcare professional.

For group 3 patients, there was a systematic dispatch of a connected blood pressure monitor with systematic teletransmission of blood pressure self-measurement values (Terraillon, Tensioscreen). Group 2 patients either had a home blood pressure self-measurement device -in which case it was these values that were taken into account at the different examination times -or they did not have a home device -in which case it was the blood pressure measurements performed by the attending physician that were entered into the file. Home blood pressure monitoring was performed according to the recommendations of the French Society of Hypertension [START_REF] Blacher | Management of hypertension in adults: the 2013 French Society of Hypertension guidelines[END_REF] (measurements in the seated position, 5 minutes of complete rest before each series of measurements, a series of three measurements in the morning and a series of three measurements in the evening for 3 consecutive days):

• Daily numbers of steps were measured with applications on the volunteers' smartphones, ewatches or activity trackers;

• Weight measurement was performed in the morning in light clothes and bare feet between getting up and breakfast (after the morning toilet).

Statistical analysis

The population eligible for clinical evaluation was made up of all risk level 2 and 3 participants who completed the recruitment process and provided their informed consent. In addition to the total population, five groups were also defined for the statistical analysis, corresponding to the clinical criteria assessed (SBP, body weight, cigarette use, weekly duration of physical activity, and daily steps). For each given criterion, the corresponding group comprised all participants who underwent at least two criteria assessments at intervals in excess of 1 month. It is important to note that each participant could belong to several groups as they could declare values for several clinical criteria.

Descriptive statistics were performed to determine the demographic characteristics, cardiovascular history, and cardiovascular and metabolic risk factors of the six populations, i.e. the overall population and the five groups. Descriptive statistics were also computed for the clinical criteria and for measurements of individual involvement in the programme. Results are presented as frequencies and percentages for categorical variables, and as means and standard deviations (SDs) for continuous variables. For each clinical criterion, the progression between inclusion and the end of the individual follow-up period was estimated for individuals in the corresponding group. As previously mentioned, none of the inter-measurement intervals were mandatory. Furthermore, participants could drop out before the end of the scheduled 18-month follow-up period. Consequently, where required, the last reported criteria measure for each individual was carried forward to the end of the total duration of 18 months. To assess the progression of each clinical criterion, Student's paired t test was performed with a type I error of 5% and under the null hypothesis of an absence of progression. If the t test was significant, a linear regression model was fitted to the data. A step-down procedure with a threshold of 0.2 was used to select the final covariates from among those tested, i.e. sex, age, criteria measurements at inclusion and a history of cardiovascular events. All analyses were performed using SAS software (version 9.4; SAS Institute, Carry, NC) and R (version 3.5.1) for graphical display.

Results

Fig. 1 shows the final numbers of participants in the study population and in each of the five groups, with details of reasons for exclusion. There were 2240 participants in the overall population, of whom 827 declared at least two SBP values at intervals > 1 month. Likewise, there were 1411, 79, 148 and 83 participants who declared at least two values at intervals > 1 month for weight, cigarette use, duration of exercise and daily number of steps, respectively.

In the overall population, the mean age of participants was 62.0 ± 7.2 years and 59.3% were male (Table 1). Many patients had risk factors for cardiovascular disease: 11.3% were in secondary cardiovascular prevention, 9.1% had diabetes, 37.8% hypertension and 22.9% obesity, but few (7.4%) were active smokers. Overall, 72.1% of the study population were risk level 3 (high calculated global cardiovascular risk). Individual characteristics in each of the five groups were generally similar to those of the whole population (Table 1). Logically, involvement in the programme was higher for the five groups (Table 1). Fig. 2 shows the statistically significant effects of the interventions on SBP (-3.4 mmHg, P < 0.0001), weight (-1.5 kg, P < 0.0001), smoking (-2.2 cigarettes/day, P < 0.0001), and daily steps (+1726 steps/day, P < 0.0001), though not on weekly duration of exercise (-0.2 hours/week, P = 0.619).

For the progression of each clinical criterion, a linear regression model was fitted to the data by a step-down procedure to assess the covariates (age, sex, parameter's level at inclusion, cardiovascular risk factors and presence of a cardiovascular disease). None of the multivariable models were statistically significant, as only a marginal part of variance could be explained by the models (< 10%, data not shown), and no parameter entered any of the four multivariable models. We therefore failed to identify any specific determinants of the clinical benefits.

Discussion

The salient findings of the VIVOPTIM intervention pilot programme are that this innovative, individualized, multiprofessional, ranked management of cardiovascular risk factors had statistically significant beneficial effects on SBP, weight, smoking and daily number of steps, though not on weekly duration of exercise, after a mean follow-up period of 14 months.

We postulate that the two main explanations for our positive results are the design of the VIVOPTIM programme and the characteristics of the study population. With regards to the latter, we observed several discrepancies compared to other population-based French cohorts [START_REF] Lecoffre | LDL cholesterol in adults in metropolitan France: Mean concentration, awareness and treatment in 2015, and trends since 2006[END_REF][START_REF] Perrine | Hypertension in France: Prevalence, treatment and management in 2015 and temporal trends since 2006[END_REF][START_REF] Zins | The French CONSTANCES population-based cohort: design, inclusion and follow-up[END_REF]. For example, the smaller proportion of active smokers (7.4% in VIVOPTIM vs 18.0 in the CONSTANCES cohort [START_REF] Blacher | Management of hypertension in adults: the 2013 French Society of Hypertension guidelines[END_REF] and 21.7% in the Esteban study [START_REF] Lecoffre | LDL cholesterol in adults in metropolitan France: Mean concentration, awareness and treatment in 2015, and trends since 2006[END_REF][START_REF] Perrine | Hypertension in France: Prevalence, treatment and management in 2015 and temporal trends since 2006[END_REF]) suggests a relatively health-conscious population [START_REF] Hercberg | The Nutrinet-Sante Study: a web-based prospective study on the relationship between nutrition and health and determinants of dietary patterns and nutritional status[END_REF]. Positive results in a highly selected population of health-conscious motivated volunteers need to be confirmed at the population level, but we believe that the design of the programme also helps to motivate the participants and thus the positive results. Indeed, we considered that the management of lifestyle changes required the support of specialists capable of providing both technical support (e.g. tobaccologist, dietician, sports instructor) and psychological support (referral nurse specially trained in motivational interviews, active listening and coaching skills).

The medical literature has reported on countless intervention programmes that focus on cardiovascular risk factors [START_REF] Ebrahim | Multiple risk factor interventions for primary prevention of coronary heart disease[END_REF]. Over 20 years ago, an American Heart Association (AHA) task force on the primary prevention of coronary heart disease concluded that: 'if the burden of coronary heart disease in American society is to be substantially reduced, primary prevention must be improved' and 'Risk factor modification in the general public and persons at high risk offers the best opportunity for effectively reducing the prevalence of coronary heart disease in the United States'. [START_REF] Grundy | Primary prevention of coronary heart disease: guidance from Framingham: a statement for healthcare professionals from the AHA Task Force on Risk Reduction[END_REF]. Later, a Cochrane review [START_REF] Ebrahim | Multiple risk factor interventions for primary prevention of coronary heart disease[END_REF] highlighted the impact that lifestyle interventions have on total mortality, as well as fatal and non-fatal cardiovascular events when tailored to particular categories of patients, such as high-risk patients with hypertension or diabetes. Nevertheless, in terms of the impact of these interventions on modifiable risk factors, the marked heterogeneity between trials made pooled results of 'dubious validity' [START_REF] Ebrahim | Multiple risk factor interventions for primary prevention of coronary heart disease[END_REF]. More recently, another meta-analysis [START_REF] Sisti | The effect of multifactorial lifestyle interventions on cardiovascular risk factors: a systematic review and meta-analysis of trials conducted in the general population and high risk groups[END_REF] concluded that multifactorial lifestyle interventions lowered blood pressure, total cholesterol, body mass index and waist circumference, at both 6 and 12 months, and increased physical activity at 12 months. For the authors, multifactorial lifestyle interventions clearly represent a valid tool for reducing cardiovascular risk factors and should be implemented in at-risk groups and in primary prevention [START_REF] Sisti | The effect of multifactorial lifestyle interventions on cardiovascular risk factors: a systematic review and meta-analysis of trials conducted in the general population and high risk groups[END_REF]. In Sweden, a community and primary care-based intervention demonstrated beneficial effects on blood pressure, glycaemia and smoking [START_REF] Eliasson | Comparison of trends in cardiovascular risk factors between two regions with and without a community and primary care prevention programme[END_REF]. In overweight and obese patients, a systematic review and network meta-analysis on the impact of long-term lifestyle programmes on weight loss and cardiovascular risk factors found that a combination of diet and exercise was more effective than either diet or exercise alone [START_REF] Schwingshackl | Impact of long-term lifestyle programmes on weight loss and cardiovascular risk factors in overweight/obese participants: a systematic review and network meta-analysis[END_REF]. The existing literature on multifactorial lifestyle interventions is extremely heterogeneous: very few studies have lasted longer than 6-12 months and, to our knowledge, none have assessed the impact of individualized management of cardiovascular risk factors for > 1 year, such as was conducted in the VIVOPTIM pilot programme.

Our study has several limitations. First, given that the study population of volunteers was highly selected, our positive results cannot be directly extrapolated to the population at large: the male/female and geographical distributions were similar, but the mean age was about 6 years older than that of the 250,000 MGEN-eligible members [START_REF] Dibie | VIVOPTIM: Feedback of an e-Health experimental program of primary prevention of cardiovascular risk on 30 to 70 years old volunteers[END_REF]. Second, because most data were patientreported, discrepancies in comparison with the real world cannot be excluded, although teletransmission of data and corroboration with coaches did limit the risk. Third, because interventions were both qualitatively and quantitatively heterogeneous, individually tailored to each participant, with the potential support of one or more healthcare professionals, it was not easy to quantify or accurately assess their impact. Fourth, follow-up duration was also extremely diverse, ranging between 1 and 24 months, according to the participants' genuine motivation to change their lifestyle. Fifth, since it was difficult to invite volunteers and subsequently tell them that they had been randomized to the control group without any intervention, there was no control group in the present study.

From a financial standpoint, the VIVOPTIM programme is in keeping with both a conceptual and an operational commitment. Conceptual, because the primary objective was to show that this comprehensive end-to-end approach to patient care has beneficial effects on individual cardiovascular risk profiles and ultimately reduces the incidence of cardiovascular accidents; and operational, since the aim was to implement this approach as extensively as possible.

In light of the optimistic results of the VIVOPTIM pilot programme to date, the board of directors of the MGEN decided to extend the programme to the whole of France as from July 2018.

With this in mind, and in light of the analysis of the results of the pilot phase, the following noteworthy decisions have been made: (1) future inclusion in the programme will be both simper and quicker; [START_REF] Cdc | Vital signs: avoidable deaths from heart disease, stroke, and hypertensive disease -United States, 2001-2010[END_REF] cardiovascular risk assessment will be optimized; (3) the number of coaching sessions will be increased (up to seven); (4) a module of stress management will be added as a complement to lifestyle changes; and (5) management of interactive content will be improved, with a particular focus on leveraging individual motivation.

In conclusion, despite the limitations, the VIVOPTIM pilot programme has shown extremely promising results on weight, smoking, blood pressure, and uptake of physical exercise. This programme has the potential to have a meaningful impact on patient care and organization of the healthcare system in France.

  Abbreviations: AHA, American Heart Association; CCTIRS, Comité Consultatif sur le Traitement de l'Information en matière de Recherche dans le domaine de la Santé; CNIL, Commission Nationale Informatique et Libertés; MGEN, Mutuelle Générale de l'Education Nationale; SBP, systolic blood pressure; SD, standard deviation.

For

  each participant, there could be zero, one or multiple values for a given criterion based on individual objectives, individual progression, frequency of use of telemedicine devices and duration of follow-up in the programme. Each participant's involvement in the programme was assessed based on the number of coaching calls, the total duration of those calls and the overall duration of active participation. An academic scientific committee validated the main study design, including the content of the website and the e-coaching. Both the programme and the study received approval from the appropriate ethics and administrative committees: the Comité Consultatif sur le Traitement de l'Information en matière de Recherche dans le domaine de la Santé (CCTIRS; French Advisory Committee on Information Processing in the Field of Health) (Dossier n°15.216bis dated 13 May 2015), and the Commission Nationale Informatique et Libertés (CNIL; French Data Protection Authority) (Délibération n°2015 273 dated 13 July 2015).

Figure 1 .

 1 Figure 1. Flow chart of the VIVOPTIM programme. a Participants with < 2 reported values (or 2 values reported within < 1 month).

Figure 2 .

 2 Figure 2. A. SBP, B. weight, C. cigarette use, D. weekly duration of physical exercise and E. daily steps at inclusion and the end of follow-up. Bars show means, error bars show SDs. The results of the univariate t test on progression between inclusion and the end of individual follow-up are shown. CI, confidence interval; SBP: systolic blood pressure; SD, standard deviation.

Figure 2 [

 2 Figure2[Note to journal: besides style alterations, please replace titles with A, B, etc. but add "n = 827" etc. under bars. If titles are kept, please alter "Tobacco consumption" to "Cigarette use", "Daily walking distance" to "Daily steps". Please alter y axis of D to "Exercise duration (hours/week)". Suggest alter numbers to 1 decimal place]

Table 1

 1 Characteristics of the overall population and the five groups.Data are expressed as mean ± standard deviation or number (%). BMI: body mass index; CV: cardiovascular; SBP: systolic blood pressure; SD: standard deviation.

	Variables	Total	SBP	Weight	Cigarette use	Duration of	Number of
		(n = 2240)	(n = 827)	(n = 1411)	(n = 79)	exercise/week	steps/day
						(n = 148)	(n = 83)
	Cardiovascular risk factors
	Age (years)	62.0 ± 7.2 63.2 ± 6.7	62.2 ± 7.2	60.5 ± 7.2	61.2 ± 7.6	61.8 ± 7.5
	Female	912 (40.7) 351 (42.4)	592 (42.0)	25 (31.6)	60 (40.5)	31 (37.3)
	Risk level 2	624 (27.9) 98 (11.9)	291 (20.6)	16 (20.3)	23 (15.5)	15 (18.1)
	Risk level 3	1616	729 (88.1)	1120 (79.4) 63 (79.7)	125 (84.5)	68 (81.9)
		(72.1)
	Chronic renal failure 27 (1.2)	15 (1.8)	18 (1.3)	3 (3.8)	3 (2.0)	2 (2.4)
	Previous CV event	253 (11.3) 115 (13.9)	186 (13.2)	13 (16.5)	22 (14.9)	11 (13.3)
	Hypertension	846 (37.8) 431 (52.1)	581 (41.2)	25 (31.6)	66 (44.6)	29 (34.9)
	Diabetes	203 (9.1)	87 (10.5)	140 (9.9)	8 (10.1)	14 (9.5)	7 (8.4)
	Prediabetes	334 (14.9) 128 (15.5)	222 (15.7)	13 (16.5)	26 (17.6)	11 (13.3)
	Dyslipidaemia	734 (32.8) 306 (37.0)	505 (35.8)	25 (31.6)	50 (33.8)	25 (30.1)
	Smoking a	166 (7.4)	42 (5.1)	81 (5.7)	79 (100)	9 (6.1)	2 (2.4)
	Clinical characteristics at inclusion
	Weight (kg)	77.8 ± 14.7 78.3 ± 15.2 79.8 ± 15.1 77.4 ± 14.8	80.7 ± 15.2	82.3 ± 14.4
	BMI (kg/m 2 )	26.9 ± 4.7 27.2 ± 4.5	27.6 ± 4.6	26.3 ± 4.6	28.0 ± 4.4	28.3 ± 4.5
	Obese	512 (22.9) 203 (24.5)	394 (27.9)	16 (20.3)	50 (33.8)	26 (31.3)
	Overweight	839 (37.5) 339 (41.0)	572 (40.5)	33 (41.8)	65 (43.9)	41 (49.4)
	SBP (mmHg)	129.0 ± 9.7 130.1 ± 12.4 129.4 ± 12.0 127.2 ± 11.5 129.9 ± 11.9	130.3 ± 10.0
	Physical activity at inclusion
	Duration of exercise	2.8 ± 3.8	3.1 ± 4.0	3.0 ± 4.0	3.8 ± 4.8	3.1 ± 4.7	3.0 ± 3.7
	(hours/week)
	Number of steps	6314 ±	5609 ± 2422 5471 ± 2455 6774 ± 1884 5335 ± 2201	5592 ± 2269
	(steps/day)	1581
	Involvement in the programme
	Number of coaching 4.2 ± 2.7	6.2 ± 2.0	5.5 ± 2.3	5.7 ± 2.3	6.1 ± 1.9	6.0 ± 2.0

a Current smoker or stopped ≤ 2 years ago.

Acknowledgements

The authors would like to thank everyone involved in the VIVOPTIM programme: the VIVOPTIM project management team and the dedicated MGEN Directors, the operational partners, the professional coaches and, of course, all the volunteers who accepted to take part in the VIVOPTIM experience. This programme would not have been possible without the commitment of the Corporate Governance of the MGEN Group. Special thanks go to Isabelle Hébert, Chief Executive Officer of the MGEN Group, an inspiring entrepreneur who constantly strives to improve the healthcare of subscribers.

The authors thank Moyra Barbier for editorial assistance.

Sources of funding

The MGEN supported all expenses of the VIVOPTIM programme.

Disclosure of interest

All authors received honoraria from the MGEN for their participation as members of the VIVOPTIM committees.

Author contributions

All authors contributed to the conception or design of the work. Jacques Blacher, Virginie Femery and Anne Dubois contributed to the acquisition, analysis and interpretation of data for the work. All other authors contributed to analysis and interpretation of data of the work. Jacques Blacher and Virginie Femery drafted the manuscript. All authors critically revised the manuscript. All authors gave final approval and agree to be accountable for all aspects of work ensuring integrity and accuracy.