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NASA’s vision for future exploration missions depends on the ability to protect astronauts’ health and safety for performance of Extravehicular Activity (EVA), and to allow astronauts to safely egress from vehicles in a variety of landing scenarios (e.g. water landing upon return to Earth and undefined planetary/lunar landings). Prolonged exposure to spaceflight results in diminished tolerance to prolonged physical activity, decreased cardiac and sensorimotor function, and loss of bone mineral density, muscle mass, and muscle strength. For over 50 years exercise has been the primary countermeasure against these physiologic decrements during spaceflight, and while the resulting protection is adequate for ISS missions (i.e., Soyuz landing, microgravity EVAs), there is little information regarding time-course changes in muscle and aerobic performance. As spaceflight progresses towards longer exploration missions and vehicles with less robust exercise capabilities compared to ISS, countermeasures will need to be combined and optimized to protect crew health and performance across all organ systems over the course of exploration missions up to 3 years in duration. This will require a more detailed understanding of the dynamic effects of spaceflight on human performance. Thus, the focus of this study is quantifying decrements in physical performance over different mission durations, and to provide detailed information on the physiological rational for “why” and “when” observed changes in performance occur. The research proposed will temporally profile changes in astronauts’ cardiorespiratory fitness, muscle mass, strength, and endurance over spaceflight missions of 2 months, 6 months, and up to 1 year in duration. Additionally, an extrapolation model will provide predictions for changes associated with exploration missions 2-3 years in duration. To accomplish these objectives astronauts will be asked to participate in pre, in, post-flight measurement of muscle performance, muscle size, cardiorespiratory fitness and submaximal performance capabilities, as well as non-invasive assessment of cerebral and muscle oxygenation and perfusion (Table 1). Additionally, ambulatory and in-flight exercise, nutrition, and sleep will be monitored using a variety of commercial technologies and in-flight assessment tools. Significance: Our detailed testing protocol will provide valuable information for describing how and when spaceflight-induced muscle and aerobic based adaptations occur over the course of spaceflight missions up to and beyond 1 year. This information will be vital in the assessment as to whether humans can be physically ready for deep space exploration such as Mars missions with current technology, or if additional mitigation strategies are necessary.

Spaceflight impacts human physiology, including well documented immune system dysregulation. Diet, immune function, and the microbiome are interlinked, but diet is the only one of these factors that we have the ability to easily, and significantly, alter on Earth or during flight. As we understand dietary impacts on physiology more thoroughly, we may then improve the spaceflight diet to improve crew health and potentially reduce spaceflight-associated physiological alterations. It is expected that increasing the consumption of fruits and vegetables and bioactive compounds (e.g., omega-3 fatty acids, lycopene, flavonoids) and therefore enhancing overall nutritional intake from the nominal shelf-stable, fully-processed space food system could serve as a countermeasure to improve human immunological profiles, the taxonomic profile of the gut microbiota, and nutritional status, especially where currently dysregulated during spaceflight. This interdisciplinary study will determine the effect of the current shelf-stable spaceflight diet compared to an "enhanced" shelf-stable spaceflight diet (25% more foods rich in omega-3 fatty acids, lycopene, flavonoids, and more fruits, and vegetables in general). The NASA Human Exploration Research Analog (HERA) 2017 missions, consisting of four 45-day missions with closed chamber confinement and realistic mission simulation in a high-fidelity mock space vehicle, will serve as a platform to replicate mission stressors and the effects on crew biochemistry, immunology, and the gut microbiome. Bio sampling of crewmembers is scheduled for selected intervals pre- and in-mission. Data collection also includes dietary intake recording. Outcome measures will include immune markers (e.g., peripheral leukocyte distribution, inflammatory cytokine profiles, T cell function), the taxonomic and metatranscriptomic profile of the gut microbiome, and nutritional status biomarkers and metabolites. Statistical evaluations will determine physiological and biochemical shifts in relation to nutrient intake and study phase. To date, sample collection has been completed for 2 crewmembers from the first mission, aka Campaign 4 Mission 1. Mission 2 was terminated after 22 days due to effects of Hurricane Harvey, and sample collection was not completed. Sample collection will continue for Campaign 4 Mission 3 and 4 prior to comprehensive sample analysis. Beneficial improvements will provide evidence of the impact of diet on crew health and adaptation to this spaceflight analog, and will aid in the design and development of more-efficient targeted dietary interventions for exploration missions.

Long duration missions will require astronauts to subsist on a closed food system for at least three years. Resupply will not be an option, and the food supply will be older at the time of consumption and more static in variety than previous missions. The space food variety requirements that will both supply nutrition and support continued interest in adequate consumption for a mission of this duration is unknown. Limited food variety of past space programs (Gemini, Apollo, International Space Station) as well as in military operations resulted in monotony, food aversion, and weight loss despite relatively short mission durations of a few days up to several months. In this study, food consumption data from 10 crew members on 3-6-month International Space Station missions was assessed to determine what percentage of the existing food variety was used by crew members, if the food choices correlated to the amount of time in orbit, and whether commonalities in food selections existed across crew members. Complete mission diet logs were recorded on ISS flights from 2008 - 2014, a period in which space food menu variety was consistent, but the food system underwent an extensive reformulation to reduce sodium content. Food consumption data was correlated to the Food on Orbit by Week logs, archived Data Usage Charts, and a food list categorization table using TRIFACTA software and queries in a SQL SERVER 2012 database.

Many nutritional factors influence bone, from the basics of calcium and vitamin D, to factors which influence bone through acid/base balance, including protein, sodium, and more. Fibroblast growth factor 23 (FGF23) is a recently identified factor, secreted from osteocytes, which is involved in classic (albeit complex) feedback loops controlling phosphorus homeostasis through both vitamin D and parathyroid hormone (PTH) (1, 2). As osteocytes are gravity sensing cells, it is important to determine if there are changes in FGF23 during spaceflight. In extreme cases, such as chronic kidney disease, FGF23 levels are highly elevated. FGF23 imbalances, secondary to dietary influences, may contribute to skeletal demineralization and kidney stone risk during spaceflight.

Many nutritional factors influence bone, from the basics of calcium and vitamin D, to factors which influence bone through acid/base balance, including protein, sodium, and more. Fibroblast growth factor 23 (FGF23) is a recently identified factor, secreted from osteocytes, which is involved in classic (albeit complex) feedback loops controlling phosphorus homeostasis through both vitamin D and parathyroid hormone (PTH) (1, 2). As osteocytes are gravity sensing cells, it is important to determine if there are changes in FGF23 during spaceflight. In extreme cases, such as chronic kidney disease, FGF23 levels are highly elevated. FGF23 imbalances, secondary to dietary influences, may contribute to skeletal demineralization and kidney stone risk during spaceflight. Presented with an imbalanced dietary phosphorus to calcium ratio, increased secretion of FGF23 will inhibit renal phosphorus reabsorption, resulting in increased excretion and reduced circulating phosphorus. Increased intake and excretion of phosphorus is associated with increased kidney stone risk in both the terrestrial and microgravity environments. Highly processed foods and carbonated beverages are associated with higher phosphorus content. Ideally, the dietary calcium to phosphorus ratio should be at minimum 1:1. Nutritional requirements for spaceflight suggest that this ratio not be less than 0.67 (3), while the International Space Station (ISS) menu provides 1020 mg Ca and 1856 mg P, for a ratio of 0.55 (3). Subjects in NASA's bed rest studies, by design, have consumed intake ratios much closer to 1.0 (4). FGF23 also has an inhibitory influence on PTH secretion and 1(alpha)-hydroxylase, both of which are required for activating vitamin D with the conversion of 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D. Decreased 1,25-dihydroxyvitamin D will result in decreased intestinal phosphorus absorption, and increased urinary phosphorus excretion (via decreased renal reabsorption). Should a decrease in 1,25- dihydroxyvitamin D be necessary to reduce intestinal phosphorus absorption, calcium absorption will also proportionally be reduced, potentially leading to skeletal demineralization. Demineralization of bone can increase kidney stone risk, a medical issue that could prove detrimental to mission success. Given the interrelationships described above, we sought to determine circulating FGF23 concentrations in spaceflight and ground analog studies to better understand the potential effects of dietary phosphorus on bone and calcium metabolism. We analyzed serum from ISS astronauts participating in studies of bone biochemistry, including the Nutrition SMO and Pro K experiments, and we also evaluated FGF23 during extended-duration bed rest. Serum intact FGF23 levels were determined using an ELISA kit from Kainos laboratories in Japan. While initial evaluation of the data showed no changes over time during flight or bed rest, evaluation continues of FGF23 data in light of dietary factors, PTH, vitamin D status, and other biochemical and endocrine factors.

The Nutritional Status Assessment Supplemental Medical Objective was initiated to expand nominal clinical nutrition testing of ISS astronauts, and to gain a better understanding of the time course of changes in nutritional status during flight. The primary activity of this effort was collecting blood and urine samples during flight for analysis after return to Earth. Samples were subjected to a battery of tests. The resulting data provide a comprehensive survey of how nutritional status and related systems are affected by 4-6 months of space flight. Analysis of these data has yielded many findings to date, including: Vision. Documented evidence that biochemical markers involved in one-carbon metabolism were altered in crewmembers who experienced vision-related issues during and after flight (1). Iron, Oxidative Stress, and Bone. In-flight data document a clear association of increased iron stores, markers of oxidative damage to DNA, and bone loss (2). Exercise. Documented that well-nourished crewmembers performing heavy resistance exercise returned from ISS with bone mineral densities unchanged from preflight (3). Furthermore, the response of bone to space flight and exercise countermeasures was the same in men and women (4). Body Mass. Crewmembers lose 2-5% of their body mass in the first month of flight, and maintain the lower body mass during flight (5). Additionally, the two devices to measure body mass on orbit, the SLAMMD and BMMD, provide similar results (5). Cytokines. Findings indicated that a pattern of persistent physiological adaptations occurs during space flight that includes shifts in immune and hormonal regulation (6). Fish/Bone. Documented a relationship between fish intake and bone loss in astronauts (that is, those who ate more fish lost less bone) (7). Vitamin K. Documented that in generally well-fed and otherwise healthy individuals, vitamin K status and bone vitamin K-dependent proteins are unaffected by space flight (and bed rest) (8). Testosterone. Documented that blood concentrations of testosterone were unchanged during flight, but a transient decline occurred after landing (9). Calcium. Nutrition SMO data contributed to the ISS Program by helping understand how and why the Urine Processor Assembly clogged with calcium sulfate precipitate (10). Sample Processing. Ground-based analytical testing results have also been published (11).

Although elder self-neglect is the most common form of elder mistreatment, its pathophysiology is not well understood. Alpha-tocopherol is a lipid soluble antioxidant required for the preservation of cell membranes. Since the association between tocopherol and cognitive impairment in older adults has been described, we explored the possibility of its role in elder self-neglect. OBJECTIVE: (1) To determine whether serum tocopherol levels are associated with elder self-neglect, and (2) to assess the association of serum tocopherol levels and cognitive function in elder self-neglect. METHODS: Serum tocopherol levels were measured in a cohort of 67 self-neglecting elders and 67 matched controls, recruited for the Consortium for Research in Elder Self-neglect of Texas. Pearson s correlation tests were performed to assess bivariate associations between serum tocopherol levels and cognitive function. RESULTS: Mean serum alpha-tocopherol levels were 10.8 +/- 4.7 ug/mL in self-neglect group and 13.0 +/- 4.9 ug/mL in control group (p = 0.006, unpaired student s t-test). None of the participants from either group had alpha-tocopherol level lower than the reference range. Mean serum gamma-tocopherol levels were 2.0 +/- 1.0 ug/mL in self-neglect group and 2.0 +/- 1.1 in control group (p=0.83). Proportion of the elders with gamma-tocopherol level lower than the reference range were 4.5% (3/66) in self-neglect group and 10.4% (7/67) in control group (p=0.32, Fisher s Exact Test). Among the self-neglecting elders, no association was found between serum alpha-tocopherol levels and the Mini-Mental State Examination (MMSE) or the Wolf-Klein Clock Drawing Test (CDT) scores (r =-0.42, p=0.75 for MMSE; r=0.08, p=0.54 for CDT). No association was found between serum gamma-tocopherol levels and the MMSE or the CDT (r=-0.12, p=0.35 for MMSE; r=0.05, p=0.68 for CDT). CONCLUSION: In our sample, neither alpha-tocopherol nor gamma-tocopherol appears to have a role in pathophysiology of elder self-neglect. Nevertheless, significantly lower serum alpha-tocopherol levels in the self neglect group merits further research.

Elder self-neglect is the most common, and most compelling form of elder mistreatment. Individuals who cannot provide the basic needs for themselves may develop social, functional, and physical deficits. The CREST project has the goal of systematically characterizing these individuals, and the objective of the study reported here is to characterize aspects of their nutritional status. Self-neglect (SN) subjects referred from Adult Protective Services were recruited and consented. Control (CN) subjects were matched for age, gender, race, and socio-economic status when possible. Reported here are data on 47 SN subjects (age 77 +/- 7, mean +/- SD; body weight 76 kg +/- 26) and 40 CN subjects (77 +/- 7, 79 kg +/- 20). Blood samples were analyzed for indices of nutritional status. SN subjects had higher serum concentrations of homocysteine (p < 0.01) and methylmalonic acid (p < 0.05). Red blood cell folate levels were lower (p < 0.01) in the SN subjects and serum folate levels tended (p < 0.07) to be lower, also. C-reactive protein concentrations were higher than 10 mg/dL in 36% of SN subjects and 18% of CN subjects. Total cholesterol and triglyceride concentrations were similar in the two groups. These data demonstrate that the self-neglecting elderly population is at risk with respect to several markers of nutritional status.

Elder self-neglect is a form of elder mistreatment. The systematic characterization of self-neglecting individuals is the goal of the CREST project. Reported here is the evaluation of fat-soluble vitamin status. Self-neglect (SN) subjects were recruited and consented following referral from Adult Protective Services. Control (CN) subjects were matched for age, gender, race, and socioeconomic status, as possible. We report here on 47 SN subjects (age 77 plus or minus 7, mean plus or minus SD; body weight 76 kg plus or minus 26) and 40 CN subjects (77 y plus or minus 7, 79 kg plus or minus 20). Blood samples were analyzed for indices of fat-soluble vitamin status. Plasma retinol (p less than 0.01) was lower in SN subjects. Plasma tocopherol tended (p less than 0.06) to be lower in SN subjects, while gamma-tocopherol was unchanged. SN subjects tended to have lower serum 25-OH vitamin D (p less than 0.11), and to be vitamin D deficient (26% below 23 mmol/L). Hypercalcemia occurred more often in SN subjects (23% had values above 2.56 mmol/L), as did elevated parathyroid hormone concentrations (p less than 0.05). These data demonstrate that many nutrients are affected in the self-neglecting elderly, and that long-term deficits are evident by the nature of changes in fat soluble vitamins.

Because of the variability of collagen crosslinks, their use as markers for bone resorption is often criticized. We hypothesized that the variability could be reduced by collecting urine for 24 hours (or longer) instead of using single voids, and by not normalizing to creatinine. Urine samples were collected from 22 healthy subjects during two or more 24-hour periods. Each 24-hour pool and each 2nd void of the day were analyzed for N-telopeptide (NTX), pyridinium (PYD), and deoxypyridinoline (DPD) crosslinks. Data were analyzed by using linear regression. For NTX, R2 for the two, 2nd-void samples (n = 38) was 0.55, whereas R2 for the two 24-hour pools was 0.51 or 0.52, expressed per day or per creatinine. For PYD and DPD, R2 for the 2nd-void samples was 0.26 and 0.18, R2 for the 24-hour pools expressed per day was 0.58 and 0.74, and R2 for the 24-hour pools expressed per creatinine was 0.65 and 0.76, respectively. Regression of the 2nd void and the corresponding 24-hour pool, expressed per day, yielded R2 = 0.19, 0.19, and 0.08, for NTX, PYD, and DPD, respectively (n = 76 each). For the 2nd-void sample and its corresponding 24-hour pool, expressed per creatinine, R2 = 0.24, 0.33, and 0.08, respectively. In a separate study, the coefficient of variation for NTX was reduced (P < 0.05) when data from more than one 24-hour collection were combined. Thus, the variability inherent in crosslink determinations can be reduced by collecting urine for longer periods. In research studies, the high variability of single-void collections, compounded by creatinine normalization, may alter or obscure findings.

This minireview provides an overview of known and potential gender differences in physiological responses to spaceflight. The paper covers cardiovascular and exercise physiology, barophysiology and decompression sickness, renal stone risk, immunology, neurovestibular and sensorimotor function, nutrition, pharmacotherapeutics, and reproduction. Potential health and functional impacts associated with the various physiological changes during spaceflight are discussed, and areas needing additional research are highlighted. Historically, studies of physiological responses to microgravity have not been aimed at examining gender-specific differences in the astronaut population. Insufficient data exist in most of the discipline areas at this time to draw valid conclusions about gender-specific differences in astronauts, in part due to the small ratio of women to men. The only astronaut health issue for which a large enough data set exists to allow valid conclusions to be drawn about gender differences is orthostatic intolerance following shuttle missions, in which women have a significantly higher incidence of presyncope during stand tests than do men. The most common observation across disciplines is that individual differences in physiological responses within genders are usually as large as, or larger than, differences between genders. Individual characteristics usually outweigh gender differences per se.

Adequate nutrition is critical during long-term spaceflight, as is the ability to easily monitor dietary intake. A comprehensive nutritional status assessment profile was designed for use before, during and after flight. It included assessment of both dietary intake and biochemical markers of nutritional status. A spaceflight food-frequency questionnaire (FFQ) was developed to evaluate intake of key nutrients during spaceflight. The nutritional status assessment protocol was evaluated during two ground-based closed-chamber studies (60 and 91 d; n = 4/study), and was implemented for two astronauts during 4-mo stays on the Mir space station. Ground-based studies indicated that the FFQ, administered daily or weekly, adequately estimated intake of key nutrients. Chamber subjects maintained prechamber energy intake and body weight. Astronauts tended to eat 40--50% of WHO-predicted energy requirements, and lost >10% of preflight body mass. Serum ferritin levels were lower after the chamber stays, despite adequate iron intake. Red blood cell folate concentrations were increased after the chamber studies. Vitamin D stores were decreased by > 40% on chamber egress and after spaceflight. Mir crew members had decreased levels of most nutritional indices, but these are difficult to interpret given the insufficient energy intake and loss of body mass. Spaceflight food systems can provide adequate intake of macronutrients, although, as expected, micronutrient intake is a concern for any closed or semiclosed food system. These data demonstrate the utility and importance of nutritional status assessment during spaceflight and of the FFQ during extended-duration spaceflight.

The loss of bone during spaceflight is considered a physiological obstacle for the exploration of other planets. This report of calcium metabolism before, during, and after long-duration spaceflight extends results from Skylab missions in the 1970s. Biochemical and endocrine indexes of calcium and bone metabolism were measured together with calcium absorption, excretion, and bone turnover using stable isotopes. Studies were conducted before, during, and after flight in three male subjects. Subjects varied in physical activity, yet all lost weight during flight. During flight, calcium intake and absorption decreased up to 50%, urinary calcium excretion increased up to 50%, and bone resorption (determined by kinetics or bone markers) increased by over 50%. Osteocalcin and bone-specific alkaline phosphatase, markers of bone formation, increased after flight. Subjects lost approximately 250 mg bone calcium per day during flight and regained bone calcium at a slower rate of approximately 100 mg/day for up to 3 mo after landing. Further studies are required to determine the time course of changes in calcium homeostasis during flight to develop and assess countermeasures against flight-induced bone loss.

Space flight induces endocrine changes that perturb metabolism. This altered metabolism affects both the astronauts' body composition and the nutritional requirements necessary to maintain their health. During the last 25 years, a combination of studies conducted on Skylab (the first U.S. space laboratory), U.S. Shuttle flights, and Soviet and Russian flights provides a range of data from which general conclusions about energy and protein requirements can be drawn. We have reviewed the endocrine data from those studies and related it to changes in body composition. From these data it appears that protein and energy intake of astronauts are similar to those on Earth. However, a combination of measures, including exercise, appropriate diet, and, potentially, drugs, is required to provide the muscle health needed for long duration space flight.

Extended exposure to weightlessness results in bone loss. However, little information exists as to the precise nature or time course of this bone loss. Bone resorption results in the release of collagen breakdown products, including N-telopeptide and the pyridinium (PYD) cross-links, pyridinoline and deoxypyridinoline. Urinary pyridinoline and deoxypyridinoline are known to increase during bed rest. We assessed excretion of PYD cross-links and N-telopeptide before, during, and after long (28-day, 59-day, and 84-day) Skylab missions, as well as during short (14-day) and long (119-day) bed-rest studies. During space flight, the urinary cross-link excretion level was twice those observed before flight. Urinary excretion levels of the collagen breakdown products were also 40-50% higher, during short and long bed rest, than before. These results clearly show that the changes in bone metabolism associated with space flight involve increased resorption. The rate of response (i.e. within days to weeks) suggests that alterations in bone metabolism are an early effect of weightlessness. These studies are important for a better understanding of bone metabolism in space crews and in those who are bedridden.

Studies of calcium kinetics require administration of tracer doses of calcium and subsequent repeated sampling of biological fluids. This study was designed to develop techniques that would allow estimation of calcium kinetics by using small (micrograms) doses of isotopes instead of the more common large (mg) doses to minimize tracer perturbation of the system and reduce cost, and to explore the use of saliva sampling as an alternative to blood sampling. Subjects received an oral dose (133 micrograms) of 43Ca and an i.v. dose (7.7 micrograms) of 46Ca. Isotopic enrichment in blood, urine, saliva and feces was well above thermal ionization mass spectrometry measurement precision up to 170 h after dosing. Fractional calcium absorptions determined from isotopic ratios in blood, urine and saliva were similar. Compartmental modeling revealed that kinetic parameters determined from serum or saliva data were similar, decreasing the necessity for blood samples. It is concluded from these results that calcium kinetics can be assessed with micrograms doses of stable isotopes, thereby reducing tracer costs and with saliva samples, thereby reducing the amount of blood needed.