Older Adults with Type 2 Diabetes Store More Heat during Exercise

Intestinal epithelial injury and inflammation after physical work in temperate and hot environments in older men with hypertension or type 2 diabetes

We tested whether older adults with well-controlled type 2 diabetes or hypertension, compared with age-matched adults without chronic disease, exhibit greater intestinal damage, microbial translocation and inflammation during exertional heat stress. Twelve healthy men (age 59 years, SD 4 years), nine with type 2 diabetes (age 60 years, SD 5 years) and nine with hypertension (age 60 years, SD 4 years) walked for 180 min at 200 W/m2 in temperate conditions (wet-bulb globe temperature 16°C) and high-heat stress conditions (wet-bulb globe temperature 32°C). Serum intestinal fatty acid binding protein (IFABP), plasma soluble cluster of differentiation 14, lipopolysaccharide-binding protein (LBP), interleukin-6 and tumour necrosis factor-alpha were measured pre- and postexercise and after 60 min recovery. Total exercise duration was lower in men with hypertension and diabetes (p ≤ 0.049), but core temperature did not differ. All markers increased more in heat versus temperate conditions (p < 0.002). In the heat, individuals with type 2 diabetes had greater postexercise increases in IFABP [+545 pg/mL (95% confidence interval: 222, 869)] and LBP [+3.64 µg/mL (1.73, 5.56)] relative to healthy control subjects (p < 0.048), but these resolved after recovery. Despite reduced exercise duration, hypertensive individuals showed similar increases in IFABP and LBP to control subjects. Our findings suggest that older workers with well-controlled type 2 diabetes or hypertension might have greater vulnerability to heat-induced gastrointestinal barrier disturbance and downstream inflammatory responses when compared with otherwise healthy, age-matched adults during prolonged exercise in the heat.

Agreement between measured and self-reported physiological strain in young adults and older adults with and without common chronic diseases during simulated occupational heat stress

While monitoring physiological strain is recommended to safeguard workers during heat exposure, it is logistically challenging. The perceptual strain index (PeSI) is a subjective estimate thought to reflect the physiological strain index (PSI) that requires no direct monitoring. However, advanced age and chronic diseases (hypertension/type 2 diabetes [T2D]) influence the perception of heat stress, potentially limiting the utility of the PeSI. We therefore assessed whether the relation and agreement between the PeSI and PSI during simulated work in various environmental conditions is modified by age and T2D/hypertension. Thirteen young adults and 37 older adults without (n = 14) and with T2D (n = 10) or hypertension (n = 13) walked on a treadmill (∼200 W/m2) for 180 min or until termination (volitional fatigue, rectal temperature ≥39.5 °C) in 16, 24, 28, and 32 °C wet-bulb globe temperatures. Rectal temperature and heart rate were recorded to calculate PSI (0-10 scale). Rating of perceived exertion and thermal sensation were recorded to calculate PeSI (0-10 scale). The relation between hourly PSI and PeSI was assessed via linear mixed models. Mean bias (95% limits of agreement [LoA]) between PSI and PeSI was assessed via Bland-Altman analysis. PSI increased with PeSI (p < 0.001), but the slope of this relation was not different between young and older adults (p = 0.189) or as a function of chronic disease (within older adults; p = 0.183). The mean bias between PSI and PeSI was small (0.02), but the 95% LoA was wide (-3.3-3.4). Together, a linear relation between PeSI and PSI was observed but agreement between these measures varied considerably across individuals and thus PeSI should not be used as a surrogate marker of PSI. Caution should be taken when utilizing the PeSI to estimate physiological strain on workers.

Impacts of age, type 2 diabetes, and hypertension on circulating neutrophil gelatinase-associated lipocalin and kidney injury molecule-1 after prolonged work in the heat in men

PURPOSE

Prolonged work in the heat increases the risk of acute kidney injury (AKI) in young men. Whether aging and age-associated chronic disease may exacerbate the risk of AKI remains unclear.

METHODS

We evaluated plasma neutrophil gelatinase-associated lipocalin (NGAL) and serum kidney injury molecule-1 (KIM1) before and after 180 min of moderate-intensity work (200 W/m2) in temperate (wet-bulb globe temperature [WBGT] 16 °C) and hot (32 °C) environments in healthy young (n = 13, 22 years) and older men (n = 12, 59 years), and older men with type 2 diabetes (T2D; n = 9, 60 years) or hypertension (HTN; n = 9, 60 years).

RESULTS

There were no changes in NGAL or KIM1 concentrations following prolonged work in temperate conditions in any group. Despite a similar work tolerance, the relative change in NGAL was greater in the older group when compared to the young group following exercise in the hot condition (mean difference + 82 ng/mL; p < 0.001). Baseline concentrations of KIM1 were ~ 22 pg/mL higher in the older relative to young group, increasing by ~ 10 pg/mL in each group after exercise in the heat (both p ≤ 0.03). Despite a reduced work tolerance in the heat in older men with T2D (120 ± 40 min) and HTN (108 ± 42 min), elevations in NGAL and KIM1 were similar to their healthy counterparts.

CONCLUSION

Age may be associated with greater renal stress following prolonged work in the heat. The similar biomarker responses in T2D and HTN compared to healthy older men, alongside reduced exercise tolerance in the heat, suggest these individuals may exhibit greater vulnerability to heat-induced AKI if work is prolonged.

Exploring the contribution of inter-individual factors to the development of physiological heat strain in older adults exposed to simulated indoor overheating

Older adults are at elevated risk of heat-related mortality due to age-associated declines in thermoregulatory and cardiovascular function. However, the inter-individual factors that exacerbate physiological heat strain during heat exposure remain unclear, making it challenging to identify more heat-vulnerable subgroups. We therefore explored factors contributing to inter-individual variability in physiological responses of older adults exposed to simulated hot weather. Thirty-seven older adults (61-80 years, 16 females) rested for 8 h in 31 and 36 °C (45% relative humidity). Core (rectal) temperature, heart rate (HR), HR variability, mean arterial pressure (MAP), and cardiac autonomic responses to standing were measured at baseline and end-exposure. Bootstrapped least absolute shrinkage and selection operator regression was used to evaluate whether variation in these responses was related to type 2 diabetes (T2D, n = 10), hypertension (n = 18), age, sex, body morphology, habitual physical activity levels, and/or heat-acclimatization. T2D was identified as a predictor of end-exposure HR (with vs. without: 13 beats/min (bootstrap 95% confidence interval: 6, 23)), seated MAP (-7 mmHg (-18, 1)), and the systolic pressure response to standing (20 mmHg (4, 36)). HR was also influenced by sex (female vs. male: 8 beats/min (1, 16)). No other predictors were identified. The inter-individual factors explored did not meaningfully contribute to the variation in body temperature responses in older adults exposed to simulated indoor overheating. By contrast, cardiovascular responses were exacerbated in females and individuals with T2D. These findings improve understanding of how inter-individual differences contribute to heat-induced physiological strain in older persons.

Work-rest regimens for work in hot environments: A scoping review

BACKGROUND

To limit exposures to occupational heat stress, leading occupational health and safety organizations recommend work-rest regimens to prevent core temperature from exceeding 38°C or increasing by ≥1°C. This scoping review aims to map existing knowledge of the effects of work-rest regimens in hot environments and to propose recommendations for future research based on identified gaps.

METHODS

We performed a search of 10 databases to retrieve studies focused on work-rest regimens under hot conditions.

RESULTS

Forty-nine articles were included, of which 35 were experimental studies. Most studies were conducted in laboratory settings, in North America (71%), on healthy young adults, with 94% of the 642 participants being males. Most studies (66%) employed a protocol duration ≤240 min (222 ± 162 min, range: 37-660) and the time-weighted average wet-bulb globe temperature was 27 ± 4°C (range: 18-34). The work-rest regimens implemented were those proposed by the American Conference of Governmental and Industrial Hygiene (20%), National Institute of Occupational Safety and Health (11%), or the Australian Army (3%). The remaining studies (66%) did not mention how the work-rest regimens were derived. Most studies (89%) focused on physical tasks only. Most studies (94%) reported core temperature, whereas only 22% reported physical and/or mental performance outcomes, respectively. Of the 35 experimental studies included, 77% indicated that core temperature exceeded 38°C.

CONCLUSIONS

Although work-rest regimens are widely used, few studies have investigated their physiological effectiveness. These studies were mainly short in duration, involved mostly healthy young males, and rarely considered the effect of work-rest regimens beyond heat strain during physical exertion.

Hormonal intrauterine devices and heat exchange during exercise

Synthetic progestins in oral contraceptives are thought to blunt heat dissipation by reducing skin blood flow and sweating. However, whether progestin-releasing intrauterine devices (IUDs) modulate heat loss during exercise-heat stress is unknown. We used direct calorimetry to measure whole-body total (dry + evaporative) heat loss in young, physically active women (mean (SD); aged 24 (4) years,V ̇ O 2 peak ${\dot V_{{{\mathrm{O}}_{\mathrm{2}}}{\mathrm{peak}}}}$ 39.3 (5.3) ml/kg/min) with (IUD; n = 19) and without (Control; n = 17) IUDs in the follicular and luteal phases of the menstrual cycle during light- and moderate-intensity exercise at fixed rates of heat production (∼175 and ∼275 W/m2 ) in 30°C, ∼21% relative humidity. Between-group and -phase differences were evaluated using traditional hypothesis testing and statistical equivalence testing within pre-determined bounds (±11 W/m2 ; difference required to elicit a ±0.3°C difference in core temperature over 1 h) in each exercise bout. Whole-body total heat loss was statistically equivalent between groups within ±11 W m-2 (IUD-Control [90% CIs]; Light: -2 [-8, 5] W/m2 , P = 0.007; Moderate: 0 [-6, 6] W/m2 , P = 0.002), as were dry and evaporative heat loss (P ≤ 0.023), except for evaporative heat loss during moderate-intensity exercise (equivalence: P = 0.063, difference: P = 0.647). Whole-body total and evaporative heat loss were not different between phases (P ≥ 0.267), but dry heat loss was 3 [95% CIs: 1, 5] W/m2 greater in the luteal phase (P ≤ 0.022). Despite this, all whole-body heat loss outcomes were equivalent between phases (P ≤ 0.003). These findings expand our understanding of the factors that modulate heat exchange in women and provide valuable mechanistic insight of the role of endogenous and exogenous female sex hormones in thermoregulation. KEY POINTS: Progestin released by hormonal intrauterine devices (IUDs) may negatively impact heat dissipation during exercise by blunting skin blood flow and sweating. However, the influence of IUDs on thermoregulation has not previously been assessed. We used direct calorimetry to show that IUD users and non-users display statistically equivalent whole-body dry and evaporative heat loss, body heat storage and oesophageal temperature during moderate- and high-intensity exercise in a warm, dry environment, indicating that IUDs do not appear to compromise exercise thermoregulation. However, within IUD users and non-users, dry heat loss was increased and body heat storage and oesophageal temperature were reduced in the luteal compared to the follicular phase of the menstrual cycle, though these effects were small and unlikely to be practically meaningful. Together, these findings expand our understanding of the factors that modulate heat exchange in women and have important practical implications for the design of future studies of exercise thermoregulation.

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.

Physiological responses to 9 hours of heat exposure in young and older adults. Part I: Body temperature and hemodynamic regulation

Aging is associated with an elevated risk of heat-related mortality and morbidity, attributed, in part, to declines in thermoregulation. However, comparisons between young and older adults have been limited to brief exposures (1-4 h), which may not adequately reflect the duration or severity of the heat stress experienced during heat waves. We therefore evaluated physiological responses in 20 young (19-31 yr; 10 females) and 39 older (61-78 yr; 11 females) adults during 9 h of rest at 40°C and 9% relative humidity. Whole body heat exchange and storage were measured with direct calorimetry during the first 3 h and final 3 h. Core temperature (rectal) was monitored continuously. The older adults stored 88 kJ [95% confidence interval (CI): 29, 147] more heat over the first 3 h of exposure (P = 0.006). Although no between-group differences were observed after 3 h [young: 37.6°C (SD 0.2°C) vs. older: 37.7°C (0.3°C); P = 0.216], core temperature was elevated by 0.3°C [0.1, 0.4] (adjusted for baseline) in the older group at hour 6 [37.6°C (0.2°C) vs. 37.9°C (0.2°C); P < 0.001] and by 0.2°C [0.0, 0.3] at hour 9 [37.7°C (0.3°C) vs. 37.8°C (0.3°C)], although the latter comparison was not significant after multiplicity correction (P = 0.061). Our findings indicate that older adults sustain greater increases in heat storage and core temperature during daylong exposure to hot dry conditions compared with their younger counterparts. This study represents an important step in the use of ecologically relevant, prolonged exposures for translational research aimed at quantifying the physiological and health impacts of hot weather and heat waves on heat-vulnerable populations.NEW & NOTEWORTHY We found greater increases in body heat storage and core temperature in older adults than in their younger counterparts during 9 h of resting exposure to hot dry conditions. Furthermore, the age-related increase in core temperature was exacerbated in older adults with common heat-vulnerability-linked health conditions (type 2 diabetes and hypertension). Impairments in thermoregulatory function likely contribute to the increased risk of heat-related illness and injury seen in older adults during hot weather and heat waves.

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.

Body mass index, but not sex, influences exertional heat stroke risk in young healthy men and women

Exertional heat stroke (EHS) remains a persistent threat for individuals working or playing in the heat, including athletes and military and emergency service personnel. However, influence of biological sex and/or body mass index (BMI) on the risk of EHS remain poorly understood. The purpose of this study was to retrospectively assess the influence of sex and BMI on risk of EHS in the active-duty US Army. We analyzed data from 2016 to 2021, using a matched case-control approach, where each individual with a diagnosis of EHS was matched to five controls based on calendar time, unit ID, and job category, to capture control individuals who were matched to EHS events by location, time, and activity. We used a multivariate logistic regression model mutually adjusted for sex, BMI, and age to compare 745 (n = 61 F) individuals (26 ± 7 yr) with a diagnosed EHS to 4,290 (n = 384 F) case controls (25 ± 5 yr). Group average BMI were similar: 26.6 ± 3.1 (EHS) and 26.5 ± 3.6 kg/m² (CON). BMI was significantly (P < 0.0001) associated with higher risk of EHS with a 3% increase in risk of EHS for every unit increase in BMI. Notably, sex was not associated with any difference in risk for EHS (P = 0.54). These data suggest that young healthy people with higher BMI have significantly higher risk of EHS, but, contrary to what some have proposed, this risk was not higher in young women.

The serum irisin response to prolonged physical activity in temperate and hot environments in older men with hypertension or type 2 diabetes

Current labor demographics are changing, with the number of older adults increasingly engaged in physically demanding occupations expected to continually rise, which are often performed in the heat. Given an age-related decline in whole-body heat loss, older adults are at an elevated risk of developing heat injuries that may be exacerbated by hypertension (HTN) and type 2 diabetes (T2D). Elevated irisin production may play a role in mitigating the excess oxidative stress and acute inflammation associated with physically demanding work in the heat. However, the effects of HTN and T2D on this response remain unclear. Therefore, we evaluated serum irisin before and after 3-h of moderate intensity exercise (metabolic rate: 200 W/m²) and at the end of 60-min of post-exercise recovery in a temperate (wet-bulb globe temperature (WBGT) 16 °C) and high-heat stress (WBGT 32 °C) environment in 12 healthy older men (mean ± SD; 59 ± 4 years), 10 men with HTN (60 ± 4 years), and 9 men with T2D (60 ± 5 years). Core temperature (T_co) was measured continuously. In the heat, total exercise duration was significantly lower in older men with HTN and T2D (both, p ≤ 0.049). Despite T_co not being different between groups, T_co was higher in the hot compared to the temperate condition for all groups (p < 0.001). Similarly, serum irisin concentrations did not differ between groups under either condition but were elevated relative to the temperate condition during post-exercise and end-recovery in the heat (+93.9 pg/mL SEM 26 and + 70.5 pg/mL SEM 38 respectively; both p ≤ 0.014). Thus, our findings indicate similar irisin responses in HTN and T2D compared to healthy, age-matched controls, despite reduced exercise tolerance during prolonged exercise in the heat. Therefore, older workers with HTN and T2D may exhibit greater cellular stress during prolonged exercise in the heat, underlying greater vulnerability to heat-induced cellular injury.

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.

The association of indoor heat exposure with diabetes and respiratory 9-1-1 calls through emergency medical dispatch and services documentation

BACKGROUND

People with pre-existing medical conditions, who spend a large proportion of their time indoors, are at risk of emergent morbidities from elevated indoor heat exposures. In this study, indoor heat of structures wherein exposed people received Grady Emergency Services based care in Atlanta, GA, U.S., was measured from May to September 2016.

METHOD

ology: In this case-control study, analyses were conducted to investigate the effect of indoor heat on the odds of 9-1-1 calls for diabetic (n = 90 cases) and separately, for respiratory (n = 126 cases), conditions versus heat-insensitive emergencies (n = 698 controls). Generalized Additive Models considered both linear and non-linear indoor heat and health outcome associations using thin-plate regression splines.

RESULTS

Hotter and more humid indoor conditions were non-linearly associated with an increasing likelihood of receiving emergency care for complications of diabetes and severe respiratory distress. Higher heat indices were associated with increased odds of a diabetes (odds ratio for change from 30 to 31 °C: 1.12, 95% CI: 1.08-1.16) or respiratory 9-1-1 medical call versus control (odds ratio for change from 34 to 35 °C: 1.18, 95% CI: 1.09-1.28) call. Both diabetic and respiratory distress patients were more likely to be African-American and/or have comorbidities.

CONCLUSIONS

In this study, the statistical association of indoor heat exposure with emergency morbidities (diabetic, respiratory) was demonstrated. The study also showcased the value and utility of data gathered by emergency medical dispatch and services from inaccessible private indoor sources (i.e., domiciles) for environmental health.

Exercise/Physical Activity in Individuals with Type 2 Diabetes: A Consensus Statement from the American College of Sports Medicine

ABSTRACT

This consensus statement is an update of the 2010 American College of Sports Medicine position stand on exercise and type 2 diabetes. Since then, a substantial amount of research on select topics in exercise in individuals of various ages with type 2 diabetes has been published while diabetes prevalence has continued to expand worldwide. This consensus statement provides a brief summary of the current evidence and extends and updates the prior recommendations. The document has been expanded to include physical activity, a broader, more comprehensive definition of human movement than planned exercise, and reducing sedentary time. Various types of physical activity enhance health and glycemic management in people with type 2 diabetes, including flexibility and balance exercise, and the importance of each recommended type or mode are discussed. In general, the 2018 Physical Activity Guidelines for Americans apply to all individuals with type 2 diabetes, with a few exceptions and modifications. People with type 2 diabetes should engage in physical activity regularly and be encouraged to reduce sedentary time and break up sitting time with frequent activity breaks. Any activities undertaken with acute and chronic health complications related to diabetes may require accommodations to ensure safe and effective participation. Other topics addressed are exercise timing to maximize its glucose-lowering effects and barriers to and inequities in physical activity adoption and maintenance.

Heat Safety in the Workplace: Modified Delphi Consensus to Establish Strategies and Resources to Protect the US Workers

The purpose of this consensus document was to develop feasible, evidence-based occupational heat safety recommendations to protect the US workers that experience heat stress. Heat safety recommendations were created to protect worker health and to avoid productivity losses associated with occupational heat stress. Recommendations were tailored to be utilized by safety managers, industrial hygienists, and the employers who bear responsibility for implementing heat safety plans. An interdisciplinary roundtable comprised of 51 experts was assembled to create a narrative review summarizing current data and gaps in knowledge within eight heat safety topics: (a) heat hygiene, (b) hydration, (c) heat acclimatization, (d) environmental monitoring, (e) physiological monitoring, (f) body cooling, (g) textiles and personal protective gear, and (h) emergency action plan implementation. The consensus-based recommendations for each topic were created using the Delphi method and evaluated based on scientific evidence, feasibility, and clarity. The current document presents 40 occupational heat safety recommendations across all eight topics. Establishing these recommendations will help organizations and employers create effective heat safety plans for their workplaces, address factors that limit the implementation of heat safety best-practices and protect worker health and productivity.

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.

Physiological factors characterizing heat-vulnerable older adults: A narrative review

More frequent and intense periods of extreme heat (heatwaves) represent the most direct challenge to human health posed by climate change. Older adults are particularly vulnerable, especially those with common age-associated chronic health conditions (e.g., cardiovascular disease, hypertension, obesity, type 2 diabetes, chronic kidney disease). In parallel, the global population is aging and age-associated disease rates are on the rise. Impairments in the physiological responses tasked with maintaining homeostasis during heat exposure have long been thought to contribute to increased risk of health disorders in older adults during heatwaves. As such, a comprehensive overview of the provisional links between age-related physiological dysfunction and elevated risk of heat-related injury in older adults would be of great value to healthcare officials and policy makers concerned with protecting heat-vulnerable sectors of the population from the adverse health impacts of heatwaves. In this narrative review, we therefore summarize our current understanding of the physiological mechanisms by which aging impairs the regulation of body temperature, hemodynamic stability and hydration status. We then examine how these impairments may contribute to acute pathophysiological events common during heatwaves (e.g., heatstroke, major adverse cardiovascular events, acute kidney injury) and discuss how age-associated chronic health conditions may exacerbate those impairments. Finally, we briefly consider the importance of physiological research in the development of climate-health programs aimed at protecting heat-vulnerable individuals.

Individual Responses to Heat Stress: Implications for Hyperthermia and Physical Work Capacity

Background

Extreme heat events are increasing in frequency, severity, and duration. It is well known that heat stress can have a negative impact on occupational health and productivity, particularly during physical work. However, there are no up-to-date reviews on how vulnerability to heat changes as a function of individual characteristics in relation to the risk of hyperthermia and work capacity loss. The objective of this narrative review is to examine the role of individual characteristics on the human heat stress response, specifically in relation to hyperthermia risk and productivity loss in hot workplaces. Finally, we aim to generate practical guidance for industrial hygienists considering our findings. Factors included in the analysis were body mass, body surface area to mass ratio, body fat, aerobic fitness and training, heat adaptation, aging, sex, and chronic health conditions.

Findings

We found the relevance of any factor to be dynamic, based on the work-type (fixed pace or relative to fitness level), work intensity (low, moderate, or heavy work), climate type (humidity, clothing vapor resistance), and variable of interest (risk of hyperthermia or likelihood of productivity loss). Heat adaptation, high aerobic fitness, and having a large body mass are the most protective factors during heat exposure. Primary detrimental factors include low fitness, low body mass, and lack of heat adaptation. Aging beyond 50 years, being female, and diabetes are less impactful negative factors, since their independent effect is quite small in well matched participants. Skin surface area to mass ratio, body composition, hypertension, and cardiovascular disease are not strong independent predictors of the heat stress response.

Conclusion

Understanding how individual factors impact responses to heat stress is necessary for the prediction of heat wave impacts on occupational health and work capacity. The recommendations provided in this report could be utilized to help curtail hyperthermia risk and productivity losses induced by heat.

Type 2 diabetes does not exacerbate body heat storage in older adults during brief, extreme passive heat exposure

Aging exacerbates hyperthermia and cardiovascular strain during passive heat exposure, but it remains unclear whether those effects worsen in older adults with type 2 diabetes (T2D). We examined these responses in unacclimatized, physically active, older individuals with (n = 13, mean ± SD age: 60 ± 8 years, HbA1c: 7.0 ± 1.0%) and without (Control, n = 30, 62 ± 6 years) well-controlled T2D during a brief, 3-h passive exposure to extreme heat (44°C, 30% relative humidity). Metabolic heat production, dry heat gain, total heat gain (metabolic heat production + dry heat gain), evaporative heat loss, body heat storage (summation of heat gain/loss), rectal and mean skin temperatures as well as heart rate were measured continuously. No between-group differences were observed for metabolic heat production (T2D vs. Control; 53 ± 5 vs. 55 ± 7 W/m²), dry heat gain (48 ± 9 vs. 47 ± 11 W/m²), total heat gain (101 ± 10 vs. 102 ± 14 W/m²) and evaporative heat loss (83 ± 10 vs. 85 ± 12 W/m²) over the 3 h (all P > 0.05). Consequently, the changes in body heat storage (380 ± 93 vs. 358 ± 172 kJ, P = 0.67) were similar between groups. Moreover, no between-group differences in rectal and mean skin temperatures or heart rate were measured. We conclude that unacclimatized, physically active, older adults with well-controlled T2D do not experience greater hyperthermia and cardiovascular strain compared to their healthy counterparts while resting in extreme heat for a brief, 3-h period.

Occupational heat stress management: Does one size fit all?

Heat stress is a deadly occupational hazard that is projected to increase in severity with global warming. While upper limits for heat stress designed to protect all workers have been recommended by occupational safety institutes for some time, heat stress continues to compromise health and productivity. In our view, this is largely explained by the inability of existing guidelines to consider the inter-individual (age, sex, disease, others) and intra-individual (medication use, fitness, hydration, others) factors that cause extensive variability in physiological tolerance to a given heat stress. In conditions that do not exceed the recommended limits, this 'one size fits all' approach to heat stress management can lead to reductions in productivity in more heat-tolerant workers, while compromising safety in less heat-tolerant workers who may develop heat-related illness, even in temperate conditions. Herein, we discuss future directions in occupational heat stress management that consider this individual variability.

Wilderness Medical Society Clinical Practice Guidelines for Diabetes Management

The Wilderness Medical Society convened an expert panel in 2018 to develop a set of evidence-based guidelines for the treatment of type 1 and 2 diabetes, as well as the recognition, prevention, and treatment of complications of diabetes in wilderness athletes. We present a review of the classifications, pathophysiology, and evidence-based guidelines for planning and preventive measures, as well as best practice recommendations for both routine and urgent therapeutic management of diabetes and glycemic complications. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks or burdens for each recommendation.

Physiology of sweat gland function: The roles of sweating and sweat composition in human health

The purpose of this comprehensive review is to: 1) review the physiology of sweat gland function and mechanisms determining the amount and composition of sweat excreted onto the skin surface; 2) provide an overview of the well-established thermoregulatory functions and adaptive responses of the sweat gland; and 3) discuss the state of evidence for potential non-thermoregulatory roles of sweat in the maintenance and/or perturbation of human health. The role of sweating to eliminate waste products and toxicants seems to be minor compared with other avenues of excretion via the kidneys and gastrointestinal tract; as eccrine glands do not adapt to increase excretion rates either via concentrating sweat or increasing overall sweating rate. Studies suggesting a larger role of sweat glands in clearing waste products or toxicants from the body may be an artifact of methodological issues rather than evidence for selective transport. Furthermore, unlike the renal system, it seems that sweat glands do not conserve water loss or concentrate sweat fluid through vasopressin-mediated water reabsorption. Individuals with high NaCl concentrations in sweat (e.g. cystic fibrosis) have an increased risk of NaCl imbalances during prolonged periods of heavy sweating; however, sweat-induced deficiencies appear to be of minimal risk for trace minerals and vitamins. Additional research is needed to elucidate the potential role of eccrine sweating in skin hydration and microbial defense. Finally, the utility of sweat composition as a biomarker for human physiology is currently limited; as more research is needed to determine potential relations between sweat and blood solute concentrations.

Could wearing motorcycle protective clothing compromise rider safety in hot weather?

Motorcycle protective clothing (PPE) effectively reduces the risk of injury in crashes, however in hot conditions many motorcyclists ride unprotected. Recent work found available motorcycle PPE to be thermally inefficient in hot weather with potential to cause significant thermal strain under average Australian summer conditions. The current study investigated the potential for the cognitive and psychophysical concomitants of thermal strain to compromise reaction times, mood and fatigue with potential consequences for motorcyclists' safety.

METHOD

Volunteers wearing motorcycle PPE participated in a 90 min trial (cycling 30 W) in 35 °C, 40%RH with overhead radiant heaters and a fan to simulate wind speed. Heart rate, core and skin temperature were recorded continuously. Reaction time and subjective ratings of thermal sensation and comfort, workload and mood were recorded at baseline, during rest breaks at 25 min intervals and on completion of the trail. Repeated measures analysis assessed each participant's performance against their own baseline.

RESULTS

Core temperatures increased by 2 °C (p < .0001), skin temperatures (3 °C, (p < .0001) and heart rates (66bpm, p < .0001). Reaction times fluctuated 36 ms 8% (p < .0001) over the trial. Subjective workload increased 68% (p = 0.001) and mood deteriorated 33 points (p < .0001) including feeling less alert (p = <.0001), contented (p = 0.001) and calm (p = 0.0004). Multivariate repeated measures analysis found significant associations between core temperature and workload (p = 0.01), mood (p = 0.001) and reaction time (<.0001). Skin temperature and workload (p = 0.02), mood (p = 0.01) and reaction time (<.0001). Subjective ratings of temperature sensation and wetness discomfort were associated respectively with increased workload (p = 0.0001, p = 0.004), mood change (p < .0001, p = 0.04) and reaction time (p < .0001, p < .0001).

CONCLUSIONS

The physiological impact of wearing thermally inefficient motorcycle PPE in hot conditions could impair motorcyclists cognitive and psychophysical functioning and, potentially, their riding performance and safety. These outcomes indicate an urgent need for manufacturers to develop motorcycle PPE that is effective and suitable for use, in hot conditions.

Free-living, continuous hypo-hydration, and cardiovascular response to exercise in a heated environment

Chronic dehydration (DEH) and heat stress combined with poor cardiovascular (CV) health may influence physiological responses to exercise. We examined the effects of free-living induced hypo-hydration on physiological responses to exercise in a heated environment and whether resting CV health is related to these changes. Participants (N = 16, 20.6 ± 1.2 years) were randomized to 3 days of voluntary fluid restriction (DEH) or intake (hydration [HYD]) followed by an exercise bout. CV health was assessed by flow-mediated dilation (FMD), pulse wave analysis, and heart rate variability (HRV). HYD was assessed by weight, urine color, and specific gravity (USG). Exercise trials were conducted in a heated environment (30.3 ± 0.8°C, 27.4 ± 7.4% RH) on a cycle ergometer for 30 min. Heart rate (HR), weighted skin (T_sk ) and mean body temperature (T_b ) and skin blood flow (SBF) were assessed during exercise. Pre-exercise weight (P < 0.005), urine color, and USG (P < 0.001) were different in between trials. HR was greater in DEH (153 ± 26 bpm) versus HYD (144 ± 23 bpm, P = 0.02) after exercise. No group differences were found, but a time interaction P < 0.001) for all temperature responses and time-by-trial interaction for T_re (P < 0.01) and T_sk (P < 0.001) was observed. Greater changes in T_re (P = 0.02) and T_sk (P < 0.01) were associated with increased FMD. Free-living, continuous DEH alters weight, blood, and urine markers of HYD as well as HR response during exercise. Resting CV health was related to increased change in T_re and T_sk , suggesting CV health plays a role in the mechanism of heat dissipation when DEH even in college-age men and women.

Effect of all-extremity high-intensity interval training vs. moderate-intensity continuous training on aerobic fitness in middle-aged and older adults with type 2 diabetes: A randomized controlled trial

Aging and diabetes are associated with decreased aerobic fitness, an independent predictor of mortality. Aerobic exercise is prescribed to improve aerobic fitness; however, middle-aged/older diabetic patients often suffer from mobility limitations which restrict walking. Non-weight-bearing/low-impact exercise is recommended but the optimal exercise prescription is uncertain. The goal of this randomized controlled trial was twofold: 1) to test if high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT), implemented on a non-weight-bearing all-extremity ergometer, are feasible, well-tolerated and safe in middle-aged/older adults with type 2 diabetes; and 2) to test whether all-extremity HIIT is more effective in improving aerobic fitness than MICT. A total of 58 sedentary individuals with type 2 diabetes (46 to 78 years; 63 ± 1) were randomized to all-extremity HIIT (n = 23), MICT (n = 19) or non-exercise control (CONT; n = 16). All-extremity HIIT and MICT, performed 4×/week for 8 weeks under supervision, resulted in no adverse events requiring hospitalization or medical treatment. Aerobic fitness (VO_2peak) improved by 10% in HIIT and 8% in MICT and maximal exercise tolerance increased by 1.8 and 1.3 min, respectively (P ≤ 0.002 vs. baseline; P ≥ 0.9 for HIIT vs. MICT). In conclusion, all-extremity HIIT and MICT are feasible, well-tolerated and safe and result in similar improvements in aerobic fitness in middle-aged/older individuals with type 2 diabetes. These findings have important implications for exercise prescription for diabetic patients; they indicate that all-extremity exercise is a feasible alternative to weight-bearing exercise and those who are unable or unwilling to engage in HIIT may receive similar benefits from MICT.

Towards establishing evidence-based guidelines on maximum indoor temperatures during hot weather in temperate continental climates

Rising environmental temperatures represent a major threat to human health. The activation of heat advisories using evidence-based thresholds for high-risk outdoor ambient temperatures have been shown to be an effective strategy to save lives during hot weather. However, although the relationship between weather and human health has been widely defined by outdoor temperature, corresponding increases in indoor temperature during heat events can also be harmful to health especially in vulnerable populations. In this review, we discuss our current understanding of the relationship between outdoor temperature and human health and examine how human health can also be adversely influenced by high indoor temperatures during heat events. Our assessment of the existing literature revealed a high degree of variability in what can be considered an acceptable indoor temperature because there are differences in how different groups of people may respond physiologically and behaviorally to the same living environment. Finally, we demonstrate that both non-physiological (e.g., geographical location, urban density, building design) and physiological (e.g., sex, age, fitness, state of health) factors must be considered when defining an indoor temperature threshold for preserving human health in a warming global climate.

The recommended Threshold Limit Values for heat exposure fail to maintain body core temperature within safe limits in older working adults

PURPOSE

The American Conference of Governmental and Industrial Hygienists (ACGIH®) Threshold Limit Values (TLV® guidelines) for work in the heat consist of work-rest (WR) allocations designed to ensure a stable core temperature that does not exceed 38°C. However, the TLV® guidelines have not been validated in older workers. This is an important shortcoming given that adults as young as 40 years demonstrate impairments in their ability to dissipate heat. We therefore evaluated body temperature responses in older adults during work performed in accordance to the TLV® recommended guidelines.

METHODS

On three occasions, 9 healthy older (58 ± 5 years) males performed a 120-min work-simulated protocol in accordance with the TLV® guidelines for moderate-to-heavy intensity work (360 W fixed rate of heat production) in different wet-bulb globe temperatures (WBGT). The first was 120 min of continuous (CON) cycling at 28.0°C WBGT (CON[28°C]). The other two protocols were 15-min intermittent work bouts performed with different WR cycles and WBGT: (i) WR of 3:1 at 29.0°C (WR3:1[29°C]) and (ii) WR of 1:1 at 30.0°C (WR1:1[30°C]). Rectal temperature was measured continuously. The rate of change in mean body temperature was determined via thermometry (weighting coefficients: rectal, 0.9; mean skin temperature, 0.1) and direct calorimetry.

RESULTS

Rectal temperature exceeded 38°C in all participants in CON[28°C] and WR3:1[29°C] whereas a statistically similar proportion of workers exceeded 38°C in WR1:1[30°C] (χ²; P = 0.32). The average time for rectal temperature to reach 38°C was: CON[28°C], 53 ± 7; WR3:1[29°C], 79 ± 11; and WR1:1[30°C], 100 ± 29 min. Finally, while a stable mean body temperature was not achieved in any work condition as measured by thermometry (i.e., >0°C·min^-1; all P<0.01), heat balance as determined by direct calorimetry was achieved in WR3:1[29°C] and WR1:1[30°C] (both P ≥ 0.08).

CONCLUSION

Our findings indicate that the TLV® guidelines do not prevent body core temperature from exceeding 38°C in older workers. Furthermore, a stable core temperature was not achieved within safe limits (i.e., ≤38°C) indicating that the TLV® guidelines may not adequately protect all individuals during work in hot conditions.

Disrupted circadian rhythms of body temperature, heart rate and fasting blood glucose in prediabetes and type 2 diabetes mellitus

We report a progressive disruption of 24-h rhythms in fasting blood glucose (FBG), body temperature (BT) and heart rate (HR) associated with metabolic dysfunction and the development of prediabetes (PD) and type 2 diabetes mellitus (T2DM) in overweight middle-aged (40-69 years old) humans. Increasing BT and HR mean values and declining 24-h BT and HR amplitudes accompany adverse changes in metabolic state. Increased nocturnal BT and a phase delay of the 24-h BT rhythm, deviant 24-h HR profile and a phase advance of the 24-h HR and FBG rhythms are early signs of the PD metabolic state. In T2DM, the 24-h FBG rhythm is no longer detectable, and the 24-h amplitudes of BT and HR are greatly diminished. In addition, lepton and creatinine values were lowered in T2DM. Moreover, positive correlations between FBG and body mass index, BMI, and negative correlations between the 24-h amplitude of FBG and BMI indicate that overweight is an additional factor causing disruption of the circadian rhythms. Further studies on circadian disruption as a consequence of metabolic dysfunction are necessary. The quantitative analysis of changing circadian BT and HR rhythms may provide prognostic markers of T2DM and therapeutic targets for its prevention and correction.

No effect of ascorbate on cutaneous vasodilation and sweating in older men and those with type 2 diabetes exercising in the heat

Aging and chronic disease such as type 2 diabetes (T2D) are associated with impairments in the body's ability to dissipate heat. To reduce the risk of heat-related injuries in these heat vulnerable individuals, it is necessary to identify interventions that can attenuate this impairment. We evaluated the hypothesis that intradermal administration of ascorbate improves cutaneous vasodilation and sweating in older adults via nitric oxide synthase (NOS)-dependent mechanisms during exercise in the heat and whether these improvements, if any, are greater in individuals with T2D. Older males with (n = 12, 61 ± 9 years) and without (n = 12, 64 ± 7 years) T2D performed two 30-min bouts of cycling at a fixed rate of metabolic heat production of 500 W (~70% peak oxygen uptake) in the heat (35°C); each followed by a 20- and 40-min recovery, respectively. Cutaneous vascular conductance (CVC) and sweat rate were measured at four intradermal microdialysis sites treated with either (1) lactated Ringer (Control), (2) 10 mmol/L ascorbate (an antioxidant), (3) 10 mmol/L L-NAME (non-selective NOS inhibitor), or (4) a combination of ascorbate + L-NAME. In both groups, ascorbate did not modulate CVC or sweating during exercise relative to Control (all P > 0.05). In comparison to Control, L-NAME alone or combined with ascorbate attenuated CVC during exercise (all P ≤ 0.05) but had no influence on sweating (all P > 0.05). We show that in both healthy and T2D older adults, intradermal administration of ascorbate does not improve cutaneous vasodilation and sweating during exercise in the heat. However, NOS plays an important role in mediating cutaneous vasodilation.

Heat remains unaccounted for in thermal physiology and climate change research

In the aftermath of the Paris Agreement, there is a crucial need for scientists in both thermal physiology and climate change research to develop the integrated approaches necessary to evaluate the health, economic, technological, social, and cultural impacts of 1.5°C warming. Our aim was to explore the fidelity of remote temperature measurements for quantitatively identifying the continuous redistribution of heat within both the Earth and the human body. Not accounting for the regional distribution of warming and heat storage patterns can undermine the results of thermal physiology and climate change research. These concepts are discussed herein using two parallel examples: the so-called slowdown of the Earth's surface temperature warming in the period 1998-2013; and the controversial results in thermal physiology, arising from relying heavily on core temperature measurements. In total, the concept of heat is of major importance for the integrity of systems, such as the Earth and human body. At present, our understanding about the interplay of key factors modulating the heat distribution on the surface of the Earth and in the human body remains incomplete. Identifying and accounting for the interconnections among these factors will be instrumental in improving the accuracy of both climate models and health guidelines.

Physiological and perceptual effects of a cooling garment during simulated industrial work in the heat

OBJECTIVE

Evaluate physiological and perceptual responses using a phase change cooling (PCC) garment during simulated work in the heat.

METHODS

Twenty males wearing compression undergarments, coverall suit, gloves, and hard-hat, completed two randomly assigned trials (with PCC inserts or control, CON) of simulated industrial tasks in the heat (34.2 ± 0.05 °C, 54.7 ± 0.3%RH). Trials consisted of two 20 min work bouts, a maximum performance bout, and 10 min of recovery.

RESULTS

Physiological strain index (PSI) was lower during PCC after the second work bout and during recovery (all P < 0.05). PCC reduced heat storage (27.0 ± 7.6 W m^-2) compared to CON (42.7 ± 9.9 W m^-2, P < 0.001). Perceptual strain index (PeSI) was reduced with PCC compared to CON (P < 0.001), however performance outcomes were not different between trials (P = 0.10).

CONCLUSIONS

PCC during work in the heat attenuated thermal, physiological, and perceptual strain. This PCC garment could increase safety and reduce occupational heat illness risk.

Update on Management of Type 1 Diabetes and Type 2 Diabetes in Athletes

Optimal blood glucose management still remains the biggest challenge in active individuals with diabetes, particularly in insulin users, but some newer strategies have been introduced to maintain blood glucose control. Recent studies emphasize the importance of exercise intensity on glycemic balance. In individuals with type 1 and type 2 diabetes, both resistance and high-intensity intermittent exercise have been shown to confer beneficial physiological adaptations in training studies, while also showing acute glycemic benefits from single sessions. At the same time, anyone training at higher intensities also should take into consideration potential impairments in thermoregulation in individuals with diabetes, which can increase the risk of heat stress during exercise in hot and/or humid conditions. Recent studies of medication effects on electrolyte balance and hydration give a more complete picture of potential exercise risks for athletes with diabetes. Use of the latest diabetes-related technologies also may benefit the athlete with diabetes.

Hyperthermia and cardiovascular strain during an extreme heat exposure in young versus older adults

We examined whether older individuals experience greater levels of hyperthermia and cardiovascular strain during an extreme heat exposure compared to young adults. During a 3-hour extreme heat exposure (44°C, 30% relative humidity), we compared body heat storage, core temperature (rectal, visceral) and cardiovascular (heart rate, cardiac output, mean arterial pressure, limb blood flow) responses of young adults (n = 30, 19-28 years) against those of older adults (n = 30, 55-73 years). Direct calorimetry measured whole-body evaporative and dry heat exchange. Body heat storage was calculated as the temporal summation of heat production (indirect calorimetry) and whole-body heat loss (direct calorimetry) over the exposure period. While both groups gained a similar amount of heat in the first hour, the older adults showed an attenuated increase in evaporative heat loss (p < 0.033) in the first 30-min. Thereafter, the older adults were unable to compensate for a greater rate of heat gain (11 ± 1 ; p < 0.05) with a corresponding increase in evaporative heat loss. Older adults stored more heat (358 ± 173 kJ) relative to their younger (202 ± 92 kJ; p < 0.001) counterparts at the end of the exposure leading to greater elevations in rectal (p = 0.043) and visceral (p = 0.05) temperatures, albeit not clinically significant (rise < 0.5°C). Older adults experienced a reduction in calf blood flow (p < 0.01) with heat stress, yet no differences in cardiac output, blood pressure or heart rate. We conclude, in healthy habitually active individuals, despite no clinically observable cardiovascular or temperature changes, older adults experience greater heat gain and decreased limb perfusion in response to 3-hour heat exposure.

Restoration of thermoregulation after exercise

Performing exercise, especially in hot conditions, can heat the body, causing significant increases in internal body temperature. To offset this increase, powerful and highly developed autonomic thermoregulatory responses (i.e., skin blood flow and sweating) are activated to enhance whole body heat loss; a response mediated by temperature-sensitive receptors in both the skin and the internal core regions of the body. Independent of thermal control of heat loss, nonthermal factors can have profound consequences on the body's ability to dissipate heat during exercise. These include the activation of the body's sensory receptors (i.e., baroreceptors, metaboreceptors, mechanoreceptors, etc.) as well as phenotypic factors such as age, sex, acclimation, fitness, and chronic diseases (e.g., diabetes). The influence of these factors extends into recovery such that marked impairments in thermoregulatory function occur, leading to prolonged and sustained elevations in body core temperature. Irrespective of the level of hyperthermia, there is a time-dependent suppression of the body's physiological ability to dissipate heat. This delay in the restoration of postexercise thermoregulation has been associated with disturbances in cardiovascular function which manifest most commonly as postexercise hypotension. This review examines the current knowledge regarding the restoration of thermoregulation postexercise. In addition, the factors that are thought to accelerate or delay the return of body core temperature to resting levels are highlighted with a particular emphasis on strategies to manage heat stress in athletic and/or occupational settings.

Heart rate variability during high heat stress: a comparison between young and older adults with and without Type 2 diabetes

We examined whether older individuals with and without Type 2 diabetes (T2D) experience differences in heart rate variability (HRV) during a 3-h exposure to high heat stress compared with young adults. Young (Young; n = 22; 23 ± 3 yr) and older individuals with (T2D; n = 11; 59 ± 9 yr) and without (Older; n = 25; 63 ± 5 yr) T2D were exposed to heat stress (44°C, 30% relative humidity) for 3 h. Fifty-five HRV measures were assessed for 15 min at baseline and at minutes 82.5-97.5 (Mid) and minutes 165-180 (End) during heat stress. When compared with Young, a similar number of HRV indices were significantly different (P < 0.05) in Older (Baseline: 35; Mid: 29; End: 32) and T2D (Baseline: 31; Mid: 30; End: 27). In contrast, the number of HRV indices significantly different (P < 0.05) between Older and T2D were far fewer (Baseline: 13, Mid: 1, End: 3). Within-group analyses demonstrated a greater change in the Young group's HRV during heat stress compared with Older and T2D; the number of significantly different (P < 0.05) HRV indices between baseline and End were 42, 29, and 20, for Young, Older, and T2D, respectively. Analysis of specific HRV domains suggest that the Young group experienced greater sympathetic activity during heat stress compared with Older and T2D. In conclusion, when compared with young, older individuals with and without T2D demonstrate low HRV at baseline and less change in HRV (including an attenuated sympathetic response) during 3 h high heat stress, potentially contributing to impaired thermoregulatory function.

Age, human performance, and physical employment standards

The proportion of older workers has increased substantially in recent years, with over 25% of the Canadian labour force aged ≥55 years. Along with chronological age comes age-related declines in functional capacity associated with impairments to the cardiorespiratory and muscular systems. As a result, older workers are reported to exhibit reductions in work output and in the ability to perform and/or sustain the required effort when performing work tasks. However, research has presented some conflicting views on the consequences of aging in the workforce, as physically demanding occupations can be associated with improved or maintained physical function. Furthermore, the current methods for evaluating physical function in older workers often lack specificity and relevance to the actual work tasks, leading to an underestimation of physical capacity in the older worker. Nevertheless, industry often lacks the appropriate information and/or tools to accommodate the aging workforce, particularly in the context of physical employment standards. Ultimately, if appropriate workplace strategies and work performance standards are adopted to optimize the strengths and protect against the vulnerability of the aging workers, they can perform as effectively as their younger counterparts. Our aim in this review is to evaluate the impact of different individual (including physiological decline, chronic disease, lifestyle, and physical activity) and occupational (including shift work, sleep deprivation, and cold/heat exposure) factors on the physical decline of older workers, and therefore the risk of work-related injuries or illness.

Temperature of Ingested Water during Exercise Does Not Affect Body Heat Storage

PURPOSE

The objective of this study was to examine the effect of ingested water temperature on heat balance during exercise as assessed by direct calorimetry.

METHODS

Ten healthy males (25 ± 4 yr) cycled at 50% V˙O2peak (equivalent rate of metabolic heat production (M-W) of 523 ± 84 W) for 75 min under thermocomfortable conditions (25°C, 25% relative humidity) while consuming either hot (50°C) or cold (1.5°C) water. Four 3.2 mL·kg⁻¹ boluses of hot or cold water were consumed 5 min before and at 15, 30, and 45 min after the onset of exercise. Total heat loss (HL = evaporative heat loss (HE) ± dry heat exchange (HD)) and M-W were measured by direct and indirect calorimetry, respectively. Change in body heat content (ΔHb) was calculated as the temporal summation of M-W and HL and adjusted for changes in heat transfer from the ingested fluid (Hfluid).

RESULTS

The absolute difference for HL (209 ± 81 kJ) was similar to the absolute difference of Hfluid (204 ± 36 kJ) between conditions (P = 0.785). Furthermore, the difference in HL was primarily explained by the corresponding changes in HE (hot: 1538 ± 393 kJ; cold: 1358 ± 330 kJ) because HD was found to be similar between conditions (P = 0.220). Consequently, no difference in ΔHb was observed between the hot (364 ± 152 kJ) and cold (363 ± 134 kJ) conditions (P = 0.971) during exercise.

CONCLUSION

We show that ingestion of hot water elicits a greater HL relative to cold water ingestion during exercise. However, this response was only compensated for the heat of the ingested fluid as evidenced by similar ΔHb between conditions. Therefore, our findings indicate that relative to cold water ingestion, consuming hot water does not provide a thermoregulatory advantage. Both hot and cold water ingestion results in the same amount of heat stored during prolonged moderate-intensity exercise.

Body temperature regulation in diabetes

The effects of type 1 and type 2 diabetes on the body's physiological response to thermal stress is a relatively new topic in research. Diabetes tends to place individuals at greater risk for heat-related illness during heat waves and physical activity due to an impaired capacity to dissipate heat. Specifically, individuals with diabetes have been reported to have lower skin blood flow and sweating responses during heat exposure and this can have important consequences on cardiovascular regulation and glycemic control. Those who are particularly vulnerable include individuals with poor glycemic control and who are affected by diabetes-related complications. On the other hand, good glycemic control and maintenance of aerobic fitness can often delay the diabetes-related complications and possibly the impairments in heat loss. Despite this, it is alarming to note the lack of information regarding diabetes and heat stress given the vulnerability of this population. In contrast, few studies have examined the effects of cold exposure on individuals with diabetes with the exception of its therapeutic potential, particularly for type 2 diabetes. This review summarizes the current state of knowledge regarding the impact of diabetes on heat and cold exposure with respect to the core temperature regulation, cardiovascular adjustments and glycemic control while also considering the beneficial effects of maintaining aerobic fitness.

Local infusion of ascorbate augments NO-dependent cutaneous vasodilatation during intense exercise in the heat

Recent work demonstrates that nitric oxide (NO) contributes to cutaneous vasodilatation during moderate (400 W of metabolic heat production) but not high (700 W of metabolic heat production) intensity exercise bouts performed in the heat (35°C). The present study evaluated whether the impairment in NO-dependent cutaneous vasodilatation was the result of a greater accumulation of reactive oxygen species during high (700 W of metabolic heat production) relative to moderate (500 W of metabolic heat production) intensity exercise. It was shown that local infusion of ascorbate (an anti-oxidant) improves NO-dependent forearm cutaneous vasodilatation during high intensity exercise in the heat. These findings provide novel insight into the physiological mechanisms governing cutaneous blood flow during exercise-induced heat stress and provide direction for future research exploring whether oxidative stress underlies the impairments in heat dissipation that may occur in older adults, as well as in individuals with pathophysiological conditions such as type 2 diabetes. Nitric oxide (NO)-dependent cutaneous vasodilatation is reportedly diminished during exercise performed at a high (700 W) relative to moderate (400 W) rate of metabolic heat production. The present study evaluated whether this impairment results from increased oxidative stress associated with an accumulation of reactive oxygen species (ROS) during high intensity exercise. On two separate days, 11 young (mean ± SD, 24 ± 4 years) males cycled in the heat (35°C) at a moderate (500 W) or high (700 W) rate of metabolic heat production. Each session included two 30 min exercise bouts followed by 20 and 40 min of recovery, respectively. Cutaneous vascular conductance (CVC) was monitored at four forearm skin sites continuously perfused via intradermal microdialysis with: (1) lactated Ringer solution (Control); (2) 10 mm ascorbate (Ascorbate); (3) 10 mm l-NAME; or (4) 10 mm ascorbate + 10 mm l-NAME (Ascorbate + l-NAME). At the end of each 500 W exercise bout, CVC was attenuated with l-NAME (∼35% CVCmax ) and Ascorbate + l-NAME (∼43% CVCmax ) compared to Control (∼60% CVCmax ; all P < 0.04); however, Ascorbate did not modulate CVC during exercise (∼60% CVCmax ; both P > 0.87). Conversely, CVC was elevated with Ascorbate (∼72% CVCmax ; both P < 0.03) but remained similar to Control (∼59% CVCmax ) with l-NAME (∼50% CVCmax ) and Ascorbate + l-NAME (∼47% CVCmax ; all P > 0.05) at the end of both 700 W exercise bouts. We conclude that oxidative stress associated with an accumulation of ascorbate-sensitive ROS impairs NO-dependent cutaneous vasodilatation during intense exercise.

Can intradermal administration of angiotensin II influence human heat loss responses during whole body heat stress?

It is unclear if angiotensin II, which can increase the production of reactive oxygen species (oxidative stress), modulates heat loss responses of cutaneous blood flow and sweating. We tested the hypothesis that angiotensin II-induced increases in oxidative stress impair cutaneous perfusion and sweating during rest and exercise in the heat. Eleven young (24 ± 4 yr) healthy adults performed two 30-min cycling bouts at a fixed rate of metabolic heat production (400 W) in the heat (35°C). The first and second exercises were followed by a 20- and 40-min recovery. Four microdialysis fibers were placed in the forearm skin for continuous administration of either: 1) lactated Ringer (control), 2) 10 μM angiotensin II, 3) 10 mM ascorbate (an antioxidant), or 4) a combination of 10 μM angiotensin II + 10 mM ascorbate. Cutaneous vascular conductance (CVC; laser-Doppler perfusion units/mean arterial pressure) and sweating (ventilated capsule) were evaluated at each skin site. Compared with control, angiotensin II reduced both CVC and sweating at baseline resting and during each recovery in the heat (all P < 0.05). However, during both exercise bouts, there were no differences in CVC or sweating between the treatment sites (all P > 0.05). When ascorbate was coinfused with angiotensin II, the effect of angiotensin II on sweating was abolished (all P > 0.05); however, its effect on CVC at baseline resting and during each recovery remained intact (all P < 0.05). We show angiotensin II impairs cutaneous perfusion independent of oxidative stress, while it impairs sweating through increasing oxidative stress during exposure to an ambient heat stress before and following exercise.

The Influence of Arc-Flash and Fire-Resistant Clothing on Thermoregulation during Exercise in the Heat

We evaluated the effect of arc-flash and fire-resistant (AFR) clothing ensembles (CE) on whole-body heat dissipation during work in the heat. On 10 occasions, 7 males performed four 15-min cycling bouts at a fixed rate of metabolic heat production (400 W) in the heat (35°C), each separated by 15-min of recovery. Whole-body heat loss and metabolic heat production were measured by direct and indirect calorimetry, respectively. Body heat storage was calculated as the temporal summation of heat production and heat loss. Responses were compared in a semi-nude state and while wearing two CE styles: (1) single-piece (coveralls) and (2) two-piece (workpant + long-sleeve shirt). For group 1, there was one non-AFR single-piece CE (CE1STD) and three single-piece CE with AFR properties (CE2AFR, CE3AFR, CE4AFR). For group 2, there was one non-AFR two-piece CE (CE5STD) and four two-piece CE with AFR properties (CE6AFR, CE7AFR, CE8AFR, CE9AFR). The workpants for CE6AFR were not AFR-rated, while a cotton undershirt was also worn for conditions CE8AFR and CE9AFR and for all single-piece CE. Heat storage for all conditions (CE1STD: 328 ± 55, CE2AFR: 335 ± 87, CE3AFR: 309 ± 95, CE4AFR: 403 ± 104, CE5STD: 253 ± 78, CE6AFR: 268 ± 89, CE7AFR: 302 ± 70, CE8AFR: 360 ± 36, CE9AFR: 381 ± 99 kJ) was greater than the semi-nude state (160 ± 124 kJ) (all p ≤ 0.05). No differences were measured between single-piece uniforms (p = 0.273). Among the two-piece uniforms, heat storage was greater for CE8AFR and CE9AFR relative to CE5STD and CE6AFR (all p ≤ 0.05), but not CE7AFR (both p > 0.05). Differences between clothing styles were measured such that greater heat storage was observed in both CE1STD and CE2-4AFR relative to CE5STD. Further, heat storage was greater in CE2AFR and CE4AFR relative to CE6AFR, while it was greater in CE4AFR compared to CE7AFR. Body heat storage during work in the heat was not influenced by the use of AFR fabrics in the single- or two-piece uniforms albeit less heat was stored in the two-piece uniforms when no undershirt was worn. However, heat storage was comparable between clothing styles when an undershirt was worn with the two-piece uniform.