MONITORING METABOLIC STATUS

Predicting Decrements in Physiological and Cognitive Performance

Committee on Metabolic Monitoring for Military Field Applications

Standing Committee on Military Nutrition Research

Food and Nutrition Board

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance MONITORING METABOLIC STATUS Predicting Decrements in Physiological and Cognitive Performance Committee on Metabolic Monitoring for Military Field Applications Standing Committee on Military Nutrition Research Food and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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. International Standard Book Number 0-309-09159-4 (Book) International Standard Book Number 0-309-53052-0 (PDF) Library of Congress Control Number: 2004108091 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm. A.Wulf are chair and vice chair, respectively, of the National Research Council www.national-academies.org

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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)

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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)

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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.

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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: 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? What monitoring technologies would be required (that may not currently exist) to predict these intermediate targets in critical pathways? What tools currently exist for monitoring metabolic status that could be useful in the field? What algorithms are available that might provide useful predictions from combined sensor signals? What additional measurement would improve specificity of the predictions? 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 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

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance Contents     EXECUTIVE SUMMARY   1 1   RATIONALE FOR MILITARY INTEREST AND CURRENT CAPABILITIES IN MONITORING METABOLISM   15      Need for Physiological Monitoring,   15      Recent Evolution of Monitoring Research,   18      Current Research Efforts,   20      Current Status of Field Applications of Physiological Monitoring,   24      The Physiological Status Monitor,   25      Example Application: Characteristics of a Heat Casualty,   30      References,   32 2   THE STUDY OF INDIVIDUAL DIFFERENCES: STATISTICAL APPROACHES TO INTER-AND INTRAINDIVIDUAL VARIABILITY   37      Overview,   37      Sex and Gender,   38      Research: What Are We Really Trying to Do?,   39      Systems Theory and the Study of Individuals,   47      Summary,   48      References,   48 3   MONITORING OVERALL PHYSICAL STATUS TO PREDICT PERFORMANCE   53      General Considerations When Monitoring Physical Status,   54      Physiological Measurements,   55      Self-Assessments Measurements,   68      Summary,   76      References,   77

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance 4   PHYSIOLOGICAL BIOMARKERS FOR PREDICTING PERFORMANCE   85      Biomarkers of Bone Health,   85      Biomarkers of Muscle Metabolism and Fatigue,   91      Biomarkers of Hydration and Renal Function,   101      Biomarkers of Stress and Immune Function,   114      Human Odors as Biomarkers,   126      Human Tears as Biomarkers,   133      Summary,   134      References,   135 5   STRATEGIES FOR MONITORING COGNITIVE PERFORMANCE   159      The Problem of Sleepiness and Cognitive Degradation in Military Settings,   160      Useful Approaches for Predicting Operator Alertness,   163      Other Central Nervous System Monitoring Technologies,   177      Heart-Rate Measures,   179      Other Measures,   181      Summary,   184      References,   186 6   CONCLUSIONS AND RECOMMENDATIONS   195      Question 1,   196      Question 2,   200      Question 3,   200      Question 4,   203      Question 5,   204      Research Recommendations,   207      Reference,   208     APPENDIXES     A   Examples of Physiological and Cognitive Markers of Performance,   209 B   Metabolic Monitoring at the NASA: A Concept for the Military, Kira Bacal,   219 C   Workshop Agenda,   233 D   Workshop Manuscripts,   237      OVERVIEW          Predicting and Protecting Performance Using Metabolic Monitoring Strategies: It’s all Wet Stuff Anyway, Isn’t It?, Karl E.Friedl,   237      Current Status of Field Applications of Physiological Monitoring for the Dismounted Soldier, Reed W.Hoyt, Karl E.Friedl,   247

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance      BIOMARKERS AND MONITORING TECHNOLOGIES FOR HEAT PRODUCTION AND HYDRATION STATUS AND CARBOHYDRATE METABOLISM          Biomarkers of Physiological Strain During Exposure to Hot and Cold Environments, Andrew J.Young, Michael N.Sawka, Kent B.Pandolf,   257      Hydration Status Monitoring, Robert Carter III, Samuel N. Cheuvront, Margaret A.Kolha, Michael N.Sawka,   270      Technology for the Measurement of Blood Lactate, David C.Klonoff,   280      Utility of Insulin-Like Growth Factor-I for Assessing Metabolic Status During Military Operational Stress Bradley C.Nindl, Scott J.Montain,   283      BIOMARKERS AND TECHNOLOGIES FOR MONITORING PHYSIOLOGICAL STATUS AND WORK CAPACITY          The Use of Portable Accelerometers in Predicting Activity Energy Expenditure, Kong Y.Chen,   296      Energy Transformations and Metabolism During Human Locomotion: Sensing Opportunities in a Conservative World, Peter G.   310      BIOMARKERS AND TECHNOLOGIES FOR MONITORING MUSCLE PROTEIN TURNOVER AND METABOLISM          Biomarkers for Change in Protein Turnover of Muscle, Robert Wolfe, Elisabet Børsheim,   329      Amino Acids as Biomarkers for Fatigue, T.P.Stein,   335      BIOMARKERS AND TECHNOLOGIES FOR PREDICTING BONE TURNOVER          Biomarkers of Bone and Muscle Turnover: Effects of Exercise, Clifford J.Rosen, Wesley G.Beamer, Leah Rae Donahue,   345      Biomarkers for Monitoring Bone Turnover and Predicting Bone Stress, Michael Kleerekoper,   350      Biomarkers to Predict the Occurrence of Bone Stress and Matrix Abnormalities due to Sustained and Intense Physical Activity, Wendy M.Kohrt, Catherine M.Jankowski,   356

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Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance      BIOMARKERS AND TECHNOLOGIES FOR MONITORING COGNITIVE AND PHYSIOLOGICAL STATUS IN RELATION TO STRESS          Autonomic Nervous System Activity and Its Relationship to Attention and Working Memory, Julian F.Thayer, Bjorn Helge Johnsen,   366      Sweat Patch as a Novel Approach to Monitor the Level of Activity of the Stress System: Potential Application for Studies Conducted in the Field, Giovanni Cizza, Farideh Eskandari, Terry Phillips, Esther M.Sternberg,   372      BIOMARKERS AND TECHNOLOGIES FOR MONITORING MENTAL STATUS, COGNITIVE FUNCTION, AND ALERTNESS          Biomarkers for Brain Hypometabolism due to Sleep Deprivation, Nancy Wesensten,   381      Electroencephalographic Indictors of Impaired Aviator Status During Sleep Deprivation, John A.Caldwell,   392      Circulating Plasma Markers of Cognitive Status, Harris R.Lieberman, Mark D.Kellogg, Gaston P.Bathalon,   400      FUTURE POSSIBILITIES FOR MONITORING PHYSIOLOGICAL AND COGNITIVE FUNCTION          Circulating Plasma Markers of Cognitive Status: Odors as Biomarkers, Gary K.Beauchamp,   414      Molecular Markers of Mechanical Activity/Inactivity Induced Anabolic and Catabolic States in Striated Muscle, Kenneth M.Baldwin, Fadia Haddid, Gregory R.Adams,   420 E   Biographical Sketches of Workshop Speakers,   435 F   Biographical Sketches of Committee Members,   445