Associations between physical activity and the built environment in patients with schizophrenia: a multi-centre study

Objective

This study investigated the variance in walking, moderate and vigorous physical activity (PA), explained by neighbourhood design and other environmental variables above and beyond the variance accounted for by demographical variables.

Method

A total of 138 patients (46♀) with schizophrenia (mean age = 41.2±12.5 years) from 13 different centres in Belgium were included in this 4-month cross-sectional study. The built environment was rated using the Instruments for Assessing Levels of Physical Activity and Fitness (ALPHA) environmental questionnaire, which was validated first. PA levels were assessed with the International Physical Activity Questionnaire.

Results

Validity coefficients for the ALPHA ranged between 0.44 and 0.86 and test-retest reliability intraclass correlation coefficients ranged between 0.64 and 0.84. Regression analyses showed that environmental variables were related to all types of PA. The variance explained by the models including demographic and environmental variables ranged from 20% for vigorous PA up to 68% for walking. Minutes of walking (r= 0.63, P< .001) and of moderate-intensity PA (r = 0.43, P< .001) were related to emotional satisfaction with the environment. Moderate-intensity PA was also related to the presence of PA supplies at home (r= 0.49, P< .001).

Conclusion

Neighbourhood design and other environmental variables show significant associations with multiple types of PA in patients with schizophrenia.     

Autonomous motivation and quality of life as predictors of physical activity in patients with schizophrenia

Aim: Being physically active is a complex behaviour in patients with schizophrenia. Several factors were identified as barriers to achieving active behaviours in this population. Therefore, the purpose of this study was to investigate among a number of barriers what predicts the most on physical activity (PA) in patients with schizophrenia.

Methods: A total of 114 patients (28♀) with schizophrenia were included. Body mass index (BMI) was calculated. Autonomous and controlled motivation (Behavioural Regulation in Exercise Questionnaire – 3), self-esteem (Rosenberg Self-esteem scale), quality of life (World Health Organization Quality of Life Scale – Brief version) and functional exercise capacity (6-minute walk test – 6MWT) were evaluated. Multiple Regression Analysis was applied to assess the effect of these variables on Total PA per week (International Physical Activity Questionnaire – short version).

Results: Autonomous motivation and domains of quality of life were positively correlated with Total PA per week. Stepwise multiple regression analyses showed that of all the candidate factors to predict PA, autonomous motivation and global domain of quality of life were found as significant predictors.

Conclusion: Our findings help to understand the importance of autonomous motivation and quality of life for PA in patients with schizophrenia. Knowledge about these predictors may provide guidance to improve PA behaviour in this population.     

Change in psychiatrists’ attitudes towards the physical health care of patients with schizophrenia coinciding with the dissemination of the consensus on physical health in patients with schizophrenia

Purpose

To evaluate the impact of the “Spanish Consensus on Physical Health in Patients with Schizophrenia” on psychiatrists’ evaluations of the physical health of patients with schizophrenia.

Method

Epidemiological, non-interventional, national, multicentre study, with two retrospective, cross-sectional data collection stages in which 229 psychiatrists evaluated 1193 clinical records of patients with schizophrenia (ICD-10) seen in January and September of 2007.

Results

Mean age of the patients was 39.7 ± 11.6 years, 65.5% were men, diagnosed for schizophrenia 14.0 ± 10.3 years ago. Forty percent of the patients suffer from a concomitant disease, the most prevalent being hypercholesterolemia (46.3%), hypertriglyceridaemia (33.5%) and arterial hypertension (26.0%). The difference in the number of patients who had all the physical measurements taken between the two cross-sectional evaluations was 13.8% (CI: 11.8%, 15.7%). The differences for each parameter were: weight 13.7% (CI: 11.7%, 15.6%), BMI 13.58% (CI: 11.6%, 15.5%), waist circumference 14.0% (CI: 12.0%, 15.39%), lipid profile 2.9% (CI: 1.9%, 3.9%) and glycaemia 2.6% (CI: 1.7%, 3.5%).

Conclusions

These results imply that the dissemination of the “Consensus on Physical Health in Schizophrenia Patients”, and possibly other actions, has made psychiatrists more aware of an integral approach to patients with schizophrenia, promoting increased monitoring of the physical health of these patients.     

Assessment of physical activity in middle-aged and older adults with schizophrenia

BACKGROUND: Regular physical activity (PA) decreases morbidity in the general population; yet, information about the amount and effects of PA in persons with schizophrenia is scant. To develop interventions to increase PA and to assess its potential benefits in this group, accurate measurement of PA is needed. The purpose of this study was to characterize PA and determine the test-retest reliability and concurrent validity of the Yale Physical Activity Scale (YPAS), a self-report measure, in persons with schizophrenia. METHODS: PA was assessed with the YPAS, a scale of motivational readiness for PA, and accelerometry in middle-aged and older persons with a diagnosis of schizophrenia (n=54) and in a comparison group with no known psychiatric diagnosis (n=27). RESULTS: On the YPAS measures, persons with schizophrenia reported on average 11 h per week of PA, whereas the non-psychiatric comparison group reported about 32 h per week. Only about 30% of schizophrenia subjects were classified as being regularly active relative to 62% of the comparison group on PA motivational stages of readiness. On the accelerometry measures, the schizophrenia group had lower levels of light activity than the comparison group, but there were no differences in moderate and vigorous activity or sedentary behavior. Only in the comparison group were there significant associations between YPAS and accelerometer variables. Several YPAS scores demonstrated high test-retest reliability in both groups, and concurrent validity was supported between the YPAS and PA motivational stages of readiness. CONCLUSIONS: We found that the YPAS is a reliable measure of PA in schizophrenia for some indices. Although the YPAS demonstrated concurrent validity with other self-report measures, it did not demonstrate concurrent validity when compared to PA measured by accelerometry in persons with schizophrenia. Use of multiple measures, both subjective and objective, is recommended when assessing PA in schizophrenia.     

Motivation and self-perception profiles and links with physical activity in adolescent girls

Research shows a decline in participation in physical activity across the teenage years. It is important, therefore, to examine factors that might influence adolescent girl's likelihood of being physically active. This study used contemporary theoretical perspectives from psychology to assess a comprehensive profile of motivational and self-perception variables in 11-16 year old English girls (n=516). A cross-sectional design was employed. Cluster analysis was conducted to (a) map cluster profiles and (b) test whether clusters differed in physical self-worth, global self-esteem, and physical activity. Results revealed a five-cluster solution depicting 40% of the sample as moderately motivated, 30% lowly motivated in two clusters, and 30% highly motivated, also in two clusters. However, differences between clusters on physical activity were quite small. Results show potential areas for intervention to enhance the motivation of adolescent girls for physical activity.     

Associations between expiratory spirometry parameters and limitations in daily life activities in patients with schizophrenia

Objective

This cross-sectional study considered whether variability in respiratory functioning could explain the variability in walking ability of individuals with schizophrenia taking into account variability in body mass index (BMI), lifestyle factors, psychiatric symptoms, antipsychotic medication use and muscular fitness.

Method

Eighty patients with schizophrenia and 40 age-, gender- and BMI-matched controls underwent a spirometry and the 6-min walk test (6MWT) and completed the International Physical Activity Questionnaire. Patients were additionally screened for psychiatric symptoms.

Results

Compared to health controls, patients with schizophrenia achieved a lower distance on the 6MWT (583.6±109.7 m versus 710.6±108.4 m, P< .001) and had a lower forced vital capacity (3.7±1.1 L versus 4.3±0.9 L, P< .001) and forced expiratory volume in 1 s (FEV1) (3.0±1.0 L versus 3.6±0.7 L, P< .001). In multiple regression analysis, 68.1% of the variance in walking distance was explained by FEV1, BMI, muscular fitness and total energy expenditure.

Conclusion

The respiratory health of patients with schizophrenia should be of concern for clinicians. In addition, future research interventions should seek to investigate the impact of an impaired respiratory health upon individuals with schizophrenia.     

Relations of physical self-concept and self-efficacy with frequency of voluntary physical activity in preadolescents: implications for after-school care programming

OBJECTIVE: This study aimed to test relations of physical self-concept and self-efficacy with voluntary physical activity in preadolescents enrolled in an after-school physical activity program. METHODS: Participants in the 2003 (n=41) and 2005 (n=84) versions of the Youth Fit For Life protocol and the control group (n=40) completed the Physical Self-Concept scale, the Exercise Barriers Self-Efficacy Scale for Children, and a recall of physical activity frequency at Weeks 1 and 12. RESULTS: Both treatment groups demonstrated significantly increased frequency of voluntary physical activity over 12 weeks. The 2005 version additionally demonstrated significant improvements in both physical self-concept and exercise barriers self-efficacy. Within the treatment groups, significant correlations between changes in physical self-concept and self-efficacy and physical activity sessions completed were found. Multiple regression indicated that 7% to 28% of the variance in voluntary physical activity was explained by the simultaneous entry of changes in physical self-concept and self-efficacy. CONCLUSION: Tenets of social cognitive and self-efficacy theory were supported and suggested that curricular elements of after-school care programming may increase overall outputs of moderate-to-vigorous physical activity in preadolescents.     

Negative symptoms are associated with lower autonomous motivation towards physical activity in people with schizophrenia

ObjectiveThis cross-sectional study examined the association between psychiatric symptoms and motivation for physical activity within the self-determination theory (SDT) framework in people with schizophrenia.MethodOver a 4-month period, 55 (17♀) inpatients with a DSM-V diagnosis of schizophrenia were assessed with the Psychosis Evaluation tool for Common use by Caregivers (PECC) and the Behavioural Regulation in Exercise Questionnaire (BREQ-2), that provided separate scores for amotivation, external, introjected and autonomous regulation. Spearman correlation coefficients were examined between these motivation scores and symptom ratings.ResultsThe BREQ-2 score for autonomous regulations (2.6 ± 1.1) was significantly correlated with the PECC negative symptoms score (10.3 ± 4.1) (r = −0.34, p = 0.011). No other significant correlations between BREQ-2 and PECC scores were found. The BREQ-2 score for external regulations (0.7 ± 0.9) was associated with older age (35.2 ± 11.3 years) (r = −0.30, p = 0.024).ConclusionsThese findings provide evidence that negative symptoms are associated with lower autonomous motivation towards physical activity in inpatients with schizophrenia. Future longitudinal research should confirm the current findings. Such research will guide physical activity approaches aimed at facilitating enhanced physical and mental health outcomes in individuals with schizophrenia.     

Changes in physical activity,physical fitness,self-perception and quality of life following a 6-month physical activity counseling and cognitive behavioral therapy program in outpatients with binge eating disorder

The aim of the current study was to explore the associations between changes in the number of binges, physical activity participation, physical fitness, physical self-perception and quality of life following a 6-month physical activity counseling and cognitive behavioral program in patients with binge eating disorder (BED). In total 34 (31 women) outpatients with BED (38.5±10.7 years) completed a 6-month 1-day per week group-based program. Participants completed the 36-item Short Form Health Survey, the Baecke Physical Activity questionnaire, the Physical Self Perception Profile and performed a 6-min walk test (6MWT) at baseline, after 3 and 6 months. Except for physical activity at work, physical strength and self-worth perception, all parameters significantly improved after 6 months. The effect sizes ranged from −0.33 for the number of binges to 1.67 for participation in sports activities. Significant increases in leisure time physical activity were associated with significant improvements in physical health related quality of life, perceived sports competence and physical fitness and in perceived body attractiveness. The significant reduction in the number of binges was associated with significant improvements in physical health related quality of life. Future research should focus on detailing which techniques can stimulate physical activity participation in patients with BED.     

Self-reported motivation to smoke in schizophrenia is related to antipsychotic drug treatment

PURPOSE: The prevalence of smoking in schizophrenia has reliably been reported as being higher than for any other psychiatric disorder. While a number of theories have been proposed to account for such high rates of smoking, little is known about the subjective motivation for why schizophrenia patients smoke in comparison with those without the disease. OBJECTIVES: The aim of the present study was to evaluate and compare smoking motivation in control subjects and schizophrenia patients, and determine if factors such as type of medication or access to cigarettes could contribute to self-reported motivation for smoking. METHODS: We assessed motivation to smoke in 61 schizophrenia inpatients and 33 non-psychiatric health worker controls at a tertiary care psychiatric facility in a cross-sectional study. Nicotine dependency and smoking behavior were evaluated using the Fagerstrom Test for Nicotine Dependence and a validated questionnaire that assesses motivation for smoking along seven different dimensions. RESULTS: Schizophrenia patients reported a stronger motivation to smoke than controls for reasons related to pleasure from the act of smoking, as well as a need for psychomotor stimulation. Scores on both these factors were significantly associated with daily antipsychotic drug dose. The sedative and anxiolytic effects of smoking were related to anticholinergic load of psychiatric medications. CONCLUSION: The findings highlight important differences in self-reported motivation to smoke between schizophrenia patients and normals. Antipsychotic drugs may also influence aspects of motivation to smoke.     

The association of 5-HTTLPR genotype and depressive symptoms is moderated by physical activity

The s allele serotonin transporter polymorphic region (5-HTTLPR) is associated with a number of physiological mechanisms that may increase the risk of elevated depressive symptoms. However, reports of a relationship between serotonin transporter polymorphic region (5-HTTLPR) genotype and depressive symptoms have thus far been inconclusive. This heterogeneity of results suggests that other factors may be moderating the relationship between 5-HTTLPR and depressive symptoms. Higher levels of physical activity are associated with lower levels of depressive symptoms. Mechanisms responsible for this association include alterations of the serotonergic system and the hypothalamic-pituitary axis. The aim of the current study was to measure the moderating effect of physical activity on the relationship between 5-HTTLPR genotype and depressive symptoms. Participants, ages 18-23, provided a saliva sample for DNA analysis and completed questionnaires to assess depressive symptoms and physical activity. A hierarchical multiple regression analysis was conducted to examine the moderating effect of physical activity on the relationship between 5-HTTLPR genotype and depressive symptoms. Analysis revealed a significant interaction between 5-HTTLPR and physical activity (p = .010). At low levels of physical activity, individuals with at least one s allele had significantly higher levels of depressive symptoms compared to ll individuals (p = .011). This finding provides preliminary support for a moderating effect of physical activity on the relationship between 5-HTTLPR and depressive symptoms.     

The level of physical activity affects adrenal and cardiovascular reactivity to psychosocial stress

Physical activity plays a key role in the control of neuroendocrine, autonomic, and behavioral responses to physical and psychosocial stress. However, little is known about how the level of physical activity modulates stress responsiveness. Here, we test whether different levels of physical activity are associated with different adrenal, cardiovascular, and psychological responses to psychosocial stress. In addition, competitiveness is assessed as a personality trait that possibly modulates the relationship between physical activity and stress reactivity. Eighteen elite sportsmen, 50 amateur sportsmen, and 24 untrained men were exposed to a standardized psychosocial laboratory stressor (Trier Social Stress Test). Repeated measures of salivary free cortisol, heart rate, and psychological responses to psychosocial stress were compared among the 3 study groups. Elite sportsmen exhibited significantly lower cortisol, heart rate, and state anxiety responses compared with untrained subjects. Amateur sportsmen showed a dissociation between sympathetic and hypothalamic-pituitary-adrenal responsiveness to stress, with significantly reduced heart rate responses but no difference in cortisol responses compared with untrained men. Different levels of competitiveness among groups did not mediate stress reactivity. Our results are in line with previous studies indicating reduced reactivity of the autonomic nervous system to psychosocial stress in trained individuals. More importantly, these findings imply a differential effect of the level of physical activity on different stress-related neurophysiological systems in response to psychosocial stress.     

A systematic review of correlates of physical activity in patients with schizophrenia

Vancampfort D, Knapen J, Probst M, Scheewe T, Remans S, De Hert M. A systematic review of correlates of physical activity (PA) in patients with schizophrenia. Objective: The present review evaluates systematically the published quantitative studies of correlates of PA in patients with schizophrenia. Method: EMBASE, PsycINFO, PubMed, ISI Web of Science, CINAHL and PEDro were searched from their inception to 1 July 2011 combining the medical subject heading ‘schizophrenia’ with ‘physical activity’ or ‘physical inactivity’ or ‘exercise’ or ‘health education’ or ‘health behaviour’ or ‘health promotion’. Results: Out of 68 potentially eligible studies, 25 papers (n = 25 013) evaluating 36 correlates were included. Correlates consistently associated with lower PA participation are the presence of negative symptoms and cardio‐metabolic comorbidity. Also, side‐effects of antipsychotic medication, lack of knowledge on cardiovascular disease risk factors, no belief in the health benefits, a lower self‐efficacy, other unhealthy lifestyle habits and social isolation correlated with lower PA participation. The quality of the PA measurement was not related to the proportion of significant associations (χ² = 3.8, P = 0.07). Current gaps in literature that need to be examined more in detail are the role of environmental and policy‐level factors on PA participation in patients with schizophrenia. Conclusion: All correlates should be confirmed in prospective studies, and interventions to improve the modifiable variables should be developed and evaluated.     

Quantifying daily physical activity and determinants in sedentary patients with Parkinson's disease

BackgroundAlthough physical activity is beneficial for Parkinson's disease (PD) patients, many do not meet the recommended levels. The range of physical activity among sedentary PD patients is unknown, as are factors that determine this variability. Hence, we aimed to (1) assess daily physical activity in self-identified sedentary PD patients; (2) compare this with criteria of a daily physical activity guideline; and (3) identify determinants of daily physical activity.MethodsDaily physical activity of 586 self-identified sedentary PD patients was measured with a tri-axial accelerometer for seven consecutive days. Physical fitness and demographic, disease-specific, and psychological characteristics were assessed. Daily physical activity was compared with the 30-min activity guideline. A linear mixed-effects model was estimated to identify determinants of daily physical activity.ResultsAccelerometer data of 467 patients who fulfilled all criteria revealed that >98% of their day was spent on sedentary to light-intensity activities. Eighty-two percent of the participants were ‘physically inactive’ (0 days/week of 30-min activity); 17% were ‘semi-active’ (1–4 days/week of 30-min activity). Age, gender, physical fitness, and scores on the Unified Parkinson's Disease Rating Scale explained 69% of the variability in daily physical activity.ConclusionsPerformance-based measurements confirmed that most self-identified sedentary PD patients are ‘physically inactive’. However, the variance in daily physical activity across subjects was considerable. Higher age, being female, and lower physical capacity were the most important determinants of reduced daily physical activity. Future therapeutic interventions should aim to improve daily physical activity in these high-risk patients, focusing specifically on modifiable risk factors.     

缓解期精神分裂症患者的病耻感及住院态度

目的 通过对缓解期精神分裂症患者病耻感及对住院态度的调查,分析缓解期精神分裂症的病耻感特点,不同治疗方式和环境对精神分裂症病耻感的影响,为减轻病耻感,提高治疗效果提供依据.方法 对浙江同德医院门诊或住院治疗的缓解期精神分裂症患者120例进行人口学特征、BPRS、CGI-SI、SSMI-C、TESS和自制的对住院态度问卷进行测量和评估,分析比较门诊或住院患者缓解期病耻感特点.结果 调查发现缓解期精神分裂症患者普遍存在被歧视、自我感觉的病耻感及对疾病的掩饰性,其中与门诊组患者比较,住院组患者的歧视因子较高,积极效应因子评分较低,两组比较差异有统计学意义（P＜0.01）;住院组患者对被欺骗、强行住院、强行治疗和被搜身等抵抗态度的发生率明显高于门诊组,两组比较差异有统计学意义（P＜0.05）.结论 门诊治疗对患者产生病耻感的影响较小,对积极效应影响小.住院患者被强制住院、强制治疗、限制自由均加重患者对住院治疗的抵抗和病耻感,采取积极有效的治疗模式或改善住院环境可能对减轻病耻感、提高生活质量有积极作用.     

家庭干预联合药物自我管理技能训练治疗精神分裂症的疗效

目的 探讨家庭干预联合药物自我管理技能训练治疗精神分裂症的效果.方法 160例精神分裂症患者随机分为观察组和对照组各80例,对照组接受常规治疗,观察组在此基础上给予家庭干预联合药物自我管理技能训练,观察2组简明精神病量表(BPRS)、社会功能缺陷筛选量表(SDSS)、生存质量测量量表(BREF)、阳性症状评定量表(SAPS)和阴性症状评定量表(SANS)评分.结果 2组治疗前各项评分差异均无统计学意义(P＞0.05),治疗6个月与治疗前比较,均明显下降,差异有统计学意义(P＜0.05);观察组优于对照组,差异有统计学意义(P＜0.05).结论 家庭干预联合药物自我管理技能训练提高了治疗依从性,改善了病情、社会功能及生活质量,精神分裂症阳性和阴性症状也明显降低.     

Physical activity in adolescents who later developed schizophrenia: A prospective case-control study from the Young-HUNT

Background: Adults suffering from schizophrenia and other psychiatric disorders report low levels of physical activity. In addition, these patients have an increased risk of overweight and poor nutritional habits. Less is known about patterns and levels of physical activity before the onset of disease. Aims: The purpose of the study was to investigate whether there were specific patterns of physical activity in the premorbid phase of schizophrenia and whether these participants differed from those with bipolar disorder (BD). A group of healthy controls (HC) was also included. Methods: The study was a prospective, longitudinal, comparative cohort design in which 15 adolescents who later developed schizophrenia and 18 with later BD were compared with HC. Data were analysed using non-parametric statistical tests. Results: Patients with a diagnosis of schizophrenia were less physically active with fewer days per week (p < 0.05) and fewer hours per week (p < 0.05) in the premorbid phase than both BD and HC. They also participated less in team sports than HC (p < 0.05). Conclusion: Our results suggest that individuals who develop schizophrenia in their teens may be at risk of establishing a lifestyle harmful to health. From a preventive perspective it is important to gain more knowledge about the connections between health habits and later development of disease.     

Physical activity and self-determined motivation of adolescents with and without autism spectrum disorders in inclusive physical education

The main purpose of this study was to compare the objectively measured physical activity (PA) and the motivation process between adolescents with (n = 25) and without (n = 75) autism spectrum disorders (ASD) in inclusive physical education (PE); and assess the associations of the PA levels to a sequence of motivational processes. Independent t-tests revealed significant PA and motivational process differences between adolescents with and without ASD. External regulation was positively correlated with the percentage of time that adolescents with ASD spent in moderate PA (r₂₅ = 0.58, p < .01) and moderate-to-vigorous PA (r₂₅ = 0.50, p < .05), and this extrinsic motive was associated with their needs of being attached or related in the class (r₂₅ = 0.53, p < .01). No significant associations of PA in PE on the motivational sequences of adolescents without ASD were observed. It is concluded that adolescents with ASD had less PA levels in PE and lower motives toward PE than adolescents without ASD, and external regulation was important in facilitating PA participation in adolescents with ASD.     

Effects of declared levels of physical activity on quality of life of individuals with intellectual disabilities

Routine physical fitness improves health and psychosocial well-being of individuals with intellectual and developmental disabilities. The current study investigated impact of physical fitness on quality of life by comparing individuals who maintain a physically active lifestyle with those who do not report exercising. We assessed several indicators of quality of life, including inclusion and community participation; satisfaction with professional services, home life, and day activities; dignity, rights, and respect received from others; fear; choice and control; and family satisfaction. Our data suggested that individuals who regularly exercise reported having more frequent outings into the community than did their peers who reported exercising infrequently; regular exercisers were also more likely to live in intermediate care facilities (ICF) as opposed to living independently or with family members. We discuss possible reasons for this as well as ideas for future research needed to expand on this area.     

Attitude towards adherence in patients with schizophrenia at discharge

Background

Purpose of the present study was to assess the attitude towards adherence at discharge and to verify its predictability using anamnestic and sociodemographic variables, factors influencing clinical treatment as well as the medical treatment applied.

Methods

Attitude towards adherence was evaluated in 369 inpatients with schizophrenic spectrum disorders within a naturalistic multicenter trial using the Compliance Rating Scale (CRS) by Kemp. Biweekly ratings of the PANSS, UKU and the Subjective Well-being under Neuroleptic Treatment Scale (SWN-K) were applied. Logistic regression and CART analyses were used to determine significant predictor variables for the attitude towards adherence at discharge.

Results

Sixty-seven percent of the patients were rated to have an attitude of active participation and moderate participation (=positive attitude towards adherence) and 33% of the patients to have an attitude of passive acceptance, occasional or permanent reluctance towards treatment as well as refusing treatment (=negative attitude towards adherence). A significant correlation was found between patients with a positive attitude towards adherence and course of all PANSS subscales. Statistical analyses revealed a reduction in PANSS general psychopathology subscore, employment status, greater illness insight and treatment with atypical antipsychotics to be significantly predictive for a positive attitude towards adherence at discharge.

Conclusions

The importance of an adequate antipsychotic treatment as a precondition for a favourable adherence attitude and the need to incorporate adherence-focused psychotherapy and psychoeducation into daily clinical practice are highlighted.