Experimental research in environmentally induced hyperthermic older persons: A systematic quantitative literature review mapping the available evidence

The heat-related health burden is expected to persist and worsen in the coming years due to an aging global population and climate change. Defining the breadth and depth of our understanding of age-related changes in thermoregulation can identify underlying causes and strategies to protect vulnerable individuals from heat. We conducted the first systematic quantitative literature review to provide context to the historical experimental research of healthy older adults - compared to younger adults or unhealthy age matched cases - during exogenous heat strain, focusing on factors that influence thermoregulatory function (e.g. co-morbidities). We identified 4,455 articles, with 147 meeting eligibility criteria. Most studies were conducted in the US (39%), Canada (29%), or Japan (12%), with 71% of the 3,411 participants being male. About 71% of the studies compared younger and older adults, while 34% compared two groups of older adults with and without factors influencing thermoregulation. Key factors included age combined with another factor (23%), underlying biological mechanisms (18%), age independently (15%), influencing health conditions (15%), adaptation potential (12%), environmental conditions (9%), and therapeutic/pharmacological interventions (7%). Our results suggest that controlled experimental research should focus on the age-related changes in thermoregulation in the very old, females, those with overlooked chronic heat-sensitive health conditions (e.g. pulmonary, renal, mental disorders), the impact of multimorbidity, prolonged and cumulative effects of extreme heat, evidence-based policy of control measures (e.g. personal cooling strategies), pharmaceutical interactions, and interventions stimulating protective physiological adaptation. These controlled studies will inform the directions and use of limited resources in ecologically valid fieldwork studies.

Adaptation behaviors modify the effects of body fat on heat-related symptoms among Taiwanese elderly

BACKGROUND

The aging process increases body fat and susceptibility to heat-related illnesses. The relationship between body composition and symptoms associated with exposure to extreme heat among the elderly is unclear. Additionally, the influence of individual adaptive behaviors in mitigating these risks has not been adequately explored.

OBJECTIVES

This study aimed to evaluate the association between body composition and heat-related symptoms as well as the potential modifying effects of heat adaptation behavior.

METHODS

The body composition of elderly individuals was measured using bioelectrical impedance analysis. Face-to-face interviews were conducted a year later to determine the heat-related symptoms and adaptive behaviors practiced for the extremely hot days of the previous year. The association between body composition indices and the presence of more than two symptoms was assessed using logistic regression analysis, while stratified analysis and interaction term in models were used to evaluate the effect modifications of adaptive behaviors.

RESULTS

Of the 859 participants, 16% reported more than two heat-related symptoms. Increased body fat mass index (fat mass in kg/squared height in meters) was associated with an elevated risk of more heat-related symptoms (odds ratio 1.11, 95% confidence interval 1.02-1.20). Each combination of staying indoors, using an umbrella and hat, and using air conditioning at noon reduced the risk association between body fat and symptoms. For females, a combination of reducing physical activity and staying indoors provided similar protective effect. Surprisingly, bathing more frequently in hot weather with heated instead of non-heated water augmented the risk correlation. Neither fan usage nor window opening displayed protective effects.

CONCLUSIONS

Elevated body fat levels, indicative of obesity, corresponded with an increased risk of heat-related symptoms. Integrating multiple adaptive behaviors can diminish the negative health impact of body fat on heat-induced symptoms. However, certain commonly adopted practices might not confer expected benefits.

Serum klotho concentrations in older men with hypertension or type 2 diabetes during prolonged exercise in temperate and hot conditions

PURPOSE

Klotho is a cytoprotective protein that increases during acute physiological stressors (e.g., exercise heat stress), although age-related declines in klotho may underlie cellular vulnerability to heat stress. The present study aimed to compare serum klotho in healthy older men and men with type 2 diabetes (T2D) or hypertension (HTN) during prolonged exercise in temperate or hot conditions.

METHODS

We evaluated serum klotho in 12 healthy older men (mean [SD]; 59 years [4]), 10 men with HTN (60 years [4]), and 9 men with T2D (60 years [5]) before and after 180 min of moderate-intensity (fixed metabolic rate of 200 W/m²; ~ 3.4 METs) exercise and 60 min of recovery in temperate (wet-bulb globe temperature (WBGT) 16 °C) and hot (WBGT 32 °C) environments. Core temperature (rectal), heart rate (HR), and heart rate reserve (HRR) were measured continuously while klotho was measured at the end of baseline, exercise, and recovery.

RESULTS

Total exercise duration was reduced during the hot condition in older men with HTN and T2D than healthy older men (both p ≤ 0.049), despite similar core temperatures, HR, and HRR. Klotho was higher than rest following exercise in the heat in healthy older men (+ 191 pg/mL [189]; p < 0.001) and responses were greater (p = 0.036) than men with HTN (+ 118 pg/mL [49]; p = 0.030), although klotho did not increase in men with T2D (+ 4 pg/mL [71]; p ≥ 0.638).

CONCLUSION

Given klotho's role in cytoprotection, older men with HTN and especially T2D may be at increased cellular vulnerability to prolonged exercise or physically demanding exercise in the heat.

Human temperature regulation under heat stress in health, disease, and injury

The human body constantly exchanges heat with the environment. Temperature regulation is a homeostatic feedback control system that ensures deep body temperature is maintained within narrow limits despite wide variations in environmental conditions and activity-related elevations in metabolic heat production. Extensive research has been performed to study the physiological regulation of deep body temperature. This review focuses on healthy and disordered human temperature regulation during heat stress. Central to this discussion is the notion that various morphological features, intrinsic factors, diseases, and injuries independently and interactively influence deep body temperature during exercise and/or exposure to hot ambient temperatures. The first sections review fundamental aspects of the human heat stress response, including the biophysical principles governing heat balance and the autonomic control of heat loss thermoeffectors. Next, we discuss the effects of different intrinsic factors (morphology, heat adaptation, biological sex, and age), diseases (neurological, cardiovascular, metabolic, and genetic), and injuries (spinal cord injury, deep burns, and heat stroke), with emphasis on the mechanisms by which these factors enhance or disturb the regulation of deep body temperature during heat stress. We conclude with key unanswered questions in this field of research.

Sex differences in temperature-related all-cause mortality in the Netherlands

PURPOSE

Over the last few decades, a global increase in both cold and heat extremes has been observed with significant impacts on human mortality. Although it is well-identified that older individuals (> 65 years) are most prone to temperature-related mortality, there is no consensus on the effect of sex. The current study investigated if sex differences in temperature-related mortality exist in the Netherlands.

METHODS

Twenty-three-year ambient temperature data of the Netherlands were combined with daily mortality data which were subdivided into sex and three age classes (< 65 years, 65-80 years,  ≥ 80 years). Distributed lag non-linear models were used to analyze the effect of ambient temperature on mortality and determine sex differences in mortality attributable to the cold and heat, which is defined as mean daily temperatures below and above the Minimum Mortality Temperature, respectively.

RESULTS

Attributable fractions in the heat were higher in females, especially in the oldest group under extreme heat (≥ 97.5th percentile), whilst no sex differences were found in the cold. Cold- and heat-related mortality was most prominent in the oldest age group (≥ 80 years) and to a smaller extent in the age group between 65-80 years. In the age group < 65 years temperature-related mortality was only significant for males in the heat.

CONCLUSION

Mortality in the Netherlands represents the typical V- or hockey-stick shaped curve with a higher daily mortality in the cold and heat than at milder temperatures in both males and females, especially in the age group ≥ 80 years. Heat-related mortality was higher in females than in males, especially in the oldest age group (≥ 80 years) under extreme heat, whilst in the cold no sex differences were found. The underlying cause may be of physiological or behavioral nature, but more research is necessary.

F, Leicht CA. Serum and plasma brain-derived neurotrophic factor concentration are elevated by systemic but not local passive heating

Brain-derived neurotrophic factor (BDNF) plays a key role in neuronal adaptations. While previous studies suggest that whole-body heating can elevate circulating BDNF concentration, this is not known for local heating protocols. This study investigated the acute effects of whole-body versus local passive heating on serum and plasma BDNF concentration. Using a water-perfused suit, ten recreationally active males underwent three 90 min experimental protocols: heating of the legs with upper-body cooling (LBH), whole-body heating (WBH) and a control condition (CON). Blood samples were collected before, immediately after and 1 h post-heating for the determination of serum and plasma BDNF concentration, platelet count as well as the BDNF release per platelet. Rectal temperature, cardiac output and femoral artery shear rate were assessed at regular intervals. Serum and plasma BDNF concentration were elevated after WBH (serum: 19.1±5.0 to 25.9±11.3 ng/ml, plasma: 2.74±0.9 to 4.58±2.0; p<0.044), but not LBH (serum: 19.1±4.7 to 22.3±4.8 ng/ml, plasma: 3.25±1.13 to 3.39±0.90 ng/ml; p>0.126), when compared with CON (serum: 18.6±6.4 to 16.8±3.4 ng/ml, plasma: 2.49±0.69 to 2.82±0.89 ng/ml); accompanied by an increase in platelet count (p<0.001). However, there was no change in BDNF content per platelet after either condition (p = 0.392). All physiological measures were elevated to a larger extent after WBH compared with LBH (p<0.001), while shear rate and rectal temperature were higher during LBH than CON (p<0.038). In conclusion, WBH but not LBH acutely elevates circulating BDNF concentration. While these findings further support the use of passive heating to elevate BDNF concentration, a larger increase in shear rate, sympathetic activity and/or rectal temperature than found after LBH appears needed to induce an acute BDNF response by passive heating.

Challenges arising for older workers from participating in a workplace intervention addressing work ability: a qualitative study from Germany

OBJECTIVE

Studies examining what renders workplace interventions to sustain and promote work ability of older workers successful have largely neglected older workers´ perspective. This paper outlines the results of a study with regard to older workers´ experiences and expectations of a workplace intervention. Based on these findings, some reflections on how to improve the design and the implementation of workplace interventions for older workers are provided.

METHODS

Semi-structured interviews were conducted with older workers (N = 8) participating in a workplace intervention undertaken at one production site of a large manufacturing company in Baden-Wurttemberg/Germany. The interview guide included questions on participants´ experiences with and expectations of the intervention. The interviews were recorded, transcribed verbatim and analyzed using qualitative content analysis according to Mayring (2014).

RESULTS

Older workers´ reported some challenges they face due to their participation in the workplace intervention. These resulted from the work environment (physical challenges), the work process design (new long work cycle), the work organization (tight time allowances, little job rotation, change of teams, age stereotypes) and the management of the workplace intervention (bad information, feeling of occupational insecurity and lack of being valued).

CONCLUSIONS

The study shows that challenges arising for older workers from their participation in the workplace intervention may have counteracted the promotion of work ability. As findings suggest, some of these challenges might have been avoided either by considering workers´ perspective during design and implementation of an intervention or by referring to evidence on aging and work ability.

Current Insights in the Age-related Decline in Sports Performance of the Older Athlete

The higher performance level of master athletes compared to non-athletes is often associated with better health throughout life. However, even the physical performance of master athletes declines with age, and this decline accelerates from about the age of 70 years onwards. A progressive loss of muscle mass, declines in force- and power-generating capacity, decreased flexibility, and the concomitant decline in specific tension characterize the muscular changes underlying performance declines. In the cardiovascular system, declines in stroke volume and cardiac output, and cardiac and vascular stiffness contribute to decreasing performance. Recent studies have shown that long-term endurance exercise in master athletes does not only have positive effects, but is associated with an increased incidence of atrial fibrillation, atherosclerotic plaques, and aortic dilation, and even more so in men than in women. Recently, larger longitudinal datasets were analysed and showed that the age-related decline in performance was similar in longitudinal and cross-sectional data. In conclusion, regular physical activity enhances the exercise capacity, and hence quality of life in old age, but it is not without risks.

Trends in Weather Conditions and Performance by Age Groups Over the History of the Berlin Marathon

The effect of different environmental conditions such as temperature, wind, barometric pressure, and precipitation has been well investigated in elite marathoners, but not by age categories (i.e., age group marathoners). The aim of the study was to investigate the potential influence of environmental conditions such as temperature, precipitation, and atmospheric pressure on marathon performance in age group marathoners competing in the ‘Berlin Marathon’ from 1974 to 2019. A total of 869,474 valid finisher records were available for analysis, of which 711,136 correspond to males and 158,338 to females. The influence of temperature, atmospheric pressure, and precipitation on marathon race times was investigated in age group marathoners grouped in 5-year-intervals. Within the 46 years of Berlin marathons under investigation, there was some level of precipitation for 18 years, and 28 years without any rain. Sunshine was predominant in 25 of the events, whilst in the other 21 years, cloud cover was predominant. Marathon race times were significantly and positively correlated with age (i.e., older runners were slower than younger runners) where the correlation was higher for males than for females. Marathon race times were significantly and positively correlated with both the hours of sunshine and the daily maximum temperature. The fastest marathon runners (meaning the minimum times) achieved the fastest race times on race days with higher maximum temperatures (i.e., 15–30°C). Daily maximum temperatures showed an influence on age group marathoners from age group 35–40 years and older. Higher precipitation levels impaired performance across most age groups. In summary, higher daily maximum temperatures (i.e., >15°C) and higher precipitation levels impaired performance of master marathoners (i.e., 35–40 years and older) competing in the ‘Berlin Marathon’ in the last 45 years. Master marathoners should start in marathon races with temperatures < 15°C and no precipitation in order to achieve a fast marathon race time.

Heat Tolerance and Occupational Heat Exposure Limits in Older Men with and without Type 2 Diabetes or Hypertension

PURPOSE

To mitigate rises in core temperature >1°C, the American Conference of Governmental Industrial Hygienists (ACGIH) recommends upper limits for heat stress (Action Limit Values; ALV), defined by wet-bulb globe temperature (WBGT) and a worker's metabolic rate. However, these limits are based on data from young men and are assumed to be suitable for all workers, irrespective of age or health status. We therefore explored the impact of aging, type 2 diabetes (T2D), and hypertension (HTN), on tolerance to prolonged, moderate-intensity work above and below these limits.

METHODS

Core temperature and heart rate were assessed in healthy, non-heat acclimatized young (18-30 y, n=13) and older (50-70 y) men (n=14), and non-heat acclimatized older men with T2D (n=10) or HTN (n=13) during moderate-intensity (metabolic rate: 200 W/m2) walking for 180 min (or until termination) in environments above (28 and 32°C WBGT) and below (16 and 24°C WBGT) the ALV for continuous work at this intensity (25°C WBGT).

RESULTS

Work tolerance in the 32°C WBGT was shorter in men with T2D (median [IQR]; 109 [91, 173] min; p=0.041) and HTN (109 [91, 173] min; p=0.010) compared to healthy older men (180 [133, 180] min). However, aging, T2D, and HTN did not significantly influence (i) core temperature or heart rate reserve, irrespective of WBGT, (ii) the probability that core temperature exceeded recommended limits (>1°C) under the ALV, and (iii) work duration before core temperature exceeded recommended limits (>1°C) above the ALV.

CONCLUSION

These findings demonstrate that T2D and HTN attenuate tolerance to uncompensable heat stress (32°C WBGT); however, these chronic diseases do not significantly impact thermal and cardiovascular strain, or the validity of ACIGH recommendations during moderate-intensity work.

The Relation between Age and Sex on Whole-Body Heat Loss during Exercise-Heat Stress

INTRODUCTION

Increasing age is associated with decrements in sweat rate that compromise whole-body total heat loss (evaporative + dry heat exchange) in both men and women during moderate-to-vigorous exercise in dry heat. Similarly, young women also display reductions in sweating (that lower evaporative heat loss) relative to young men in such conditions. Nevertheless, it remained unclear whether these effects act synergistically to exacerbate the age-related decline in whole-body total heat loss in women relative to men. We therefore assessed the interrelation between age and sex on whole-body total heat loss during light, moderate, and vigorous exercise in dry heat.

METHODS

To achieve this, we used direct and indirect calorimetry to assess whole-body total heat loss and metabolic heat production (respectively) in 46 men and 34 women age between 18 and 70 yr. Participants performed three, 30-min bouts of cycling at metabolic heat productions of 150 (light), 200 (moderate), and 250 (vigorous) W·m, each separated by 15-min recovery in dry heat (40°C, ~15% relative humidity).

RESULTS

Whole-body total heat loss was ~5% lower in women relative to men during moderate and vigorous exercise (both, P < 0.01), irrespective of age. Total heat loss declined with age during moderate and vigorous exercise in both men and women (all, P < 0.050), although the rate of that decline (~4% per decade) was similar between men and women across all exercise bouts (all, P > 0.050).

CONCLUSIONS

We show that, when assessed in dry heat, whole-body total heat loss is lower in women relative to men, irrespective of age. Furthermore, total heat loss declines with increasing age in both men and women during moderate-to-vigorous exercise, albeit the rate of that decline is not appreciably modified by sex.

Heat Exchange in Young and Older Men during Constant- and Variable-Intensity Work

PURPOSE

Current occupational heat stress guidelines rely on time-weighted averaging to quantify the metabolic demands of variable-intensity work. However, variable-intensity work may be associated with impairments in whole-body total heat loss (dry + evaporative heat loss), especially in older workers, which exacerbate heat strain relative to constant-intensity work eliciting the same time-weighted average metabolic rate. We, therefore, used direct calorimetry to evaluate whether variable-intensity work would cause decrements in the average rate of whole-body total heat loss that augment body heat storage and core temperature compared with constant-intensity work in young and older men.

METHODS

Eight young (19-31 yr) and eight older (54-65 yr) men completed four trials involving 90 min of work (cycling) eliciting an average metabolic heat production of ~200 W·m in dry-heat (40°C, 20% relative humidity). One trial involved constant-intensity work (CON), whereas the others involved 10-min cycles of variable-intensity work: 5-min low-intensity and 5-min high-intensity (VAR 5:5), 6-min low-intensity and 4-min very high-intensity (VAR 6:4), and 7-min low- and 3-min very, very high-intensity (VAR 7:3). Metabolic heat production, total heat loss, body heat storage (heat production minus total heat loss), and core (rectal) temperature were measured throughout.

RESULTS

When averaged over each 90-min work period, metabolic heat production, total heat loss, and heat storage were similar between groups and conditions (all P ≥ 0.152). Peak core temperature (average of final 10 min) was also similar between groups and conditions (both P ≥ 0.111).

CONCLUSIONS

Whole-body total heat loss, heat storage, and core temperature were not significantly influenced by the partitioning of work intensity in young or older men, indicating that time-weighted averaging appears to be appropriate for quantifying the metabolic demands of variable-intensity work to assess occupational heat stress.

Physical activity promotion in the age of climate change

The importance of the global climate crisis requires linking physical activity promotion and climate action. This article provides a first overview of interconnections between physical activity promotion and climate action, potential synergies and discrepancies, aiming to stimulate further discussion about this topic. The analysis is based on the World Health Organization’s Global Action Plan on Physical Activity 2018-2030 (GAPPA). The GAPPA covers five perspectives that are of particular relevance with respect to potential links with climate policy: (1) Infrastructures supporting active transport, (2) green spaces and recreational/exercise facilities, (3) exercise programs, (4) mass communication campaigns and mass participation events and (5) training of professionals. Our analysis demonstrates a considerable alignment between strategies for physical activity promotion and efforts for the reduction of greenhouse gas emissions. However, in some of the areas, this alignment could still be improved. Additionally, more climate-conscious policies, research and surveillance need to be developed in the field of physical activity promotion.

Individual risk factors associated with exertional heat illness: A systematic review

NEW FINDINGS

What is the topic of this review? Exertional heat illness (EHI) remains a persistent problem for athletes and individuals. This threat remains despite numerous athletic position statements and occupational guidance policies. This review explores primary evidence that demonstrates a direct association between 'known' risk factors and EHI. What advances does it highlight? Primary evidence to support 'known' risk factors associated with EHI is not comprehensive. Furthermore, it is not evident that single individual factors predispose individuals to greater risk. In fact, the evidence indicates that EHI can manifest in non-hostile compensable environments when a combination of risk factors is prevalent.

ABSTRACT

Despite the widespread knowledge of exertional heat illness (EHI) and clear guidance for its prevention, the incidence of EHI remains high. We carried out a systematic review of available literature evaluating the scientific evidence underpinning the risk factors associated with EHI. Medline, PsycINFO, SportDiscus and Embase were searched from inception to January 2019 with no date limitation, with supplementary searches also being performed. Search terms included permutations of risk and heat illness, with only studies in English included. Study selection, data extraction and quality assessment, using the QUALSYST tool, were performed by two independent reviewers. Of 8898 articles identified by the searches, 42 were included in the systematic review as primary evidence demonstrating a link between a risk factor and EHI. The quality scores ranged from 57.50 to 100%, and studies were generally considered to be of strong quality. The majority of risks attributable to EHI were categorized as those associated with lifestyle factors. The findings from the systematic review suggest complex manifestation of EHI through multiple risk factors rather than any one factor in isolation. Further research is needed to explore the accumulation of risk factors to help in development of effective preventative measures.

Skin Temperature in Master Long-Distance Runners-Results From a Field Study at the 2018 World Master Athletics Championships

Older people and athletes show impairments in thermoregulation, but this has not yet been studied during a running competition. The aim of the study was to assess (1) whether there are age-related differences in skin temperature during the last stage of a race in well-trained master athletes and (2) to what extent such differences are related to running speed and sex. To investigate this, we used thermography to measure maximum skin temperatures of the head, legs and hands of participants of the 2018 World Master Athletics (WMA) Championships when they were approximately 9,600 m into a 10,000-m road race. Of the 813 runners, 404 were analyzed (142 women, 262 men) including athletes of age groups 35 to 85. All ≥70-year-old athletes completed the race; all 16 non-finishers were younger. The hand temperature was lower than that of the head and legs (p < 0.001). Stepwise regression revealed that head ( R adj 2 = 0.143; p < 0.001) and hand temperature decreased with increasing speed ( R adj 2 = 0.092; p < 0.001). Sex was the most important determinant of leg skin temperature ( R adj 2 = 0.054; p < 0.001), men having higher leg temperatures than women, with a small negative contribution of speed ( R adj 2 increased to 0.069). In conclusion, higher running speed is associated with lower skin temperatures, and leg skin temperature is lower in women than men. The absence of an age effect on skin temperature suggests that there is no impairment in heat dissipation in well-trained older athletes.

The Heat Health Warning System in Germany—Application and Warnings for 2005 to 2019

During intense heat episodes, the human population suffers from an increased morbidity and mortality. In order to minimize such negative health impacts, the general public and the public health authorities are informed and warned by means of an advanced procedure known as a “heat health warning system” (HHWS). It is aimed at triggering interventions and at taking preventive measures. The HHWS in Germany has been in operation since 2005. The present work is aimed at showing the updated structure of an advanced HHWS that has been developed further several times during its 15 years of operation. This is to impart knowledge to practitioners about the concept of the system. In Germany, dangerous heat episodes are predicted on the basis of the numerical weather forecast. The perceived temperature as an appropriate thermal index is calculated and used to assess the levels of heat stress. The thermo-physiologically based procedure contains variable thresholds taking into account the short time acclimatization of the people. The forecast system further comprises the nocturnal indoor conditions, the specific characteristics of the elderly population, and the elevation of a region. The heat warnings are automatically generated, but they are published with possible adjustments and a compulsory confirmation by the biometeorology forecaster. Preliminary studies indicate a reduction in the heat related outcomes. In addition, the extensive duration of the strongest heat wave in summer 2018, which lasted three weeks, highlights the necessity of the HHWS to protect human health and life.

Exercise Heat Stress in Patients With and Without Type 2 Diabetes

This physiology study assesses whole-body heat loss in physically active middle-aged and older men with vs without type 2 diabetes after aerobic cycling to evaluate whether type 2 diabetes impairs heat loss and by what mechanism.