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Introduction | reduced muscle tone, palate, epiglottis, airway obstruction | AIRWAY OBSTRUCTION | Managing difficult airways is one of the most essential and challenging tasks for anesthesiologistsSecuring an open airway is important for successful FOI. In anesthetized patients with reduced muscle tone, a downward shift of the soft palate, tongue, and epiglottis close to the posterior pharyngeal wall results in narrowing of the oropharyngeal space. Partial or complete airway obstruction makes the bronchoscope difficult to be handle and located at the glottisClearing the airway during FOI involves several maneuvers, such as jaw-thrust and lingual traction, and airway devices, including intubating airways and direct laryngoscopesThe McIvor blade is a tongue retractor with a thin blade and flat handle. It is widely used during pharyngeal surgeries, such as tonsillectomy, to secure the operation field by pressing the tongue body/base and retracting them forward. The blade has also been reported to facilitate laryngeal mask airway insertion by providing additional airway space | PMC10504239 |
Methods | PMC10504239 | |||
Study | The randomized clinical trial protocol was performed in accordance with Declaration of Helsinki and approved by the Institutional Review Board of Seoul National University Bundang Hospital (approval number: B-1704-393-004; approval date: 13 June 2017) and registered at the Clinical Research Information Service (CRIS; | PMC10504239 | ||
Patients | craniofacial anomalies | CERVICAL SPINE DISEASE | American Society of Anesthesiologists (ASA) physical status class I or II patients who were > 18 years of age and scheduled for elective surgery under general anesthesia requiring orotracheal intubation were enrolled in this study. Patients with ASA class ≥ III, dentures, craniofacial anomalies, history of cervical spine diseases, who were at risk for pulmonary aspiration, and who required awake intubation were excluded. Enrolled patients were randomly allocated to a group that underwent the jaw-thrust maneuver (J group) or the McIvor blade (M group) in a 1:1 ratio. Randomization was performed by an independent anesthesiologist using a computer-generated random number table (Random Allocation Software version 1.0; Isfahan University of Medical Sciences, Isfahan, Iran), 5 min before admission to the operating room. Group information concealed within an opaque envelope was opened just before FOI attempt. | PMC10504239 |
Anesthesia and intervention | palate, glottis, epiglottis | The patients were positioned supine with their heads on a standard surgical pillow. Standard monitoring of vital signs included electrocardiography, non-invasive blood pressure measurement, and peripheral oxygen saturation measurement. After 3 min of denitrogenation with 100% oxygen, general anesthesia was induced with 1–1.5 mg kgIn the J group, an independent assistant in charge of airway maneuvers stood at the patient’s left side and applied a jaw-thrust maneuver prior to FOI. In the M group, a McIvor blade (size #4 from McIvor mouth gag set; Karl Storz GmbH, Tuttlingen, Germany) was placed with the patient’s head extended. The blade was fully inserted into the midline of the oropharyngeal space, placed at the base of the tongue, and gently lifted forward to clear the airway. This practice was performed by a maneuvering assistant who maintained the position of the patient’s head and continuously pulled the blade forward and upward (Fig. (In performing FOI, the anesthesiologist inserted the bronchoscope into the mouth along the dorsum of the patient’s tongue and advanced it through the vocal cords. Airway clearance at the level of the soft palate was assessed by checking the position of the uvula or the soft palate from the dorsum of the tongue and was classified as clear (If the uvula did not touch the tongue), partially obstructed (If the uvula was in contact with the tongue), and complete obstruction (If the whole soft palate abutted the tongue). On the contrary, airway clearance at the epiglottis level was assessed by observing whether the epiglottis touched the posterior pharyngeal wall or not and was classified as clear (full view of the glottis), partially obstructed (If the sides of the epiglottis touched the posterior pharyngeal wall and there is a partial view of the glottis), and complete obstruction (If the glottis was not completely in sight) (Fig. Bronchscopic assessment of airway clearance at the soft palate and epiglottis levels.If the approach to the vocal cord and carina was unsuccessful in 60 s or peripheral oxygen saturation decreased below 90%, two further trials were conducted after 2 min of mask ventilation with 3% sevoflurane in 100% oxygen. If successful insertion into the trachea was not performed after three trials, the FOI was recorded as a failure, and the anesthesiologist performed tracheal intubation using direct laryngoscopy.After the fiberoptic bronchoscope entered the glottis and approached the carina level, the tracheal tube was advanced over the bronchoscope into the trachea, and the bronchoscope was removed to complete the FOI. If resistance was met during tube advancement, the tracheal tube was pulled out, rotated counterclockwise in steps of 90°, and advanced until it overcame resistanceAfter FOI was completed, the tracheal tube was connected to a ventilator circuit, and manual ventilation was attempted to confirm successful intubation with the presence of end-tidal carbon dioxide (EtCO | PMC10504239 | |
Study outcome | The primary outcome was the total intubation time, defined as the duration from inserting the fiberoptic bronchoscope into the mouth to the appearance of EtCO | PMC10504239 | ||
Sample size | During a pilot study among 20 patients undergoing FOI intubation, the total intubation time was 26.5 (12.2) s when the jaw-thrust maneuver was applied (10 patients) and 20.4 (10.1) s when the McIvor blade was placed for tongue retraction (10 patients). Based on the pilot data, a sample size of 48 patients per group was required with a significance level of 95%, a power of 80%, and a 10% anticipated dropout rate. | PMC10504239 | ||
Statistical analysis | Continuous variables are presented as mean (standard deviation), and categorical variables are presented as numbers (percentages). All statistical analyses were performed using the SPSS version 21.0 software (SPSS Inc., Chicago, IL, USA). Student’s t-test was used to compare continuous variables, and the chi-squared test or Fisher’s exact test was used to analyze categorical variables. Statistical significance was set at a two-sided p value < 0.05. | PMC10504239 | ||
Author contributions | S.-H.H., S.P., and J.-W.P. conceptualized and designed the study; S.-H.H., J.-H.K., S.P. and J.-W.P. collected the original data; J.L., J.H.L, and H.G.K. analysed the data; J.L., S.-H.H. and J.-W.P. interpreted the analysis and helped with quality control; J.L., J.H.L., and H.G.K. prepared the original draft; S.-H.H., J.-H.K., and J.-W.P. reviewed and edited the draft. All authors have read and agreed to the published version of the manuscript. | PMC10504239 | ||
Data availability | The datasets used and analysed during the current study available from the corresponding author on reasonable request. | PMC10504239 | ||
Competing interests | The authors declare no competing interests. | PMC10504239 | ||
References | PMC10504239 | |||
Background | COPD | COPD | Pulmonary rehabilitation (PR) programs improve physical fitness, symptoms and quality of life (QoL) of patients with COPD. However, improved physical activity (PA) is not guaranteed after PR and the clinical benefits fade off after PR discharge. We aimed to investigate whether a 9 months PA-telecoaching program is able to improve PA of patients with COPD, after 3 months of PR and if this leads to maintenance of PR-acquired benefits. | PMC10563200 |
Methods | dyspnea, COPD | COPD, SECONDARY | Patients with COPD enrolled in a 6-month PR program were randomized to a (semi-automated) PA-telecoaching program or usual care, 3 months after PR initiation. The intervention consisted of a smartphone application with individual targets and feedback (for 6 months) and self-monitoring with a step counter (for 9 months). Patients were followed up for 9 months after randomization. Primary outcome was PA (daily step count by accelerometery), secondary outcomes were exercise tolerance, quadriceps force, dyspnea and QoL. | PMC10563200 |
Results | Seventy-three patients were included (mean ± SD: 65 ± 7 years, FEV | PMC10563200 | ||
Conclusion | The semi-automated PA-telecoaching program implemented after 3 months of PR was effective to improve the amount of PA (steps/day) during PR and after follow-up. However, this was not accompanied by the maintenance of other PR-acquired benefits. | PMC10563200 | ||
Trial registration | ClinicalTrials.gov. Identifier: NCT02702791. Retrospectively registered on March 9, 2016. Start study October 2015. | PMC10563200 | ||
Supplementary Information | The online version contains supplementary material available at 10.1186/s12966-023-01519-w. | PMC10563200 | ||
Keywords | PMC10563200 | |||
Background | dyspnea, COPD | COPD | Multidisciplinary pulmonary rehabilitation (PR) programs result in important and clinically relevant improvements for patients with symptomatic COPD, such as improved functional exercise tolerance, muscle force, symptoms of dyspnea and quality of life (QoL) [Programs aiming to improve PA outside a PR-setting, using self-monitoring and feedback strategies (i.e. step counters) have been shown effective in several (short-term) trials [Furthermore, the effect on the maintenance of PR-acquired benefits of programs using wearable technology to promote PA have not been explored in depth yet. It is tempting to speculate that enhanced PA may indeed be crucial to maintain the benefits of a PR-program.We conducted a RCT which aimed to investigate (1) Whether implementation of a (semi-automated) PA-telecoaching program, started after 3 months of PR, was effective at increasing PA after 9 months of follow-up (i.e. the long-term effects) and (2) If this PA program resulted in maintained PR-acquired benefits in terms of physical fitness (exercise tolerance, skeletal muscle strength), symptoms and health-related QoL. | PMC10563200 |
Methods | PMC10563200 | |||
Subjects | COPD | COPD | Patients with COPD who enrolled in the multidisciplinary, six months outpatient PR at the Leuven Hospital were screened for eligibility. After completing three months of PR and after one-week PA assessment, patients were invited to participate to the STEP (‘Sustaining Training Effects through Physical activity promotion’) trial. Main inclusion criteria included being older than 40 years, having cognitive ability to work with electronic devices and absence of comorbidities that interfere with the normal biomechanical movement patterns and therefore PA performance. Further details are outlined in the additional file 1. | PMC10563200 |
Design | This was a mono-center, 1:1 prospective RCT (details of randomization outlined in additional file 1). At three months of the 6 months PR-program, eligible patients were included in the study after signing a written informed consent. The trial was registered at clinicaltrials.gov (NCT02702791) and was approved by the local ethics committee (S57963). It consisted of four visits: (1) a visit at randomization, upon completion of 3 months of PR (i.e. start of the study – V0), (2) a visit at the end of PR (i.e. upon completion of 6 months of PR and 3 months after randomization – V1), (3) a visit 3 months after discharge from PR and 6 months after randomization (V2) and (4) a visit 6 months after discharge from PR and 9 months after randomization (V3) (Fig.
Study design. Four study visits: a visit at randomization (i.e. after 3 months of PR; V0), a visit at the end of PR (i.e. after 6 months of PR; V1), a visit after 3 months of follow-up from PR (V2) and a visit after 6 months of follow-up from PR (V3). Data at the start of PR (i.e. 3 months before randomization) were also used for analysis (V-1). Patients were followed up for 9 months after initiation of the PA telecoaching program. PR, pulmonary rehabilitation; V, visit; UCG, usual care group; IG, intervention groupThe first randomization visit for the first patient took place on October 2015. Last patient last visit took place on September 2019. | PMC10563200 | ||
Interventions | PMC10563200 | |||
Pulmonary rehabilitation program (PR) | The standard six-months multidisciplinary program of the Leuven Hospital, previously described in detail [ | PMC10563200 | ||
Usual Care | At randomization, patients in the UCG received an information leaflet explaining the importance of and tips on how to become more physically active. Furthermore, at V0, an interview was conducted to assess the level of the patients’ motivation and self-efficacy towards increasing and maintaining their PA level throughout the trial (likert-type scale ranging from 0 (lowest) to 10 (highest)). | PMC10563200 | ||
Intervention Group | On top of usual care, patients in the IG received a PA-telecoaching program very similar to the one used previously (NCT02158065–MrPAPP trial), which was proven effective on short-term PA [At randomization, in addition to the assessment of motivation and self-efficacy, the interview in the IG elaborated on barriers of being active, personalized strategies to become more active and a specific action plan was agreed and delivered to the patients, so they could consult it during the intervention. | PMC10563200 | ||
Assessments | Prior to each visit, PA was objectively assessed with the Dynaport Movemonitor (DAM, McRoberts BV, The Hague, the Netherlands) and the Actigraph GT3x (ACT, Actigraph LLC Pensacola, Florida, USA), two validated accelerometers(For patient characterization, spirometry, lung volumes and diffusion capacity of the lung for carbon monoxide were measured at V0. Secondary outcomes were (measured at V0, V1, V3) Exploratory outcomes (measured at V-1 and V3) included | PMC10563200 | ||
Statistical analysis | dyspnea | SECONDARY | Analyses were performed using SAS Software version 9.4. Values were expressed as mean ± standard deviation (SD) or median [percentile 25-percentile 75] (in case of non-normal distribution – Shapiro-Wilk test) or as numbers (%) in case of frequencies. Statistical significance was set a priori as p < 0.05 for all analyses. All randomized patients were invited for follow-up assessments and included in the Intention-to-treat analysis, even if they stopped using the intervention. The overall effects of the PR-program from V-1 to V0 were descriptively calculated for all patients from assessments obtained in clinical routine.First, to assess the effect of the PA-telecoaching program on change in PA (i.e. steps/day, MVPA and MI), mixed model analyses were used retrieving the interaction effects at each visit as main results. PA at V0 was chosen as reference. The models were adjusted for daylight as a proxy for seasonality [Second, to analyze the effect of the PA-telecoaching program on change of PR-acquired benefits similar mixed models were used for secondary outcomes (maximal, endurance and functional exercise tolerance, quadriceps force, symptoms of dyspnea and QoL). The change in exploratory outcomes (body weight, bone mineral density, blood glucose, lipids and insulin profile) from V-1 (start PR, i.e. 3 months before randomization) to V3 were analysed via ANCOVA analyses, adjusting for values at randomization (V0).Finally, we explored the difference in proportion of patients with long-term success between UCG and IG using chi-square analyses. Long-term success was defined as an increase above the minimal important difference (MID) at V3 as compared to start of PR (V-1) in terms of (A) functional exercise tolerance (i.e. Δ6MWD ≥ 30 m), (B) symptoms of dyspnea (CRDQ score ≥ 2.5 points) and (C) QoL(CRDQ score ≥ 10 points) [ | PMC10563200 |
Sample size calculation | Sample size calculation was based on the primary research question (i.e. effectiveness of the intervention on daily step count). To obtain a power of 80%, expecting a drop-out rate of 20%, a total of 82 patients needed to be included in this study (based on a between group difference of 1785 steps/day, SD of 2505 and α-level of 0.05). These data were based on preliminary results of the tele coaching study running in our center [ | PMC10563200 | ||
Results | PMC10563200 | |||
Patient characteristics | COPD | COPD, CHRONIC OBSTRUCTIVE PULMONARY DISEASE | In total, 73 patients were randomized to either the UCG (n = 37) or IG (n = 36) after 3 months of PR, of which 65 were followed up until the end of trial (Fig.
Flow diagram of STEP trial. Numbers refer to the total number of patients evaluated at each timepoint, independently of obtaining valid physical activity measures. PR, pulmonary rehabilitation program; COPD, Chronic Obstructive Pulmonary Disease; m, months; V, visit. Each visit (i.e. V-1, V0, V1, V2, V3) has an interval of 3 months in between
Patient characteristics at randomizationValues presented as mean ± standard deviation or as number (percentage). UCG, usual care group; IG, intervention group; BMI, n, number of patients; body mass index; kg, kilograms; m,meters; FEVCharacterization of patients at the start of PR (V-1, 3 months before randomization) is included in the Additional file 3. Overall, changes in PA in the first 3 months of PR (V-1 to V0) were modest (Δ725 ± 1822 steps/day and Δ8 ± 24 min/day MVPA). As expected, patients experienced, at the group level, prior to randomization (V-1 to V0) meaningful improvements in maximal and functional exercise tolerance and Qol (ΔWork rate (WR) = 10 ± 115 Watts, Δ6MWD = 43 ± 28 m and ΔCRDQ total = 14 ± 12 points). | PMC10563200 |
Intervention effect on physical activity | Patients who received the PA-telecoaching intervention presented clinically important improvements in steps/day compared to patients in the UCG, at each time point after randomization (Fig.
Comparison of the changes in PA between patients from both the IG and UCG, adjusted for daylight at each visit point. p-values indicate the interaction effect (with V0 as the reference). PA; physical activity; IG, intervention group; UCG, usual care group; n, number; m, months; PR, pulmonary rehabilitation. Data based on multiple imputation
Comparison of changes in PA between IG and UCG groups. V0 was considered the reference at mixed model analysisValues presented as estimates ± standard error obtained from the mixed model analysis adjusted for daylight. PA, physical activity; MVPA, moderate to vigorous PA. UCG, usual care group; IG, intervention group; min; minutes; m, meter; s, seconds. In case of missing data (for steps/day and MVPA) from the Dynaport Activity Monitor, multiple imputation was performed with the data from the Actigraph as outlined in the methodology section. At V1, V2 and V3, interaction effect with V0 as reference value are displayed | PMC10563200 | ||
Effect on secondary outcomes | SECONDARY | The PA-telecoaching program did not induce significant improvements in terms of maximal, endurance and functional exercise tolerance, muscle strength and QoL as compared to usual care (Table
Comparison of the changes in secondary outcomes between IG and UCGValues presented as estimates ± standard error. m- months, PR, pulmonary rehabilitation program; VO | PMC10563200 | |
Effect on exploratory outcomes | SE, high-density lipoprotein | The effect of the PA-telecoaching program on exploratory outcomes is displayed in Table
Effect of PA-telecoaching intervention on exploratory outcomesData are expressed as mean ± standard deviation. UCG, usual care group; IG, intervention group; DEXA, dual energy X-ray absorptiometry; g, gram; mg, milligram; dL, deciliters; HDL, high-density lipoprotein; LDL, low-density lipoprotein. Between group differences and p-values are based on ANVOCA analyses and expressed as mean ± SE. | PMC10563200 | |
Adverse events and follow-up | cancer, non-respiratory adverse, pain | ADVERSE EVENTS, CANCER, EVENT, VIRAL GASTROENTERITIS | Twenty patients (57%) experienced at least one (moderate or severe) acute exacerbation during the study in the UCG compared to 14 (47%) patients in the IG (p = 0.46). A total of 51 non-respiratory adverse events were reported during the study period, of which 20 (39%) occurred in the IG and 31 (61%) in the UCG. 47% of them led to a hospital admission. The adverse events were cardiovascular (25%), musculoskeletal (24%), internal (4%), cancer (2%) and other (45%). Two (swollen knee in UCG, joint pain in IG) were considered as “unlikely” related to the study, the other as “not” related to the study. One event (viral gastroenteritis) led to study discontinuation.After finishing 6 months of PR and 9 months after randomization, slightly more (65%) patients from the UCG continued supervised training (i.e. typically 1x/week in primary/community care) compared to the IG (42% p = 0.14). | PMC10563200 |
Discussion | COPD, diabetes [ | COPD | The semi-automated PA-telecoaching program implemented at 3 months of PR was able to induce a sustained and clinically significant [Despite the ATS/ERS recommendation of including physical activity promotion within PR [A first explanation for this apparent discrepancy across trials, is the timing of the PA-coaching intervention. Providing PA coaching interventions at the start of a PR program might be overwhelming and unrealistic in these symptomatic, inactive and deconditioned patients [The present study is supported by the “Capability, Opportunity & Motivation” for Behaviour change (COM-B) system, a framework for understanding behaviour (change) from Michie and colleagues(Despite the significant effect on the amount of PA, this intervention did not result in sustained training benefits. The latter could have been expected as several of these PR training benefits are known to be positively associated with PA in patients with COPD [In line with the results on exercise tolerance, muscle force, quality of life, body composition, BMD and blood markers of insulin and lipids were not clinically better in the IG at the end of the trial. A decrease in the level of fasted blood glucose in the IG was noted compared to the UCG, which could lower the incidence risk for diabetes [ | PMC10563200 |
Strengths and limitations | PR-benefits | To the best of our knowledge, this trial is one of the first to test a long-term effect of a PA intervention and to investigate the causal relationship between PA and PR-benefits using an interventional design after 3 months of PR and 9 months of follow-up. It therefore helps to understand the importance of achieving the long-term goals of PR as described in the guidelines for PR by major respiratory Societies [Due to the nature of the intervention, patients could not be blinded for group allocation. PR-sessions were performed in group and contamination could not be prevented. This study was conducted in a 6-month outpatient PR setting. This needs to be considered for the external validity of our findings. However, the actual PA-telecoaching intervention started after 3 months of PR. The study by Spielmanns et al. is a first external validation that the concept of starting PA coaching after shorter PR may also be successful [ | PMC10563200 | |
Conclusion | The implementation of a semi-automated PA-telecoaching program after a 3 months-PR program was effective to improve the amount of PA. Contrary to our hypothesis, this did not result in a better maintenance of other PR-acquired benefits. Further studies need to look into further strategies to maintain the overall physical fitness benefits of PR as steps-guided PA-telecoaching may not suffice to achieve this goal. | PMC10563200 | ||
Acknowledgements | The authors would like to thank physiotherapists Iris Coosemans, Veronica Barbier, Lode Claes, Ilse Muylaert, Nele Vandenbergh and the staff of the Respiratory Rehabilitation Department and Pulmonary Function Department at the University Hospital Leuven for the collection of data and for providing the exercise training program. We are also thankful to Karen Denaux, Kristien de Bent, Dr. Nina Cardinaels, Maarten Spruyt, Sofie Verschueren, Vanessa Van Geel and Willem Dewit for the collection of biological material.The authors would also like to thank the teams from the Respiratory Division (E502) and the Centre for bone densitometry (E415) (UZ Gasthuisberg, Leuven, Belgium) for their assistance with the study assessments. | PMC10563200 | ||
Authors’ contributions | SE, HD, FMR | Design of the work: TT, ML and FMR; data acquisition: ML, FMR, HD, AB and SE; data analysis: ML, FMR and HD; drafting the work: ML and FMR. All authors revised this manuscript critically for its intellectual content, gave their final approval of the version to be published and agreed to be accountable for all aspects of the work. | PMC10563200 | |
Funding | HD, FMR | This work was supported by the Flemish Research Foundation – Flanders (FWO #G.0871.13). FMR was funded by The National Council for Scientific and Technological Development (CNPq), Brazil (249579/2013–8) during the execution of this work. HD is a post-doctoral research fellow of the Flemish Research Foundation (FWO Flanders). AB is a pre-doctoral research fellow of FWO Flanders (1194320 N). WJ is a senior clinical research fellow of FWO-Flanders.The funder(s) played no role in the design of the study, the collection, analysis, and interpretation of data and in writing the manuscript. | PMC10563200 | |
Data Availability | The datasets generated and/or analysed during the current study are not publicly available but are available from the corresponding author on reasonable request. | PMC10563200 | ||
Declarations | PMC10563200 | |||
Ethics approval and consent to participate | The ethics committee of the University Hospital Leuven approved this study (S57963). All participants gave written informed consent before data collection began. | PMC10563200 | ||
Consent for publication | Not Applicable. | PMC10563200 | ||
Competing interests | The authors declare that they have no competing interests. | PMC10563200 | ||
Abbreviations | RESPIRATORY DISEASES, THORACIC | ActigraphAmerican Thoracic SocietyBone Mineral DensityChronic Obstructive Pulmonary DiseaseCardiopulmonary Exercise TestingChronic Respiratory Disease QuestionnaireDynaport MovemonitorDual Energy X-ray AbsorptiometryEuropean Respiratory SocietyHigh-Density LipoproteinIntervention GroupLow-Density LipoproteinMovement IntensityMinimal Important Differencemodified Medical Research CouncilModerate to Vigorous Physical ActivityPhysical ActivityPulmonary RehabilitationRandomized Controlled TrialQuadriceps ForceQuality of LifeStandard DeviationSustaining Training Effects through Physical activity promotionUsual Care GroupVisitWork RateSix Minutes Walking Distance | PMC10563200 | |
References | PMC10563200 | |||
Background | dehydration | DEHYDRATION, FLUID OVERLOAD | Communicated by Michalis G Nikolaidis.Older adults are susceptible to dehydration and fluid overload due to a reduced ability to maintain homeostatic control of fluid and electrolyte balance. | PMC10492686 |
Purpose | To assess fluid and electrolyte balance responses in young and older men following ingestion of commonly consumed beverages differing in composition. | PMC10492686 | ||
Methods | 12 young and 11 older men were recruited. Euhydrated body mass was recorded. Participants consumed 1L (250 ml every 15 min) of water, fruit juice, a sports drink or low-fat milk in a randomized cross-over design. Urine and blood samples were obtained before and after the drinking period and every hour thereafter for 3-h. Samples were used to determine osmolality, electrolytes (Na | PMC10492686 | ||
Results | Free water clearance was significantly higher in Young than Older at 1 and 2 h after the ingestion of W and S (p < 0.05). Net Na | PMC10492686 | ||
Conclusions | Milk, age-related loss, fluid retention | FLUID RETENTION | Milk was retained longer than other beverages in Young, but not in Older, despite similar net electrolyte balance responses. Older had higher fluid retention in the first 2 h after the ingestion of all beverages, except for milk when compared to Young, indicating an age-related loss of ability to regulate fluid balance under current study conditions. | PMC10492686 |
Supplementary Information | The online version contains supplementary material available at 10.1007/s00421-023-05241-0. | PMC10492686 | ||
Keywords | PMC10492686 | |||
Introduction | Fluid deficits, thirst | FLUID RETENTION | Ageing is accompanied with changes in the homeostatic control systems that regulate fluid and electrolyte balance (Rolls and Philips However, under free-living conditions, older adults are more prone to become dehydrated than their younger counterparts. Fluid deficits in older adults can occur through a variety of routes such as: a blunted thirst response, resulting from a decrease in the sensitivity of volume and osmoreceptors (Kenney and Chiu Data on young adults highlights that electrolyte composition, as well as certain macronutrients (i.e., protein/carbohydrate), are important in determining the fluid retention response to beverage ingestion (Maughan et al. | PMC10492686 |
Methods | The fluid and electrolyte balance responses after ingestion of four commonly consumed and commercially available beverages were tested in young and older volunteers. The beverages were: still water (as control); fruit juice with a moderate carbohydrate and potassium content; a sport drink with moderate carbohydrate and sodium content (S); and a low fat 1% milk with moderate carbohydrate, protein, and sodium and potassium content. The test beverages were specifically chosen with an energy content in a range of 230-350 kcal/L (except for water) and provided either sodium, potassium, or a mix of electrolyte content (Table | PMC10492686 | ||
Pre-trial standardization/exclusion criteria | stature | Twenty-four healthy active volunteers were recruited into two groups: n = 12 were allocated to the young group (18-35y) and n = 12 to the older group (> 55y) with participants matched for stature and body mass. One participant in the older group dropped out Participant anthropometric characteristics, hydration habits, caffeine and alcohol intake, and self-reported physical activityValues are mean (SD)*Indicates significant difference between young and older groups. (p < 0.05) | PMC10492686 | |
Participant characteristics on entry into the study | The physical activity levels of the participants varied, with the older group reporting an average of 6.7 h of moderate/intense exercise per week, compared to the young group's reported average of 5.9 h per week. Participants engaged in a range of sports or activities, with jogging more than 5 k, swimming more than 600 m, and gym combining strength and aerobic exercises being the most frequently reported in the young group. In contrast, the older group reported cycling, gym combining strength and aerobic exercises, and hill walking as their most frequently reported activities, with some participants also reporting engaging in less common activities such as ice skating and skydiving (Table | PMC10492686 | ||
Experimental procedure | BLOOD, APPENDIX | Participants attended the laboratory for four experimental trial days, each separated by 7-days. All trials were conducted in the morning after an overnight fast (> 8 h). Participants ingested 500 ml of still water (Highland SpringWater, energy, macronutrient, sodium, and potassium content of tested beveragesApart from water, test beverages were selected to provide similar carbohydrate (CHO) content, but with differing protein and electrolyte compositionImmediately at the end of the 60-min beverage ingestion period, participants were asked to empty their bladder, and subsequently each hour for the next 3 h to monitor urine volume. Participants could urinate at any time they required but they were also asked to empty their bladder completely every 60-min to track hourly urine production. If volunteers needed to urinate before the 60-min period, the urine was collected and added to the urine produced at the next 60-min time point. Urine mass was recorded to determine cumulative urine mass every 60-min and a 5 ml aliquot was retained for analysis. Blood samples were drawn immediately after the drinking period, and every 60-min for the next 3 h. All blood samples were drawn from participants after they had remained in a seated position for at least 15-min (Supplementary Appendix 1). | PMC10492686 | |
Blood, serum, and urine analysis | depression | Total urine mass (to nearest g) was measured over the 3 h post beverage ingestion. Samples of urine obtained each hour were analysed for urine osmolality, creatinine concentration and urine electrolyte content. From each urine void, a 5 ml aliquot was collected and stored at 4 °C for the analysis of urine osmolality, electrolyte content (sodium and potassium) and creatinine determination. Whole blood samples were dispensed into a serum tube for osmolality and electrolyte determinations, and an EDTA tube with plasma stored for later analysis of creatinine. Urine and serum osmolality were measured in duplicate using a freezing point depression method (Löser osmometer) on day of collection. Sodium and potassium concentration in urine and serum were measured in duplicate using flame-photometry (PFP7/C Clinical Flame Photometer, Jenway) within 5-days of collection.Macronutrient data of test beverages were obtained from product nutrition information. Beverage electrolyte data were obtained by flame-photometry analysis. | PMC10492686 | |
Data calculations and statistical analysis | All the participants achieved a positive net fluid balance of 1000(g) following the fixed volume of the fluid ingested (1L). Net fluid balance each hour was then calculated from the total mass of urine (cumulative urine output) that had been collected to that point. Electrolyte balance on each trial was determined by subtracting the amount of sodium or potassium excreted through urine from the total sodium or potassium ingested within the test beverage.Urine creatinine was used to estimate GFR (Levey et al. Cumulative urine outputs, by beverage and between groups, were compared using repeated measures ANOVA. Participant characteristics were analysed by paired t-tests. Data for net fluid balance, and electrolytes were analysed by 3-way ANOVA (beverage x time point x age group) to identify within and between group differences. All statistical analyses were completed using a statistical software package (IBM SPSS Statistics, V.23). Statistical significance was accepted at | PMC10492686 | ||
Results | gastrointestinal symptoms | ADVERSE EFFECT | Of the twenty-four participants recruited (12 young and 12 older men), n = 1 older adult participant dropped out of the study due to aversion with the blood sampling procedures. No participants experienced any adverse effect or gastrointestinal symptoms following beverage ingestion.Mean urine and serum osmolality when participants arrived at the lab, prior to beverage ingestion, was not different between young and older adults, except for urine osmolality on trial M (Table | PMC10492686 |
Cumulative urine output and urine osmolality responses to beverage ingestion | Urine mass did not differ between trials immediately after the beverage ingestion period for Young and Older. However, 1 h after the ingestion of water, the cumulative urine output for Young was significantly higher than Older. This was sustained at 2 h post drinking (p < 0.05). Urine osmolality was significantly lower in Young compared to Older at 1 h after ingestion of water; and significantly higher in Young than Older at 2 h after the ingestion of sport drink and milk, and at 3 h for water, fruit juice and sport drink (Table | PMC10492686 | ||
Net fluid balance (NFB) | NFB | At 1 and 2 h after ingesting water, there were significant differences between Young and Older. However, no significant difference was observed between age groups when comparing NFB at 3 h after ingestion of any of the different beverages. NFB after ingestion of milk was significantly different from water in Young, but not in Older (Fig. Net fluid balance following the ingestion 1L of water ( | PMC10492686 | |
Estimated GFR and free water clearance | Mean (SD) estimated GFR was lower in older participants (74.1 mL/min/1.73 mFree water clearance responses after the ingestion of 1 L of water ( | PMC10492686 | ||
Discussion | We investigated fluid and electrolyte balance in young and older adults after the ingestion of beverages with different nutrient composition and assessed their retention over three hours post ingestion. In young adults, we replicated our previous observations (Maughan et al. | PMC10492686 | ||
Gastric emptying and intestinal absorption of fluid | age-related reduction | CLOT | In the present study, the difference in fluid balance response between young and older adult groups may be influenced mostly by gastric emptying rates. In older adults an age-related reduction in gastric acid secretion would potentially allow for a greater gastric emptying rate of milk by reducing casein clot formation (Huppertz and Chi Most of the water (ingested and emptied into the gastrointestinal tract) is reabsorbed in the small intestine, and remaining water in the colon. The small intestine is highly permeable promoting a rapid balance of the digestive content through the absorption of electrolytes and nutrients (Leiper | PMC10492686 |
Renal function | volume overload | VOLUME OVERLOAD, FLUID RETENTION | The ability to concentrate urine declines with age. In the Baltimore Longitudinal Study of Ageing, individuals aged 60–79 years had a ~ 20% reduction in maximal urine osmolality, a 50% decrease in the ability to reabsorb sodium and urea, and reduced capacity to concentrate solutes, when compared with 20–39 years old group (Lindeman et al. In the present study, the volume overload induced by ingesting 1 L of fluid in 1 h, when in an already euhydrated state, leads to a more prolonged fluid retention of water in older adults, likely due to a reduced homeostatic control response compared to young adults (Beck | PMC10492686 |
Electrolyte balance | Older people are prone to expansion of total body water when challenged with a volume or sodium overload. Older adults have been reported to have a diminished capacity for renal sodium excretion (Luckey and Parsa | PMC10492686 | ||
Conclusion | fluid deficit | FLUID OVERLOAD | Further investigation is necessary to examine older adults under a fluid deficit condition to establish how older adults deal with fluid replacement and fluid overload situations. In addition, future research could aim to investigate more significant challenges to homeostasis using test drinks with greater electrolyte and macronutrient composition differences. However, under the conditions of the present study, it is evident that free water clearance is impaired in the first two hours following a fluid overload in older adults when compared with responses in young. | PMC10492686 |
Supplementary Information | Below is the link to the electronic supplementary material.Supplementary file1 (DOCX 174 KB) | PMC10492686 | ||
Author contributions | NRS | The authors’ responsibilities were as follows: NR-S and SDRG conceived the project, NR-S and SDRG developed the overall research plan, NR-S conducted the research and analysed the samples, NRS performed the statistical analysis, NR-S and SDRG wrote the manuscript, SDRG had primary responsibility for the final content; and both authors read and approved the final manuscript. The authors would like to thank Mr Chris Grigson for his technical support in the samples analysis and all the volunteers for taking part in the study. | PMC10492686 | |
Data availability | The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. | PMC10492686 | ||
Declarations | PMC10492686 | |||
Conflict of interest | Nidia | STUART | Nidia Rodriguez-Sanchez, no conflicts of interest to declare. Stuart DR Galloway, no conflicts of interest to declare. | PMC10492686 |
References | PMC10492686 | |||
Background | Body dissatisfaction is a public health issue, however, low awareness of its seriousness, and stigma, may inhibit treatment seeking. The current study evaluated engagement with videos promoting awareness of body dissatisfaction using a persuasive communication approach. | PMC10061748 | ||
Method | Men ( | PMC10061748 | ||
Results | Among both men and women, superior engagement ratings (in compassion for women, and relevance and compassion for men) were demonstrated for the persuasive appeal and informational videos relative to narrative approaches. | PMC10061748 | ||
Conclusion | Videos using clear and factual approaches may promote engagement in body image health promotion videos. Further work should be done to examine interest in such videos specific to men. | PMC10061748 | ||
Supplementary Information | The online version contains supplementary material available at 10.1186/s40359-023-01120-7. | PMC10061748 | ||
Keywords | PMC10061748 | |||
Introduction | Body dissatisfaction, negative evaluation of one’s appearance, shape, or weight, poses a serious public health issue [Social marketing campaigns are becoming increasingly common within mental health [ | PMC10061748 | ||
Theoretical background | PMC10061748 | |||
Social marketing engagement | One essential component of social marketing campaigns is that they are | PMC10061748 | ||
Persuasive communication | The type of communication that may result in greater engagement in a message has not been investigated within the context of body image. Previous research has identified two broad types of persuasive communication; narrative and informational [The effectiveness of both informational and narrative approaches has been found elsewhere throughout the literature with small effects on behavioural and attitudinal outcomes in meta-analyses [Persuasive health messages may also contain persuasive appeals, which are intended to clarify the content and meaning of narrative communication [ | PMC10061748 | ||
Impact of persuasive approaches on domains of engagement | cognitive and affective | While no literature exists examining the impacts of persuasive communication approaches on engagement, previous work suggests that narrative and informational approaches persuade using different mechanisms [Identifying whether particular domains of engagement may be particularly useful for targeted campaigns; for instance, campaigns aiming to promote socio-political change, may benefit from changing behavioural engagement, while campaigns aiming to reduce stigma may wish to impact cognitive and affective domains. As such, this study also sought to understand whether the type of persuasive communication may impact different engagement domains. | PMC10061748 | |
Current study | cognitive, affective, and behavioural engagement, eating disorders | LITTLE | Little research in body dissatisfaction and eating disorders has identified the specific approach taken in persuasive communications as either informational or narrative [As social media (and increasingly, traditional media with a social media presence) relies heavily on sharing of information (e.g., sharing a health message campaign to one’s own social media account, or through email) and engagement (e.g., comments, likes, emotional investment in the topic), the current study sought to understand the effect of different types of persuasive communication on engagement in a body image social marketing video. Thus, the current study aimed to examine the extent to which such a campaign can generate cognitive, affective, and behavioural engagement and to compare levels of engagement across informational, narrative, and persuasive appeal communication approaches. As engagement has not previously been investigated within this context, no specific hypotheses were made. However, the following research questions were explored:RQ1: Of the persuasive approaches (informational, narrative, persuasive appeal, informational and persuasive, narrative and persuasive), which results in superior engagement in the topic of body dissatisfaction mental health literacy?RQ2: Do particular persuasive communication approaches impact the cognitive, affective, and behavioural domains of engagement differently? | PMC10061748 |
Method | PMC10061748 | |||
Participants | Participants were recruited through Prolific, an online participant platform. Men and women aged 18–45 from Australia, Canada, or the United Kingdom were eligible to take part in the study. Participation was limited to persons from these countries as they are culturally similar to Australia, in which the stimulus materials were filmed. Initially, 633 participants responded to the study. After removing participants who chose to withdraw their data following debriefing where they learned the true aims of the study ( | PMC10061748 | ||
Materials | eating disorders | Three videos were professionally produced in Australia by a media company for use in a social marketing campaign (independent from and prior to the research) to raise awareness of the seriousness of body dissatisfaction; one reflected a narrative approach to communication, one an informational approach, and the other was an explicit persuasive appeal. Experts in the field of body image and eating disorders gave feedback on the scripting and information prior to the production of the videos. Permission to use the materials in the research was granted by the media company. | PMC10061748 | |
Measures | cellulite, eating disorders, ’ | The narrative video (2.48 min) featured a woman in her early thirties engaging in an internal monologue of negative body talk (e.g., “If Mia’s mum needs to lose 5 kilos to get rid of her non-existent cellulite, how many kilos do I need to lose to be part of the short-shorts sports carnival day mothers’ club?!”) while driving in the car with her child. The woman eventually realises the harshness of her self-talk and acknowledges the functionality of her body over its appearance. The woman is white and thin, and was shown sitting. The actor was pregnant at the time of filming but this was not visible within the video as a bag was covering her torso. The narrative video can be viewed at The informational video (2.54 min) was comprised of interviews with five body image experts (an academic, a dietician, a medical practitioner, and chief executive officer and education manager of two eating disorders support services) who discussed factual information about body image (e.g., “Body dissatisfaction is a problem across our society; young, old, males, females… body image problems just don’t go away with age, it’s not that you get to some level of enlightenment and say “Ok I’m fine and I’m not worried about these issues anymore”, actually they hang around for a really long time”. The information included topics such as contributing factors, sociocultural appearance pressures, appearance comparison, help-seeking for body dissatisfaction, and the potential usefulness of challenging appearance ideals. All presenters in the video were white and cisgender, and all but one were both a) thin and b) women. One presenter was a larger bodied man. Only the upper bodies, not full-body view of presenters were shown. The video can be viewed at The persuasive appeal video (1.20 min) featured the female actor from the narrative approach video presenting a direct appeal to the viewer to increase their awareness and understanding of body dissatisfaction, and question and challenge appearance ideals (e.g., “What can we do about it? I think the first thing is to be aware of it…” “Starting to have conversations within ourselves, within our social circles, within our families, within our community and hopefully then globally”. The actor briefly mentioned her own difficulties with body dissatisfaction. The actor, as previously described, was white and thin, although she was pregnant at the time. This video can be viewed at The narrative approach video was shown followed by the persuasive appeal video (4.08 min), as described above.The informational approach video was shown with footage edited in from the persuasive appeal video (3.45 min). | PMC10061748 | |
Procedure | Demographic questions included age, gender (from the following: male, female, otherA series of visual analogue scales (VAS) were used to assess weight satisfaction, shape satisfaction, and muscularity satisfaction before and after viewing the stimulus. Only pre-video exposure data around weight satisfaction, shape satisfaction, and muscularity satisfaction were used in the current analysis solely for the purposes of examining confounding effects, as the focus of the current study is on engagement outcomes. Participants were asked to indicate how satisfied they feel right now, from 0 (Post-video weight satisfaction, shape satisfaction, and muscularity satisfaction are reported elsewhere. Other measures, including mental health literacy, and behavioural intentions, were assessed both pre- and post-exposure but are reported elsewhere [A set of 18 items measured on VAS was developed specifically for the current study to measure general engagement with the videos and topic. Items were informed by previous research examining responses to health campaigns [Eight VAS items identified from the factor analysis were used to measure participant interest (behavioural engagement) in the video and topic. Participants were asked to indicate their interest, from 0 (Five VAS items identified from the factor analysis were used to measure participant compassion towards people with body dissatisfaction, as well as self-compassion. These VAS items measured affective engagement. Participants were asked to indicate the degree to which the video was respectful, increased other-directed compassion, oversimplified body image issues (reverse scored), increased blame (reverse scored), and was perceived to make other people feel more concerned about their appearance (reverse scored), from 0 (Three items identified from the factor analysis were used to measure relevance of the video and topic, which reflected cognitive engagement. Participants were asked to indicate the degree to which the video was relevant to their own lives, covered an important topic, and they could recognise their own experiences in the video, from 0 ( | PMC10061748 | ||
Ethics approval | was granted by the La Trobe University Human Ethics Committee, approval number HEC15-116. To reduce the likelihood of a biased sample with high interest in the topic of body dissatisfaction, the true purpose of the study was partially concealed. Participants were invited to take part in a study on health promotion videos and were informed that they would view either a video on body image or self-esteem. The study took place on Qualtrics online survey software, and participants completed the study in an environment of their choosing. Participants provided their consent, then completed pre-exposure measures of body satisfaction. Participants were then randomly assigned to one of the five video conditions previously described. Simple randomisation was performed automatically through the Qualtrics software on an even basis across all five conditions. After watching the video, participants completed measures of interest, compassion, relevance, and demographic variables. Following completion of the study measures, participants were then debriefed on the true aims of the study and given the option to withdraw their data. Participation took, on average, 16.96 min. | PMC10061748 | ||
Manipulation check | To ensure that the quality of the videos was reasonably similar across groups, participants were asked five questions, measured on a Likert-type scale from 1 ( | PMC10061748 | ||
Data Analysis | Analyses were separated by gender as women tend to have higher body dissatisfaction than men, which was verified using an independent samples t-test. Scores on all body satisfaction items were higher in men than in women; all | PMC10061748 | ||
Results | PMC10061748 | |||
Manipulation checks | To ensure that the quality of the videos was reasonably similar, we examined participants’ responses to the manipulation check questions. A series of one-way ANOVAs examining the differences between the five groups on the manipulation check questions were conducted. Holm corrections were used to account for multiple comparisons. The information and information + persuasive appeal videos were rated more factual than both the narrative and narrative + persuasive appeal videos ( | PMC10061748 |
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