const pptxgen = require("pptxgenjs");

let pres = new pptxgen();
// A0-ish poster: use LAYOUT_WIDE 13.3" x 7.5" but we'll treat it as a single-slide poster
// Use a wider custom layout simulating A1 landscape
pres.defineLayout({ name: "POSTER", width: 13.33, height: 9.5 });
pres.layout = "POSTER";
pres.title = "Exercise and Bone Mineral Density: A Longitudinal Study";

let slide = pres.addSlide();

// ─── COLOUR PALETTE (matching template style) ───
const HEADER_BG   = "1B3A6B"; // deep navy
const SECTION_BG  = "1B3A6B"; // navy for section headers
const SECTION_TXT = "FFFFFF";
const BODY_TXT    = "222222";
const BORDER_COL  = "1B3A6B";
const LIGHT_BG    = "FFFFFF";
const PAGE_BG     = "F2F4F7";
const ACCENT      = "2E75B6";

// ─── BACKGROUND ───
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 0, w: 13.33, h: 9.5,
  fill: { color: PAGE_BG }, line: { color: PAGE_BG }
});

// ─── HEADER BAR ───
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 0, w: 13.33, h: 1.1,
  fill: { color: HEADER_BG }, line: { color: HEADER_BG }
});

// Title
slide.addText("Exercise and Bone Mineral Density: A Longitudinal Study", {
  x: 0.2, y: 0.05, w: 12.93, h: 0.65,
  fontSize: 26, fontFace: "Calibri", bold: true, color: "FFFFFF",
  align: "center", valign: "middle", margin: 0
});

// Subtitle line
slide.addText("BMS5005 Research Methods  |  Biomedical Science", {
  x: 0.2, y: 0.7, w: 12.93, h: 0.32,
  fontSize: 11, fontFace: "Calibri", color: "BDD7EE",
  align: "center", valign: "middle", margin: 0
});

// ─── LAYOUT: 4 columns ───
// col widths: col1=3.1, col2=3.4, col3=3.4, col4=3.1  (gap 0.09 each)
const TOP_Y   = 1.18;
const COL_H   = 8.2;   // available height for content
const GAP     = 0.09;
const c1x     = 0.12;
const c1w     = 3.05;
const c2x     = c1x + c1w + GAP;
const c2w     = 3.28;
const c3x     = c2x + c2w + GAP;
const c3w     = 3.28;
const c4x     = c3x + c3w + GAP;
const c4w     = 3.05;

// Helper: draw a section header box
function sectionHeader(slide, pres, x, y, w, label) {
  slide.addShape(pres.ShapeType.rect, {
    x, y, w, h: 0.27,
    fill: { color: SECTION_BG }, line: { color: SECTION_BG }
  });
  slide.addText(label, {
    x, y, w, h: 0.27,
    fontSize: 9.5, fontFace: "Calibri", bold: true, color: SECTION_TXT,
    align: "center", valign: "middle", margin: 0
  });
}

// Helper: draw a white content panel
function contentPanel(slide, pres, x, y, w, h) {
  slide.addShape(pres.ShapeType.rect, {
    x, y, w, h,
    fill: { color: LIGHT_BG },
    line: { color: BORDER_COL, width: 0.75 }
  });
}

// Helper: add body text
function bodyText(slide, x, y, w, h, textArr, fontSize) {
  slide.addText(textArr, {
    x, y, w, h,
    fontSize: fontSize || 7.2, fontFace: "Calibri", color: BODY_TXT,
    align: "left", valign: "top", margin: [3,4,3,4], wrap: true
  });
}

// ═══════════════════════════════════════
// COLUMN 1: Introduction + Aims & Hypotheses
// ═══════════════════════════════════════

// INTRODUCTION
sectionHeader(slide, pres, c1x, TOP_Y, c1w, "INTRODUCTION");
const introH = 3.48;
contentPanel(slide, pres, c1x, TOP_Y+0.27, c1w, introH);
bodyText(slide, c1x, TOP_Y+0.27, c1w, introH, [
  { text: "Exercise is crucial for maintaining bone health and preventing conditions such as osteoporosis and fractures, particularly in women as bones begin to weaken after reaching peak bone mass at approximately age 30 (Rizzoli et al., 2010). ", options: {} },
  { text: "\n\nBone mineral density (BMD) is the key measure of bone strength and is influenced by factors including age, sex, hormonal status, physical activity, and nutritional intake. Post-menopausal women are especially vulnerable to bone loss due to declining oestrogen levels, while ageing men also experience gradual BMD reduction.", options: {} },
  { text: "\n\nThis study investigates how a structured, combined exercise programme (resistance training + impact/jumping exercise) affects BMD in different age and gender groups over a 12-month period. Understanding these differences is critical for designing targeted exercise interventions that can reduce the burden of osteoporosis across the life course.", options: {} }
], 7.3);

// AIMS & HYPOTHESES
const aimsY = TOP_Y + 0.27 + introH + 0.13;
const aimsH = 4.18;
sectionHeader(slide, pres, c1x, aimsY, c1w, "AIMS & HYPOTHESES");
contentPanel(slide, pres, c1x, aimsY+0.27, c1w, aimsH);
bodyText(slide, c1x, aimsY+0.27, c1w, aimsH, [
  { text: "Aim:", options: { bold: true } },
  { text: " To investigate how a 12-month combined exercise programme affects BMD in pre-menopausal women (30–40 yrs), post-menopausal women (40–50 yrs), young adult males (30–40 yrs), and older adult males (40–50 yrs).", options: {} },
  { text: "\n\nHypotheses:", options: { bold: true } },
  { text: "\n• Pre-menopausal women and young adult males will show the greatest BMD increases (~1–2%) following the exercise intervention.", options: {} },
  { text: "\n• Post-menopausal women and older adult males will show smaller BMD increases due to age-related hormonal and physiological changes.", options: {} },
  { text: "\n• There will be a statistically significant difference in BMD change between at least two groups as measured by two-way ANOVA (p < 0.05).", options: {} },
  { text: "\n\nExpected Results:", options: { bold: true } },
  { text: "\nIf pre-menopausal women and younger males show the largest BMD gains, this will highlight the importance of early exercise intervention before age-related bone loss accelerates (Royal Osteoporosis Society, n.d.; Giangregorio et al., 2014).", options: {} }
], 7.3);

// ═══════════════════════════════════════
// COLUMN 2: Method
// ═══════════════════════════════════════

sectionHeader(slide, pres, c2x, TOP_Y, c2w, "METHOD");
const methH = COL_H;
contentPanel(slide, pres, c2x, TOP_Y+0.27, c2w, methH);
bodyText(slide, c2x, TOP_Y+0.27, c2w, methH, [
  { text: "Study Design\n", options: { bold: true } },
  { text: "This is a 12-month longitudinal randomised controlled study. 120 participants will be randomly recruited from community church settings and randomly assigned to one of four groups (n = 30 per group):\n", options: {} },
  { text: "\n• Group 1:", options: { bold: true } },
  { text: " Pre-menopausal women, aged 30–40 years", options: {} },
  { text: "\n• Group 2:", options: { bold: true } },
  { text: " Post-menopausal women, aged 40–50 years", options: {} },
  { text: "\n• Group 3:", options: { bold: true } },
  { text: " Young adult males, aged 30–40 years", options: {} },
  { text: "\n• Group 4:", options: { bold: true } },
  { text: " Older adult males, aged 40–50 years\n", options: {} },
  { text: "\nAll participants must be generally healthy and currently inactive (not regularly exercising).\n", options: {} },
  { text: "\nBMD Measurement – DXA Scanning\n", options: { bold: true } },
  { text: "BMD will be measured at the hip and lumbar spine using Dual-energy X-ray Absorptiometry (DXA) scans — the gold standard clinical tool for measuring bone density (Albano et al., 2020). DXA uses two low-dose X-ray beams at different energy levels to distinguish bone from soft tissue, calculating bone mineral content and density. It is a quick, painless, and widely validated test (Cleveland Clinic, 2020; Garg and Kharb, 2013). DXA scans will be performed at baseline (0 months), mid-point (6 months), and study end (12 months). Care will be taken to avoid common operator errors such as inconsistent positioning and equipment calibration drift (Albano et al., 2020; Lewiecki and Lane, 2008).\n", options: {} },
  { text: "\nNutritional Standardisation\n", options: { bold: true } },
  { text: "To control for dietary confounders, all participants will be prescribed 1,000 mg calcium and 800 IU vitamin D daily, as evidence supports this combination in reducing fracture risk and supporting bone density (Weaver et al., 2015). Dietary intake will be monitored throughout the study using food diaries.\n", options: {} },
  { text: "\nExercise Intervention\n", options: { bold: true } },
  { text: "All groups follow the same exercise protocol combining:\n", options: {} },
  { text: "\n• Resistance training", options: { bold: true } },
  { text: " (3×/week): Squats, lunges, and deadlifts using progressive overload with free weights.", options: {} },
  { text: "\n• Impact training", options: { bold: true } },
  { text: " (2×/week): Jumping exercises including hopping, drop jumps, and plyometric drills — these apply mechanical stress to bone, stimulating osteogenesis (Hinton, Nigh and Thyfault, 2015).\n", options: {} },
  { text: "\nSessions are supervised to ensure compliance and correct technique. Exercise volume and intensity will be progressively increased every 4 weeks.\n", options: {} },
  { text: "\nStatistical Analysis\n", options: { bold: true } },
  { text: "A two-way ANOVA will compare mean BMD changes across groups and time points, with group (4 levels) and time (3 levels) as independent variables (Qualtrics, 2023). Tukey's post hoc test will identify which specific group pairs differ significantly (Frost, 2019; Abdi and Williams, 2010). Statistical significance is set at p < 0.05; p-values will be reported and interpreted in context (Nahm, 2017).", options: {} }
], 7.1);

// ═══════════════════════════════════════
// COLUMN 3: Method cont. + Safety concerns
// ═══════════════════════════════════════

sectionHeader(slide, pres, c3x, TOP_Y, c3w, "METHOD CONT.");
const methContH = 4.45;
contentPanel(slide, pres, c3x, TOP_Y+0.27, c3w, methContH);
bodyText(slide, c3x, TOP_Y+0.27, c3w, methContH, [
  { text: "Outcome Measures\n", options: { bold: true } },
  { text: "Primary outcome: Change in BMD (g/cm²) at the femoral neck and lumbar spine (L1–L4) from baseline to 12 months.\n", options: {} },
  { text: "\nSecondary outcomes: BMD change at 6 months; comparison of BMD change between all four groups; assessment of whether age and sex moderate exercise response.\n", options: {} },
  { text: "\nInclusion/Exclusion Criteria\n", options: { bold: true } },
  { text: "Inclusion: Healthy adults aged 30–50 yrs, sedentary at baseline, able to participate in moderate-intensity exercise.\n", options: {} },
  { text: "\nExclusion: Current osteoporosis diagnosis, musculoskeletal injury, use of bone-altering medications (e.g. bisphosphonates, corticosteroids), pregnancy, or chronic conditions that contraindicate exercise.\n", options: {} },
  { text: "\nData Integrity\n", options: { bold: true } },
  { text: "All DXA scans will be performed on the same calibrated machine by the same trained operator to minimise inter-operator variability (Albano et al., 2020; Lewiecki and Lane, 2008). Participant positioning will follow standardised protocols at every time point.", options: {} }
], 7.1);

// SAFETY CONCERNS
const safetyY = TOP_Y + 0.27 + methContH + 0.13;
const safetyH = 3.28;
sectionHeader(slide, pres, c3x, safetyY, c3w, "RISK ASSESSMENT & SAFETY");
contentPanel(slide, pres, c3x, safetyY+0.27, c3w, safetyH);
bodyText(slide, c3x, safetyY+0.27, c3w, safetyH, [
  { text: "Exercise Risks\n", options: { bold: true } },
  { text: "Resistance and impact training carry a low-to-moderate risk of musculoskeletal injury (e.g. muscle strains, joint soreness). All sessions will be supervised by a qualified exercise physiologist. Participants will complete a structured warm-up and cool-down. Exercise intensity will be introduced progressively (Giangregorio et al., 2014).\n", options: {} },
  { text: "\nDXA Radiation Exposure\n", options: { bold: true } },
  { text: "DXA involves minimal ionising radiation (equivalent to a few hours of background radiation) and is considered clinically safe. Pregnant women are excluded. Scans will be performed only three times over the 12-month period (Cleveland Clinic, 2020).\n", options: {} },
  { text: "\nMitigating Actions\n", options: { bold: true } },
  { text: "• Pre-participation health screening and PAR-Q questionnaire\n• Exclusion of high-risk individuals (e.g. severe osteoporosis)\n• First aid equipment available at all exercise sessions\n• Adverse event protocol in place; any injuries reported and reviewed", options: {} }
], 7.1);

// ═══════════════════════════════════════
// COLUMN 4: Ethical & Legal + References
// ═══════════════════════════════════════

sectionHeader(slide, pres, c4x, TOP_Y, c4w, "ETHICAL & LEGAL CONSIDERATIONS");
const ethH = 3.78;
contentPanel(slide, pres, c4x, TOP_Y+0.27, c4w, ethH);
bodyText(slide, c4x, TOP_Y+0.27, c4w, ethH, [
  { text: "Ethical Approval\n", options: { bold: true } },
  { text: "Ethical approval will be sought from the institutional ethics committee prior to recruitment. All procedures will comply with the Declaration of Helsinki principles for research involving human participants.\n", options: {} },
  { text: "\nInformed Consent\n", options: { bold: true } },
  { text: "All participants will receive a detailed participant information sheet. Written informed consent will be obtained before enrolment. Participants retain the right to withdraw at any time without detriment.\n", options: {} },
  { text: "\nConfidentiality & GDPR\n", options: { bold: true } },
  { text: "All data will be anonymised and stored securely on password-protected institutional servers. Raw data will be retained for 5 years then destroyed, in accordance with GDPR requirements.\n", options: {} },
  { text: "\nEquality & Access\n", options: { bold: true } },
  { text: "Recruitment via community church ensures diversity of participants. The study does not discriminate based on race, religion, or socioeconomic status. Exercise modifications are available for participants with minor mobility limitations.\n", options: {} },
  { text: "\nVulnerable Populations\n", options: { bold: true } },
  { text: "Post-menopausal women with low BMD may be at higher fracture risk. Exercise protocols follow safe exercise guidelines for individuals with low bone mass (Giangregorio et al., 2014).", options: {} }
], 7.1);

// REFERENCES
const refY = TOP_Y + 0.27 + ethH + 0.13;
const refH = 4.17;
sectionHeader(slide, pres, c4x, refY, c4w, "REFERENCES");
contentPanel(slide, pres, c4x, refY+0.27, c4w, refH);
bodyText(slide, c4x, refY+0.27, c4w, refH, [
  { text: "Abdi, H. and Williams, L. (2010) Encyclopedia of Research Design.\n\n", options: { italic: true } },
  { text: "Albano, D. et al. (2020) 'Operator-related errors and pitfalls in dual energy X-ray absorptiometry', ", options: {} },
  { text: "Academic Radiology.", options: { italic: true } },
  { text: " doi: 10.1016/j.acra.2020.07.028\n\n", options: {} },
  { text: "Cleveland Clinic (2020) ", options: {} },
  { text: "DEXA Scan: Bone Density Test.", options: { italic: true } },
  { text: " Available at: my.clevelandclinic.org\n\n", options: {} },
  { text: "Frost, J. (2019) Using post hoc tests with ANOVA. Available at: statisticsbyjim.com\n\n", options: {} },
  { text: "Garg, M. and Kharb, S. (2013) 'Dual energy X-ray absorptiometry: Pitfalls in measurement', ", options: {} },
  { text: "Indian Journal of Endocrinology and Metabolism,", options: { italic: true } },
  { text: " 17(2), p.203.\n\n", options: {} },
  { text: "Giangregorio, L. et al. (2014) 'Too fit to fracture: Exercise recommendations for individuals with osteoporosis', ", options: {} },
  { text: "PMC3891842.\n\n", options: {} },
  { text: "Hinton, P.S., Nigh, P. and Thyfault, J. (2015) 'Effectiveness of resistance training or jumping-exercise to increase BMD', ", options: {} },
  { text: "Bone,", options: { italic: true } },
  { text: " 79, pp.203–212.\n\n", options: {} },
  { text: "Lewiecki, E.M. and Lane, N.E. (2008) 'Common mistakes in clinical use of BMD testing', ", options: {} },
  { text: "Nature Clinical Practice Rheumatology,", options: { italic: true } },
  { text: " 4(12), pp.667–674.\n\n", options: {} },
  { text: "Nahm, F.S. (2017) 'What the P values really tell us', ", options: {} },
  { text: "Korean Journal of Pain,", options: { italic: true } },
  { text: " 30(4), p.241.\n\n", options: {} },
  { text: "Qualtrics (2023) What is ANOVA testing? Available at: qualtrics.com\n\n", options: {} },
  { text: "Royal Osteoporosis Society (n.d.) Exercise for bones. Available at: theros.org.uk\n\n", options: {} },
  { text: "Weaver, C.M. et al. (2015) 'Calcium plus vitamin D supplementation and risk of fractures', ", options: {} },
  { text: "Osteoporosis International,", options: { italic: true } },
  { text: " 27(1), pp.367–376.", options: {} }
], 6.3);

// ─── FOOTER ───
slide.addShape(pres.ShapeType.rect, {
  x: 0, y: 9.3, w: 13.33, h: 0.2,
  fill: { color: HEADER_BG }, line: { color: HEADER_BG }
});
slide.addText("Created for BMS5005 Assessment 2  |  Birmingham City University  |  2026", {
  x: 0, y: 9.3, w: 13.33, h: 0.2,
  fontSize: 6, fontFace: "Calibri", color: "FFFFFF",
  align: "center", valign: "middle", margin: 0
});

// ─── WRITE FILE ───
pres.writeFile({ fileName: "/home/daytona/workspace/bmd-poster/BMD_Poster.pptx" })
  .then(() => console.log("Poster created successfully."))
  .catch(err => console.error("Error:", err));

const {
  Document, Packer, Paragraph, TextRun, HeadingLevel,
  AlignmentType, SpacingType
} = require("docx");
const fs = require("fs");

const doc = new Document({
  styles: {
    default: {
      document: {
        run: { font: "Calibri", size: 24 }
      }
    }
  },
  sections: [{
    properties: {},
    children: [

      // ── DOCUMENT TITLE ──
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { after: 200 },
        children: [
          new TextRun({
            text: "BMS5005 Assessment 2 – Reflective Questions",
            bold: true, size: 32, font: "Calibri"
          })
        ]
      }),
      new Paragraph({
        alignment: AlignmentType.CENTER,
        spacing: { after: 400 },
        children: [
          new TextRun({
            text: "Exercise and Bone Mineral Density: A Longitudinal Study",
            bold: false, size: 24, italics: true, font: "Calibri"
          })
        ]
      }),

      // ── QUESTION 1 ──
      new Paragraph({
        heading: HeadingLevel.HEADING_1,
        spacing: { before: 200, after: 120 },
        children: [
          new TextRun({
            text: "Question 1: What guided your research design choices for your study?",
            bold: true, size: 28, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "The research design choices in this study were guided by a combination of methodological rigour, practicality, and alignment with the existing scientific literature on bone mineral density (BMD) and exercise.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Longitudinal Design",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "A 12-month longitudinal design was chosen because BMD changes are gradual physiological adaptations that require sustained measurement over time. A cross-sectional design would only capture a snapshot and would not allow us to track whether BMD is changing as a result of the exercise intervention. The 12-month duration mirrors protocols used in comparable clinical trials — for example, Hinton, Nigh and Thyfault (2015) found that a 12-month resistance and jumping-exercise programme produced measurable BMD changes in men with low bone mass. Three measurement points (baseline, 6 months, 12 months) provide insight into the trajectory of change, not just the outcome.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Participant Selection and Group Structure",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "The four-group structure (pre-menopausal women, post-menopausal women, young adult males, older adult males) was selected to capture the biological variation in BMD response to exercise across age and sex. Post-menopausal women represent a clinically high-risk group because oestrogen withdrawal accelerates bone resorption. Comparing them against younger women and males of similar age allows us to isolate the impact of menopausal status. Randomly recruiting from community church settings was chosen as a practical, accessible, and low-cost approach to reaching a diverse sample of sedentary adults, minimising selection bias that might occur if recruitment were limited to gym or clinical settings.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Choice of BMD Measurement Tool (DXA)",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "DXA scanning was chosen as the primary outcome measure because it is the internationally recognised gold standard for bone density assessment in both clinical and research settings (Albano et al., 2020; Cleveland Clinic, 2020). It is validated, reproducible, and widely available in NHS and academic hospitals. Awareness of its limitations — such as susceptibility to operator error, patient positioning inconsistencies, and the influence of soft tissue composition — shaped our protocol to standardise all scans using the same trained operator and calibrated machine, as recommended by Lewiecki and Lane (2008) and Garg and Kharb (2013).",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Exercise Intervention Selection",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "The combined resistance training and impact/jumping programme was informed by evidence that mechanical loading — via both muscle contraction forces and ground reaction forces — is one of the most effective stimuli for bone formation (Hinton, Nigh and Thyfault, 2015; Giangregorio et al., 2014; Royal Osteoporosis Society, n.d.). Using both modalities together strengthens the intervention by targeting bone through two distinct mechanical pathways. The frequency (resistance 3×/week; impact 2×/week) was modelled on protocols used in published RCTs to ensure comparability and to balance stimulus with recovery.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Nutritional Standardisation",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "Prescribing 1,000 mg calcium and 800 IU vitamin D daily to all participants was guided by evidence from Weaver et al. (2015), whose meta-analysis showed calcium plus vitamin D supplementation reduces fracture risk. Standardising this across all groups controls for dietary variability and ensures BMD changes can be more confidently attributed to exercise rather than nutritional differences.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "Statistical Approach",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 320 },
        children: [
          new TextRun({
            text: "A two-way ANOVA was selected because this study involves two independent variables — group (4 levels: sex × age) and time (3 levels: baseline, 6 months, 12 months) — and we wish to examine both main effects and interaction effects simultaneously. Tukey's post hoc test was chosen for pairwise comparisons because it controls the family-wise error rate and is considered appropriate when comparing multiple groups following a significant ANOVA (Frost, 2019; Abdi and Williams, 2010). P-values will be interpreted carefully in context, avoiding over-reliance on significance thresholds alone, in line with guidance from Nahm (2017).",
            size: 24, font: "Calibri"
          })
        ]
      }),

      // ── QUESTION 2 ──
      new Paragraph({
        heading: HeadingLevel.HEADING_1,
        spacing: { before: 200, after: 120 },
        children: [
          new TextRun({
            text: "Question 2: If your research is successful, who or what will it impact?",
            bold: true, size: 28, font: "Calibri", color: "1B3A6B"
          })
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      }),

      new Paragraph({
        spacing: { after: 160 },
        children: [
          new TextRun({
            text: "If this research produces the hypothesised results — that a 12-month combined exercise programme significantly improves BMD across groups, with greater gains in younger participants — it has the potential to create meaningful impact across multiple levels.",
            size: 24, font: "Calibri"
          })
        ]
      }),

      new Paragraph({
        spacing: { after: 120 },
        children: [
          new TextRun({
            text: "1. Individuals and Patients",
            bold: true, size: 24, font: "Calibri", color: "1B3A6B"
          })
        ]
      }),
      new Paragraph({
        spacing: { after: 160 },
        children: [
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            text: "The most immediate impact would be on individuals at risk of osteoporosis — particularly post-menopausal women and middle-aged men. Finding that exercise significantly improves BMD provides a non-pharmacological, low-cost, accessible strategy to prevent bone loss. If younger adults are shown to benefit most, this underscores the importance of adopting bone-strengthening exercise habits before significant bone loss begins (typically after age 30–40), offering a preventive rather than reactive approach to bone health.",
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            text: "GPs, physiotherapists, endocrinologists, and allied health professionals could use this evidence to tailor exercise prescriptions for patients with low BMD or those at high fracture risk. If group-specific differences are identified (e.g. post-menopausal women responding differently than younger men), this would justify the development of personalised exercise recommendations rather than generic guidance, improving the quality and effectiveness of osteoporosis management in clinical practice.",
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            text: "Osteoporosis affects approximately 3.5 million people in the UK and costs the NHS an estimated £4.4 billion per year in fracture-related care. Research demonstrating the effectiveness of structured community-based exercise programmes could inform national public health campaigns, NHS bone health guidelines, and physical activity recommendations from bodies such as the Royal Osteoporosis Society and Public Health England. It could also support commissioning of exercise-based osteoporosis prevention services in community settings.",
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            text: "This study contributes to the growing body of evidence on exercise and bone health. The inclusion of both sexes and two age groups within a single controlled study is a methodological strength that allows direct, meaningful comparisons — something that many existing studies, which focus on a single demographic, cannot provide. Findings could serve as a foundation for larger-scale multi-centre RCTs, and the methodology could be replicated across different ethnic populations or age ranges to further broaden generalisability.",
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            text: "By demonstrating the value of early exercise intervention, successful results could reduce the incidence of osteoporotic fractures, which are a significant cause of disability, loss of independence, and mortality in older adults. Reducing fracture rates would ease the burden on NHS orthopaedic services, reduce hospital stays, and lower the long-term costs associated with post-fracture rehabilitation and care home placements. This has implications not only for the healthcare system but for the wider economy through improved quality of life, maintained workforce participation, and reduced care dependency.",
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      ...[
        "Abdi, H. and Williams, L. (2010) Encyclopedia of Research Design. Available at: https://personal.utdallas.edu/~herve/abdi-NewmanKeuls2010-pretty.pdf (Accessed: 28 April 2026).",
        "Albano, D., Agnollitto, P.M., Petrini, M., Biacca, A., Ulivieri, F.M., Sconfienza, L.M. and Messina, C. (2020) 'Operator-related errors and pitfalls in dual energy X-ray absorptiometry: How to recognize and avoid them', Academic Radiology. doi: 10.1016/j.acra.2020.07.028.",
        "Cleveland Clinic (2020) DEXA scan (DXA): Bone density test, what is it & how it's done. Available at: https://my.clevelandclinic.org/health/diagnostics/10683-dexa-dxa-scan-bone-density-test (Accessed: 28 April 2026).",
        "Frost, J. (2019) Using post hoc tests with ANOVA. Available at: https://statisticsbyjim.com/anova/post-hoc-tests-anova/ (Accessed: 17 April 2026).",
        "Garg, M. and Kharb, S. (2013) 'Dual energy X-ray absorptiometry: Pitfalls in measurement and interpretation of bone mineral density', Indian Journal of Endocrinology and Metabolism, 17(2), p.203. doi: 10.4103/2230-8210.109659.",
        "Giangregorio, L. et al. (2014) 'Too fit to fracture: Exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture'. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC3891842/ (Accessed: 17 April 2026).",
        "Hinton, P.S., Nigh, P. and Thyfault, J. (2015) 'Effectiveness of resistance training or jumping-exercise to increase bone mineral density in men with low bone mass: A 12-month randomized clinical trial', Bone, 79, pp.203–212. doi: 10.1016/j.bone.2015.06.008.",
        "Lewiecki, E.M. and Lane, N.E. (2008) 'Common mistakes in the clinical use of bone mineral density testing', Nature Clinical Practice Rheumatology, 4(12), pp.667–674. doi: 10.1038/ncprheum0928.",
        "Nahm, F.S. (2017) 'What the P values really tell us', Korean Journal of Pain, 30(4), p.241. doi: 10.3344/kjp.2017.30.4.241.",
        "Qualtrics (2023) What is ANOVA (analysis of variance) testing? Available at: https://www.qualtrics.com/articles/strategy-research/anova/ (Accessed: 28 April 2026).",
        "Royal Osteoporosis Society (n.d.) Exercise for bones. Available at: https://theros.org.uk/information-and-support/bone-health/exercise-for-bones/ (Accessed: 17 April 2026).",
        "Weaver, C.M. et al. (2015) 'Calcium plus vitamin D supplementation and risk of fractures: An updated meta-analysis from the National Osteoporosis Foundation', Osteoporosis International, 27(1), pp.367–376. doi: 10.1007/s00198-015-3386-5."
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