Effects of air pollution exposure on inflammatory and endurance performance in recreationally trained cyclists adapted to traffic-related air pollution.

The aim of the present study was to analyze the effects of traffic-related air pollution (TRAP) on markers of inflammatory, neuroplasticity, and endurance performance-related parameters in recreationally trained cyclists who were adapted to TRAP during a 50-km cycling time trial (50-km cycling TT). Ten male cyclists performed a 50-km cycling TT inside an environmental chamber located in downtown Sao Paulo (Brazil), under TRAP or filtered air conditions. Blood samples were obtained before and after the 50-km cycling TT to measure markers of inflammatory [interleukin-6 (IL-6), C-reactive protein (CRP), interleukin-10 (IL-10), intercellular adhesion molecule-1 (ICAM-1)] and neuroplasticity [brain-derived neurotrophic factor (BDNF)]. Rating of perceived exertion (RPE), heart rate (HR), and power output (PO) were measured throughout the 50-km cycling TT. There were no significant differences between experimental conditions for responses of IL-6, CRP, and IL-10 (P > 0.05). When compared with exercise-induced changes in filtered air condition, TRAP provoked greater exercise-induced increase in BDNF levels (TRAP = 3.3 ± 2.4-fold change; Filtered = 1.3 ± 0.5-fold change; P = 0.04) and lower exercise-induced increase in ICAM-1 (Filtered = 1.1 ± 0.1-fold change; TRAP = 1.0 ± 0.1-fold change; P = 0.01). The endurance performance-related parameters (RPE, HR, PO, and time to complete the 50-km cycling TT) were not different between TRAP and filtered air conditions (P > 0.05). These findings suggest that the potential negative impacts of exposure to pollution on inflammatory, neuroplasticity, and performance-related parameters do not occur in recreationally trained cyclists who are adapted to TRAP.

When physical activity meets the physical environment: precision health insights from the intersection.

BACKGROUND: The physical environment can facilitate or hinder physical activity. A challenge in promoting physical activity is ensuring that the physical environment is supportive and that these supports are appropriately tailored to the individual or group in question. Ideally, aspects of the environment that impact physical activity would be enhanced, but environmental changes take time, and identifying ways to provide more precision to physical activity recommendations might be helpful for specific individuals or groups. Therefore, moving beyond a "one size fits all" to a precision-based approach is critical. MAIN BODY: To this end, we considered 4 critical aspects of the physical environment that influence physical activity (walkability, green space, traffic-related air pollution, and heat) and how these aspects could enhance our ability to precisely guide physical activity. Strategies to increase physical activity could include optimizing design of the built environment or mitigating of some of the environmental impediments to activity through personalized or population-wide interventions. CONCLUSIONS: Although at present non-personalized approaches may be more widespread than those tailored to one person's physical environment, targeting intrinsic personal elements (e.g., medical conditions, sex, age, socioeconomic status) has interesting potential to enhance the likelihood and ability of individuals to participate in physical activity.

Does Higher Self-Reported Cardiorespiratory Fitness Reduce the Odds of Hospitalization From COVID-19?

BACKGROUND: Regular physical activity and higher cardiorespiratory (CR) fitness enhance immune function, possibly reducing coronavirus disease 2019 (COVID-19) infection severity. The aim was to assess the association between physical activity and self-reported CR fitness on COVID-19 infection characteristics. METHODS: Participants formerly testing positive for COVID-19 completed an online questionnaire measuring COVID-19 infection characteristics and complications, self-reported CR fitness level, physical activity, and sociodemographic and health-related characteristics. Self-reported CR fitness was determined as the pace to cover 4.8 km without becoming overly fatigued (with slow walking, brisk walking, jogging, and running corresponding to low, moderate, good, and excellent levels of fitness, respectively). RESULTS: A total of 263 individuals completed the survey. Compared with the lowest level of self-reported CR fitness, the odds of hospitalization significantly decreased by 64% (odds ratio = 0.36; 95% confidence interval, 0.13-0.98; P = .04) in individuals reporting the ability to maintain a brisk walk. In individuals reporting the ability to maintain a jogging pace, the further reduction in hospitalization was not significant (odds ratio = 0.22; 95% confidence interval, 0.05-1.04; P = .05). For COVID-19 symptom severity and number, there were no significant associations with self-reported CR fitness or physical activity levels. CONCLUSIONS: For individuals with low self-reported CR fitness, improving CR fitness represents a strategy to reduce the risk of hospitalization from COVID-19.

Blueberry supplementation reduces the blood lactate response to running in normobaric hypoxia but has no effect on performance in recreational runners.

BACKGROUND: Blueberries are concentrated with anthocyanins possessing antioxidant properties. As these properties counter fatigue, blueberry supplementation may improve performance and recovery, particularly in hypoxia, where oxidative stress is elevated. METHODS: This study examined the effects of blueberry supplementation on running performance, physiological responses, and recovery in normobaric hypoxia. Eleven experienced runners completed a 30-minute time-trial (TT) in normobaric hypoxia (%O2 = 15.5 %) on separate days after supplementation with four days of blueberries (BLU) or four days of placebo (PLA). Heart rate (HR), oxygen saturation (SaO2) and ratings of perceived exertion (RPE) were monitored during the TT. Blood lactate and fraction of exhaled nitric oxide (FENO) were assessed pre-TT, post-TT, and during recovery. RESULTS: No significant differences were observed in the distance run during the TT, HR, SaO2, and RPE. The post-TT increase in blood lactate was significantly lower in BLU than PLA (p = 0.036). Pre-TT and post-TT FENO did not differ between conditions. Blood lactate recovery following the TT was similar between conditions. CONCLUSIONS: Four days of blueberry supplementation did not alter running performance or cardiovascular and perceptual responses in normobaric hypoxia. Supplementation lowered the blood lactate response to running, however, the significance of this finding is uncertain given the absence of an ergogenic effect.

Effects of low-intensity and high-intensity cycling with diesel exhaust exposure on soluble P-selectin, E-selectin, I-CAM-1, VCAM-1 and complete blood count.

BACKGROUND: Exposure to particulate matter 2.5 µm or less (PM2.5) that contains transition metals may play a role in systemic oxidative stress and inflammation. Exposure to diesel exhaust (DE) can increase adhesion molecules, which are important in the inflammatory response; however, it is unclear how exercising in DE affects adhesion molecules and how exercise intensity modulates this response. AIM: To determine how DE exposure during exercise of varying intensities affects adhesion molecules and markers of systemic inflammation. METHODS: Eighteen males performed 30 min cycling bouts at low intensity and high intensity (30% and 60% of power at VO2peak (peak oxygen consumption) and a control condition (rest)). Each trial was performed once breathing filtered air (FA) and once breathing DE (300 µg/m3 of PM2.5, six trials in total). Prior to, immediately post, 1 and 2 hours post exposure, blood was drawn to measure parameters of a complete blood count and soluble (s) platelet-Selectin, endothelin-Selectin, intracellular cell adhesion molecule (sICAM)-1 and vascular cell adhesion molecule (sVCAM)-1. Data were analysed using repeated-measures analysis of variance. RESULTS: Two hours following high-intensity exercise, sICAM-1 was significantly less in DE compared with FA (p=0.008). Immediately following rest (p=0.013) and high-intensity exercise (p=0.042) in DE, sICAM-1 was significantly greater than immediately following low-intensity exercise in DE. There were no significant differences in other markers between DE and FA. CONCLUSIONS: Based on this study, healthy individuals may not experience an acute increase in adhesion molecules and systemic inflammatory markers from exercising in DE compared with FA, and higher exercise intensities do not appear to increase the likelihood that DE will affect adhesion molecules and systemic inflammatory markers.

Four Days of Blueberry Powder Supplementation Lowers the Blood Lactate Response to Running But Has No Effect on Time-Trial Performance.

Blueberries are abundant with anthocyanins possessing antioxidant and anti-inflammatory properties. As these properties combat fatigue and promote recovery, blueberry supplementation may enhance performance and recovery. Thus, the objectives were to examine the effects of two blueberry supplementation protocols on running performance, physiological responses, and short-term recovery. Using a randomized, double-blind, placebo (PLA)-controlled crossover design, 14 runners completed an 8-km time trial (TT) after supplementation with 4 days of blueberries (4DAY), 4 days of a PLA, or 2 days of placebo followed by 2 days of blueberries (2DAY). Heart rate and ratings of perceived exertion were monitored during the TT. Blood lactate, vertical jump, reactive strength index, and salivary markers were assessed before and after. No significant differences were observed for time to complete the TT (PLA: 3,010 ± 459 s; 2DAY: 3,014 ± 488 s; 4DAY: 3,011 ± 423 s), heart rate, ratings of perceived exertion, or any of the salivary markers. An interaction effect (p = .027) was observed for blood lactate, with lower post-TT concentrations in 4DAY (5.4 ± 2.0 mmol/L) than PLA (6.6 ± 2.5 mmol/L; p = .038) and 2DAY (7.4 ± 3.4 mmol/L; p = .034). Post-TT decreases in vertical jump height were not different, whereas the decline in reactive strength index was less following 4DAY (-6.1% ± 13.5%) than the other conditions (PLA: -12.6% ± 10.1%; 2DAY: -11.6% ± 11.5%; p = .038). Two days of supplementation did not influence performance or physiological stress. Although 4 days of supplementation did not alter performance, it blunted the increase in blood lactate, perhaps reflecting altered lactate production and/or clearance, and offset the decrease in dynamic muscle function post-TT, as indicated by the reactive strength index differences.

The pulmonary and autonomic effects of high-intensity and low-intensity exercise in diesel exhaust.

BACKGROUND: Exposure to air pollution impairs aspects of pulmonary and autonomic function and causes pulmonary inflammation. However, how exercising in air pollution affects these indices is poorly understood. Therefore, the purpose of this study was to determine the effects of low-intensity and high-intensity cycling with diesel exhaust (DE) exposure on pulmonary function, heart rate variability (HRV), fraction of exhaled nitric oxide (FeNO), norepinephrine and symptoms. METHODS: Eighteen males performed 30-min trials of low-intensity or high-intensity cycling (30 and 60% of power at VO2peak) or a resting control condition. For each subject, each trial was performed once breathing filtered air (FA) and once breathing DE (300µg/m3 of PM2.5, six trials in total). Pulmonary function, FeNO, HRV, norepinephrine and symptoms were measured prior to, immediately post, 1 h and 2 h post-exposure. Data were analyzed using repeated-measures ANOVA. RESULTS: Throat and chest symptoms were significantly greater immediately following DE exposure than following FA (p < 0.05). FeNO significantly increased 1 h following high-intensity exercise in DE (21.9 (2.4) vs. 19.3 (2.2) ppb) and FA (22.7 (1.7) vs. 19.9 (1.4)); however, there were no differences between the exposure conditions. All HRV indices significantly decreased following high-intensity exercise (p < 0.05) in DE and FA. The exception to this pattern was LF (nu) and LF/HF ratio, which significantly increased following high-intensity exercise (p < 0.05). Plasma norepinephrine (NE) significantly increased following high-intensity exercise in DE and FA, and this increase was greater than following rest and low-intensity exercise (p < 0.05). DE exposure did not modify any effects of exercise intensity on HRV or norepinephrine. CONCLUSIONS: Healthy individuals may not experience greater acute pulmonary and autonomic effects from exercising in DE compared to FA; therefore, it is unclear if such individuals will benefit from reducing vigorous activity on days with high concentrations on particulate matter.

The effect of low and high-intensity cycling in diesel exhaust on flow-mediated dilation, circulating NOx, endothelin-1 and blood pressure.

INTRODUCTION: Exposure to air pollution impairs aspects of endothelial function such as flow-mediated dilation (FMD). Outdoor exercisers are frequently exposed to air pollution, but how exercising in air pollution affects endothelial function and how these effects are modified by exercise intensity are poorly understood. OBJECTIVES: Therefore, the purpose of this study was to determine the effects of low-intensity and high-intensity cycling with diesel exhaust (DE) exposure on FMD, blood pressure, plasma nitrite and nitrate (NOx) and endothelin-1. METHODS: Eighteen males performed 30-minute trials of low or high-intensity cycling (30% and 60% of power at VO2peak) or a resting control condition. For each subject, each trial was performed once while breathing filtered air (FA) and once while breathing DE (300ug/m3 of PM2.5, six trials in total). Preceding exposure, immediately post-exposure, 1 hour and 2 hours post-exposure, FMD, blood pressure and plasma endothelin-1 and NOx concentrations were measured. Data were analyzed using repeated-measures ANOVA and linear mixed model. RESULTS: Following exercise in DE, plasma NOx significantly increased and was significantly greater than FA (p<0.05). Two hours following DE exposure, endothelin-1 was significantly less than FA (p = 0.037) but exercise intensity did not modify this response. DE exposure did not affect FMD or blood pressure. CONCLUSION: Our results suggest that exercising in DE did not adversely affect plasma NOX, endothelin-1, FMD and blood pressure. Therefore, recommendations for healthy individuals to moderate or avoid exercise during bouts of high pollution appear to have no acute protective effect.

Physiological responses to diesel exhaust exposure are modified by cycling intensity.

BACKGROUND: Outdoor exercisers are frequently exposed to diesel exhaust (DE) that contains particulate matter (PM) air pollution. How the respiratory and metabolic responses to exercise are affected by DE exposure and how these responses change with exercise intensity are unknown. PURPOSE: This study aimed to determine the respiratory and metabolic responses to low- and high-intensity cycling with DE exposure containing high levels of PM. METHODS: Eighteen males age 24.5 ± 6.2 yr performed 30-min trials of low-intensity (30% of power at V˙O2peak) and high-intensity (60% of power at V˙O2peak) cycling as well as rest. Each trial was performed once while breathing filtered air (FA) and once while breathing DE (300 µg·m of PM2.5) for a total of six trials, each separated by 7 d. During the trials, minute ventilation (V˙E), oxygen consumption (V˙O2), CO2 production (V˙CO2), RER, and perceived exertion for lungs (RPELungs) and legs (RPELegs) were measured. Work of breathing, respiratory muscle V˙O2, ratio of O2 consumption to power output, and gross efficiency were estimated. RESULTS: The RER was significantly lower (0.02 lower, P = 0.008), and the RPELungs (0.9 greater, P = 0.001) and the RPELegs (0.6 greater, P = 0.017) were significantly greater, in DE compared with FA. During low-intensity exercise, V˙E (44.5 ± 8.9 vs 40.5 ± 8.0 L·min, P < 0.001), V˙O2 (27.9 ± 5.4 vs 24.9 ± 4.4 mL·kg·min, P = 0.001), and V˙CO2 (25.9 ± 5.3 vs 23.5 ± 4.5 mL·kg·min, P = 0.006) were significantly greater in DE. This pattern was not seen during high-intensity cycling. CONCLUSIONS: Respiratory and metabolic responses to low-intensity, but not high-intensity, cycling in DE exceed FA. Practically, the greater responses during low-intensity exercise in DE could have implications for individuals with cardiopulmonary disease. Also, the elevated RPE during DE could impair performance in self-paced exercise.

The health effects of exercising in air pollution.

The health benefits of exercise are well known. Many of the most accessible forms of exercise, such as walking, cycling, and running often occur outdoors. This means that exercising outdoors may increase exposure to urban air pollution. Regular exercise plays a key role in improving some of the physiologic mechanisms and health outcomes that air pollution exposure may exacerbate. This problem presents an interesting challenge of balancing the beneficial effects of exercise along with the detrimental effects of air pollution upon health. This article summarizes the pulmonary, cardiovascular, cognitive, and systemic health effects of exposure to particulate matter, ozone, and carbon monoxide during exercise. It also summarizes how air pollution exposure affects maximal oxygen consumption and exercise performance. This article highlights ways in which exercisers could mitigate the adverse health effects of air pollution exposure during exercise and draws attention to the potential importance of land use planning in selecting exercise facilities.

The effect of pre-exercise diesel exhaust exposure on cycling performance and cardio-respiratory variables.

PURPOSE: To determine the effect of pre-exercise exposure to diesel exhaust (DE) on 20-km cycling performance, pulmonary function, and cardio-respiratory variables during exercise. METHODS: Eight endurance-trained males participated in the study. Test days consisted of a 60-min exposure to either filtered air (FA) or DE, followed by a 20 km cycling time trial. Exposures to DE were at a concentration of 300 µg/m³ of PM(2.5). Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were measured before and after exposure, and after exercise. Oxygen consumption (VO2) and carbon dioxide production (VCO2), minute ventilation (V(E)), tidal volume (V(T)), breathing frequency (F(B)), heart rate and oxyhemoglobin saturation (SpO2), were collected during the time trials. The effect of condition on time trial duration, an order effect, and mean cardio-respiratory variables were each analysed using paired T-tests. Repeated-measures ANOVA were used to assess the effect of DE exposure on pulmonary function. RESULTS: There was a main effect of condition (FA vs. DE) on the change in FEV1 from baseline, and in exercise heart rate. Post hoc tests revealed that exercise-induced bronchodilation was significantly attenuated following DE compared to FA. There were no main effects of condition on 20 km cycling performance, or VO2, VCO2, V(E), V(T), F(B) and SpO2 during a 20 km time trial. CONCLUSION: A 60-min exposure to DE prior to exercise significantly attenuated exercise-induced bronchodilation and significantly increased heart rate during exercise. Pre-exercise exposure to diesel exhaust did not significantly impair 20 km cycling time trial performance.

The effects of exercise in hypoxic and normoxic conditions on endothelin-1 and arterial compliance.

The purpose of this study was to determine the effects of short-term normoxic and hypoxic exercise on plasma endothelin-1 and nitric oxide levels, and the relationship of arterial compliance and pulmonary artery pressure to endothelin-1. Seven endurance-trained males completed two incremental and two steady-state exercise tests performed at ventilatory threshold in normoxia and hypoxia (fraction of inspired oxygen = 0.14). Plasma endothelin-1was measured throughout steady-state tests. Arterial compliance using applanation tonometry, plasma nitric oxide and pulmonary artery pressure using Doppler echocardiography were measured before and after exercise. Small arterial compliance and pulmonary artery pressure significantly increased following exercise. There were no main effects of condition or time for plasma endothelin-1and nitric oxide levels. There were no significant relationships between plasma endothelin-1 and arterial compliance or pulmonary artery pressure. In conclusion, mechanisms other than the endothelial system may play a role in the exercise-induced changes in small artery compliance in this study population. Moderate hypoxia and a 30-minute steady-state exercise have limited effects on plasma endothelin-1 in endurance-trained males.

From good intentions to proven interventions: effectiveness of actions to reduce the health impacts of air pollution.

BACKGROUND: Associations between air pollution and a multitude of health effects are now well established. Given ubiquitous exposure to some level of air pollution, the attributable health burden can be high, particularly for susceptible populations. OBJECTIVES: An international multidisciplinary workshop was convened to discuss evidence of the effectiveness of actions to reduce health impacts of air pollution at both the community and individual level. The overall aim was to summarize current knowledge regarding air pollution exposure and health impacts leading to public health recommendations. DISCUSSION: During the workshop, experts reviewed the biological mechanisms of action of air pollution in the initiation and progression of disease, as well as the state of the science regarding community and individual-level interventions. The workshop highlighted strategies to reduce individual baseline risk of conditions associated with increased susceptibility to the effects of air pollution and the need to better understand the role of exposure duration in disease progression, reversal, and adaptation. CONCLUSION: We have identified two promising and largely unexplored strategies to address and mitigate air pollution-related health impacts: reducing individual baseline risk of cardiovascular disease and incorporating air pollution-related health impacts into land-use decisions.

The effects of lower body positive and negative pressure on the hypoxic ventilatory decline.

PURPOSE: Lower body negative pressure (LBNP) augments the acute hypoxic ventilatory response (AHVR) in humans, presumably through altered central integration of baro- and chemoreceptor afferents. This study investigated the effects of LBNP and lower body positive pressure (LBPP) on hypoxic ventilatory decline (HVD) in humans. METHODS: Nine individuals (4 females and 5 males) were tested in a supine position with the lower body supported inside a hypo/hyperbaric chamber. During each test the participant was exposed in a random order to LBNP at -37.5mmHg, LBPP at +37.5mmHg and to ambient pressure (LBAP) at 0mmHg. Blood pressure, expired gases and haemoglobin O(2) saturation were continuously recorded. Hypoxia was administered in a single step to a PET O2 of 50mmHg for 20min. For all tests PET CO2 was maintained at the pre-hypoxic resting level. RESULTS: The peak ventilation was significantly greater during LBNP (36.0+/-10.8Lmin(-1)) than during ambient pressure (29.4+/-8.1Lmin(-1); p=0.032). However, peak ventilation was not significantly different between LBPP and ambient pressure. The HVD was not significantly different across the three conditions (p=0.144). Both mean arterial pressure and pulse pressure were not affected by 37.5mmHg of either LBPP (p=0.941) or LBNP (p=0.275). Baroreflex slope was decreased by both hypoxia and LBNP. CONCLUSION: These data suggest that LBNP increases AHVR through an effect on the baroreflex, while LBPP has no effect on AHVR. Since LBNP increases AHVR without affecting HVD, these findings support that the mechanism accounting for the HVD includes afferent output originating from the peripheral rather than the central chemosensitive tissues.

Performance of a compact end-tidal forcing system.

The purpose of the present study was to develop and validate a new compact, portable end-tidal forcing (ETF) system capable of reliably controlling end-tidal gases. The system consists of compressed gas sources (air, N(2) and CO(2)) that are connected via three solenoid valves to a humidification chamber and an inspiratory reservoir bag from which the participant breathes. This computer-controlled system compares actual end-tidal gas partial pressures with target pressures and mixes the gases on a breath-by-breath basis. This leaves no unused exhaust gas and keeps gas requirements to a minimum. Eight participants underwent two different 30-min protocols that included each possible combination of end-tidal O(2) partial pressure (PET O2) and end-tidal CO(2) partial pressure (PET O2) control at two different levels (PET O2 at 55 and 75 mmHg; and PET CO2 at 4 and 7 mmHg above resting). The ETF system maintained the mean PET CO2 at 0.13 mmHg from the target values, with a pooled S.D. across conditions of +/-0.91 mmHg and a 95% confidence interval (CI) of +/-0.63 mmHg. The mean PET CO2 was held at 0.49 mmHg from its target values, with a pooled S.D. across conditions of +/-1.31 mmHg and a 95% CI of +/-0.91 mmHg. To demonstrate suitability of this system for measuring chemosensitivity to hypoxia, hypoxic ventilatory response (HVR) tests were conducted in a subset of five participants. During a 20-min HVR test both PET CO2 and PET O2 were not significantly different from their target values. These data demonstrate the performance of a portable, compact, economical system that controls PET CO2 within 1 mmHg and PET O2 within 2 mmHg of their respective target values.

The physiology of rock climbing.

In general, elite climbers have been characterised as small in stature, with low percentage body fat and body mass. Currently, there are mixed conclusions surrounding body mass and composition, potentially because of variable subject ability, method of assessment and calculation. Muscular strength and endurance in rock climbers have been primarily measured on the forearm, hand and fingers via dynamometry. When absolute hand strength was assessed, there was little difference between climbers and the general population. When expressed in relation to body mass, elite-level climbers scored significantly higher, highlighting the potential importance of low body mass. Rock climbing is characterised by repeated bouts of isometric contractions. Hand grip endurance has been measured by both repeated isometric contractions and sustained contractions, at a percentage of maximum voluntary contraction. Exercise times to fatigue during repeated isometric contractions have been found to be significantly better in climbers when compared with sedentary individuals. However, during sustained contractions until exhaustion, climbers did not differ from the normal population, emphasising the importance of the ability to perform repeated isometric forearm contractions without fatigue becoming detrimental to performance. A decrease in handgrip strength and endurance has been related to an increase in blood lactate, with lactate levels increasing with the angle of climbing. Active recovery has been shown to provide a better rate of recovery and allows the body to return to its pre-exercised state quicker. It could be suggested that an increased ability to tolerate and remove lactic acid during climbing may be beneficial. Because of increased demand placed upon the upper body during climbing of increased difficulty, possessing greater strength and endurance in the arms and shoulders could be advantageous. Flexibility has not been identified as a necessary determinant of climbing success, although climbing-specific flexibility could be valuable to climbing performance. As the difficulty of climbing increases, so does oxygen uptake (VO(2)), energy expenditure and heart rate per metre of climb, with a disproportionate rise in heart rate compared with VO(2). It was suggested that these may be due to a metaboreflex causing a sympathetically mediated pressor response. In addition, climbers had an attenuated blood pressure response to isometric handgrip exercises when compared with non-climbers, potentially because of reduced metabolite build-up causing less stimulation of the muscle metaboreflex. Training has been emphasised as an important component in climbing success, although there is little literature reviewing the influence of specific training components upon climbing performance. In summary, it appears that success in climbing is not related to individual physiological variables but is the result of a complex interaction of physiological and psychological factors.