MONITORING METABOLIC STATUS
Predicting Decrements in Physiological and Cognitive Performance
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
Support for this project was provided by U.S. Army Medical Research and Materiel Command through contract no. DAMD17–99–1-9478. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702–5014, is the awarding and administering acquisition office. The views presented in this report are those of the Institute of Medicine Committee on Metabolic Monitoring for Military Field Applications and are not necessarily those of the funding agency.
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COMMITTEE ON METABOLIC MONITORING FOR MILITARY FIELD APPLICATIONS
JOHN E.VANDERVEEN (chair),
San Antonio, Texas
BRUCE R.BISTRIAN,
Clinical Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JOHN A.CALDWELL,
Air Force Research Laboratory, Brooks City Air Force Base, San Antonio, Texas
JOHANNA T.DWYER,
Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland, and Tufts University and New England Medical Center, Boston, Massachusetts
JOHN W.ERDMAN,
Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign
HELEN W.LANE,
Habitability, Environmental Factors, and Bioastronautics Office, NASA Johnson Space Center, Houston, Texas
MELINDA M.MANORE,
Department of Nutrition and Food Management, Oregon State University, Corvallis
WILLIAM P.MORGAN,
Exercise Psychology Laboratory, University of Wisconsin, Madison
PATRICK M.O’NEIL,
Weight Management Center, Medical University of South Carolina, Charleston
ESTHER M.STERNBERG,
Section on Neuroendocrine Immunology and Behavior, National Institute of Mental Health, Bethesda, Maryland
BEVERLY J.TEPPER,
Department of Food Science, Rutgers University, New Brunswick, New Jersey
JULIAN THAYER,
Gerontology Research Center, National Institute on Aging, Baltimore, Maryland
Consultants
KIRA BACAL,
Wyle Laboratories and Life Sciences, Houston, Texas
MARY I.POOS,
Academic and Intellectual Partnerships, Food and Drug Administration, Rockville, Maryland (from November 2003)
Staff
MARIA ORIA, Study Director
MARY I.POOS, Study Director (through November 2003)
LESLIE J.VOGELSANG, Research Assistant
SANAIT B.TESFAGIORGIS, Senior Project Assistant
HARLEEN K.SETHI, Senior Project Assistant (through August 2003)
COMMITTEE ON MILITARY NUTRITION RESEARCH
JOHN W.ERDMAN (chair),
Department of Food Science and Human Nutrition, University of Illinois at Urbana-Champaign
BRUCE R.BISTRIAN,
Clinical Nutrition, Beth Israel Deaconess Medical Center, Boston, Massachusetts
JOHANNA T.DWYER,
Office of Dietary Supplements, National Institutes of Health, Bethesda, Maryland, and Tufts University and New England Medical Center, Boston, Massachusetts
HELEN W.LANE,
Habitability, Environmental Factors, and Bioastronautics Office, NASA Johnson Space Center, Houston, Texas
MELINDA M.MANORE,
Department of Nutrition and Food Management, Oregon State University, Corvallis
WILLIAM P.MORGAN,
Exercise Psychology Laboratory, University of Wisconsin, Madison
PATRICK M.O’NEIL,
Weight Management Center, Medical University of South Carolina, Charleston
ESTHER M.STERNBERG,
Section on Neuroendocrine Immunology and Behavior, National Institute of Mental Health, Bethesda, Maryland
BEVERLY J.TEPPER,
Department of Food Science, Rutgers University, New Brunswick, New Jersey
U.S. Army Grant Representative
COL KARL E.FRIEDL,
Commander, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts
Staff
MARIA ORIA, Project Director
MARY I.POOS, Project Director (through November 2003)
LESLIE J.VOGELSANG, Research Assistant
SANAIT TESFAGIORGIS, Senior Project Assistant
HARLEEN K.SETHI, Senior Project Assistant (through August 2003)
FOOD AND NUTRITION BOARD
CATHERINE E.WOTEKI (chair),
College of Agriculture, Iowa State University, Ames
ROBERT M.RUSSELL (vice-chair),
Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts
LARRY R.BEUCHAT,
Center for Food Safety and Quality Enhancement, University of Georgia, Griffin
SUSAN A.FERENC,
SAF*RISK, LC, Madison, Wisconsin
NANCY F.KREBS,
Department of Pediatrics, University of Colorado Health Sciences Center, Denver
SHIRIKI KUMANYIKA,
Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia
REYNALDO MARTORELL,
Department of International Health, Emory University, Atlanta, Georgia
LYNN PARKER,
Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, DC
BARBARA O.SCHNEEMAN,
Department of Nutrition, University of California, Davis
NICHOLAS J.SCHORK,
Polymorphism Research Laboratory, University of California, San Diego
JOHN W.SUTTIE,
Department of Biochemistry, University of Wisconsin, Madison
STEVE L.TAYLOR,
Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln
BARRY L.ZOUMAS,
Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park
Staff
LINDA D.MEYERS, Director
GAIL E.SPEARS, Staff Editor
GERALDINE KENNEDO, Administrative Assistant
ELISABETH RIMAUD, Financial Associate
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
John Greenleaf, NASA, retired; J.Richard Jennings, University of Pittsburgh Medical Center; Gordon O.Matheson, Stanford University; Alan H.Morris, Intermountain Health Care; David C.Nieman, Appalachian State University; Clifford J.Rosen, St. Joseph Hospital, Bangor, Maine; Ronenn Roubenoff, Millennium Pharmaceuticals, Inc.; Stella L.Volpe, University of Pennsylvania.
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Hugh Tilson, University of North Carolina at Chapel Hill. Appointed by the National Research Council and Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Preface
This publication is the latest in a series of reports based on reviews of the scientific literature and workshops sponsored by the Standing Committee on Military Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), the Institute of Medicine (IOM), and the National Academies. An ad hoc committee under the auspices of CMNR, the Committee on Metabolic Monitoring for Military Field Applications, was appointed to organize a workshop and prepare a report based on that workshop and a review of the relevant scientific literature. Other workshops or symposia conducted by CMNR have dealt with military weight management programs; caffeine for mental task performance; food components to enhance performance; nutritional needs in hot, cold, and high-altitude environments; nutrition and physical performance; cognitive testing methodology; fluid replacement and heat stress; and antioxidants and oxidative stress. These workshops form part of the response that the CMNR provides to the Commander of the U.S. Army Medical Research and Materiel Command regarding issues brought to the committee through the Military Operational Medicine Research Program at Fort Detrick, Maryland, and the U.S. Army Research Institute of Environmental Medicine at Natick, Massachusetts.
HISTORY OF THE COMMITTEE
The CMNR was established in October 1982 following a request by the Assistant Surgeon General of the Army that the Board on Military Supplies of the National Academy of Sciences set up a special committee to advise the U.S. Department of Defense (DOD) on the need for and conduct of nutrition research and related issues. This newly formed committee was transferred to the oversight of FNB in 1983. The committee’s primary tasks are to identify factors that may critically influence the physical and mental performance of combat military personnel under all environmental extremes, to identify knowledge gaps, to recommend research that would remedy these deficiencies, to identify approaches
for studying the relationship of diet to physical and mental performance, and to review and advise on military feeding standards.
As a standing committee of IOM, the membership of CMNR changes periodically, however the disciplines represented consistently have included human nutrition, nutritional biochemistry, performance physiology, food science, dietetics, psychology, and clinical medicine. For issues that require broader expertise than exists within the committee, CMNR has convened workshops, utilized consultants, or appointed subcommittees and ad hoc committees with expertise in the desired area to provide additional state-of-the art scientific knowledge and informed opinion to aid in the deliberations.
BACKGROUND
The U.S. military’s concerns about the individual combat service member’s ability to avoid performance degradation and the need to maintain both mental and physical capabilities in highly stressful situations have led to an interest in developing methods by which commanders could monitor the status of the combat service members in the field. This includes the ability to monitor physical and mental status of the combat service member, as well as monitoring his or her environment (e.g., ambient temperature, chemical exposure). This ability would allow commanders to determine when individuals needed to rest, eat, or consume fluids, or if their condition had deteriorated to the point that they needed to be replaced rather than risk combat injury.
Similarly, in the civilian sector, the ability to monitor physiological and cognitive status would also be crucial for individuals in situations such as sustained fire-fighting operations, chemical and other hazardous materials clean-up, industrial chemical plant work, and extended work shifts in emergency medicine. Metabolic monitoring techniques would also be valuable in the practice of telemedicine, and would enable health care workers to predict when an individual might need special attention or transport to a medical facility.
Technological advances in biological sensing of the past decade have not been accompanied by concomitant advances in the interpretation of biological signals to assess physiological status. A meaningful assessment calls for organization and interpretation of data and contextual information (e.g., ambient conditions, individual recent and historical reference points) from multiple sensors in a multidisciplinary effort between signal processing, mathematical modeling, and physiology. This is of special interest wherever physiological monitoring may predict problems in advance of a crisis.
For example, detection of high rates of bone and muscle turnover may be indicative of increased susceptibility to injury during an intensive physical training program and might provide an indication for optimal rest periods. Reduced cellular metabolism caused by glucose and insulin derangement may be signaled by early decrements in cognitive status, neurological functioning, or muscle action, allowing a combat service member operating in extreme conditions to
take corrective actions. Dehydration may be marked by changes in skin turgidity, electrical impedance, heart rate, and/or skin temperature thus alerting an individual to impending risk of impaired performance and heat injury.
THE COMMITTEE’S TASK
Under the auspices of the Standing Committee on Military Nutrition Research, the Committee on Metabolic Monitoring for Military Field Applications was appointed to examine the state-of-the-science with respect to identification of biomarkers to predict individual health and performance outcomes related to regulation of water and substrate metabolism and cognitive function. This is a subset of a larger military effort in physiological monitoring. This study is focused on metabolic regulation during prolonged, exhaustive efforts where nutrition, hydration, and repair mechanisms may be mismatched to intakes and rest, or where specific metabolic derangements are present (e.g., following toxic chemical exposures or psychological threats). This report provides the Committee’s response to the following questions posed by DOD:
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What are the most promising biomarkers for prediction of (a) excessive rates of bone and muscle turnover, (b) reduced glucose and energy metabolism (e.g., bioelectrical indicators of muscle and mental fatigue), (c) dehydration, and (d) decrements in cognitive function?
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What monitoring technologies would be required (that may not currently exist) to predict these intermediate targets in critical pathways?
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What tools currently exist for monitoring metabolic status that could be useful in the field?
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What algorithms are available that might provide useful predictions from combined sensor signals? What additional measurement would improve specificity of the predictions?
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What is the committee “blue sky” forecast for useful metabolic monitoring approaches (i.e., 10- to 20-year projection)? What are the current research investments that may lead to revolutionary advances?
ORGANIZATION OF THE REPORT
Chapter 1 of the report provides background information and the current status of military capabilities in monitoring and predicting physiological and cognitive status of individual combat service members. Chapter 2 provides a discussion of the importance of gathering individual data rather than group means and the need for individual baseline information. The role of physiological biomarkers and self-assessments in evaluating overall physical status are presented in Chapter 3. Potential biomarkers for monitoring bone and muscle turnover, hydration status and renal function, and stress and immune function are discussed in Chapter 4. Chapter 5 addresses monitoring of alertness
and cognitive function and Chapter 6 presents the committee’s conclusions and recommendations, including the committee’s responses to the specific questions posed by the military in the Statement of Task. Appendix A presents a table that lists examples of physiological and cognitive markers of performance. Appendix B presents a discussion of metabolic monitoring strategies and algorithms under development at NASA that has implications for the military. Finally, the workshop agenda and workshop speaker manuscripts, as well as biographical sketches of workshop speakers and committee members are presented in Appendixes C through F.
ACKNOWLEDGMENTS
I wish to commend the workshop speakers for their excellent contributions to the workshop. Their manuscripts, presentations, participation in discussions, and willingness to take time from very busy schedules to prepare and deliver outstanding presentations made it possible for the committee to conduct a review of the area and prepare this report. Their thoughtful responses to questions posed by committee members and workshop participants also contributed immeasurably to the quality of the review. It would be neglectful not to mention the many experts who attended this open meeting at their own initiative and expense. Their questions and comments contributed in no small measure to broadening the exchange of scientific information.
Special thanks are extended to the U.S. Air Force personnel at Brooks City-Base in San Antonio, Texas, who hosted the committee’s workshop. We thank COL Tom Travis, Commander of the School of Aerospace Medicine. COL Travis not only granted the committee permission to use the School’s facilities, but took time from his busy schedule to address the workshop and share some of the history of the School of Aerospace Medicine with the committee and workshop attendees. Dr. Stefan Constable deserves special mention; he provided key assistance throughout the planning and execution of the workshop, including doing initial legwork on space availability, providing contact names and background information for catering needs, arranging transportation for committee members and speakers between the Base and the hotel each day, and providing names of San Antonio companies that could provide recording and transcription service. His assistance was truly invaluable. Thanks are also extended to SGT Monica Mandichak and Ms. Mary Bacerra for their assistance in setting up and demonstrating the microphones and audiovisual equipment in the Aerospace Medicine auditorium, and to Mr. Marvin Lee and SSGT Arnold Ashenbeck of the motor pool for providing transport buses and drivers who picked up and delivered workshop participants with punctuality and courtesy.
I express my deepest appreciation to the members of the committee who participated extensively during the workshop and in discussions and preparation of this report, and to Dr. Kira Bacal, who provided her considerable expertise in medical informatics and remote medical decision algorithms in her role as a
consultant to the committee. Special thanks are also due to the FNB staff. In particular, I wish to acknowledge the skill and dedication of Dr. Mary I.Poos, the senior staff officer for CMNR, in organizing the workshop and preparing this report. She was instrumental in identifying and securing the expert panel of speakers, providing guidance to the committee members, and organizing and editing the report. I also want to recognize the efforts of Ms. Leslie J.Vogelsang, research assistant to CMNR, for providing outstanding expertise in recording committee deliberations, incorporating committee-drafted sections into the report, and checking all the references. The efforts of Ms. Harleen K.Sethi and Ms. Sanait Tesfagiorgis in providing excellent logistical support to committee members and workshop speakers are also recognized. Thanks are due to Dr. Maria Oria for integrating responses to reviewer comments and incorporating them into the final report. Thanks are also due to Ms. Gail Spears for copyediting the report. Finally, I wish to recognize Dr. Allison A.Yates, director emeritus of FNB during this study, for her continued interest and oversight of the CMNR during her tenure and Dr. Linda Meyers, who took the responsibilities as director of FNB in September 2003, for her role while completing the project.
JOHN E.VANDERVEEN, Chair
Committee on Metabolic Monitoring for Military Field Applications