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The athlete's diet: nutritional goals and dietary strategies.

When talented, motivated and highly trained athletes meet for competition the margin between victory and defeat is usually small. When everything else is equal, nutrition can make the difference between winning and losing. Although the primary concern of many athletes is to supplement the diet with protein, vitamins and minerals, and a range of more exotic compounds, key dietary issues are often neglected. Athletes must establish their nutritional goals, and must also be able to translate them into dietary strategies that will meet these goals. Athletes are often concerned with dietary manipulations in the period around competition, but the main role of nutrition may be to support consistent intensive training which will lead to improved performance. Meeting energy demand and maintaining body mass and body fat at appropriate levels are key goals. An adequate intake of carbohydrate is crucial for maintaining muscle glycogen stores during hard training, but the types of food and the timing of intake are also important. Protein ingestion may stimulate muscle protein synthesis in the post-exercise period, promoting the process of adaptation in the muscles. Restoration of fluid and electrolyte balance after exercise is essential. If energy intake is high and a varied diet is consumed, supplementation of the diet with vitamins and minerals is not warranted, unless a specific deficiency is identified. Specific strategies before competition may be necessary, but this requirement depends on the demands of the sport. Generally, it is important to ensure high pre-competition glycogen stores and to maintain fluid balance. There is limited evidence to support the use of dietary supplements, but some, including perhaps creatine and caffeine, may be beneficial.

Adaptation, Physiological↗

Low-frequency loud acoustic stimulation and goal-directed arm movements.

OBJECTIVE: To analyse the effects of low-frequency loud acoustic stimulation on goal-directed movements involving the arm. Low-frequency sound stimulation impairs eye stability, evokes a subjective tilt of the visual surround in subjects presenting Tullio's phenomenon and induces, in normal subjects, short-latency evoked potentials in the neck and limb muscles. MATERIAL AND METHODS: Healthy subjects performed goal-directed movements in the horizontal plane with the right (dominant) arm to a fixed 3 degree-wide target positioned at an angle of 30 degrees, with the instruction to perform fast and accurate movements to the target and to hold the final position. This fast-pointing task was performed in association with sound-induced vestibular-otolithic stimulation (110 dB SPL, 500 Hz) in the absence of visual guidance (i.e. pointing at a memorized target in the absence of target or pointer cues). Pointing errors were analysed by computing the constant errors made by the subjects (mean error). Pointing errors were also correlated with movement kinematics (movement duration, peak velocity, time to peak velocity) and with the reaction time of movement. RESULTS: The low-frequency loud acoustic stimulation modified the final position of the arm-pointing task at the memorized target in the absence of vision. CONCLUSION: Goal-directed movements are achieved by means of sensory interactions between visual, somatosensory and vestibular information and the vestibular-otolithic signals contribute to the accuracy of voluntary arm movements.

Acoustic Stimulation↗

Predicting motivational regulations in physical education: the interplay between dispositional goal orientations, motivational climate and perceived competence.

In this study, we examined the main and interactive effects of students' goal orientations, perceived competence and perceptions of the motivational climate on the motivational styles advanced by self-determination theory. The participants were 328 British secondary school students aged 13.6 +/- 0.6 years (mean +/- s). Moderated hierarchical regression analyses revealed task orientation, perceived competence and perceptions of a mastery climate to be positive predictors of self-determined styles of motivation. Perceived competence in physical education was negatively associated with amotivation. Significant interaction effects for mastery climate x task orientation and for ego orientation x perceived competence emerged. The results indicate that: (1) for students endorsing a high task orientation, the perception that the class climate was high in mastery cues was associated with increased intrinsic motivation; and (2) for students high in ego orientation, the belief that one was competent increased, while perceptions of incompetence attenuated intrinsic motivation. Additionally, a three-way interaction between ego orientation, performance climate and perceived competence emerged. In light of achievement goal and self-determination frameworks, we propose that studying the potential interplay between both individual and situational goal perspectives and the moderating effect of perceived competence may further enhance our understanding of motivation in physical education.

Adolescent↗

Global self-esteem, goal achievement orientations, and self-determined behavioural regulations in a physical education setting.

We examined a theoretical model of global self-esteem that incorporated constructs from achievement goal and self-determination theories. The model hypothesized that self-determined or autonomous motives would mediate the influence of achievement goal orientation on global self-esteem. The adapted version of the Behavioural Regulation in Exercise Questionnaire (Mullan et al., 1997), the Perception of Success Questionnaire (Roberts & Balague, 1991), and Rosenberg's (1965) self-esteem scales were administered to 634 high school students aged 11 - 15 years. A structural equation model supported the hypotheses and demonstrated that autonomous motives mediated the effect of goal orientations on global self-esteem. The results suggest that generalized motivational orientations influence self-esteem by affecting autonomous motivation and is consistent with theory that suggests that experiences relating to intrinsic motivation are the mechanism by which global motivational orientations are translated into adaptive outcomes like self-esteem. The findings suggest that physical activity interventions that target autonomous motives in physical activity contexts are likely to enhance young people's general self-esteem.

Achievement↗

Voluntary euthanasia, physician-assisted suicide, and the goals of medicine.

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value.

Attitude of Health Personnel↗

Classification of problems, clinical findings and treatment goals in patients with low back pain using the ICIDH-2 beta-2.

PURPOSE: This study aimed to explore problems, clinical findings and treatment goals presented by patients with low back pain and their physiotherapists, and to which extent this information could be classified according to the ICIDH-2 Beta-2. METHOD: An explorative field trial of 12 physiotherapists and 28 patients with low back pain in outpatient practices. RESULTS: Pain and impairments related to muscles, joints and structures of the lower back, pelvis and hips were most often presented. Functioning related to daily activities and participation in society was often described in the treatment goals, but vaguely formulated. Most of the problems and clinical findings could be classified according to the ICIDH-2 Beta-2. However, several treatment goals could not be classified. CONCLUSIONS: There was a lack of specification in several of the detailed codes of the Body, Function and Structure Dimension, particularly regarding classification of pain and muscle functions. The main limitation concerned the detailed version of the Body Function and Structure Dimension, which provided no additional precision compared with the short version when classifying pain and other impairments. However, the ICIDH-2 offers a tool to enhance the precision of clinical findings and the possibilities for performing a multidimensional evaluation of functioning related to patients with low back pain.

Adult↗

The future of patient-centered care: scenarios, visions, and audacious goals.

The U.S. health care system is transforming. It must. Patient-centered care (PCC) is a core quality that the system should include. This article presents the highlights of a project on the future of PCC created for the Picker Institute. As an example of futures work, this project developed four images or stories of what might happen, as well as a vision and audacious goals for what should happen to PCC. The first and most likely scenario is an increase in patient-centeredness as a function of current trends. However, in the second scenario, health care could become even more stressed and leave PCC behind as it seeks to lower cost without focusing on quality. The third scenario envisions more excellent systems that integrate PCC seamlessly into their work. The fourth scenario sees collaboration and shared responsibility, in association with advanced information tools, thereby enabling PCC to contribute to preventing illness and lowering health care costs. The scenarios indicate that the patient-centeredness of health care could improve slightly, stall, or advance significantly. The PCC Vision calls for each of us to be in charge of our health, and to get the care we need (not less and not more) in timely, effective, and personal ways consistent with our values. The audacious goals set an agenda with priorities from the PCC community. These include shared decision making by consumers, ensuring health care professionals are trained in supporting active patients, anticipating health and long-term care needs for individuals, adopting the Institute of Medicine's (IOM) simple rules for health care, and making the patient perspective a priority in policy and planning. Each of us and our organizations are confronted with the challenge of this vision and audacious goals. Health care professionals and provider systems, whether conventional or alternative in nature, face these issues. While complementary and alternative medicine (CAM) providers often get higher marks from consumers for their attention, many CAM modalities are largely provider-determined. Patient-centered care will require more empowerment and activation of patients and consumers.

Chronic Disease↗

Physical activity and weight loss: does prescribing higher physical activity goals improve outcome?

BACKGROUND: Recommending increased physical activity facilitates long-term weight loss, but the optimal level of physical activity to recommend is unknown. OBJECTIVE: The objective of the study was to evaluate the efficacy for long-term weight loss of recommendations for much higher physical activity than those normally used in behavioral treatments. DESIGN: Overweight men and women (n = 202) were randomly assigned to either a standard behavior therapy (SBT) for obesity, incorporating an energy expenditure (EE) goal of 1000 kcal/wk, or to a high physical activity (HPA) treatment, in which the goal was an EE of 2500 kcal/wk. To help HPA treatment group participants achieve this high exercise goal, their treatment included encouragement to recruit 1-3 exercise partners into the study, personal counseling from an exercise coach, and small monetary incentives. RESULTS: The HPA treatment group reported achieving higher mean (+/- SD) physical activity levels than did the SBT group at 6 mo (EE of 2399 +/- 1571 kcal/wk compared with 1837 +/- 1431 kcal/wk), 12 mo (EE of 2249 +/- 1751 kcal/wk compared with 1565 +/- 1309 kcal/wk), and 18 mo (EE of 2317 +/- 1854 kcal/wk compared with 1629 +/- 1483 kcal/wk) (all P < 0.01). Mean (+/- SEM) cumulative weight losses at 6, 12, and 18 mo in the HPA treatment group were 9.0 +/- 7.1, 8.5 +/- 7.9, and 6.7 +/- 8.1 kg, respectively. In the SBT group, the corresponding weight losses were 8.1 +/- 7.4, 6.1 +/- 8.8, and 4.1 +/- 7.3 kg, respectively. Between-group differences in weight loss were significant at 12 and 18 mo. CONCLUSION: These results suggest that recommendations of higher levels of physical activity (EE of 2500 kcal/wk) promote long-term weight loss better than do conventional recommendations.

Adult↗

Flow-related techniques for preoperative goal-directed fluid optimization.

BACKGROUND: Improved postoperative outcome has been demonstrated by perioperative maximization of cardiac stroke volume (SV) with fluid challenges, so-called goal-directed therapy. Oesophageal Doppler (OD) has been the most common technique for goal-directed therapy, but other flow-related techniques and parameters are available and they are potentially easier to apply in clinical practice. The objective of this investigation was therefore to use OD for preoperative SV maximization and compare the findings with a Modelflow determined SV, with an OD estimated corrected flow time (FTc), with central venous oxygenation ( Svo2 ) and with muscle and brain oxygenation assessed with near infrared spectroscopy (NIRS). METHODS: Twelve patients scheduled for radical prostatectomy were anaesthetized before optimization of SV estimated by OD. A fluid challenge of 200 ml colloid was provided and repeated if at least a 10% increment in OD SV was obtained. Values were compared with simultaneously measured values of Modelflow SV, FTc, Svo2 and muscle and cerebral oxygenation estimated by NIRS. RESULTS: Based upon OD assessment, optimization of SV was achieved after the administration of 400-800 ml (mean 483 ml) of colloid. The hypothetical volumes administered for optimization based upon Modelflow and Svo2 differed from OD in 10 and 11 patients, respectively. Changes in FTc and NIRS were inconsistent with OD guided optimization. CONCLUSION: Preoperative SV optimization guided by OD for goal-directed therapy is preferable compared with Modelflow SV, FTc, NIRS and Svo2 until outcome studies for the latter are available.

Aged↗

Using goal attainment scaling to improve the quality of long-term care: a group-randomized trial.

OBJECTIVE: To assess the effect of a 6-month interdisciplinary customized intervention based on goal attainment scaling and aimed at improving the quality of care provided by long-term care facilities to frail older adults. DESIGN: A pair-matched group-randomized trial with quality of care measurements taken before and after the intervention and 6 months later. SETTING: Forty unregulated small-to-medium sized long-term care facilities delivering inadequate care to at least one resident. Facilities were matched on baseline quality of care, health district, and size. One member of each pair was then randomly allocated to the intervention, the other acting as a control. STUDY PARTICIPANTS: The trial involved 201 frail older adults randomly selected from the 40 participating facilities. INTERVENTION: The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted quality improvement goals with the facility manager, which were then recorded on a goal attainment follow-up guide. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were meant to assist the manager and staff to implement permanent changes in the areas of care targeted for improvement. Main outcome measure. Quality of care measured with the Quality of Care (QUALCARE) Scale, a multidimensional instrument that uses a 5-point scale to assess six subdimensions of care: environmental, physical, medical management, psychosocial, human rights, and financial. A score greater than 2 is considered indicative of inadequate care. RESULTS: The intervention effect on the overall quality of care was neither clinically nor statistically significant. Change from baseline to the end of the intervention averaged .21 and .22 in the experimental and control conditions, respectively (P = 0.86). CONCLUSION: Attainment of preset quality improvement objectives did not translate into detectable improvements in the care provided to residents.

Activities of Daily Living↗

A comparative evaluation of two day hospitals. Goal attainment scaling of behavior therapy vs. milieu therapy.

Previous attempts at program evaluation of partial hospitalization programs have consisted largely of descriptive and anecdotal reports of programs and patient characteristics. There have been no comparative or experimental studies of the effectiveness of differing day treatment programs. In the current study, Goal Attainment Scaling, a goal-oriented program evaluation system, was used with 56 randomly selected partial hospitalization patients who attended two day hospitals: one program was based on behavioral-educational methods, and the other was an eclectic program based on the concepts of a therapeutic community. Patients attending the behavioral-educational program showed greater attainment of their therapeutic goals than did the patients involved in the eclectic program. The greater effectiveness of the behavioral-educational day program increased from the 3-month follow-up to the 2-year follow-up.

Adolescent↗

Toward the attainment of low-risk drinking goals: a 10-year progress report.

BACKGROUND: The Healthy People 2010 goals include reducing the proportion of U.S. adults whose alcohol consumption exceeds recommended daily and weekly limits, relative to baseline levels observed in 1991-1992. To date, there has been no assessment of initial progress toward attaining these goals. METHODS: Consumption data from the 1991-1992 National Longitudinal Alcohol Epidemiology Survey (n = 42,862) and the 2001-2003 National Epidemiologic Survey on Alcohol and Related Conditions (n = 43,093) were used to evaluate the trend in the proportion of U.S. adults adhering to and exceeding recommended drinking limits. These included weekly limits of no more than 14 standard drinks for men and no more than 7 standard drinks for women and daily limits of no more than 4 standard drinks for men and 3 standard drinks for women. The percentages exceeding the limits are compared for the two time periods, for the total adult population and sociodemographic subgroups, and the association between risk drinking and sociodemographic characteristics is disaggregated into a series of conditional odds ratios. RESULTS: The proportion of U.S. adults classified as regular drinkers whose intake exceeded recommended daily or weekly limits declined from 32.1% to 29.3% in the 10-year period. The reduction in risk drinking occurred solely among persons who exceeded the daily drinking limits less than once a week but did not exceed the weekly limits. There was a very small but significant increase in the proportion of adults exceeding the weekly limits, from 9.4% to 10.3%. Reduction of sociodemographic disparities in adherence to drinking limits was limited. CONCLUSIONS: Progress to date is limited and may reflect changes in population composition rather than changes in drinking habits. Attainment of Healthy People goals and reduction of disparities in risk drinking will require sustained effort and more targeted prevention programs.

Adolescent↗

Can goal-based advance planning guide medical care in the nursing home?

OBJECTIVE: To determine whether a goal-based system of advance planning, which allows patients to choose among five "pathways of care" (longevous, ameliorative/comprehensive, ameliorative/basic, palliative/comfort, or palliative/hospice), enables physicians to select treatment options in specified clinical situations. DESIGN: A pencil and paper test was administered in which clinicians were presented five common clinical scenarios and were asked which of four possible treatment options they would recommend, given a predetermined "pathway of care." SETTING: A 725-bed teaching nursing home and affiliated continuing care retirement community. MEASUREMENTS: The proportion of correct answers was measured for each clinician, for each clinical scenario, and for each pathway. RESULTS: Of the test answers, 78% coincided with the reference answers. The greatest rate of correct answers was found for the ameliorative/comprehensive pathway and the palliative/hospice pathway. CONCLUSION: Establishing pathways of care by asking nursing home residents to prioritize their goals of care may help clinicians narrow the range of appropriate options when facing an acute medical problem. Key Words: Advance planning; goals of care; treatment limitations

Journal Article↗

Linear QoS goals of additive and concave metrics in ad hoc cognitive packet routing.

This paper addresses two scalability problems related to the cognitive map of packets in ad hoc cognitive packet networks and proposes a solution. Previous works have included latency as part of the routing goal of smart packets, which requires packets to collect their arrival time at each node in a path. Such a requirement resulted in a packet overhead proportional to the path length. The second problem is that the multiplicative form of path availability, which was employed to measure resources, loses accuracy in long paths. To solve these problems, new goals are proposed in this paper. These goals are linear functions of low-overhead metrics and can provide similar performance results with lower cost. One direct result shown in simulation is that smart packets driven by a linear function of path length and buffer occupancy can effectively balance the traffic of multiple flows without the large overhead that would be needed if round-trip delay was used. In addition, energy-aware routing is also studied under this scheme as well as link selection based on their expected level of security.

Journal Article↗

Children with Developmental Coordination Disorder respond similarly to age-matched controls in both speed and accuracy if goal-directed movements are made across the midline.

BACKGROUND: The conventional view among many clinicians is that crossing the midline in children with Developmental Coordination Disorder (DCD) results in degradation of their performance. However, no kinematic data yet exist to support this view. We therefore tested this assumption in an experimental setting. METHODS: A group of age- and gender-matched children with DCD (n = 48) and a group of typically developing children (n = 48) were compared while performing goal-directed movements with a pen on a XY-tablet. We examined whether speed or accuracy changed if the goal-directed movements were made towards targets positioned either at the midline, the contralateral (crossed) side or the ipsilateral (uncrossed) side of the body midline. RESULTS: Our results showed that movements in the contralateral workspace were less accurate for both groups of children in the tested age range (6-11 years). The movements made towards the targets in the midline were the fastest, and the pen pressure for movements in the ipsilateral space was the highest. However, these effects were similar for children with and without DCD. As expected, children with DCD made more errors, were slower and pressed more erratically on their pen, but this difference was irrespective of the position of their hand in the workspace. CONCLUSION: Crossing the midline in children with DCD for small amplitude movements (2.5 cm), as tested in this study, does not result in increased degradation of the goal-directed movements compared with their typically developing peers. This implies that, contrary to expectation, there is no evidence for a preferential deficit in DCD in brain structures involved in making movements in the contralateral workspace.

Case-Control Studies↗

Setting performance goals in geriatric nursing.

Behavioural techniques are increasingly being applied in the geriatric field as part of a broader emphasis on psychological and social treatments in the care of the elderly. The nurse is in the best position to analyse a patient's performance and manage an intervention programme; however, some nurses have had little experience of autonomously diagnosing problems and setting performance goals. The authors argue that it is important to set such goals and give examples of how performance may be objectively specified, prerequisites made explicit, criteria for success defined and the consequences of goal attainment or non-attainment discussed with those most concerned. A complex situation drawn from the geriatric setting which was used as part of a teaching workshop to help nurses define suitable targets for intervention is described in the Appendix.

Aged↗

Achieving lipid goals in real life: the Dutch DISCOVERY study.

DISCOVERY Netherlands was an open-label, randomised, multicentre study (D3560/L00003) designed to compare the effects of rosuvastatin with those of atorvastatin, simvastatin or pravastatin on low-density lipoprotein cholesterol (LDL-C) goal achievement in a primary care setting. Patients (n = 1,215) with type IIa or type IIb hypercholesterolaemia and cardiovascular risk of >20% or a history of coronary heart or other atherosclerotic vascular disease were randomised to receive treatment with rosuvastatin 10 mg (n = 621), atorvastatin 10 mg (n = 189), simvastatin 20 mg (n = 194) or pravastatin 40 mg (n = 211) for 12 weeks. Significantly, more patients achieved 1998 and 2003 European LDL-C goals with rosuvastatin than with other statins after 12 weeks (p < 0.001). Rosuvastatin reduced LDL-C and total cholesterol levels significantly more than other statins, both in patients who were statin-naïve and in patients who had received previous statin treatment (p < 0.05). All treatments were similarly well tolerated. In conclusion, greater reductions in LDL-C were achieved with rosuvastatin compared with atorvastatin, simvastatin and pravastatin, enabling more patients to achieve European LDL-C goals.

Anticholesteremic Agents↗

Attainment of glycaemic goals in type 2 diabetes with once-, twice-, or thrice-daily dosing with biphasic insulin aspart 70/30 (The 1-2-3 study).

AIM: This observational study in patients with type 2 diabetes failing oral agent therapy with or without basal insulin was conducted to assess whether addition and self-titration of biphasic insulin aspart 70/30 (BIAsp 30) could achieve American Association of Clinical Endocrinologists (AACE)/International Diabetes Federation (IDF) and American Diabetes Association (ADA) glycemic targets (HbA(1c)< or =6.5 and <7%). METHODS: Enrolled patients (n = 100, HbA(1c)> or =7.5 and < or =10%) were > or =18 years of age, had diabetes > or =12 months and had received a stable antidiabetic regimen for at least 3 months [minimum of two oral antidiabetic drugs (OADs) or at least one OAD plus once-daily basal insulin < or =60 U]. Patients discontinued prior basal insulin and added one injection of BIAsp 30 (12 U or 70-100% of prior basal insulin dose within 15 min of dinner initiation). Patients self-titrated their BIAsp 30 dose with investigator guidance every 3 or 4 days to achieve pre-breakfast fasting blood glucose (FBG) of 80-110 mg/dl. At 16 weeks, a pre-breakfast injection of 6 U of BIAsp 30 was added if week 15 HbA(1c) exceeded 6.5%; the added dose was titrated to achieve pre-dinner BG of 80-110 mg/dl. After an additional 16 weeks, 3 U of pre-lunch BIAsp 30 was added if HbA(1c) exceeded 6.5%. This added dose was adjusted based on 2-h post-lunch BG to achieve postprandial glucose of 100-140 mg/dl. Subjects achieving an HbA(1c)< or =6.5% at 15 and 31 weeks completed the study at weeks 16 and 32 respectively. RESULTS: Addition of once-daily BIAsp 30 before dinner enabled 21% of the patients to achieve AACE and IDF targets (HbA(1c)< or =6.5%) and 41% to achieve ADA targets (HbA(1c) <7%). With two daily injections of BIAsp 30, these glycaemic goals were achieved by 52 and 70% of subjects. With three daily BIAsp 30 injections, 60% of patients achieved HbA(1c)< or =6.5%, and 77% achieved HbA(1c) <7.0%. CONCLUSIONS: This clinical trial demonstrates that initiation of once-daily BIAsp 30 to type 2 diabetes patients poorly controlled on various OAD regimens was an effective treatment approach for achieving glycaemic goals. Additional patients safely achieved these goals by increasing the number of BIAsp 30 injections from one to two, and then, if uncontrolled, from two to three doses per day. Eventually, most patients previously uncontrolled on OADs with or without basal insulin were controlled by the addition and vigorous titration of BIAsp 30 to oral agent therapy.

Administration, Oral↗