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To explore the utility of exercise training for improving daytime functioning in adults with obstructive sleep apnea (OSA).
Forty-three sedentary and overweight/obese adults aged 18-55 years with at least moderate-severity untreated OSA (apnea-hypopnea index ≥ 15) were randomized to 12 weeks of moderate-intensity aerobic and resistance exercise training (n = 27) or low-intensity stretching control treatment (n = 16). As part of a trial investigating the efficacy of exercise training on OSA severity, daytime functioning was assessed before and following the intervention. Sleepiness, functional impairment due to sleepiness, depressive symptoms, mood, and quality of life (QOL) were evaluated with validated questionnaires, and cognitive function was assessed with a neurobehavioral performance battery. OSA severity was measured with one night of laboratory polysomnography before and following the intervention.
Compared with stretching control, exercise training resulted in significant improvements in depressive symptoms, fatigue and vigor, and aspects of QOL (p < 0.05). Sleepiness and functional impairment due to sleepiness also were improved following exercise versus control to a similar degree in terms of effect sizes (d > 0.5), though these changes were not statistically significant. No neurobehavioral performance improvements were found. Reduced fatigue following exercise training was mediated by a reduction in OSA severity, but changes in OSA severity did not significantly mediate improvement in any other measure of daytime functioning.
These data provide preliminary evidence that exercise training may be helpful for improving aspects of daytime functioning of adults with OSA. Larger trials are needed to further verify the observed improvements.
Clinicaltrials.gov identification number NCT00956423.
Kline CE; Ewing GB; Burch JB; Blair SN; Durstine JL; Davis JM; Youngstedt SD. Exercise training improves selected aspects of daytime functioning in adults with obstructive sleep apnea. J Clin Sleep Med 2012;8(4):357-365.
The most common complaint among individuals with obstructive sleep apnea is impaired daytime functioning,1 which includes excessive daytime sleepiness and fatigue,2 as well as decrements in cognitive function,3 mood,4 and quality of life (QOL).5 Unfortunately, continuous positive airway pressure (CPAP), the standard first-line treatment for OSA, does not always improve daytime functioning. Improvements are related to compliance to CPAP use,6 as improvements in daytime functioning can be reversed by even a single night of CPAP non-use.7 Moreover, residual symptoms often remain despite optimal compliance.6
Exercise training has been shown to reduce OSA severity, even in the absence of significant weight loss.8–10 As a result, improvements in daytime functioning might follow.8 However, it is plausible that exercise training might improve daytime functioning in individuals with untreated OSA even in the absence of a reduction in OSA severity, since exercise training has been shown to improve cognitive function,11 reduce daytime sleepiness,12 increase energy and reduce fatigue,13 improve mood,14 and enhance QOL15 in various adult populations.
Current Knowledge/Study Rationale: Impaired daytime functioning is the most common complaint of obstructive sleep apnea (OSA). Exercise has been shown to improve numerous components of daytime functioning in other populations, but there is little supporting evidence that it improves daytime functioning in adults with OSA.
Study Impact: Exercise training significantly reduced depressive symptoms and fatigue while increasing vigor and selected aspects of quality of life, largely independent of the effects of exercise on OSA severity. These data provide preliminary evidence that exercise training may be a useful adjunct or alternative treatment to improve daytime functioning in adults with OSA.
The limited available research is supportive of this hypothesis. In epidemiologic studies of individuals with OSA, physical activity has been significantly associated with higher levels of vigor, vitality, and QOL, and lower levels of fatigue.16,17 Conversely, lack of exercise has been associated with higher daytime sleepiness in obese males with OSA.18 Moreover, in an uncontrolled study of adults with OSA, six months of exercise training elicited significant improvements in QOL, mood, and daytime sleepiness.8
We present here the daytime functioning outcomes from a randomized controlled trial in which the primary aim was to examine the efficacy of exercise training on OSA severity.9 The daytime functioning variables were regarded as secondary outcomes, and impairments in daytime functioning were not required for inclusion in the study. Nonetheless, we hypothesized that exercise training would result in moderate-sized improvements in these measures compared to the control treatment. An additional aim of the study was to determine whether daytime functioning improvements were mediated by exercise-induced reductions in OSA severity.
A detailed description of the overall study methodology can be found elsewhere.9 The study utilized a randomized controlled experimental design involving assignment of sedentary adults with untreated OSA to an exercise training or stretching control treatment, with assessments of daytime functioning prior to and following a 12-week intervention. The study was approved by the Institutional Review Boards of the University of South Carolina and the WJB Dorn VA Medical Center, and participants provided informed consent before participation.
Participants in the current study are from the same cohort whose OSA severity and sleep quality data were previously published.9 Individuals aged 18-55 years who had at least moderate-severity OSA (apnea-hypopnea index [AHI] ≥ 15), were sedentary (i.e., self-reported exercise < 2 days/week), and were overweight/obese (i.e., body mass index [BMI] > 25) were eligible to participate in the study. Exclusion criteria included current treatment for OSA, uncontrolled hypertension (i.e., > 159/99 mm Hg), plans to lose weight, pregnancy, inability to exercise, and known or suspected significant cardiovascular, pulmonary, or metabolic disease. Medication use, including antidepressant or anxiolytic medications, was not an exclusion criterion as long as the medication dose was stable before (i.e., > 3 mo) and throughout the study.
Participants were recruited through local sleep clinics, media advertisements, and word of mouth. Initial eligibility was determined via a brief standardized phone screen. Individuals eligible following the phone screen were mailed a packet of questionnaires, including the Berlin Questionnaire.19 Individuals who were previously diagnosed with OSA or classified as "high risk" for OSA based on the Berlin Questionnaire were invited to the laboratory to review the protocol and provide informed consent. Individuals then were screened for OSA with one night of laboratory polysomnography (PSG), with an AHI ≥ 15 required for inclusion. As an additional inclusion criterion, individuals underwent a physical and physician-supervised graded exercise test for detection of underlying cardiovascular disease and/or adverse responses to exercise.
Enrolled participants visited the laboratory on 2 occasions before baseline assessment. During these visits, participants were familiarized with the experimental questionnaires and practiced the neurobehavioral performance battery used in this study. Following the introductory visits, participants completed baseline assessments of PSG, daytime functioning, and neurobehavioral performance, and were randomized to one of the 12-week treatments. Once the intervention was completed, the same assessments that were performed at baseline were repeated following a day of non-exercise. A summary of the study flow is provided in Figure 1.
AHI, apnea-hypopnea index; GXT, graded exercise test; OSA, obstructive sleep apnea; PSG, polysomnography.
Summary of recruitment and participant flow through studyAHI, apnea-hypopnea index; GXT, graded exercise test; OSA, obstructive sleep apnea; PSG, polysomnography.
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Prior to randomization, treatment allocations were prepared by an individual otherwise unaffiliated with the study and placed in sealed opaque envelopes. Participants were randomly assigned by a 3:2 ratio to an exercise training treatment or a stretching control treatment, respectively.
Descriptions of the exercise training and stretching control treatments are provided in Table 1. Although no change in OSA was expected from the stretching control treatment, it was chosen to control for the potential confounding influence of interpersonal interaction on outcomes related to the study. However, because blinding of treatment was not possible, both interventions were presented as active treatments. Expectancy regarding changes in daytime sleepiness, mood and health was assessed with 5-point Likert scales (1: much worse; 5: much better) at the time of randomization allocation.
Description of treatments
A single night of laboratory PSG (Alice 5, Philips Respironics, Murrysville, PA), fixed at 8 h time in bed, was performed at baseline and post-intervention. A standard recording montage was used,20 which was previously described.9 Assessments were evaluated using standard criteria for the scoring of sleep stages and respiratory events20 by a single registered PSG technician blinded to treatment assignment.
An apnea was defined as a ≥ 90% reduction in airflow for ≥ 10 s, and a hypopnea was defined as a ≥ 30% reduction in airflow accompanied by a ≥ 4% drop in oxygen saturation (SpO2). The AHI (i.e., number of apneas and hypopneas per hour of sleep), oxygen desaturation index (ODI; i.e., the number of SpO2 reductions ≥ 4% per hour of sleep), and percentage of total sleep time spent with SpO2 < 90% (TST90) were retained for analysis.
Mood, sleepiness and QOL questionnaires were administered in the evening prior to overnight laboratory PSG at baseline and post-intervention. Questionnaires were introduced using a standardized script and administered in sequential order.
The Center for Epidemiological Studies—Depression scale (CES-D)21 is a questionnaire that assesses the frequency of 20 depressive symptoms, with scores ranging from 0 to 60. The questionnaire has excellent reliability and validity.21 Scores ≥ 16 indicate significant depressive symptoms.21
The Profile of Mood States (POMS)22 assesses a wide spectrum of mood dimensions. The questionnaire assesses the intensity of 65 different emotions/feelings on a 5-point scale (0: not at all; 4: extremely). Subscale scores of fatigue and vigor, as well as a global Total Mood Disturbance (TMD) score, were retained for analysis.22
The Epworth Sleepiness Scale (ESS) assesses the likelihood of falling asleep during 8 everyday sedentary activities. Response options for each activity range from 0 (would never dose) to 3 (high chance of dozing). Scores > 10 represent excessive daytime sleepiness. The ESS has a 5-month test-retest reliability of r = 0.82, differentiates between adults with and without OSA, and has been validated against the Multiple Sleep Latency Test.23
The 10-item Functional Outcomes of Sleep Questionnaire (FOSQ-10)24 is a shortened version of the 30-item FOSQ that estimates how daytime sleepiness affects one's ability to perform certain tasks in the dimensions of general productivity, social outcomes, activity level, vigilance, and intimacy. Individual questions are rated on a scale of 1 (yes, extreme difficulty) to 4 (no difficulty), averaged among the 5 subscales, and then multiplied by 5 to derive a total score. Lower scores indicate greater impairment from sleepiness. The questionnaire has been validated by its ability to distinguish between controls and OSA patients, is sensitive to change following OSA treatment, and has adequate internal consistency (α = 0.87).24
The Medical Outcomes Study 36-item Short Form survey (SF-36) is a scale that evaluates 8 various health-related QOL concepts.25 Individual responses in each concept are calculated to form subscale scores that range from 0 to 100. Lower scores indicate a greater likelihood of disability due to illness. Subscales have good internal consistency (α = 0.73–0.96) and test-retest reliability (r = 0.60–0.81).25 The questionnaire has been validated by its ability to differentiate between clinical morbidities.25
Neurobehavioral performance was assessed on a morning separate from laboratory PSG at baseline and post-intervention. All testing was conducted between 07:00-09:00, and participants arrived following an overnight fast. Participants went through abbreviated practice versions of each test before the full versions were administered.
The Psychomotor Vigilance Task (PVT; Ambulatory Monitoring, Inc., Ardsley, NY)26 is an electronic 10-min simple visual reaction time test that assesses sustained attention. Measures of median reaction time (RTmed), lapses (i.e, responses > 500 ms), and the reciprocal of the slowest 10% of responses (RRT10slow) were analyzed. Performance on this task has been shown to be impaired in adults with OSA.27
The Stroop Color-Word Test (SCWT)28 is a test of cognitive interference in which participants are required to read aloud words or colors while timed during 3 different tasks: randomly ordered words (task A); randomly ordered blocks of colors (task B); and randomly ordered words with conflicting colors (e.g., the word red in green ink). An interference score, calculated as the ratio of time on task C to the time on task B, was retained for analysis. Performance on the SCWT is impaired in individuals with OSA.29
The Trail-Making Test (TMT)30 is a task that assesses frontal-lobe function. In Part A of the TMT, participants connect 25 consecutively numbered circles in ascending numerical order. In Part B, participants connect 25 circles, alternating between ascending sequences of numbers and letters (i.e., 1, A, 2, B). The difference between the time to complete Part B and Part A was retained for analysis. Performance on the TMT has been shown to be impaired in adults with OSA.31
Participant sample size was estimated based upon the primary outcome for the parent study, change in AHI.9 Statistical power was 83% to detect the expected change in AHI with a total of 40 participants randomized by a 3:2 ratio. The unbalanced treatment allocation allowed for similar power as a 1:1 allocation, but permitted a more thorough investigation into the possible benefits of exercise training on OSA severity and its associated consequences.
Data from all randomized participants were utilized for all analyses with one exception: because one participant's baseline PVT scores were > 3 standard deviations different from the remaining sample, PVT data for this participant were excluded from analysis. Otherwise, all analyses were based on the intent-to-treat principle, and baseline data for participants who discontinued the study were carried forward for analysis. Participants who discontinued the study (n = 5) did not differ from those who completed the study on any demographic, OSA severity, or daytime functioning measures at baseline. Moreover, analyses restricted to those who completed the study (n = 38) did not differ from those presented here. All analyses were performed using SAS version 9.2 (SAS Institute, Cary, NC). Data are presented as mean ± standard error.
Baseline participant characteristics were compared between treatments with independent sample t-tests. Changes in outcome variables were evaluated with generalized linear models, with the post-intervention value for each variable as the dependent variable, treatment condition as the independent variable, and baseline value as a covariate. All statistical tests were 2-tailed. Results were considered to be statistically significant when p ≤ 0.05. Due to the small sample size and the fact that the study was not powered to detect these secondary outcomes, no statistical adjustment was made for multiple outcome measures.
There are inherent limitations of a study with multiple outcome measures and small sample size, leading to increased probability of type I and type II errors, respectively. Therefore, effect sizes, which characterize the magnitude of a treatment effect and are independent of sample size, were also calculated for outcome variables. Hedges' d effect sizes were calculated by dividing the difference between the baseline and post-intervention changes in the exercise training and control treatments by the pooled baseline standard deviation, then correcting for small sample-size bias.32 According to convention, effect sizes of d = 0.2, d = 0.5, and d = 0.8 were considered small, medium, and large in magnitude, respectively.32
Because increased OSA severity has been associated with increased sleepiness and fatigue and reductions in vigor,1,18 basic mediational analyses were conducted to evaluate whether exercise training improved daytime functioning through reductions in OSA severity. Proposed mediators included AHI, ODI, and TST90. Mediation analysis was performed using MacKinnon's product of coefficients test.33 Linear regression models were constructed to obtain coefficients associated with (1) the effect of the intervention on the proposed mediator (i.e., α coefficient) and (2) the effect of the proposed mediator on the outcome measure (i.e., β coefficient). The product of coefficients was obtained by multiplying the α and β coefficients, and asymmetric 95% confidence limits based on the distribution of the product of coefficients were created using the PRODCLIN program.33 Confidence intervals that did not include zero indicated a statistically significant mediation effect.
A summary of participant recruitment is provided in Figure 1. Forty-three participants were randomized to either an exercise training (n = 27) or a stretching control treatment (n = 16). Five individuals discontinued participation before study completion.
Baseline participant characteristics are summarized in Table 2. No statistically significant differences between treatments were found for any of the demographic characteristics. Exercise training participants had significantly higher ESS scores than stretching participants at baseline (t41 = −2.74, p = 0.01). No other baseline differences in daytime functioning were found between treatments. In addition, participants reported similar expectancy for improvements in mood, sleepiness, and overall health between treatments. Adherence, defined as the rate of attendance to prescribed sessions, did not differ between treatments (exercise: 87.0 ± 3.7%, control: 79.7 ± 5.3%).9
Baseline participant characteristics
Table 3 summarizes the effects of exercise training on OSA severity and body weight. As previously reported,9 exercise training resulted in a 25% reduction in AHI that was significantly greater than that following the stretching control (F1,40 = 9.54, p < 0.01). There was also a reduction in ODI following exercise training compared to control (F1,40 = 5.05, p = 0.03), but not for TST90. The change in body weight did not significantly differ between the two treatments.9
OSA severity and body weight prior to and following treatment
Table 4 provides a summary of the changes in mood between treatments following the intervention. Exercise training resulted in a significantly greater decrease in depressive symptoms compared with the stretching control treatment, as measured by the CES-D (F1,40 = 5.33, p = 0.03). This corresponded with a moderate effect size improvement when compared to control (d = −0.54).
Depressive symptoms, mood, and sleepiness prior to and following treatment
A summary of changes in POMS-related mood measures is provided in Table 4. Exercise training significantly decreased fatigue (F1,40 = 3.83, p = 0.05) and increased vigor (F1,40 = 5.91, p = 0.02) compared to control. These findings were associated with moderate-sized improvements for both fatigue (d = −0.61) and vigor (d = 0.57). Although the global measure of mood disturbance, TMD, was not statistically significantly decreased following exercise training compared to control, a moderate-sized decrease was noted (d = −0.42).
A summary of the changes in sleepiness following the treatments is presented in Table 4. Exercise training produced a moderate-sized reduction (d = −0.67) in ESS compared to control, though this reduction was not statistically significant. Similarly, exercise training resulted in a moderate-sized improvement in FOSQ-10 score (d = 0.61), despite the increase not being statistically significant.
A summary of changes in QOL is provided in Table 5. Compared to control, exercise training resulted in significant improvements in physical functioning (F1,40 = 4.57, p = 0.04), vitality (F1,40 = 5.00, p = 0.03), and mental health (F1,40 = 4.11, p = 0.04). Small- to moderate-sized improvements (d > 0.35) following exercise training compared to control were noted for all SF-36 subscales except for bodily pain, social functioning, and role limitations due to emotional health.
Health-related quality of life prior to and following treatment
Table 6 summarizes the results relating to neurobehavioral performance. When compared with control, no significant changes between treatments were noted for any of the performance measures following exercise training. In addition, effect size calculations revealed no notable post-intervention difference in any neurobehavioral performance parameters except for a slightly greater reduction in TMT Difference score in the stretching control treatment compared to exercise training (d = 0.23).
Neurobehavioral performance prior to and following treatment
The intervention produced significant improvements in AHI and ODI, as previously reported (AHI: α̂ = 10.41 [3.61], p < 0.01; ODI: α̂ = 8.52 [3.79], p = 0.03).9 Changes in AHI and ODI were significant predictors of reduction in POMS fatigue (AHI: β̂ = −0.15 [0.07], p = 0.03; ODI: β̂ = −0.17 [0.06], p < 0.01), and reduced TST90 predicted improvements in SF-36 physical function (β̂ = 1.15 [0.43], p = 0.01). Furthermore, reduction in ODI was a significant predictor of reduced PVT lapses (β̂ = −0.03 [0.01], p = 0.04). Mediation analyses indicated that the effect of exercise training on POMS fatigue was mediated by reductions in AHI and ODI (α̂β̂ 95% confidence limits: AHI [0.21, 3.57], ODI [0.16, 3.25]). No other significant mediation effects were noted for any of the other daytime functioning variables.
As secondary outcomes of a randomized trial that evaluated the efficacy of exercise training on OSA severity, the aim of the current analysis was to investigate the effect of exercise training on the daytime functioning of individuals with OSA. Exercise training resulted in moderate effect-size improvements in depressive symptoms, vigor, fatigue, physical and mental health aspects of QOL, and sleepiness. Of all the variables that were improved following exercise training, only reduction in fatigue was found to be mediated by exercise-induced reductions in OSA severity.
Exercise training resulted in significant improvements in fatigue and vigor, with corresponding moderate-sized effects (d > 0.55). These findings are consistent with an extensive literature showing improvements in fatigue and vigor following exercise training in other populations.13 Moreover, the results of the present study extend the findings of prior uncontrolled research that indicated significant improvements in fatigue and vigor following exercise training in individuals with OSA,8 as well as strong epidemiologic associations of levels of fatigue and vigor with physical activity levels in individuals with OSA.17 The observed improvements in vigor and fatigue are similar to those achieved by CPAP. For example, a recent study found that three weeks of therapeutic CPAP produced moderate-sized improvements (d ∼ 0.50) in fatigue and vigor compared to placebo CPAP.34
Exercise training also elicited significant improvements in depressive symptoms and some aspects of QOL. A higher level in the vitality dimension of QOL has been associated with a higher level of physical activity in previous cross-sectional research of individuals with OSA,16,17 and a significant improvement in role limitations due to physical problems following exercise training was previously noted in a small uncontrolled study of apneics.8 Exercise training improved most of the QOL components that are most detrimentally affected by OSA, including physical functioning, general health perception, and vitality.35 The QOL improvements achieved with exercise training in the current study are comparable to those achieved with CPAP therapy.35
The antidepressant effects of exercise have been well-documented in other populations.14 However, to our knowledge, no previous exercise training trials have investigated the effect of exercise training on depressive symptoms in adults with OSA. Given that depression is the most prevalent mental health condition observed in adults with OSA4 and the effects of CPAP on attenuating depressive symptoms are inconsistent,36 the results of the current study suggest that exercise training may be a useful nonpharmacologic therapy for reducing symptoms of depression in OSA patients.
In contrast to most other aspects of daytime functioning, there is minimal evidence that exercise significantly reduces sleepiness.37 In adults with OSA, epidemiologic research has associated higher daytime sleepiness with lack of exercise,18 and experimental research has documented a moderate reduction in ESS score (d ≥ −0.55) following 3 and 6 months of exercise training, respectively.8,10 The magnitude of improvement noted in the present study for ESS and FOSQ-10 scores following exercise training compared to control (d > 0.60) is consistent with prior research involving adults with OSA. Moreover, the ∼2.5 point ESS reduction following exercise training in the present study is comparable to the effects of CPAP therapy.38 However, due to the lack of statistically significant improvement in these parameters of sleepiness, the results should be interpreted with caution.
Neurobehavioral performance was the only dimension of daytime functioning that did not appear to be at least modestly improved with exercise training. However, given the moderate efficacy of exercise at reducing AHI and ODI9 and the apparent lack of impairment in neurobehavioral performance in our study sample compared to normative values and previously published reports of individuals with OSA,27,29,31 it is not surprising that improvements in neurobehavioral performance were not observed.
Because this study relied upon effect sizes to demonstrate improvements in many aspects of daytime functioning following exercise training, the results should be considered preliminary. The lack of detection of statistical significance for many of these measures can be attributed to the sample size (N = 43), which was powered to detect expected reductions in AHI and not necessarily the secondary outcomes of daytime functioning.9 However, it is noteworthy that effect sizes, which are independent of sample size limitations, revealed that exercise training produced moderate-sized improvements in most aspects of daytime functioning compared to the control treatment.
It has been hypothesized that individuals with OSA may be disinclined to exercise due to the impaired daytime functioning that is associated with the disorder, especially excessive sleepiness and fatigue.18 Thus, individuals who would be willing to exercise, such as the participants in the current study, may not be representative of the general OSA population. Conversely, individuals with significant daytime functioning impairment may be more likely to seek treatment than individuals with milder or absent daytime dysfunction. Our results suggest that participants were of similar impairment when compared to the overall OSA population, as the baseline daytime functioning of participants in the current study was similar to previously published OSA population samples (e.g., sleepiness,2 depressive symptoms4).
Similarly, as with any intervention study, the self-selection of participants introduces a potential bias toward those who may benefit from the intervention being studied. Furthermore, with a study in which participants could not be blinded to their treatment, expectancy effects could plausibly have driven the improvements in subjective daytime functioning. However, in the present study, both interventions were presented as active treatments, and no difference in expectancy for mood, sleepiness, or health improvements was noted between treatments following randomization. Therefore, that exercise training resulted in improved daytime functioning compared to a control condition of similar baseline expectancy suggests that the observed results were not driven by expectancy effects. Nevertheless, to reduce expectancy concerns, it would be prudent in future studies to include objective measures of sleepiness, such as the Multiple Sleep Latency Test or Maintenance of Wakefulness Test.
The different time commitments imposed by the two treatments is another potential limitation, as differing amounts of interaction with study staff could have theoretically influenced the subjective ratings of daytime functioning. However, we do not believe this factor significantly biased the outcomes of the present study. The treatment durations were chosen after carefully considering the advantages and disadvantages of having equal treatment durations. The stretching control and exercise training conditions were presented as "low intensity" and "moderate intensity" physical activity interventions, with the dosages of these activities in accordance with established guidelines.39 Compared with participants in the exercise training treatment, stretching treatment participants had a greater opportunity for interpersonal interaction with study staff per hour of treatment while they were individually led through their flexibility program, such that total interaction was comparable or perhaps greater for the stretching group. Moreover, in our view, 150 minutes/week of flexibility exercises might have seemed excessive. We surmised that reduced treatment duration for the stretching intervention would provide an appropriate balance between controlling for behavioral confounds and having credible active treatments for which there were no differences in any of the expectancy measures.
Intermediate assessments of vigor, fatigue, and sleepiness were not performed in the current study. It is possible that initiation of an exercise program may produce temporary increases in fatigue and sleepiness along with decreased energy, and may discourage continuation of exercise training in participants who already are tired and sleepy from the underlying OSA. There were no anecdotal reports of this phenomenon in the current study, which might be explained by the gradual progression of exercise dose during the initial four weeks of the study. Such a progression is important for beginning any exercise program, but may be even more essential for individuals with OSA. Future research should employ more frequent assessment of sleepiness, fatigue/energy, mood, and QOL changes with exercise training in order to develop a better understanding of the time course of these changes.
It is unknown how exercise training would affect the daytime functioning of individuals currently being treated with CPAP therapy or oral appliances. Although the moderate efficacy of exercise training on OSA severity8–10 indicates that it is likely insufficient as a stand-alone therapy for OSA, this trial demonstrates the potential utility of exercise training to reduce daytime functioning decrements in OSA. Because CPAP or oral appliance use fails to completely normalize daytime functioning in many cases6,40 and most of the daytime functioning improvements following exercise training were independent of OSA improvement in the current study, combining exercise training with CPAP or oral appliance therapy may be an effective treatment option for augmenting improvements in sleepiness, fatigue, and QOL. Future trials involving combinations of exercise training with CPAP or oral appliance therapy are needed to determine whether exercise training results in additive improvements in daytime functioning relative to CPAP or oral appliances alone.
In conclusion, our results indicated that exercise training produced moderate improvements in selected aspects of daytime functioning that are impaired in individuals with OSA, including depressive symptoms, vigor and fatigue, and aspects of QOL. Because of the reliance of effect sizes to demonstrate improvement in some aspects of daytime functioning and the small sample size of the study, the results need to be verified by larger trials. Nevertheless, these data provide preliminary evidence that exercise may be a valuable therapy for improving aspects of daytime functioning in adults with OSA, regardless of changes in OSA severity.
This was not an industry supported study. Dr. Blair receives book royalties from Human Kinetics and has received honoraria from Alere, Technogym, Santec, Clarity, and Jenny Craig. He has also received honoraria for lectures and consultations from scientific, educational, and lay groups. The other authors have indicated no financial conflicts of interest.
This work was supported by Public Health Dissertation Grant 1R36CD000695-1 from the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. Additional funding support for this work was provided by NHLBI T32 HL082610.
The authors gratefully acknowledge SleepMed of South Carolina and the WJB Dorn VA Sleep Laboratory for their assistance with recruitment and polysomnographic sleep assessments, respectively. The authors also are indebted to Shannon Crowley, Morgan Porter, Elizabeth Rose and Megan Wallner for their assistance with data collection. The work was performed in Dr. Youngstedt's Chronobiology Laboratory, the Clinical Exercise Research Center at the University of South Carolina, and the WJB Dorn VA Medical Center Sleep Laboratory.
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Iber C, Ancoli-Israel S, Chesson AL, Quan SF, authors. The AASM Manual for the scoring of sleep and associated events: rules, terminology and technical specifications. 2007. Westchester, IL: American Academy of Sleep Medicine;
Radloff LS, author. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 2011;1:385–401
McNair DM, Lorr M, Droppleman LF, authors. Profile of Mood States Manual. 1971. San Diego: Educational and Industrial Testing Services;
Johns MW, author. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540–5. [PubMed]
Chasens ER, Ratcliffe SJ, Weaver TE, authors. Development of the FOSQ-10: a short version of the Functional Outcomes of Sleep Questionnaire. Sleep. 2009;32:915–9. [PubMed Central][PubMed]
Ware JE Jr.; Kosinski M, Gandek B, authors. SF-36 Health Survey: Manual & Interpretation Guide. 2004. Lincoln, RI: QualityMetric Incorporated;
Dinges DF, Powell JW, authors. Microcomputer analyses of performance on a portable, simple visual RT task during sustained operations. Behav Res Meth Instr Comp. 1985;17:652–5
Kim H, Dinges DF, Young T, authors. Sleep-disordered breathing and psychomotor vigilance in a community-based sample. Sleep. 2007;30:1309–16. [PubMed Central][PubMed]
Golden C, Freshwater S, authors. A Manual for the Adult Stroop Color and Word Test. 2002. Chicago: Stoelting;
Verstraeten E, Cluydts R, Pevernagie D, Hoffmann G, authors. Executive function in sleep apnea: controlling for attentional capacity in assessing executive attention. Sleep. 2004;27:685–93. [PubMed]
Reitan RM, Davison LA, authors. Clinical neurophysiology: current status and applications. 1974. New York: John Wiley;
Bedard MA, Montplaisir J, Malo J, Richer F, Rouleau I, authors. Persistent neuropsychological deficits and vigilance impairment in sleep apnea syndrome after treatment with continuous positive airways pressure (CPAP). J Clin Exp Neuropsychol. 1993;15:330–41. [PubMed]
Hedges LV, Olkin I, authors. Statistical methods for meta-analysis. 1985. New York: Academic Press;
Mackinnon DP, Fritz MS, Williams J, Lockwood CM, authors. Distribution of the product confidence limits for the indirect effect: program PRODCLIN. Behav Res Methods. 2007;39:384–9. [PubMed Central][PubMed]
Tomfohr LM, Ancoli-Israel S, Loredo JS, Dimsdale JE, authors. Effects of continuous positive airway pressure on fatigue and sleepiness in patients with obstructive sleep apnea: data from a randomized controlled trial. Sleep. 2011;34:121–6. [PubMed Central][PubMed]
Jing J, Huang T, Cui W, Shen H, authors. Effect on quality of life of continuous positive airway pressure in patients with obstructive sleep apnea syndrome: a meta-analysis. Lung. 2008;186:131–44. [PubMed]
Habukawa M, Uchimura N, Kakuma T, et al., authors. Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: contribution of daytime sleepiness to residual depressive symptoms. Sleep Med. 2010;11:552–7. [PubMed]
Loprinzi PD, Cardinal BJ, authors. Association between objectively-measured physical activity and sleep, NHANES 2005-2006. Ment Health Phys Act. 2011;4:65–9
Marshall NS, Barnes M, Travier N, et al., authors. Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis. Thorax. 2006;61:430–4. [PubMed Central][PubMed]
American College of Sports Medicine. ACSM's Guidelines for Exercise Testing and Prescription. 2010. 8th ed. Philadelphia: Lippincott Williams & Wilkins;
Ghazal A, Sorichter S, Jonas I, Rose EC, authors. A randomized prospective long-term study of two oral appliances for sleep apnoea treatment. J Sleep Res. 2009;18:321–8. [PubMed]


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alcoholism, Roman
John Maxwell O'Brien and Barney Rickenbacker
annals and annalists
Tim Cornell
Asinius Quadratus, Gaius
Howard Hayes Scullard and Antony Spawforth
Cincius Alimentus, Lucius, Roman senator and historian
Alexander Hugh McDonald and Antony Spawforth
Claudius Atticus Herodes (2), Tiberius, 'Herodes Atticus'
Ewen Bowie and Antony Spawforth
Claudius Balbillus, Tiberius, Roman tribunus militum and author, 43 CE
Howard Hayes Scullard and Barbara Levick
Cornificius, Quintus
Theodore John Cadoux and Robin Seager
Cremutius Cordus, Aulus
Alexander Hugh McDonald and Barbara Levick
Aulus Cremutius Cordus, the historian, writing under *Augustus (Suet.Tib. 61. 3) and *Tiberius, treated the period from the Civil Wars to at least 18
Dexippus, Publius Herennius, Athenian notable and historian, 3rd cent. CE
Alexander Hugh McDonald and Antony Spawforth
Athenian notable and historian (3rd cent. CE), author of (1) an account of the Successor-period (Τὰ μετὰ Ἀλέξανδρον), lost; (2) a History from mythical times to
education, Roman
J. V. Muir
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subset: commoncrawl


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African Agency in International Politics
Jonathan Fisher
International Relations theory has tended to overlook the role of Africa and Africans in the international system. Traditionally, the discipline's most influential theorists have focused instead on relationships between and perspectives of "major powers." A growing body of work, however, has challenged these more limited efforts to conceptualize African agency in international politics. This scholarship has emphasized the significant space available to, and carved-out by, African states in molding the agendas of international institutions, and the role of African governments and advocacy networks in influencing the trajectory of major international debates around issues such as aid, development, trade, climate change, and migration. The study of African agency in international politics continues to wrestle with two key debates: the meanings of "agency" and "African." Much of the literature focuses primarily on the role and influence of African states rather than that of African citizens and communities. This focus provides, at best, only a partial and qualified view of the ways in which African agency is secured and exercised at the global level, particularly given the significant structural constraints imposed on Africa by global economic and political inequalities. The extent to which contemporary analysis captures the breadth of African engagement with the international system is also compromised by current state-centric approaches. It is thus necessary to examine a range of approaches adopted by scholars to deepen and nuance the study of African agency in international politics, including work on agenda-setting, mesolevel dynamics and microlevel dynamics.
Arms Control and Arms Reductions in Foreign Policy
Harald Mueller
Arms control is a strategy by governments to overcome the security dilemma with institutionalized cooperation. It comes in three versions, arms control proper, with stability as the main objective; non-proliferation as a sub-category of arms control, so understood with the main objective being to preserve the distributive status quo concerning certain weapon types; and disarmament, with the objective to eliminate a specific weapon type. Confidence building is a crosscutting functional concept lumping together many different measures that can serve all three versions.
Arms control does not reject self-help as a basis of national security, but entrusts a significant piece of it to cooperation with potential enemies. Hence, arms control—with the exception of unilateral, hegemonic arms control imposed on others, and of non-proliferation for preserving an existing oligopoly—is a difficult subject for realism and neorealism, but also for post-modernism. It presents a solvable puzzle for rationalists and no problem at all for constructivists who, to the contrary, can dig into norms, discourses, and identities.
Concerning stability and change, arms control can be looked at from two opposite perspectives. Since it aims at stability, critical security approaches have labeled it as a conservative, status quo orientated strategy. But there is also a transformational perspective: arms control as a vehicle to induce and reinforce a fundamental redefinition of the relationship between states. Naturally, the concept of disarmament shows the greatest affinity to the transformational perspective.
A related issue is whether arms control is a result of political circumstances, a dependent variable without a political impact of its own, or whether it has causal effect on interstate relations. Constructivism proposes a dialectical relationship in which arms control and broader policy influence each other. From this reflection, the question of the conditions of success and failure flows naturally. Conducive interstate relations (or extrinsic shocks), technology, domestic structures, learning, leadership, perception, and ideology have been candidates for the independent master variable.
Three models tackle the relationship of arms control and historical time: the enlightenment intuition of steady progress; a series of waves, each of which leaves the world in a more cooperative state than the previous one; and the circle—arms control ebbs and flows alternatively, but achievements are fully lost in each ebb period.
We can distinguish four arms control discourses: arms control as the maiden of deterrence; arms control subordinated to defense needs; arms control under the imperative of disarmament; and arms control as the instrument of human security, the survival and well-being of human individuals, notably civilians.
As with all politics, arms control involves justice issues: the distribution of values (security/power), access to participation in decision making, and the granting of recognition as legitimate actor. Arms control negotiations are ripe with justice claims, and failure through incompatible justice demands happens frequently. Also, emotions play a key role: frustration and ensuing resentment, anger, and existential fear can prevent success. Finally, compassion, empathy, and trust are ingredients in successful arms control processes.
Autocratic Regimes and Foreign Policy
Marianne Kneuer
The foreign policy of autocratic regimes reflects the research interest in the international behavior and decision making of domestic actors in nondemocratic regimes. The regime type (its nature, structure, leadership constellation, legitimation strategies, relation between leadership and public) thus is presumed to have explanatory power for the foreign policy actions and decisions of autocratic actors.
Capitalist Peace Theory: A Critical Appraisal
Gerald Schneider
Capitalist peace theory (CPT) has gained considerable attention in international relations theory and the conflict literature. Its proponents maintain that a capitalist organization of an economy pacifies states internally and externally. They portray CPT either as a complement or as a substitute to other liberal explanations such as the democratic peace thesis. They, however, disagree about the facet of capitalism that is supposed to reduce the risk of political violence. Key contributions have identified three main drivers of the capitalist peace phenomenon: the fiscal constraints that a laissez-faire regimen puts on potentially aggressive governments, the mollifying norms that a capitalist organization creates; and the increased ability of capitalist governments to signal their intentions effectively in a confrontation with an adversary. Defining capitalism narrowly through the freedom entrepreneurs enjoy domestically, this article evaluates the key causal mechanisms and empirical evidence that have been advanced in support of these competing claims. The article argues that CPT needs to be based on a narrow definition of capitalism and that it should scrutinize motives and constraints of the main actors more deeply. Future contributions to the CPT literature should also pay close attention to classic theories of capitalism, which all considered individual risk taking and the dramatic changes between booms and busts to be key constitutive features of this form of economic governance. Finally, empirical tests of the proposed causal mechanism should rely on data sets in which capitalists appear as actors and not as "structures." If the literature takes these objections seriously, CPT could establish itself as central theory of peace and war in two respects. First, it could serve as an antidote to the theory of imperialism and other "critical" approaches that see in capitalism a source of conflict rather than of peace. Second, it could become an important complement to commercial liberalism that stresses the external openness rather than the internal freedoms as an economic cause of peace and that particularly sees trade and foreign direct investment as pacifying forces.
Constitution-Making in Comparative Perspective
Gabriel L. Negretto
Constitution-making has been a central political activity in the modern era. Enacting a new constitution was an essential ingredient in the foundation of republics, the creation of new states, the inauguration of democratic regimes, and the reequilibration of democracies during or after a political crisis. Constitution writing has also become a crucial part of the process of overcoming a legacy of violent internal conflict and a component of authoritarian regimes that seek to gain legitimacy by emulating the formalities of representative democracies. This article surveys the most important concepts and issues related to the comparative analysis of constitution-making. Although it draws examples from constitutions made in a wide variety of settings, special attention is paid to constitutional texts adopted or implemented under competitive conditions.
Diplomacy in Foreign Policy
Kenneth Weisbrode
Diplomacy's role in foreign policy is hampered by multiple understandings of what diplomacy is and does. A broad definition of diplomacy holds that it encompasses more than the promotion of peaceful international relations. Instead, it applies to the sum of those relations—peaceful, hostile, and everything in between. Thus, foreign relations—so long as they involve the interests, direction, and actions of a sovereign power—may be regarded as being synonymous with diplomatic relations, whereby foreign policy relates to the theory and practice of setting diplomatic priorities; planning for contingencies; advancing strategic, operational, and tactical diplomatic aims; and adjusting those aims to domestic and foreign constraints. This conception of diplomacy is functional: it emphasizes the roles of diplomats and recognizes that many other people perform these roles besides official envoys; and it illustrates that diplomatic settings—and the means, methods, and tools of diplomacy—undergo continuous change. The basic mediating purpose of diplomacy, however, has endured, as has much of its institutional apparatus—embassies, ambassadors, treaties, and so on. This is likely to remain the case so long as there are multiple polities in the world, all having to relate to one another.
Ecological Modernization and the Politics of Sustainable Development in the Global Palm Oil Industry
Rory Padfield
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Politics. Please check back later for the full article.
The global palm oil industry has been the target of vociferous criticism from various local and international commentators for its role in the Southeast Asian 2015 haze crisis, as well as for environmental degradation and social conflict in large parts of the global South. In the face of negative media attention and public criticisms, the industry has made explicit policy intentions to embrace more sustainable practices. This is demonstrated in the increased membership to the leading certification body, the Roundtable for Sustainable Palm Oil, and the creation of the Sustainable Palm Oil Manifesto by five of the largest firms. The backdrop to the policy transformation is an emerging politics of sustainable development: a clear recognition of the need for the sustainable production of palm oil at international and national levels, while facing up to the localized political realities of economies reliant on the export of primary commodities. In light of the actual and intended changes in palm oil environmental governance, three related questions are raised and need to be addressed: First, to what extent is the global palm oil industry an example of so-called "ecological modernization," whereby environmental problems are solvable within the context of existing institutions, power structures, and continued economic growth? Second, in countries that produce and consume palm oil, how are the politics of sustainable development shaping the emergence and adoption of sustainability discourses? Third, in terms of the heterogeneity of palm oil producers in the sectors and geographies in which they operate, how inclusive are current sustainability narratives and the specific mechanisms to support the transition towards the sustainable production of palm oil? The arguments made are supported by a review of corporate environmental governance, company policies, government reports, grey literature produced by non-state actors, and interviews with key industry personnel. In addition to a novel analysis of current sustainability trends in the global palm oil industry, the paper contributes to our understanding of the relevance and reach of critical social and political theories, such as the ecological modernization theory, in the context of the global South.
Foreign Aid as Foreign Policy Tool
Clair Apodaca
The majority of countries around the world are engaged in the foreign aid process, as donors, recipients, or, oftentimes, both. States use foreign aid as a means of pursuing foreign policy objectives. Aid can be withdrawn to create economic hardship or to destabilize an unfriendly or ideologically antagonistic regime. Or, conversely, aid can be provided to bolster and reward a friendly or compliant regime.
Although foreign aid serves several purposes, and not least among them the wish to increase human welfare, the primary reason for aid allocations or aid restrictions is to pursue foreign policy goals. Strategic and commercial interests of donor countries are the driving force behind many aid programs. Not only do target countries respond to the granting of bilateral and multilateral aid as an incentive, but also the threat of aid termination serves as an effective deterrent. Both the granting and the denial of foreign assistance can be a valuable mechanism designed to modify a recipient state's behavior.
Donors decide which countries will receive aid, the amount of aid provided, the time frame in which aid is given, and the channel of aid delivery. The donor's intentions and the recipient's level of governance determine the type or sector of foreign aid. States can choose between bilateral or multilateral methods of disbursing foreign assistance in order to pursue their interests. Although bilateral disbursements allow the donor state to have complete control over the aid donation, the use of multilateral forums has its advantages. Multilateral aid is cheaper, it disperses accountability, and it is often viewed as less politically biased.
Foreign aid, once the exclusive foreign policy instrument of rich powerful states, is now being provided by middle-income countries, too. The motivation for foreign aid allocations by nontraditional donors parallels the motives of traditional Development Assistance Committee (DAC) donors. A main difference between traditional and nontraditional aid donors is that nontraditional aid donors generally do not place conditionalities on their loans.
The issue of fungibility can obstruct the donor government's purpose behind the allocation of foreign aid. If the preferences of the recipient government are different from those of the donor, the recipient can often divert the aid and use it for other purposes. A recipient government may reallocate its budget after it determines how much aid it is slated to receive. The recipient government will redirect its resources to areas it deems a priority that cannot be funded externally, for example the military or prestige projects.
Foreign-Imposed Regime Change
Dan Reiter
International actors sometimes force targeted states to change their governments, a process known as Foreign-Imposed Regime Change (FIRC). This foreign policy tool serves as a surprisingly active locus for several theoretical debates in international relations and comparative politics. On the international relations side, evaluation of FIRC as a policy tool has implications for the following debates: whether foreign policy decisions are affected by individual leaders or are determined by structural conditions; whether democracies are more peaceful in their relations with other states; how belligerents choose their war aims; what factors make for successful military occupation; what motivates states to go on ideological crusades; whether international actors can successfully install democracy in postconflict settings; determinants of international trade; and others. On the comparative politics side, FIRC speaks to what may be the two most important questions in all of comparative politics: what factors help a state maintain internal order, and what factors help a state make the transition to democracy?
FIRC also plays an absolutely central role in foreign policy debates, especially for the United States. FIRC is arguably responsible for both the greatest success in the history of American foreign policy, the post-1945 pacification of Germany and Japan, and one of the greatest disasters in U.S. foreign policy history, the 2003 invasion of Iraq and its catastrophic aftermath. Further, FIRC has played a ubiquitous role in American foreign policy since America's emergence as a great power, as the United States has frequently used both overt and covert means to impose regime change in other countries, especially in Latin America. FIRC has also been a tool used by other major powers, especially the Soviet Union after 1945 in Eastern Europe and elsewhere. Into the second decade of the 21st century FIRC remains a controversial foreign policy tool, as some debate the wisdom of pursuing FIRC in Libya in 2011, and others consider the possibility of pursuing FIRC in countries such as Syria.
FIRC can be discussed as a theoretical phenomenon and as the subject of empirical research, focusing on its nature, causes, and effects. The article contains five sections. The first section discusses the definition and frequency of FIRC. The second section describes the causes of FIRC, why actors sometimes seek to impose regime change on other states. The third section covers the international consequences of FIRC, especially whether FIRC reduces conflict between states. The fourth section addresses the domestic consequences of FIRC, especially whether FIRC is usually followed by stability and/or democracy. The final section concludes.
Foreign Policy Learning
Guy Ziv
An improved understanding of foreign policy learning necessitates a clarification of what foreign policy learning is, who learns, and how such learning occurs. Cognitive and social psychologists, sociologists, and political scientists situated in a variety of subfields have contributed to the understanding of foreign policy learning, a multidisciplinary area of inquiry. Learning theorists seek to show how a change in an actor's beliefs due to experience or observation can lead to changes at other units, such as organizations and within the government. This cognitive dimension is important because actors may pursue a new course of action for politically expedient reasons rather than having genuinely "learned"—a distinction referred to as "complex" vs. "simple" learning.
Foreign policy learning can be internal or external. The former type of learning entails what individuals, governments, or organizations learn from their prior experience. Learning theorists who focus on the individual level of analysis borrow insights from political psychology in an effort to shed light on the personal characteristics, the belief structures, and the cognitive psychological mechanisms of political actors that can better inform policymaking. Leaders whose cognitive structures are described as relatively open and complex—like Soviet leader Mikhail Gorbachev, whose learning brought about the dramatic changes that ultimately led to the demise of the Soviet Union—are more likely to alter their beliefs than their cognitively closed and simple counterparts.
Yet external learning occurs as well. Policy diffusion studies show that learning can result from demonstration effects. Foreign policy learning via diffusion is not instrumental, but instead occurs through osmosis. Privatization in the former communist states, China's Foreign Direct Investment liberalization, and the diffusion of environmental norms in the European Union are examples of learning that is contagious, not chosen. A more conscious mode of learning than diffusion is policy transfer, which entails policymakers' transferring ideas from one country and implementing them in another. Technological innovations, unlike lessons that involve political ideology, are generally easier lessons to transfer—for example, Japan's success in applying lessons from the West to modernize its army in the second half of the 19th century.
The constraints to foreign policy learning are formidable. Decision makers are not always open to reconsidering views that challenge their beliefs. Leaders tend to resort to, and misuse, analogies that prevent learning. Even a change in a decision maker's beliefs may not lead to foreign policy change, given the myriad political pressures, bureaucratic hurdles, and economic realities that often get in the way of implementing new ideas. Indeed, foreign policy learning and foreign policy change are not synonymous.
Scholars face significant obstacles in studying foreign policy learning. There is no consensus on the definition of learning, on what constitutes learning, on how actors learn, when they learn, or on how to assess whether learning has taken place. Despite attempts to make sense of the confusion, scholars face the daunting challenge of improving understanding of how learning is shaped and funneled through the interaction of agents and the structures in which they are situated, as well as the relationship between learning and foreign policy change.
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I keep chickens. Three gorgeous ladies, called Teapot, Marmalade and Sugarlump. They provide copious eggs for my breakfast table, assuming the conditions are right. I am a diligent feeder and talk to them regularly, but am shamefully remiss when assessing the safety and integrity of their coop and checking for beasties in their ears, unless something is obviously wrong, and by then it is usually too late.
Chicken management is like portfolio management. Companies tend to perform well when they are healthy, well-managed and there is a healthy and robust environment in which they can operate. For this reason, investors must be mindful of the health of the wider global economic and financial system in which they operate. At Hermes EOS, our engagement programme does just that. We work to promote good stewardship of clients' assets, but also the health of the wider system in which they operate. We want a system that acts in the interest of its principals rather than its agents. To do this, we:
- Encourage reliable legal and regulatory frameworks: By intensifying dialogue with legislators and regulators, we encourage reliable legal and regulatory frameworks which provide transparency, afford equal rights for investors and protect minority interests, for example through controls on related party transactions.
- Support continued improvement in corporate governance: The development, review and continuous improvement of Corporate Governance Codes in various markets are essential as our economies develop. Key aspects of such codes should be guidance on constructive dialogue between investors and directors to enhance accountability and information exchange and the investor role in the director appointment process. We also seek innovation in the development of best practice in enhanced audit committee and auditor reporting in the UK and elsewhere.
- Promote active investor stewardship: We engage with regulatory authorities and standard setters globally to develop country specific Stewardship Codes, which encourage investors to be engaged owners of the investee companies, for example, in Singapore, Denmark, Sweden and Taiwan.
- Advocate high quality and holistic reporting: We push company reporting that provides investors with a clear articulation of the performance of the underlying business and communicates the factors that materially affect the ability of an organisation to create value over time, for example, by promoting integrated reporting with key regulators and companies we engage with around the world. We will continue to support initiatives, such as the International Integrated Reporting Council, which promote company reporting on material sustainability issues.
- Focus on the long term: We continue the dialogue on long-termism and the efficiency of the financial system with key regulators and legislators, for example, the European Commission and the ongoing clarification of fiduciary duty by constituents of the investment chain – led by asset owners – to include the identification and management of long-term risks, including those related to environmental, social and governance issues.
- Encourage greater alignment of interests: We encourage better alignment of the terms in fund manager contracts with the needs of asset owners and their beneficiaries, including on performance measurement, use of benchmarks and compensation, for example, by promoting the key messages of the Model Mandate Initiative of the International Corporate Governance Network. We also seek to bring about innovation through the way we work with clients.
Back to my breakfast table and to Teapot, Marmalade and Sugarlump. I start the year knowing that their chicken coop is clean and intact, the vet has given the all clear and the ladies are healthy and safe, for now. This year will no doubt bring plenty of surprises and it is important that we remain vigilant so that we are well-placed to respond to them as they arise. This is especially true given the dynamic, complex and inter-connected nature of today's global economic and financial system.
Looking into 2016


text:
Thursday, June 11, 2009
7 comments:
I'm impressed! I only managed a salad with yesterday's bag of goodies! Left a belated comment on your local birding post.
- 6:37 AM, June 12, 2009
- Lynne at Hasty Brook said...
That pancake looks delish!
I'll bet it smells even better.
- 10:12 AM, June 12, 2009
- Beth said...
It was yummy! Thanks again, Babe.
- 10:38 PM, June 13, 2009
- Jennifer Hanson said...
I've been yearning for scallion pancakes myself lately, but I just bought a big bag of scallions from the local Asian market. All my friends who have CSA shares live with other people, and they're still awash in produce. I love the idea, but it sounds like it's much too much food for a single-person household like mine. So I try (mostly unsuccessfully) to have some kind of deck garden, and work the local farm stands and markets otherwise.
- 1:33 PM, June 14, 2009
- Patrick Belardo said...
It'd definitely be a lot for one person. I think we might be challenged with two of us. If you're willing to put in the time to make lots of dishes and freeze stuff when you get it, it could be done. But that could be tough. Susan does it with one person, so maybe she can comment.
- 1:36 PM, June 14, 2009
- Mike said...
CSAs are fun. You never know exactly what you'll get. Unfortunately, you can also find yourself afflicted with vegetables you have no use for. The one I used a couple of years ago had an inordinate fondness for Japanese turnips, a rather useless vegetable in my opinion.
- 10:36 AM, June 16, 2009
- Kasha said...
Hey there! I love your blog about birds and I am so excited for you and your food Co-op. I too joined one and love it. I was wondering if you would be willing to add my humble blog to your amazing blog's bloglist? I will be adding your blog to mine and would feel honored to be on a blog such as this. Thank you so much!
- 2:52 PM, June 16, 2009


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Ávila "yemas" (egg yolk cakes)
Sweetened egg yolks
Waar is het typisch in Spanje?
- Autonome regio: Castilla y Leon
This is undoubtedly one of the most famous confectionery products from Castella y León; it is also the most typical product from the city of Ávila.
The origin of these sweets is quite confused: they could come from a recipe from one of the convents that abound in the city or it could be that their manufacture was begun about 130 years ago by MrIsabelo Sánchez. His cake shop, which still exists today, sells the brand 'Yemas de Santa Teresa'. These sweets are round in shape and their orangey yellow colour comes from the egg yolk, their main ingredient. On the outside they are covered with icing sugar. On the palate they are outstandingly delicate as they melt in the mouth without pressure and they have a pleasant crunchy texture because of the layer of sugar covering them. This sweetness is tempered by a little lemon juice.
Meer informatie
- Productsoort: Others
- Seizoen: All year round.
- Oorsprong: Ávila egg yolk cakes are made in three confectioner's shops in the city, although they are sold throughout the province and even in other cities outside the region of Castella y León..
- Waar te kopen: Ávila egg yolk cakes are sold in most confectioner's in Ávila and in Castilla y Léon and in many specialised shops throughout Spain..
- Recepten: Ávila Egg Yolk Cakes
- Energy: High
- Cholesterol: Average
- Opmerkingen: Rich in sugars, proteins and fats.


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Nicola Kantorowicz Fellow
My work is always abstract - using colour, light and symbolism to express spiritual concepts. Working in a traditional manner the design is built up from a mosaic of small pieces of glass. Leadlines form a web of intricate pattern. Glass is richly painted, building up layers of tone and texture. For more decorative pieces, sandblasting and acid-etching are used to create panels for today's interiors.
23 Sedgefield Close – Sonning Common – Oxfordshire – RG4 9TS
Tel:0118 9724746
- 2005: St Peter's Church, Marsh Baldon, Oxfordshire - single lancet in south aisle in celebration of the ministry of Revd Marcus Braybrooke
- 2005: St Giles Church, Great Coxwell, Oxfordshire - two light window in south aisle
- 1999: the west window, St Andrew's Church, Tangmere, Chichester - RAF memorial window
- 1999: two hanging panels for St Luke's Church, Chiddingstone Causeway, Kent, and one for St Mary's Church Chiddingstone, Kent, all in celebration of the Millennium
- 1998: west window, Boxgrove Priory, Chichester, Sussex
- 1997: St Mary's Church, Green Street Green, Orpington, Kent -coloured glazing scheme for the sanctuary cross
- 1997: window for the Worshipful Company of Bowyers, St Botolph's without Bishopgate, City of London
- 1995: the "Unity Window", St Martin's Church, Canterbury, Kent
- 1994: Lady chapel window, Church of the Good Shepherd, Borough Green
- 1994: East window, St George in Owlsmoor, Sandhurst, Berkshire
- 1994: Idlewell's Shopping Centre, Sutton in Ashfield, Nottingham.
- 1993: Lady chapel window, St Michaels's Church, Sittingbourne, Kent


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Elsie F.
June 15, 1885
Sept. 10, 1952
Nov, 17, 1879
Oct. 9, 1959
William Howard Townsend, son of Miles Townsend and Martha Jane Moore Townsend, married Elsie F. (Unknown).
Contributed on 1/4/07 by robinfife
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Samuel Heath products are available from selected bathroom showrooms and department stores
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Bruce Wilson has been looking deeper into ties between Invisible Children, the group behind "Kony 2012," and a secretive fundamentalist Christian organization known variously as The Family and The Fellowship—which, as it turns out, is said to be a force behind Uganda's "Kill the Gays" bill. For a primer on The Family, by the way, there's no better place to start than Jeff Sharlet's book.
What Wilson dug up is now detailed in an extensive blog post. There's a lot to sort through, but it's exhaustively-researched stuff.
Read the rest
At least two of Invisible Children's programs have involved collaboration with The Fellowship and and its members, and by 2007 -- according to accounts from both Invisible Children and Fellowship members -- Invisible Children had partially merged its developing school and mentoring programs in Uganda with The Fellowship's Ugandan educational and leadership training system, which works to raise up a cadre of elite Jesus-centered leaders who will transform their nation along "Biblical" lines - with one apparent objective being the categorical elimination of homosexuality.


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Civil war of football recruiting awaits Jefferson County
Louisville figures to be the site of a new kind of Kentucky derby over the next year as the new head football coaches at the state's top two universities race neck and neck to recruit an unusually large group of elite Jefferson County prospects.
Kentucky coach Joker Phillips won an initial recruiting battle over Louisville's Charlie Strong on National Signing Day Wednesday when Central High School linebacker Tim Patterson, regarded as the state's top 2010 prospect, picked the Wildcats over the Cardinals.
The race for many of Louisville's top players in 2011 could also go down to the wire.
"The new Mason-Dixon Line starts at the county line. The civil war is on," Seneca High School coach Louis Dover said. "Louisville is the biggest city in Kentucky, and it's got the most kids who play football. ... Coach Strong knows that if he wants to win, he has to close it off, and Coach Phillips knows he cannot let that door close. He's got a foot in that door, and it's got to stay open."
In 2011, Jefferson County figures to produce one of its strongest crops of major-college football talent in a long time. Expect Phillips, the longtime UK assistant who was promoted last month, and Strong, the charismatic former Florida defensive coordinator, to recruit Louisville with a fervor.
"We also talk about the heart and soul of our program has to be the state of Kentucky," Phillips said on Wednesday. "What's the most populated city in Kentucky? It's Louisville.
"There's 28 schools in Jefferson County, and we've got to be in them, and we've got to be in them heavy."
U of L has already landed commitments from quarterback DaMarcus Smith of Seneca, receiver DeVante Parker of Ballard, and running back Jerrell Moore and lineman Jamon Brown of Fern Creek.
Phillips countered with a commitment from highly regarded Eastern player Jon Davis, who projects as a college tight end but can play multiple positions.
Of course, all those commitments are non-binding, and UK and U of L's recruitment of those players could extend all the way until next signing day.
"Coach Strong got a few early commitments from DaMarcus and DeVante and kind of got the snowball going, and it was up to Joker to respond, and he did with the class he signed here at the end, especially Patterson here in Louisville," Ballard coach Mike Jackson said.
Coaches in Jefferson County said Phillips has earned their respect because of the long-term relationships he's built with them and their players. That was the case with the Patterson signing. Phillips was instrumental in bringing former Central stars Corey Peters, Ridge Wilson and Mister Cobble to UK, and he used those recruiting trips to the downtown school as a basis for getting to know Patterson.
"He's done an outstanding job," said Mike Glaser, coach of 2009 Class 6-A champion St. Xavier. "The important thing is he establishes a rapport with the kids early. That's always been Joker's trait; he finds all about them way before their senior year. He's got good rapport with all the coaches in the state."
Fern Creek coach Curtis Higgins said Strong has quickly done a nice job trying to catch up with Phillips in building those ties.
"I'm a Louisville grad, so obviously I have some Louisville bias, but I think the UK staff over the past four or five years --- even while (former U of L coach Bobby) Petrino was here --- really built relationships," Higgins said. "They honestly blew (recently fired coach Steve) Kragthorpe's staff away in battling for recruits, and now they finally have some competition."
Trinity coach Bob Beatty said Phillips and Strong understand that pleasing fans and building buzz are important parts of their jobs and that winning recruiting battles in Jefferson County can help achieve that.
"Joker has always done a great job recruiting Jefferson County in the 10 years I've been here," he said. "... Anybody knows that if you're in the state, you're going to try to win that state and that puts you in good standing with the media. Marty Schottenheimer once told me, 'Don't get on the bad side of the media because you can win the Super Bowl and still lose.' So they'll win in the eyes of the media if they get the most guys in-state."
Of more importance, landing those players would help elevate the Cats or Cards on the field.
Seneca's Smith, a 6-foot-1, 180-pound dual-threat player, missed all of last season with a torn anterior cruciate ligament in a knee but should start the 2010 season as a Mr. Football front-runner.
Dover said he outplayed four-star Southern California QB signee Jesse Scroggins at a camp last summer and held his own at another camp against Ohio junior Braxton Miller, who has scholarship offers from Ohio State, Alabama, Michigan, Notre Dame and many others.
"He throws constantly," Dover said. "... He carries his books in one hand and a bag of footballs in the other."
Dover said Phillips and Smith had a great "heart-to-heart" conversation that Smith "really appreciated" after he committed to Strong, and Dover said he has "no doubt ... it's going to be a last-minute decision between (UK and U of L)."
"He felt almost like he let Coach Phillips down a little by committing, but I have no doubt Coach Phillips will keep coming," Dover said. "I don't think Joker is going to lose any ground; it'll be a war till the end. DaMarcus told Coach Phillips he's firm in his commitment, but really, he's 17 years old, and how firm is a 17-year-old's decision when he has a year to think about it?"
Ballard's Parker is another Jefferson County gem whose early commitment to U of L has Phillips playing catch-up.
Jackson said Parker (6-2, 180) ran a legit sub-4.5-second 40-yard dash at a national underclassman combine last summer. He also has great ability to shake defenders in the open field, making him a potential deep threat or slot target.
"DeVante is the kind of player that doesn't come around very often, especially in Kentucky, and I told him when he committed that other schools aren't going to back off," Jackson said. "We're getting mail three times a week from Alabama, Clemson, Oregon, the very, very top schools, and with UK being the other in-state school, they're not giving up.
"Joker believes in building relationships, and he wants to build one there. I know he's going to keep trying."
Jackson said Phillips is also interested in 6-1, 205-pound Ballard linebacker Flo Hardin.
"He's thick," Jackson said. "He looks like a beast, and he can move."
Fern Creek's Higgins said Moore, another speedster, appears firm in his commitment to U of L but that Brown could potentially be swayed. Another Tigers star, Jalen Harrington (6-3, 210), whose size and versatility Higgins compared to Patterson's, is uncommitted and considering the Cats.
Glaser mentioned cornerback Daylen Hall and multipurpose back Lamont McMurray as potential targets for UK.
Hall (5-10, 1850), who blocked nine kicks and had seven interceptions in 2009, is "fast as can be," Glaser said.
"(UK's coaches are) excited about Daylen Hall, and all our kids would love to play at a program like Kentucky," he said. "They think Coach Phillips can take them to another level."
Of course, Strong will be strong in his pursuit of all these prospects, too, and the next 12 months should shape up to be an exciting time for football in Jefferson County.
"(Phillips and Strong) are just two great guys," Seneca's Dover said. "The state of Kentucky doesn't realize what they have right now. As big as the basketball rivalry is, the football rivalry is always going to be second, but it's going to get giant. The recruiting, like I said, is going to be a civil war."


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Jason Cameron tackles big projects on "Desperate Landscapes," but the DIY Network star says little changes can reap good results, too.
"Maybe it's just sanding your deck down and repainting it," he said. "That can go a long way toward getting rid of the desperation."
Cameron will talk about his makeovers and landscaping ideas at the Epcot International Flower & Garden Festival on Friday, Saturday and Sunday. On "Desperate Landscapes," he and his team move into high gear to revive struggling yards.
Homeowners frequently are nominated for the show by their neighbors, Cameron said.
"We do what we can to go in and...


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Topic: Nicholsen vs Ledger
Who do you think was a better Joker. This means to disrespect for Ledger and its just a comparison to see who you think was the better Joker.
They are very diferent kinds of Jokers, Nicholsen is more funny wheras Ledgers Joker is more of a cycopath.
I haven't seen Dark Knight yet but i have seen Batman 1989 and i think i will like Ledgers Joker better in the end


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07 January, 2014 | (01 hr)
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What human rights risks are companies facing when doing business China? How can they manage those risks without running afoul of the Chinese government? This webcast will tackle these issues, as well as address the following questions:
- What ought to be included when we talk about human rights risks?
- Do MNCs approach human rights risks in China any
differently than Chinese enterprises?
- How do companies make sure human rights policies and
practices are consistent around the globe?
- What has improved in China in the past several years?
Who should attend
Executives involved in human rights policy and implementation. Ethics, Compliance, Risk, HR, Legal and Operational Executives as well as those running operations in China
David Hoffman
David Hoffman is senior vice president and managing director of The Conference Board China Center. Based in Beijing, Hoffman is responsible for the center's strategy, research agenda, research program delivery, partner relationships with Chinese government organizations, and value delivery ...Full Bio
Mark Hodge
Mark Hodge, Executive Director, Global Business Initiative on Human Rights (www.global-business-initiative.org). GBI exists to advance human rights in a business context around the world. The underlying vision is a global community of corpo...Full Bio
Ellen Hexter
Ellen Hexter is senior advisor, enterprise risk management at The Conference Board. She has served on the faculty of The Conference Board Directors' Institute and worked with boards to provide director training in risk management practices and the role of the board in ERM oversight.


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- Sylvie de Toledo's group helps grandparents who are raising their grandchildren
- In 2011, there were at least 2.7 million of those grandparents in the United States
- The added responsibility often comes with financial, emotional challenges
- Do you know a hero? Nominations are open for 2013 CNN Heroes
Los Angeles (CNN) -- After years of struggling with depression, Nikki de Toledo killed herself with a prescription drug overdose when she was 27.
She didn't leave a suicide note, but she did leave her 8-year-old son, Kevin.
Kevin's grandparents, Ginette and André de Toledo, immediately took over custody, because Kevin's father lived abroad and had never been a part of his life.
It wasn't an easy transition, though.
"It was a very difficult time for my parents because they weren't able to grieve," said Nikki's sister, Sylvie. "They were immediately responsible for raising an 8-year-old who also was grieving in his own way. And it was different than the way my parents were grieving. It was a pretty tough time for our family."
It's often the grandparents who step up when a parent dies or is unable to take care of a child for other reasons, such as incarceration, abuse or mental illness. In 2011, there were at least 2.7 million grandparents raising a grandchild in the United States, according to the U.S. Census Bureau's American Community Survey.
But the sudden shift in responsibility can be incredibly stressful.
Grandparents may be living on fixed incomes, and the additional dependents can cause costs to soar. There's also an emotional adjustment when an empty nest is no longer empty.
"When that call comes ... your whole life changes," Sylvie de Toledo said. "It's turned inside out and upside down."
De Toledo said she watched her parents, then in their mid-50s, struggle with their new responsibilities. It affected their marriage and their health.
Also, like many children who lose a parent, Kevin had emotional issues that followed him into his teenage years.
"Kevin was a difficult teenager," said de Toledo, a 58-year-old social worker. "The trauma and grief and loss of a parent abandoning you, so to speak ... it's a huge, huge loss."
Around the same time, de Toledo started noticing more of her work clients -- children and grandparents -- dealing with similar challenges.
"The most common thread was that they all felt alone and isolated," she said. "They didn't know anyone in the same situation that they were in."
Determined to bring some of these families together, de Toledo began holding a support group for about 10 of them. When attendance began to skyrocket, she started her own nonprofit, Grandparents as Parents, to help more people cope with the process.
Today, more than a quarter-century later, there are 20 support groups across Los Angeles, and the nonprofit works with more than 3,000 families a year, providing them with financial assistance, legal advice and emotional support.
More than 90% of the caregivers are grandparents, but the nonprofit also assists aunts, uncles, siblings and close friends who have stepped up to care for children when their biological parents can't.
CNN Hero Sylvie de Toledo
"We are a one-stop shop for relative caregivers," de Toledo said. "So many times, the families are completely overwhelmed. The kids come to them with a dirty diaper and a T-shirt that's way too big for them."
Do you know a hero? Nominations are open for 2013 CNN Heroes
When someone calls for help, de Toledo is usually the first person they talk to. She listens to their story and then helps them prioritize their needs so the situation isn't so overwhelming.
"It's sort of like a jigsaw puzzle," she said. "You have to figure out how to put the pieces back together to build a whole, happy, healthy individual child."
Lourdes Aguylar called seven years ago when her daughter dropped off three children ages 3, 9, and 10 months. Aguylar received immediate assistance -- food, toys and clothes -- and with the group's help she later became legal guardian of the children.
Over the years, the group has also helped provide the children with psychological, educational and medical support. But perhaps most importantly, Aguylar said, they have become part of a larger family -- a group of caregivers and children who back each other.
"You know you're not the only one," she said.
More on CNN: Grandparents get tech-savvy to keep in touch
In addition to weekly support groups, there are monthly picnics for families and friends as well as opportunities for the families to attend events together, such as the theater, amusement parks and sporting events.
The nonprofit gets its money through grants, private donations and corporate sponsors, but it also helps grandparents apply for government assistance. de Toledo said many grandparents don't realize there are special programs that may be available to them.
"We have seen countless families who have maxed out credit cards and used all of their savings before they even ask for help," she said.
Even if they do know there is help out there, many don't know how to navigate the system and may need help using online systems or filling out paperwork. So de Toledo and her staff or volunteers will walk them through the process.
Louise Reaves, 60, got in touch with de Toledo to help her navigate the court system and get custody and benefits for her young granddaughter. Six years ago, Reaves' daughter dropped the baby off at her house, promising to return when she got back on her feet; she hasn't come back.
"Sylvie was able to walk me through everything that I needed," Reaves said. "I was able to get medical assistance for (my granddaughter). I was able to get clothing for her ... rent. They helped me get on my feet where I could help myself."
She credits the group with keeping her family together.
"Without me joining (the group), I don't know where we would be," she said. "I'm going to be honest with you. I don't know if (my granddaughter) would be in a group home or a foster home or what. It was rough."
More on CNN: Caregiver lives rerouted, enriched by aging parents
De Toledo said her group has kept thousands of children from entering the foster care system, and they've also kept siblings from being separated.
"We've literally saved families," she said.
But the true heroes, she said, are the caregivers.
"It's really the grandparents and the relatives who are doing this that deserve the recognition for putting their own lives on hold," she said. "I just was able to plant a seed with something that happened in my own family. ...
"From a family tragedy, something wonderful has happened."
Want to get involved? Check out the Grandparents as Parents website at www.grandparentsasparents.org and see how to help.


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