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AIM: This study aimed to investigate the association between physical activity (PA), lifestyle, and symptoms of depression, anxiety, and stress. METHODS: A cross-sectional study was carried out using an online questionnaire. PA (International Physical Activity Questionnaire), lifestyle (Short Multidimensional Inventory Lifestyle Evaluation), and mental health (Depression, Anxiety, and Stress Scale-21) were assessed. Mean scores were compared between groups of physically active and inactive participants, controlling for gender, education, and income. Furthermore, associations were made between the variables, and individual network analyses were carried out for each mental health domain. The sample consisted of 353 individuals (age = 33.8 [12.2], 59.2% women). RESULTS: In network analyses, PA was indirectly related to depression and stress through the relationship with other lifestyle domains such as diet and nutrition or through stress management and social support. The same path was observed for anxiety; however, a direct partial correlation was also observed between PA and anxiety, suggesting that PA seems to intervene more directly in this aspect of mental health. CONCLUSION: It is concluded that PA is indirectly (via stress management, diet and nutrition, and social support) associated with depression and stress and has direct and indirect associations (via stress management and social support) with anxiety.

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BACKGROUND: Understanding the relationship of social network use and addictive behaviors with adolescent psychosocial health is crucial in today's digital age. AIM: To verify the associations between social network use, messaging applications, and the addictive behaviors to social network with psychosocial health in Spanish adolescents. METHODS: A cross-sectional study was developed with 632 adolescents, aged 12 to 17 years from the Region of Murcia, Spain. The assessment of social network use (Facebook, Twitter, Instagram, Snapchat, and TikTok) involved evaluating the frequency of use of each social network individually using a single-item scale with five response options. WhatsApp use (i.e., a messaging application) was evaluated in the same manner. The Short Social Networks Addiction Scale-6 Symptoms was employed to assess potential addictive behaviors to social network use. The psychosocial health was assessed using the Strengths and Difficulties Questionnaire. Generalized linear regression models were conducted, and predictive probabilities of having psychosocial health problems were calculated. RESULTS: The predicted probability of presenting psychosocial health problems in the medium users and high users of social networks was 19.3% (95% confidence interval [CI] 13.0 to 27.7), and 16.2% (95% CI 10.2 to 24.6) higher compared to low users, respectively. High usage of Instagram, TikTok, Snapchat, and Facebook was associated with increased probabilities of psychosocial health problems, with Facebook showing the highest probabilities, at 31.3% (95% CI 14.8 to 54.2) for medium users and 51.9% (95% CI 26.5 to 76.3) for high users. Additionally, adolescents with addictive behaviors to social network use had from 19.0 to 25.2% probabilities of experiencing psychosocial health problems. Finally, the highest probabilities of having psychosocial health problems were identified in adolescents with high addictive behaviors when using social networks (28.9%; 95% CI 19.3 to 40.8%) and the lowest in those with low addictive behaviors (6.8%; 95% CI 3.3 to 13.6%). CONCLUSION: Adolescents who use social networks more frequently and exhibit more addictive behaviors related to their use are more likely to experience psychosocial health problems compared to those who do not. Facebook showed the strongest association, followed by Snapchat, Instagram, and TikTok. Our data also revealed that adolescents exhibit various signs of addictive behaviors to social network use.

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Virtual reality (VR) exercise aims to offer positive affective and sensory experiences through an immersive experience rich in audiovisual stimuli. Notwithstanding, there is a paucity of large sample size studies comparing the acute effects of VR exercise compared with a matched exercise performed in a non-VR environment. The study compared the acute effects of a VR exercise session versus a matched non-VR exercise session in effect, pleasure, enjoyment, perceived exertion, and heart rate. This is a crossover randomized clinical trial. The time, difficulty, and exercise type of the non-VR exercise were matched to VR exercise. Before and immediately after each session, participants responded to the Borg's Perceived Exertion Scale, the Feeling Scale and the Felt Arousal Scale, and the Physical Activity Enjoyment Scale. The analyses were conducted with Generalized Linear Models, Wilcoxon's, and T-test for paired samples. A total of 83 adults (40 females) aged 35.46 years were included in the study. Participants in the VR condition had a greater increase in affect (mean change difference = 0.95, 95% confidence interval [CI] = 0.83-1.06, P < 0.001), arousal (mean change difference = 0.37, 95% CI = 0.23-9.50, P < 0.001). The pleasure and enjoyment median after the VR session were higher. In conclusion, the immersive VR exercise was more strenuous, but resulted in a better affective response, greater pleasure, and enjoyment.

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Background: High-intensity intermittent training has emerged as an option for treating major depressive disorder (MDD). However, short sprint training (sSIT), an efficient HIIT modality, has not been tested yet for this purpose. The sSIT has been proven to induce the same metabolic adaptations, with the advantage of promoting lower muscle fatigue than other HIIT protocols. Methods: Seventeen adult women diagnosed with moderate/severe MDD were randomly allocated into a sSIT group (n=9) or a control condition (n=8). The sSIT group completed, over two weeks, six 6-10-min sessions which consisted of 3-12 "all out" sprints of 5 s interspersed with low-intensity recovery of 30-45 s. The week before and after the intervention, both groups were evaluated with the Hamilton Depression Rating Scale of 21-itens (HAM-D21), and for physical fitness and incidental physical activity. Results: The sSIT group exhibited significant improvements for HAM-D21 scores (24.6±8.2 vs. 16.8±10.1), maximum aerobic power (140±15 vs. 155±15 W), countermovement jump (13.0±3.4 vs. 14.9±3.1 cm), % of body fatness (32.4±4.4 vs. 29.3±3.8%), and 4-days number of steps (13,626±11,309 vs. 16,643±15,371) after the training period when compared to the control group. Conclusion: Less than 1 hour of a sSIT protocol over two weeks have demonstrated to reduce depressive symptoms, while improving aerobic fitness and body composition, and increasing incidental physical activity in a sample of women diagnosed with MDD.

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People with mental illness tend to present low levels of physical activity and high levels of sedentary behavior. The study aims to compare these levels in mental illness patients, exploring the role of socioeconomic development and treatment setting. This cross-sectional study used accelerometers and the Simple Physical Activity Questionnaire (SIMPAQ) to assess physical activity and sedentary behavior in mental illness individuals living in 23 countries. Two-way ANOVAs were used to evaluate the interaction between socioeconomic development and the treatment settings on physical activity and sedentary behavior. A total of 884 (men = 55.3%) participants, mean age of 39.3 (SD = 12.8), were evaluated. A significant interaction between socioeconomic development and treatment settings was found in sedentary behavior (F = 5.525; p = 0.019; η2p = 0.009; small effect size). Main effects were observed on socioeconomic development (F = 43.004; p < 0.001; η2p = 0.066; medium effect size) and treatment setting (F = 23.001; p < 0.001; η2p = 0.036; small effect size) for sedentary behavior and physical activity: socioeconomic development (F = 20.888; p < 0.001; η2p = 0.033; small effect size) and treatment setting (F = 30.358; p < 0.001; η2p = 0.047; small effect size), showing that HIC patients were more active, while MIC patients were more sedentary. Moreover, despite of inpatients had presented higher levels of physical activity than outpatients, they also spent more time sitting. Socioeconomic development plays an important role in sedentary behavior in patients with mental disorders, warning the need to develop new strategies to reduce these levels in this population.

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Although evidence regarding the effects of high-intensity interval training (HIIT) on mental health has increased in recent years, there is still no consensus regarding the effects of HIIT on the symptoms of depression and anxiety in a healthy population. Therefore, this systematic review aimed to investigate the effects of HIIT on depressive and/or anxiety symptoms in healthy individuals. The following four databases were searched: PubMed, Scopus, Embase, and PsycINFO. Only randomized clinical trials (RCTs) were included. We performed a random-effects meta-analysis based on standardized mean difference (SMD). The risk of bias was assessed using the RoB 2.0 tool, and the certainty of the evidence was evaluated based on recommendations GRADE. Eight RCTs evaluating 471 participants (81% female) were considered eligible for inclusion. The results of the meta-analysis showed that HIIT-based interventions had no significant effect on reducing anxiety (SMD = -0.17; 95% CI: -0.53, 0.19; p = 0.27) and depressive symptoms (SMD = -0.38; 95% CI: -1.06, 0.30; p = 0.17) compared with the passive control group. In conclusion, HIIT does not improve symptoms of depression and anxiety in healthy individuals. This finding is based on evidence of very low certainty. Therefore, the evidence is still not consistent enough to support HIIT as a viable strategy to reduce both outcomes because of the limited number of included studies and the overall quality of evidence.

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This meta-analysis of randomised clinical trials aimed to compare the effects of high-intensity interval training (HIIT) and its different protocols versus moderate-intensity continuous training (MICT) and/or control on total cholesterol, HDL, LDL, triglycerides, HbA1c levels, and fasting glucose in individuals with type 2 diabetes mellitus (T2DM). The search strategy was performed in PubMed/MEDLINE, Cochrane CENTRAL, EMBASE, Web of Science, Sport DISCUS, and PEDro, until January 2023. A total of 31 studies (1092 individuals) were included. When compared to control, HIIT decreased total cholesterol by -0.31 mmol/L (95% CI -0.49; -0.12), LDL by -0.31 mmol/L (95% CI -0.49; -0.12), triglycerides by -0.27 mmol/L (95% CI -0.33; -0.2), HbA1c by -0.75% (95% CI -0.97; -0.53), fasting glucose by -1.15 mmol/L (95% CI -1.44; -0.86), and increased HDL by 0.24 mmol/L (95% CI 0.06; 0.42). No difference was found in the comparison between HIIT versus MICT for any of the outcomes analysed, however subgroup analysis showed that a moderate-interval (>30s to < 2 min) and moderate-term (>4 to < 12 weeks) HIIT protocol reduced total cholesterol, when compared to MICT. HIIT is able to improve lipid profile and glycaemic control in T2DM individuals, and specific protocols can be recommended for improving total cholesterol levels.

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This review aimed to verify the effects of vitamin E supplementation on oxidative stress, inflammatory response, muscle damage, soreness, and strength in healthy adults after exercise. We searched the MEDLINE, EMBASE, SPORTDiscus, Cochrane CENTRAL, and Web of Science from inception to August 2023, with no language restrictions. We included randomized placebo-controlled trials evaluating the supplementation of vitamin E on the abovementioned outcomes after a bout of physical exercise in healthy participants (no restriction for publication year or language). Meta-analyses were conducted to compare vitamin E and placebo supplementations to obtain a 95% confidence interval (95%IC). Twenty studies were included (n=298 participants). The effect of supplementation was assessed between 0 h and 96 h after the exercise. Compared to placebo, vitamin E had no effects on lipid (95%IC= -0.09 to 0.42), protein (-2.44 to 3.11), SOD (-1.05 to 0.23), interleukin-6 (-0.18 to 1.16), creatine kinase (-0.33 to 0.27), muscle soreness (-1.92 to 0.69), and muscle strength (-1.07 to 0.34). Heterogeneity for the analyses on carbonyls, interleukin-6 (1 h and 3 h), and muscle soreness ranged between 70 to 94%. Supplementing with vitamin E should not be recommended to support the recovery process in healthy individuals after exercise, given the lack of efficacy in the analyzed variables following an exercise session.

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We investigated whether mood and lifestyle-related indicators of physical health are differentially expressed according to self-reported levels of depressive symptoms among young adults with a current episode of major depression. In a cross-sectional study, we recruited 94 young adults (females = 67, 71.3%; males = 27, 28.7%; aged 18-35 years) with a current episode of major depression. We assessed their mood with the Profile of Mood States (POMS), and Beck Anxiety Inventory-(BAI), sleep with the Pittsburgh Sleep Quality Index (PSQI), physical activity with the Simple Physical Activity Questionnaire (SIMPAQ), and their cardiorespiratory fitness. Participants' depression levels were classified as follows using established cut-points: (a) Mild Depressive Symptoms (MIDS, BDI-II 14-19 points, n = 17), (b) Moderate Depressive Symptoms (MODS, BDI-II 20-28 points, n = 37) or (c) Severe Depressive Symptoms (SEDS, BDI-II 29-63 points, n = 40). As expected, we found that young adults with SEDS, when compared to those with MODS and MIDS, showed higher depressive mood on the POMS, and they exhibited greater anxiety symptoms, lower reported 'vigor' on physical activity measures, worse sleep quality as expressed by their global score sleep; daytime dysfunction; and sleep disturbance, and they showed lower cardiorespiratory fitness. Those with moderate depressive symptoms only differed from those with mild symptoms with respect to hostility, fatigue and mood disturbance. Although there was a gradient whereby worse mental and physical health indicators were more closely related to the SEDS depression categorization, while healthier indicators were associated with the MIDS category, some parameters were not different between the MDD severity groups, particularly when comparing MIDS and MODS. Clinicians treating patients with MDD should consider these factors when designing lifestyle-based interventions.

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INTRODUCTION: Lifestyle Medicine comprises six domains: diet, substance use, physical activity, stress management, social connection, and sleep. The comprehensive assessment of lifestyle is challenging, but the "Short Multidimensional Inventory on Lifestyle Evaluation" (SMILE) was developed to fill out this gap. In this paper, we describe the development and the psychometric properties (internal consistency, concurrent and convergent validity) of a shorter version of the SMILE among university students. METHODS: Data from a cross-sectional study including 369 students from 10 Brazilian universities were used. Considering a theoretical nomological net, we performed exploratory factor analysis to obtain the most parsimonious, interpretable and good-fitting model. RESULTS: The final model was called U-SMILE, comprised 24 items, and presented acceptable internal consistency (Cronbach's α = 0.73, McDonald's ω = 0.79). To evaluate the concurrent validity of the U-SMILE, we compared it to the original SMILE and found a high correlation between the instruments (Spearman's r= 0.94). Furthermore, we evaluated convergent validity by examining the U-SMILE correlation with the PHQ-9 (Spearman's r= -0.517), and GAD-7 (Spearman's r= -0.356), two validated instruments to screen for depression and anxiety, respectively. DISCUSSION: Our findings suggest that the U-SMILE is a valid instrument for assessing lifestyle among university students. We recommend that the use of U-SMILE to evaluate overall lifestyle scores rather than individual domain scores. Finally, we discuss the importance of clarifying the definitions of lifestyle and related constructs in future research.

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OBJECTIVES: To examine the theoretical substitutions of screen exposure, non-screen sitting time, moderate and vigorous physical activity with depressive and anxiety symptoms in South American adults during the COVID-19 pandemic. DESIGN: A cross-sectional study during the first months of the COVID-19 pandemic with data from 1981 adults from Chile, Argentina, and Brazil. METHODS: Depressive and anxiety symptoms were assessed using the Beck Depression and Anxiety Inventories. Participants also reported physical activity, sitting time, screen exposure, sociodemographic, and tobacco use data. Isotemporal substitution models were created using multivariable linear regression methods. RESULTS: Vigorous physical activity, moderate physical activity, and screen exposure were independently associated with depression and anxiety symptoms. In adjusted isotemporal substitution models, replacing 10 min/day of either screen exposure or non-screen sitting time with any intensity of physical activity was associated with lower levels of depressive symptoms. Improvements in anxiety symptoms were found when reallocating either screen exposure or non-screen sitting time to moderate physical activity. Furthermore, replacing 10 min/day of screen exposure with non-screen sitting time was beneficially associated with anxiety (B = -0.033; 95 % CI = -0.059, -0.006) and depression (B = -0.026; 95 % CI = -0.050, -0.002). CONCLUSIONS: Replacement of screen exposure with any intensity of physical activity or non-screen sitting time could improve mental health symptoms. Strategies aiming to reduce depressive and anxiety symptoms highlight physical activity promotion. However, future interventions should explore specific sedentary behaviors as some will relate positively while others negatively.

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Although there is consistent evidence of the beneficial effects of leisure physical activity (PA) on mental health, the role of PA in the domestic, transport, and occupational domains is inconclusive. This study aimed to analyze the relationship between domain-specific PA and depressive symptoms and examine whether the association is moderated by age in a representative sample of the Brazilian population. Cross-sectional data of 89,923 (52.4% female) individuals aged ≥15 years were analyzed. Depressive symptoms were assessed using the Patient Health Questionnaire-9. Physical activity (min/week) performed in different domains (domestic, transport, occupation, and leisure) was self-reported. Generalized additive models with penalized splines were used to explore associations. Lower leisure-time PA and higher levels of PA in the domestic, occupational, and transport domains at distinct PA thresholds were associated with higher depressive symptoms. Leisure PA, even at lower levels, was associated with lower depressive symptoms compared to no PA at all. The increase in depressive symptoms as a function of occupational PA was observed only at PA levels higher than 40 h/week. Although non-leisure PA levels were related to higher depressive symptoms among the total sample, higher domestic and transport PA levels were related to lower depressive symptoms among older adults. This study provides insights into the non-linearity and age-group dependence of the relationship between domain-specific PA and depressive symptoms in a middle-income country. The evidence suggests that care should be taken on recommending PA regardless of context or domain.

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AIM: To analyze the prospective dose-response relationships between total and domain-specific physical activity (PA) with incident clinical depression. METHODS: We used data from two waves (Wave 1: August/2008-December 2010; Wave 2: September/2012-December/2014) of the Brazilian Longitudinal Health Study (ELSA-Brasil) cohort study. Self-reported PA (total, transport, and leisure-time) was the main exposure. Incident clinical depression (new cases of depression between waves) was assessed through the Clinical Interview Schedule-Revised (CIS-R). Poisson regression models, adjusting for potential confounders, were used for data analysis. RESULTS: In 12,709 adults (53.8 % women, mean age: 51.9 ± 9.0), moderate and high volumes of total PA (1-149 min/week: RR = 0.81, 0.58-1.13, 150-299 min/week: RR = 0.55, 95%CI: 0.40-0.76; ≥300 min/week: RR = 0.64, 95%CI: 0.52-0.80), and any volume of leisure-time PA (1-149 min/week: RR = 0.65, 95%CI: 0.50-0.83; 150-299 min/week: RR = 0.67, 95%CI: 0.52-0.88; RR = 0.61, 95%CI: 0.45-0.82) were associated with a lower risk of incident clinical depression. Transport PA protective only in the lower category (0.1-4.4 mMET-h/wk) (RR = 0.71, 95%CI: 0.54-0.94). LIMITATIONS: Other PA domains such as occupational and domestic were not assessed; the use of self-report measures for PA which may be subject to bias and recall issues; lack of assessment of additional potential confounders, such as sedentary behavior and family history of depression. CONCLUSION: Total and leisure-time PA were associated with lower incidence of clinical depression, even at lower doses. Low, moderate, and high volumes of total and leisure-time PA were associated with lower risk of incident clinical depression. Public health PA interventions aiming to prevent development of clinical depression should consider focusing on leisure-time PA.

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OBJECTIVES: To assess alcohol use and perceived change in alcohol consumption (before and during the pandemic) in Brazilians during the COVID-19 pandemic, their correlates, and their associations with depressive, anxiety and co-occurring depressive and anxiety symptoms (D&A). METHODS: This is a cross-sectional study comprising 992 individuals in self-isolation. A self-report questionnaire was used to assess whether participants were drinking during self-isolation and whether they changed their drinking behavior (drinking less, more, or no change) from before to during the pandemic. D&A symptoms were assessed using the Beck Depression and Anxiety Inventories (BDI and BAI). RESULTS: A total of 68.5% of participants reported alcohol consumption during the pandemic, and 22.7% of these reported increased alcohol use. Smoking was positively associated with alcohol consumption during the pandemic. Alcohol consumption was associated with anxiety (OR = 1.40, 95%CI 1.06-1.85, p < 0.01) and D&A (OR = 1.38, 95%CI 1.02-1.87, p = 0.033) symptoms. CONCLUSIONS: Drinking during self-isolation was prevalent and was associated with risk factors for alcohol use disorders. The long-term effects of high drinking rates and increased consumption should be proactively monitored and assessed.

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Background:The combined supplementation of vitamins C and E potentially can mitigate oxidative stress (OS) and accelerate recovery following exercise. However, there is little evidence and a lack of consensus on the effects of these vitamins for this purpose. The objective of this systematic review was to summarize the evidence on the effects of the combined supplementation of vitamins C and E in OS, inflammatory markers, muscle damage, muscle soreness, and musculoskeletal functionality following acute exercise. Methods: The search was carried out from inception until March 2021, on MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and SPORT Discus. We included placebo-controlled randomized clinical trials (RCTs) that evaluated the effects of combined supplementation of vitamins C and E in OS, inflammatory markers, muscle damage, muscle soreness, and muscle strength following a single bout of exercise. Random-effect meta-analyses were used to compare pre to post-exercise mean changes in subjects who received supplementation with vitamins C and E or placebo versus controls. Data are presented as standard mean difference (SMD) and 95% confidence interval (95% CI). Results: Eighteen RCTs, accounting for data from 322 individuals, were included. The use of vitamins attenuated lipid peroxidation (SMD= -0.703; 95% CI= -1.035 to -0.372; p < 0.001), IL-6 (SMD= -0.576; 95%CI= -1.036 to -0.117; p = 0.014), and cortisol levels (SMD= -0.918; 95%CI= -1.475 to -0.361; p = 0.001) immediately, and creatine kinase levels 48 h following exercise (SMD= -0.991; 95%CI= -1.611 to -0.372; p = 0.002). Supplementing the combination of vitamins had no effects on protein carbonyls, reduced/oxidized glutathione ratio, catalase, interleukin-1Ra, C-reactive protein, lactate dehydrogenase, muscle soreness, and muscle strength. Conclusion: Prior supplementation of the combination of vitamins C and E attenuates OS (lipid peroxidation), the inflammatory response (interleukin-6), cortisol levels, and muscle damage (creatine kinase) following a session of exercise.

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ABSTRACT Objective: Substance misuse can lead to several consequences for physical and mental health. Physical exercise is an important ally to pharmacological and psychotherapeutic treatment for substance use. However, the literature is still scarce regarding long-term interventions. Thus, this study aims to describe the acceptability and effects of combined physical training intervention (aerobic and strength). Methods: This study comprises an n-of-1 clinical trial that was performed with a 64-year-old male individual with alcohol use disorder. The treatment lasted 12 weeks and evaluated the association of multidisciplinary interventions on quality of life, depressive symptoms, cognitive impairment, and anxiety. Results: The participant improved general quality of life (12.5%), no alterations were found for depressive symptoms, there was an improvement in cognition (20%), as well a reduction in the trait (16.2%) and state (14.7%) anxiety symptoms of the participant. Conclusions: These findings allude to the importance of non-drug therapeutic resources such as structured physical exercise, associated with other offers in the treatment of alcohol use disorder.

RESUMO Objetivo: O uso de substâncias psicoativas pode levar a diversas consequências à saúde física e mental. O exercício físico é um importante aliado ao tratamento farmacológico e psicoterápico para o uso de substâncias. No entanto, a literatura ainda é escassa em relação às intervenções de longa duração. Dessa forma, este estudo objetiva descrever a aceitabilidade e os efeitos de uma intervenção de treinamento físico combinado (aeróbico e força). Métodos: Este estudo compreende um n-of-1 clinical trial que foi realizado com um indivíduo do sexo masculino, de 64 anos de idade, com transtorno por uso de álcool. O tratamento teve a duração de 12 semanas e avaliou a associação de intervenções multiprofissionais sobre a qualidade de vida, sintomas depressivos, comprometimento cognitivo e ansiedade. Resultados: O participante melhorou a qualidade de vida geral (12,5%), não foram encontradas alterações para sintomas depressivos, houve melhora na cognição (20%), bem como redução nos sintomas de ansiedade traço (16,2%) e estado (14,7%) do participante. Conclusões: Esses achados aludem à importância de recursos terapêuticos não medicamentosos como o exercício físico estruturado, associados às demais ofertas no tratamento para o transtorno por uso de álcool.

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Abstract Objectives To assess alcohol use and perceived change in alcohol consumption (before and during the pandemic) in Brazilians during the COVID-19 pandemic, their correlates, and their associations with depressive, anxiety and co-occurring depressive and anxiety symptoms (D&A). Methods This is a cross-sectional study comprising 992 individuals in self-isolation. A self-report questionnaire was used to assess whether participants were drinking during self-isolation and whether they changed their drinking behavior (drinking less, more, or no change) from before to during the pandemic. D&A symptoms were assessed using the Beck Depression and Anxiety Inventories (BDI and BAI). Results A total of 68.5% of participants reported alcohol consumption during the pandemic, and 22.7% of these reported increased alcohol use. Smoking was positively associated with alcohol consumption during the pandemic. Alcohol consumption was associated with anxiety (OR = 1.40, 95%CI 1.06-1.85, p < 0.01) and D&A (OR = 1.38, 95%CI 1.02-1.87, p = 0.033) symptoms. Conclusions Drinking during self-isolation was prevalent and was associated with risk factors for alcohol use disorders. The long-term effects of high drinking rates and increased consumption should be proactively monitored and assessed.