Osteoporose e perda auditiva: resultados da Pesquisa Nacional do Exame de Saúde e Nutrição da Coreia de 2009 a 2011

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Osteoporosis

and

hearing

loss:

findings

from

the

Korea

National

Health

and

Nutrition

Examination

Survey

2009---2011

夽

Jun-Il

Yoo

_,

_Ki

_Soo

_Park

_,

_Sung-Hyo

_Seo

_,

_Hyun

_Woo

_Park

a_{GyeongsangNationalUniversityHospital,DepartmentofOrthopaedicSurgery,Jinju,RepublicofKorea} b_{GyeongsangNationalUniversity,InstituteofHealthSciences,Jinju,RepublicofKorea}

c_{GyeongsangNationalUniversitySchoolofMedicine,DepartmentofPreventivemedicine,Jinju,RepublicofKorea}

d_{GyeongsangNationalUniversityHospital,DepartmentofOtorhinolaryngology-HeadandNeckSurgery,Jinju,RepublicofKorea}

Received24July2018;accepted17December2018 Availableonline18February2019

KEYWORDS

Osteoporosis; Femurneck; Age-relatedhearing impairment;

Puretoneaudiometry

Abstract

Introduction:Age-relatedhearingimpairmentisthemostcommonsensorydysfunctioninolder adults.Inosteoporosis,themassoftheossicleswillbedecreased,affectingthebonedensity ofthecochlea,andinterferingwiththesoundtransmissiontothecochlea.Agerelatedhearing lossmightbecloselyrelatedtoosteoporosis.

Objective:Todeterminetherelationshipbetweenage-relatedhearingimpairmentand osteo-porosis by investigating the relationship between hearing loss and cortical bone density evaluatedfromfemurneckbonemineraldensity.

Methods:WeuseddatafromtheKoreaNationalHealthandNutritionExaminationSurveyto examinetheassociationsbetweenosteoporosisandage-relatedhearingimpairmentfrom2009

to2011. Total number ofparticipants was 4861including2273men and2588 womenaged

50yearsorolder.Osteoporosiswasdefinedasabonemineraldensity2.5standarddeviations belowaccordingtotheWorldHealthOrganizationdiagnosticclassification.Age-relatedhearing impairmentwasdefinedasthepure-toneaveragesoftestfrequencies0.5,1,2,and4kHzata thresholdof40dBorhigheronthemoreimpairedhearingside.

Results:TotalfemurT-score(p<0.001),lumbar-spine T-score(p<0.001)and, femurneck T-score(p<0.001)were significantlylowerintheosteoporosisgroup comparedtothenormal group.Thresholdsofpure-toneaverageswere significantlydifferentinnormalcomparedto osteopenia,and osteoporosis groups. In addition,there were significantlyhigher pure-tone averagesthresholdsintheosteoporosisgroupcomparedtoothergroups(p<0.001).

夽 _{Pleasecitethisarticleas:YooJ-I,ParkKS,SeoS-H,ParkHW.Osteoporosisandhearingloss:findingsfromtheKoreaNationalHealthand} NutritionExaminationSurvey2009---2011.BrazJOtorhinolaryngol.2020;86:332---8.

∗_{Correspondingauthor.}

E-mail:[email protected](H.W.Park).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.

https://doi.org/10.1016/j.bjorl.2018.12.009

1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen

Afteradjustingforallcovariates,theoddsratioforhearinglosswassignificantlyincreasedby 1.7foldwithreducedfemurneckbonemineraldensity(p<0.01).However,lumbarspinebone mineraldensitywasnotstatisticallyassociatedwithhearingloss(p=0.22).

Conclusion: Ourresultssuggestthatosteoporosisissignificantlyassociatedwithariskofhearing loss.Inaddition,femurneckbonemineraldensitywassignificantlycorrelatedwithhearingloss, butlumbarspinebonemineraldensitywasnot.

© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Osteoporose; Colodofêmur; Deficiênciaauditiva relacionadaàidade; Audiometriatonal

Osteoporoseeperdaauditiva:resultadosdaPesquisaNacionaldoExamedeSaúdee Nutric¸ãodaCoreiade2009a2011

Resumo

Introduc¸ão: Aperdaauditivaassociadaaoenvelhecimentoéadisfunc¸ãosensorialmaiscomum emidosos.Naosteoporose,amassadosossículosdiminuieafetaadensidadeósseadacóclea, oqueiráinterferirnatransmissãodosomparaamesma.Aperdaauditivaassociadaàidade podeestarintimamenterelacionadaàosteoporose.

Objetivo: Determinararelac¸ãoentredeficiênciaauditivarelacionadaàidadeeosteoporose, investigararelac¸ãoentreperdaauditivaedensidadeósseacorticalavaliadaapartirda densi-dademineralósseadocolodofêmur.

Método: Utilizamos dadosdaKoreaNational HealthandNutritionExaminationSurveypara examinarasassociac¸õesentreosteoporoseeperdaauditivaassociadaaoenvelhecimentode 2009a2011.Onúmerototaldeparticipantesfoide4.861,incluiu2.273homense2.588

mul-heres com50 anosoumais.A osteoporose foidefinidacomo densidade mineralóssea com

2,5desvios-padrãoabaixodamédia,deacordocomaclassificac¸ãodiagnósticadaOrganizac¸ão MundialdaSaúde.Aperdaauditivaassociadaaoenvelhecimentofoidefinidacomoasmédias detompurodasfrequênciasdetestede0,5,1,2e4kHzaumlimiarde40dBousuperiorno ladodaaudic¸ãomaisafetado.

Resultados: OT-scoretotaldofêmur(p<0,001),oT-scoredacolunalombar(p<0,001)eo T-scoredocolodofêmur(p<0,001)foramsignificantementemenoresnogrupocomosteoporose emcomparac¸ãoaogruponormal.Oslimiaresdemédiasdetompuroforamsignificantemente diferentes nosgrupos normaisem comparac¸ãocomaqueles comosteopenia eosteoporose. Alémdisso, houvelimiaressignificantementemaioresdemédiasdetom puronogrupo com osteoporose em comparac¸ãocom osoutros grupos (p<0,001).Apóso ajuste para todas as covariáveis,aoddsratiodaperdaauditivamostrouestarsignificantementeaumentadaem1,7 vezcomdensidademineralósseareduzidanocolodofêmur(p<0,01).Noentanto,adensidade mineralósseadacolunaLnãoseassociouestatisticamenteàperdaauditiva(p=0,22).

Conclusão:Nossosresultadossugeremqueaosteoporoseestásignificantementeassociadaao riscodeperdaauditiva.Alémdisso,adensidademineralósseadacolunalombarnãose cor-relacionou com a perda auditiva,apenas a densidade mineral óssea do colo do fêmur foi significantementecorrelacionada.

© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

As population aging is occurring in many Countries, the importanceof health life expectancyof elderly peopleis becomingamajorconcern.Furthermore,thereisagrowing interestinchronicandagingdiseasesthataffectthehealth expectancyof elderly people.1---3 _{Of these agingdiseases,}

age-relatedhearingimpairment(ARHI)isthemostcommon sensorydysfunctioninolderadults.ARHIreducesthequality of life for the elderlyand makes communication difficult

often with resulting social isolation.4---6 _{Several studies}

havesuggestedtheriskfactorsforARHIincludetraditional cardiovascular risk factors, such as hypertension, chronic kidney disease, and diabetes mellitus.7---10 _{As a result, it}

appearsthatsystemicconditionscanaffecthearingloss. Recently,Yehetal.11 _{performedthelargest}

population-based study to evaluate the risk of sudden sensorineural hearingloss (SSNHL)inanationalcohortofAsianpatients withosteoporosis.Theyreporteda1.76foldincreaseinthe incidenceofSSNHLforpatientswithosteoporosiscompared

with the comparison group after covariates such as age, sex,medicalcomorbidities,geographicalarea,andmonthly incomewereconsidered. Inaddition,theysuggested that demineralizationofthe cochlear capsule wasfoundtobe correlatedwithhearinglossinpatientswithmetabolicbone disorders.However, another study investigating 120 post-menopausal women, showed no statistical significance at lowfrequencies,irrespectiveofbonemineraldensity(BMD) values.12

Zehnder et al., investigating bone metabolism in the otic capsule, suggested that OPG, a potent inhibitor of osteoclasts,is present in theinner earandis secreted as perilymph toinhibitbone remodelingof theotic capsule, andinparticularthecochlea.13_{Kanzakietal.demonstrated}

thatvariousparts ofossicles were thinnedand weakened and that the ligaments between the stapes and the oval windowalso disappeared.In hearing thresholdstudied by acousticbrainstemresponse,theoverallhearingthreshold washigherintheOpg---/---mousemodelthaninthenormal groupasageincreased.Inparticular,thehearingthreshold of20dBormorewasobservedinthehighfrequencyabove 20kHz.However,theycouldnotconfirmwhichossicleswere morevulnerable.14

Whenthesoundispresentedtotheexternalearcanal,it istransmittedthroughtheossiclesvibrationtothecochlea. Thatossicularvibrationisdirectlyproportionaltothe stiff-nessof thetympanicmembrane, inter-ossicular jointand oval window, and inversely proportional to the mass of the tympanic membrane and ossicles.15,16 _{Mass helps to}

transmitlowfrequency vibrationand prejudicethe trans-mission of high-frequency sounds, while stiffness helps high-frequencyvibrationanddisturbslow-frequencies trans-mission.Variousmiddleearpathologiescanaffectthesound transmissionasvibrationtotheinner earbychangingthe mass of the ossicles and the stiffness of the middle ear. Examplesofpathologiesassociatedwithincreasedstiffness includenegativemiddleearpressure,otosclerosis,andotitis media.Definiteexampleofdecreasedstiffnessisan ossic-ular disruption, when vibration cannot be transmitted to thecochlea. Inosteoporosis, themass ofthe ossicleswill bedecreased, affecting the bone density of the cochlea, which will interfere with the sound transmission to the cochlea.15,17

Ourhypothesiswasthatagerelatedhearinglosscouldbe closelyrelatedtoosteoporosis,andthatBMDlevelsatthe femurneck,whichoccupiesalargeportionofthecortical bone,wouldreflecttheconditionmorethantheBMDlumbar spinelevels.

Therefore,the purposeof thisstudy wastodetermine the relationship between ARHI and osteoporosis and to investigatetherelationshipbetweencorticalbone density evaluatedfromlumbarspine(L-spine)andfemurneckBMD, andhearingloss.

Methods

Ethicsstatement

Data from the 2009---2011 Korean National Health and NutritionExaminationSurvey(KNHANES)wasreviewedand approved by the Institutional Review Board of the Korea

Exclude those with age <50 years (n=11,008)

Exclude those with no data of bone mineral density and pure tone audiometry Total n=17,720 assessed for eligibility

KNHANES V-1 (2009, n=7,90) KNHANES V-2(2010, n=7,920) KNHANES V-3(2011, n=2,757) n=6,712, age ≥ 50 years KNHANES V-1 (2009, n=3,045) KNHANES V-2(2010, n=2,722) KNHANES V-3(2011, n=945) n=4,861, age ≥ 50 years Men (n=2,273) Women(n-2,588)

Figure1 Flowsheetofstudyparticipants.

CentersforDiseaseControlandPrevention(KCDC)(Approval no.2009-01CON-03-2C,2010-02CON-21-C,and 2011-02CON-06-C). Written informed consent was obtained from all participantswhenthe2009,2010,and2011KNHANESwere conducted.

Studypopulation

KNHANES has been a nationwide representative cross-sectionalsurveyfortheKoreanpopulationwithaclustered, multistage,stratified,androllingsamplingdesign.KNHANES consists of a health interview, health examination, and dietarysurvey.Thesurveydataiscollectedfromhousehold interviews and direct standardized physical examinations conducted in specially equipped mobileexamination cen-ters. The data was collected from 17,720 participants in 2009(n=7920),2010(n=7043),and2011(n=2757).Patients under50yearsofageandwithnoregistereddataonbone mineral density or pure tone audiometry were excluded. After these exclusions, a totalof 4861 participants (2273 men and 2588 women) with normal tympanic membrane wereanalyzed(Fig.1).

Assessmentofosteoporosis

BoneMineralContent(BMC)andBoneMineralDensity(BMD) fromtotalfemur,andfromfemoralneckandlumbarspine (L1---L4) were measured by trained technicians using DXA (QDR4500A,Hologic Inc.,Waltham,MA,USA).Osteopenia or osteoporosiswerediagnosed withsupplying bytheDXA manufacturer18 _{using T-score of the total femur, femoral}

neck, and lumbar spine according to the criteria of the WorldHealthOrganization(T-score≥−1;normal,−2.5< T-score<−1;osteopenia,T-score≤−2.5;osteoporosis).19

Table1 Demographicsandclinicalcharacteristicsofthestudypopulation.

Variable Normal Osteopenia Osteoporosis p-value

n=1299 n=2388 n=1174

Age(years) 60.19±7.74 63.29±8.38 69.25±8.48 <0.001

Malegender(%) 957(73.67) 1109(46.44) 207(17.63) <0.001

BMI(kg/m2_{,mean±SD) 24.93±2.79 23.92±3.07 23.04±3.09 <0.001}

Currentsmoker(yes,%) 293(22.61) 417(17.58) 128(11.01) <0.001

Monthlyalcoholhistory(yes,%) 816(63.16) 1041(44.02) 285(24.57) <0.001

Moderatephysicalactivity(%) 164(12.67) 291(12.26) 131(11.26) 0.544

Hypertension(%) 514(39.63) 936(39.36) 520(44.41) 0.012

Diabetesmellitus(%) 215(16.58) 357(15.01) 158(13.49) 0.161

Hypercholesterolemia(%) 253(19.51) 428(18.00) 163(13.92) 0.003

L-spineT-score(mean±SD) 0.20±0.92 −1.37±0.76 −2.88±0.76 <0.001

FemurneckT-score(mean±SD) −0.11±0.67 −1.39±0.61 −2.48±0.74 <0.001

TotalfemurT-score(mean_±SD) 0.62_±0.68 _−0.50±0.64 _−1.52±0.78 <0.001

Phosphorusintake(mg) 1289.58±511.87 1116±495.88 910.59±423.39 <0.001 Calciumintake(mg) 582.86_±384.52 492.59_±335.33 381.07_±276.09 <0.001 Serumcreatinine(mg/dL) 0.91±0.23 0.83±0.20 0.77±0.26 <0.001 VitaminD(ng/mL) 20.24±6.76 19.64±7.24 18.80±7.28 <0.001 ALP(U/L) 229.73±72.62 249.65±71.14 268.85±82.42 <0.001 PTH(pg/mL) 65.67±24.69 68.0±27.86 73.96±41.14 <0.001

BMI,bodymassindex;ALP,alkalinephosphatase;PTH,parathyroidhormone.

Assessmentofhearingthreshold

Forevaluationofhearingthreshold,pure-toneaudiometry wasconductedwithaSA203audiometer(Entomed;Malmö, Sweden)inasoundproofboothandinstructionsweregiven bya trainedotolaryngologist.In asoundproof booth, sub-jectsputonaheadset,andpushedabuttonwhentheyheard apuretonesound.Onlyairconductionthresholdwas mea-sured.Thepure-toneaverages(PTA)werecalculatedasthe averageofthresholdat0.5,1,2and4kHz.Hearinglosswas definedasthePTAofthreshold40dBorhigher.

Assessmentofcovariates

InformationonthestudypopulationincludingBMI,smoking, alcoholconsumption, physicalactivity,andmedical condi-tionswereobtainedfromKNHANESdata.BMIwascalculated fromtheheightwhichwasmeasuredtothenearest0.1cm withastadiometer.

Hypertension was defined as a systolic Blood Pressure (BP)of140mmHg,adiastolicBPof90mmHg,ortreatment withantihypertensiveagents.Diabetesmellituswasdefined by a fasting plasma sugar level >126mg/dL, treatment withoral hypoglycemicagentsorinsulin,ordiagnosis bya physician.

In termsof smoking,the participantswerecategorized eitherascurrentsmokersorothers.Aparticipantwas con-sidered to have a ‘‘monthly alcohol ingestion history’’ if he/shedrankmorethanoncepermonthoverthepastyear. Amoderatephysicalactivitydoneforatleast20minatime and more than threetimes a week wasconsidered to be regularexercise.

Biochemicalanalysis

Serum 25 (OH)D and parathyroid hormone (PTH) levels were measured using a gamma counter (1470 Wizard; Perkin Elmer, Turku, Finland) and LIAISON (DiaSorin) with radioimmunoassay (25 (OH)D 125I RIA Kit; DiaSorin) and chemiluminescenceimmunoassay(N-tactPTHAssaykit; Dia-Sorin),respectively.

Statisticalanalysis

Tocompare PTA bypresence of osteoporosis, ANOVA with Bonferroni correction was performed. Multiple logistic regression analyses were also performed to estimate the associationbetweenT-scoreandhearingloss.Dataare pre-sentedasOR(95%CI)afteradjustingforcertainfactorsin eachmodel using hierarchicalanalysis(Model 1: adjusted forage;Model2:adjustedfor age,currentsmoking, alco-holuse,regularexercise,andbodyfat percentage;Model 3:Adjustedforage, currentsmoking, alcoholuse,regular exercise).

Toreflectthesamplingweights,complexsampling anal-yseswasperformed.Allstatisticalanalyseswereperformed usingtheSAS(version9.3;SASInstitute,Cary,NC,USA).All datawithp<0.05wereacceptedasstatisticallysignificant results.

Results

Subject characteristics are shown in Table 1 (p<0.001). Osteopeniaandosteoporosisweremorecommoninwomen

Right ear Left era Normal Normal HEARING THRESHOLD HEARING THRESHOLD 60 50 40 30 10 0 20 2000Hz 3000Hz 4000Hz 6000Hz PTA 1000Hz 500Hz 2000Hz 3000Hz 4000Hz 6000Hz PTA 1000Hz 500Hz 70 60 50 40 30 10 0 20 70 * * * * * * * * * * * * * * FREQUENCY FREQUENCY Osteopenia Osteopenia Osteoporosis Osteoporosis

Figure2 Correlationbetweenhearingthresholdandfrequencyofeachgroup.PTA,puretoneaverage;averagethresholdat500, 1000,2000,4000Hz.

than men. Current smoking (p<0.001), monthly alcohol drinking(p<0.001),BMI(p<0.001)weresignificantlyhigher inthenormalgroupcomparedtotheosteopeniaand osteo-porosisgroup.However,moderatephysicalactivity,diabetes mellitus, and hypercholesterolemia were not significantly different.

L-spineT-score(p<0.001),femurneckT-score(p<0.001) and, total femur T-score (p<0.001) were all significantly decreasedintheosteoporosisgroupcomparedtocontrols. Calcium (p<0.001), phosphorus intake (p<0.001), serum creatinine (p<0.001), and vitaminD (p<0.001) were also significantlydecreasedintheosteoporosisgroup.However, alkaline phosphatase p<0.001) and parathyroid hormone (p<0.001)weresignificantlyincreasedin theosteoporotic group.

Thresholdsof PTA weresignificantly differentbetween thenormalandosteopenia,andosteoporosisgroups. Signi-ficantlyhigherPTAthresholdwasseenin theosteoporosis groupcomparedtotheothergroups(p<0.001)(Fig.2, Sup-plement1).

After adjustment for all covariates, such as the age, gender, hypertension, phosphorous intake, serum creati-nine,vitaminD,hypercholesterolemia,andmonthlyalcohol history, the Odds Ratio for hearing loss were significan-tly increased 1.7 fold with decreasing femur neck BMD (p<0.01). However, L-spine and femur shaft BMD were notstatistically correlatedwith hearingloss, respectively (p=0.22and0.16)(Table2).

Table2 Logisticregressionanalysisforbonemineral den-sitybypresenceofhearingloss.

Variables OR 95%Wald p-value

FemurneckBMDa _{1.655 1.491---1.837 <0.01}

FemurshaftBMDa _{0.922 0.821---1.034 0.16}

L-spineBMDa _{0.953 0.883---1.029 0.22}

BMD,bonemineraldensity.

a _{Adjusted covariates such as age, gender, hypertension,}

phosphorousintake,serumcreatinine,vitaminD,

hypercholes-terolemia,andmonthlyalcoholhistory.

Discussion

The principle findingof the present study is thatthere is a significant correlation between osteoporosis and ARHI. AlthoughL-spineBMDandhearinglosswerenotsignificantly related,femurneckBMDandhearinglossweresignificantly related.

Several studies have reported an association between osteoporosisandhearinglossintheolderpopulation. How-ever,thisrelationshipiscontroversial.Jungetal.performed a case-control study using 1009 postmenopausal women. Theyreportednoassociationbetweenbonemineraldensity and hearingimpairment inthe study population.20

Never-theless, a number of other studies report that ARHI and osteoporosis are related. Recently, Ye et al. investigated

hearing loss in the Taiwanese health insurance database from1998to2008with16,600casesdiagnosedwith osteo-porosisand30,080caseswithoutosteoporosis.Theyfound thattherelativeriskofhearinglossintheosteoporoticgroup was1.76timeshigherthaninthecontrolgroup,asaresult ofmatchingage,sex,diabetes,hypertension, cardiovascu-lardisease,andchronickidneydisease.Ourstudy,inclose agreementwiththesefindings,showedthattheoddsratioof hearinglossintheosteoporoticgroupwas1.7timeshigher. However,webelievethatourdataismoreobjectivedueto theuseofpuretonethresholdcomparedtotheiranalysisin whichthediagnosticcodewasused.

Inthisstudy,L-spineBMDwasnotassociatedwith hear-ingloss.SeventyfivepercentofL-spinesarecomposedof trabecularbonewhile75%ofthefemurneckarecomposed ofcorticalbone.21 _{Sincetheconfiguration oftheproximal}

femurissimilartothatofossicles,especiallythemalleus, andascavitationofboneincreasesinosteoporosis,asimilar phenomenonoccursintheossicles.Therefore,itseems rea-sonablethatthecorrelationwillbemoresignificantinthe femurneckthaninthefemurshaftandL-spine.22_Aprevious

studyreportedanassociationbetweenBMDandhearingloss in postmenopausalpatients.12 _{Although themechanism of}

hearinglossisunclear,ithasbeensuggestedthat deminer-alization of the otic capsule is associated withsecondary neuronal degeneration, resulting in sensorineural hearing loss.23,24

Therewereseverallimitationstothisstudy.First,itwasa cross-sectionalstudyandretrospectiveindesign.Therefore, wecouldnotevaluatethecausalitybetweenbonemineral densityandhearingloss.Prospectivelydesignedstudiesare necessarytoclarifythisrelationship.Second,thereisalack ofexplanationforthemechanismofaction.Therefore, well-designedexperimental studieswillbe necessarytoclarify this mechanism. Third,we could not reflectmild hearing lossandyoungadults.Therefore,inthefuture,large-scale studiesincludingmildhearinglossandyoungadultswillbe necessary.Finally,therearedifferencesinbiochemical fac-torsineastAsianthatcanaffect osteoporosisandhearing losscomparedtothatinWesterncountries.Inparticular,the proportionofvitaminDdeficiencyinelderlypeopleishigher inKoreathaninWesterncountries.However,inthisstudy, biochemicalfactorsincludingvitaminDwere adjustedfor statisticalanalysis.

Conclusion

Osteoporosisissignificantlyassociatedwithariskofhearing loss.Inaddition,lumbarspinebonemineraldensityal den-sitywasnotcorrelatedwithhearingloss,whilefemurneck bonemineraldensitywassignificantlycorrelated.

Funding

ThisstudywasfundedbytheMinistryofSMEsandStartups, RepublicofKorea(ProjectNo.P0002726).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

The funder had no role in study design, data collec-tionandanalysis,decisiontopublish,orpreparationofthe manuscript.

Appendix

A.

Supplementary

data

Supplementarymaterialrelatedtothisarticlecanbefound, intheonlineversion,atdoi:10.1016/j.bjorl.2018.12.009.

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