NUTRIENT COMPOSITION OF RATIONS FOR SHORT-TERM, HIGH-INTENSITY COMBAT OPERATIONS

Committee on Optimization of Nutrient Composition of Military Rations for Short-Term, High-Stress Situations

Committee on Military Nutrition Research

Food and Nutrition Board

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations NUTRIENT COMPOSITION OF RATIONS FOR SHORT-TERM, HIGH-INTENSITY COMBAT OPERATIONS Committee on Optimization of Nutrient Composition of Military Rations for Short-Term, High-Stress Situations Committee on Military Nutrition Research Food and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by the United States Army (award number DAMD17-99-1-9478 with the National Academy of Sciences). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the sponsoring agency that provided support for the project. International Standard Book Number: 0-309-09461-3 (Book) International Standard Book Number: 0-309-54982-5 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations COMMITTEE ON OPTIMIZATION OF NUTRIENT COMPOSITION OF MILITARY RATIONS FOR SHORT-TERM, HIGH-STRESS SITUATIONS JOHN W. ERDMAN (Chair), Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign BRUCE R. BISTRIAN, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA PRISCILLA M. CLARKSON, School of Public Health and Health Sciences, University of Massachusetts, Amherst JOHANNA T. DWYER, Office of Dietary Supplements, National Institutes of Health, Washington, DC BARBARA P. KLEIN, Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign HELEN W. LANE, Johnson Space Center, National Aeronautics and Space Administration, Houston, TX MELINDA M. MANORE, Department of Nutrition, Oregon State University, Corvallis PATRICK M. O’NEIL, Weight Management Center, Institute of Psychiatry, Medical University of South Carolina, Charleston ROBERT M. RUSSELL, Human Nutrition Research Center on Aging, Tufts University, Boston, MA BEVERLY J. TEPPER, Department of Food Sciences, Cook College of Rutgers University, New Brunswick, NJ KEVIN D. TIPTON, School of Sport and Exercise Sciences, University of Birmingham, Birmingham, England ALLISON A. YATES, Environ Health Sciences Institute, Arlington, VA Staff MARIA P. ORIA, Study Director JON Q. SANDERS, Senior Program Assistant LESLIE J. SIM, Research Associate IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations FOOD AND NUTRITION BOARD CATHERINE E. WOTEKI (Chair), College of Agriculture, Iowa State University, Ames ROBERT M. RUSSELL (Vice-Chair), Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin MICHAEL P. DOYLE, Center for Food Safety, University of Georgia, Griffin SUSAN FERENC, Food Products Association, Washington, DC NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia REYNALDO MARTORELL, Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, School of Medicine, University of Maryland, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Harvard University, Boston, MA BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ELIZABETH RIMAUD, Financial Associate

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: E. Wayne Askew, University of Utah, Salt Lake City Barry Braun, Energy Metabolism Laboratory, University of Massachusetts, Amherst William J. Evans, University of Arkansas for Medical Sciences, Little Rock William C. Franke, Rutgers, State University of New Jersey, New Brunswick Marc K. Hellerstein, University of California, Berkeley Janet R. Hunt, USDA-ARS Grand Forks Human Nutrition Research Center, ND Molly Kretsch, United States Department of Agriculture, Beltsville, MD Ron J. Maughan, School of Sport and Exercise Science, Loughborough University, UK Robert Nesheim, Salinas, CA Michael D. Sitrin, Western New York Veterans Administration Medical Center, Buffalo, NY Douglas W. Wilmore, Ilauea, HI Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recom-

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations mendations nor did they see the final draft of the report before its release. The review of this report was overseen by Richard N. Miller, M.D. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Preface This report, titled Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations, is the product of the work of the Committee on Optimization of Nutrient Composition of Military Rations for Short-Term, High-Stress Situations under the auspices of the Standing Committee on Military Nutrition Research (CMNR). The CMNR was established in 1982 to advise the US Department of Defense on the need for and conduct of nutrition research and related issues. This report was produced in response to a request by the US Army Medical Research and Materiel Command to the Institute of Medicine (IOM) to convene a committee to review and recommend the nutritional composition of rations for short-term, high-stress situations. The specific questions posed to the committee evolved from discussions between the standing CMNR and the Military Nutrition Division of the US Army Research Institute of Environmental Medicine (USARIEM) at Natick, Massachusetts. A 12-member committee was formed that had expertise on micronutrients, protein, energy balance and sports nutrition, gastroenterology, clinical medicine, food processing and technology, eating behavior and intake regulation, clinical nutrition, dietetics, and psychology. The committee’s task was to conduct a study to determine the optimal nutrient content of a new combat ration. The committee first discussed the limitations of the current rations for use during future military deployments and combat operations and the expected impact of combat operations on nutrient status, health, and performance. Operating within specific design constrains, the committee then recommended nutritional composition of a new ration designed for short-term use by soldiers during high-tempo, stressful combat missions. The nutritional composition of this new ration was optimized to best sustain physical and cognitive performance and to prevent possible adverse health consequences, despite limitations imposed by ration design and mission constraints. The committee focused on dehydration, the gastrointestinal gut processes, and the function of the immune system as health issues of highest concern. Also, the committee considered the potential health and performance

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations impact of subsistence on this ration during its intended use in combat operations. Although it was not stated in the questions posed, the committee found that some of the answers to the questions needed further confirmation with research that particularly addresses the unique circumstances of combat missions, that is, a combination of multiple stressors that rarely occurs in nonmilitary operations. Therefore, the committee proposed very specific areas of research that are critical to continue improvement of the assault rations. Among the chief design constraints of this daily ration are that it must fit within 0.12 cubic feet and weigh 3 lb or less. The ration would be targeted for use by average male soldier of 80 kg body mass, 16 percent fat, relatively fit, age range 18–45 years (probably average < 25 years), with no chronic metabolic disease, but potential incidence of some common food allergies. During combat operations, the expected daily energy expenditure is 4,000–4,500 kcal/per day, achieved through intermittent periods of high energy expenditure (> 50 percent VO2 max) mixed with longer periods of low-intensity movement sustained for 20 hours per day. Soldiers will rely on this ration for three to seven days followed by one to three days of recovery when they will have access to more nutritionally complete meals (i.e., ad lib food availability served in field kitchen setting). These three- to seven-day missions might be repeated several times for up to a month. To provide context for the recommendations, assumptions of the characteristics of the soldiers’ diets and health, the missions, and other issues were formulated that were based on information gathered at open sessions with sponsor representatives and other military personnel. The committee carried out its work over 15 months and held three meetings. The first meeting of the committee was held in conjunction with a two-day workshop. The workshop was hosted by the USARIEM and the Natick Soldier Center (NSC) in Natick, Massachusetts, August 11–13, 2004. Speakers addressed the issues brought to the committee by the USARIEM. These presentations were the basis for the committee’s deliberations and recommendations and are included in this report as individually authored papers in Appendix B. Two additional meetings of the committee were held on October 21–22 and November 18–19, 2004. Throughout the project, the committee had the privilege of having access to information collected directly in the field where soldiers were deployed to military missions of the type relevant to its task. For example, a survey that was designed to collect information on various aspects of eating behavior was conducted in Afghanistan. This very recent data collection was the basis for the committee’s outlining of the assumptions and, consequently, the development of the recommendations. The committee would like to express its most sincere appreciation for the work and professionalism of CPT Chad Koenig, Research Dietitian of the Military Nutrition Division (MND) at USARIEM. He not only incorporated the committee’s suggestions into the survey and conducted it, but

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations also summarized the survey data for the committee and presented the conclusions at the November meeting. The committee expresses its appreciation to Douglas Dauphinee, Research Program Coordinator of the MND at USARIEM, for all the help provided during the preparations stages of the workshop at USARIEM. Special thanks go also to Andrew Young, Chief of the MND and representative from the Department of Defense for this task, for generously giving his time and help and for being available to clarify the task of the committee. Special thanks are extended to Scott Montain, Research Physiologist at MND, USARIEM. His assistance was truly invaluable during the committee’s work. He helped delineate the task and provided numerous reports and other data to the committee in a timely manner. In addition, the committee thanks COL Karl Friedl who continues to support the work of the CMNR and was readily available to provide the appropriate contacts needed to gather information for the committee. On behalf of the committee, I sincerely thank the workshop participants and speakers for addressing topics critical to the completion of the committee’s work. Each speaker not only provided an excellent presentation, but was available for multiple interactions during the workshop, prepared a manuscript of the presentation (see Appendix B), and worked with IOM staff throughout the revision process. These presentations were important reference sources for the committee and have been used as scientific basis throughout the report. The committee expresses its deepest appreciation to other staff members at the Combat Feeding Directorate (CFD), Research, Development and Engineering Command, NSC, who offered their insights about the multiple questions on food development at the CFD: Betty Davis, Team Leader of Performance Enhancement and Food Safety; Matthew Kramer, Research Psychologist at Product Optimization and Evaluation Team; and Patrick Dunne, Senior Advisor at the CFD. In addition, the military leaders that answered and clarified the committee’s concerns on health issues during current deployments deserve the committee’s most sincere appreciation. They are Mr. Terry Phelps, Deputy Director of the Special Operations Command Surgeon; LTC Christopher, Division Surgeon of the 82nd Airborne Division; and MAJ Steve Lewis, Social Work Officer of the 82nd Airborne Division. Without their contributions many of the health considerations that drove the recommendations would have eluded the committee. We thank MAJ Lolita Burrell for providing such valuable contacts. The committee owes a strong debt of gratitude to the Food and Nutrition Board (FNB) staff for their professionalism and effectiveness in ensuring that our committee adhered to its task statement, for providing discipline and experience in helping to assemble the report and effectively respond to reviewers, and for providing background research support and organizing our meetings. In particular, we thank Senior Program Officer Maria Oria, who worked tirelessly on numerous drafts and revisions. Ably assisting Dr. Oria in her efforts were

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Senior Program Assistant Jon Sanders and Research Associate Leslie Sim. Finally, the committee is also grateful to the overall guidance and continuous support of Linda Meyers, FNB Director. I also extend my deep gratitude to my fellow committee members, who participated in our discussions in this study in a professional and collegial manner, and who approached its task statement with great seriousness and intellectual curiosity. I appreciated the opportunity to work with these colleagues from several disciplines, several of whom I would never have met in my professional research and administration circles. John W. Erdman, Jr., Chair

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   15      The Committee’s Task,   15      Organization of the Report,   17      Energy Expenditure and Food Consumption During Military Operations or Training,   18      Impact of Highly Intense Operations on Health and Performance,   19      Development of Rations for Military Operations,   24      References,   27 2   ANSWERS TO THE MILITARY’S QUESTIONS   30      Assumptions,   31      Question A,   36      Questions B and C,   41      Question D,   60      Water Requirements,   114      References,   115 3   GENERAL CONSIDERATIONS AND SUMMARY OF THE RATION DESIGN   133      Committee’s Approach to Ration Design,   133      Health Concerns,   142      Food Matrix Considerations,   143      Monitoring Ration Performance and Use,   150      Future Needs,   151      References,   153

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations     APPENDIXES     A   WORKSHOP AGENDA   157 B   WORKSHOP PAPERS   162      Specifying Optimal Nutrient Composition for Military Assault Rations Andrew J. Young and Gerald A. Darsch   162      Physiological Demands of Combat Operations Scott J. Montain   169      Carbohydrate and Fat Intake: What is the Optimal Balance? Jørn Wulff Helge   180      Carbohydrate–Protein Balance for Physical Performance Kevin D. Tipton   191      Carbohydrate Ingestion During Intense Activity Edward F. Coyle   201      Macronutrient Composition of Military Rations for Cognitive Performance in Short-Term, High-Stress Situations Randall J. Kaplan   208      Do Structured Lipids Offer Advantages for Negative Energy Balance Stress Conditions? R. J. Jandacek   227      Optimum Protein Intake in Hypocaloric States L. John Hoffer   235      Vitamins C and E in the Prevention of Oxidative Stress, Inflammation, and Fatigue from Exhaustive Exercise Maret G. Traber and Angela Mastaloudis   243      Zinc, Magnesium, Copper, Iron, Selenium, and Calcium in Assault Rations: Roles in Promotion of Physical and Mental Performance Henry C. Lukaski and James G. Penland   256      Effect of Inadequate B Vitamin Intake and Extreme Physical Stress Lynn B. Bailey and Kristina von Castel-Dunwoody   270      Optimization of the Nutrient Composition of Military Rations for Short-Term, High-Stress Situations: Sodium, Potassium, and Other Electrolytes Susan Shirreffs   280      Other Bioactive Food Components and Dietary Supplements Rebecca B. Costello and George P. Chrousos   289      Effect of Physical Activity and Other Stressors on Appetite: Overcoming Underconsumption of Military Operational Rations, Revisited R. James Stubbs, Stephen Whybrow, Neil King, John E. Blundell, and Marinos Elia   307

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations      Optimization of Immune Function in Military Personnel Simin Nikbin Meydani and Faria Eksir   330      Optimization of Nutrient Composition for Assault Rations: Interaction of Stress with Immune Function Ronenn Roubenoff   336      The Potential Impact of Probiotics and Prebiotics on Gastrointestinal and Immune Health of Combat Soldiers Mary Ellen Sanders and Joshua Korzenik   341      Developing a Low Residue Diet Joanne L. Slavin   361      Diet and Kidney Stones: Optimizing Military Field Rations Linda K. Massey   366      Assault Rations: Organoleptic, Satiability, and Engineering Challenges Dennis H. Passe   372      Foods for People under Stress: Special Considerations Steven M. Wood   389      Food Intake Regulation: Liquid versus Solid Richard D. Mattes   404      A General Model of Intake Regulation: Diurnal and Dietary Composition Components John M. de Castro   411 C   BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS   422 D   BIOGRAPHICAL SKETCHES OF COMMITTEE MEMBERS AND STAFF   431 E   ACRONYMS AND ABBREVIATIONS   438 F   GLOSSARY   444

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