2
Answers to the Military’s Questions

This chapter presents the committee’s conclusions and recommendations regarding the specific questions posed by the military on the optimal nutrient composition of the assault ration. Chapter 3 provides additional comments and suggestions related to food ration development because the success of the ration is ultimately associated with its acceptability by the soldiers in the field.

The need for specific nutrients is influenced by the health status and specific scenario and environmental conditions in which soldiers are deployed. To provide context for the recommendations, assumptions of the characteristics of the soldiers’ diets and health, the missions, and other issues were formulated. These assumptions were compiled throughout the deliberations of the committee, open sessions with sponsor representatives and other military personnel, information from a field survey conducted in Afghanistan, and available literature. As a result, a worst-case scenario was constructed so that the recommended assault ration would diminish, to the extent possible, significant losses of body fat and protein, which, if allowed to occur, might prevent soldiers completing an assault mission from being redeployed to a subsequent mission in the immediate future.

Finally, where the committee identified gaps in the information available, research needs to establish nutrient requirements and to unravel food technology challenges are provided. This chapter presents the assumptions, along with the committee’s conclusions and recommendations, and research needs specific for each nutrient.



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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations 2 Answers to the Military’s Questions This chapter presents the committee’s conclusions and recommendations regarding the specific questions posed by the military on the optimal nutrient composition of the assault ration. Chapter 3 provides additional comments and suggestions related to food ration development because the success of the ration is ultimately associated with its acceptability by the soldiers in the field. The need for specific nutrients is influenced by the health status and specific scenario and environmental conditions in which soldiers are deployed. To provide context for the recommendations, assumptions of the characteristics of the soldiers’ diets and health, the missions, and other issues were formulated. These assumptions were compiled throughout the deliberations of the committee, open sessions with sponsor representatives and other military personnel, information from a field survey conducted in Afghanistan, and available literature. As a result, a worst-case scenario was constructed so that the recommended assault ration would diminish, to the extent possible, significant losses of body fat and protein, which, if allowed to occur, might prevent soldiers completing an assault mission from being redeployed to a subsequent mission in the immediate future. Finally, where the committee identified gaps in the information available, research needs to establish nutrient requirements and to unravel food technology challenges are provided. This chapter presents the assumptions, along with the committee’s conclusions and recommendations, and research needs specific for each nutrient.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations ASSUMPTIONS The assault ration recommended in this report is designed for healthy male soldiers with an average body weight of 80 kg, approximately 16 percent body fat who are relatively fit and within an age range of 18–45 years (average < 25 years) while on military assault missions. As evident in Table 1-1, the ration recommended does not meet the military recommended nutrient intakes for garrison in AR 40-25 (US Departments of Army, Navy, and Air Force, 2001) nor does it meet the recommended nutrient intakes for civilians (IOM, 1997a, 1998, 2000, 2001b, 2002a, 2004). For very active male soldiers in the field, daily energy intakes rarely are over 3,000 kcal (IOM, 1995) and unpublished data suggest they average 2,400 kcal (see Montain, 2004 in Appendix B), which in the event of energy expenditures of 4,500 kcal are significantly hypocaloric. Prolonged and continuous use of this hypocaloric ration as the sole source of sustenance at such high energy expenditures will lead to substantial weight loss. The committee emphasizes that this ration is meant to be used for repetitive three- to seven-day missions that last for a maximum total period of one month and that include recovery periods of 24 to 72 hours between missions. With the expected energy expenditures of 4,500 kcal/day during the missions, it is possible that some soldiers might lose as much as 10 percent body weight before the end of the month, even with refeeding between missions; this degree of weight loss could result in adverse, but mild performance decrements. However, there is not likely to be any serious consequences for health. Therefore, it is recommended that weight loss be measured after one month of use, and if weight loss is higher than 10 percent for a soldier, he should not be sent on assault missions until weight is regained to within 5 percent of initial weight. Scenarios Before and After Deployment on Assault Missions The committee assumes that, before being deployed on a mission, soldiers may be living in one of three general scenarios: A base in the United States or a foreign country in which food is relatively abundant and consumed on an ad libitum, uncontrolled basis. Soldiers have ready access to beverages, often including alcohol, and dietary supplements. A more highly controlled environment in a military theatre of operations. In such an environment, food consumption is ad libitum from either field kitchens or conventional foods in a garrison situation. There is a variable but generally more limited availability of other substances including food and dietary supplements. A recovery site where soldiers are in the process of rehabilitation from a prior assault mission. Food choice is even more limited, with fewer menu

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations items available, and provided ad libitum but in a more controlled environment than in the field kitchen. Nevertheless, the amount of food and calories available are more abundant than while deployed on an assault mission. The probability of soldiers deploying from any of these scenarios will no doubt vary, depending on the theatre of operations for the assault mission. Diets Prior to Assault Mission Food Consumption It is unclear what foods and beverages soldiers would be likely to consume before an assault mission. Existing literature and soldier interviews indicate that their food usually comes from a field kitchen. The soldiers may be eating Meals, Ready-to-Eat (MREs) or hot meals with bread and dessert served in a portable cafeteria line, but without fresh fruits or vegetables. Food in the pre-deployment setting is generally provided ad libitum. The committee assumes that the soldiers’ diet prior to the assault mission is ad libitum from a field kitchen without fresh fruits or vegetables. Alcohol Consumption Although military policy strictly prohibits alcohol consumption in the field operations, some alcoholic beverages are probably available in the local environment in many theatres of military operations. Some soldiers may have consumed alcohol in the days immediately before the mission. The likelihood of this happening depends on whether soldiers are deployed to the mission from a controlled environment or not (see scenarios above). Available information suggests that excessive alcohol consumption is unlikely to be a major problem among those being deployed on assault missions in the field. The committee assumes that soldiers may consume alcohol before the assault mission, but this is unlikely to be a major problem. Use of Dietary Supplements and Other Substances Dietary supplements, caffeine, and other substances such as tobacco may be available locally from several sources, as well as from shipments from home. As a result, effects of these on nutrient requirements as well as withdrawal symptoms may be relevant. The committee assumes that a soldier may use supplements and caffeine before the assault mission and withdrawal symptoms may interfere with performance. The general use of tobacco products is also assumed.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Diets Immediately Before Assault Mission Existing reports suggest that immediately (i.e., a day or hours) before the assault mission, soldiers are well hydrated. Indeed, because soldiers know that fluids are likely to be limited during the mission, with only four to five liters of water available, they may attempt to overhydrate themselves for a few hours before the mission. While a soldier could eat in excess or use protein-rich supplements in the period immediately prior to deployment on an assault mission, in general it has been reported that soldiers pay little attention to nutritional considerations during this time. It has also been reported that approximately 40 percent of the soldiers increase energy intake (primarily as carbohydrate) prior to deployment. Alcohol is strictly prohibited, although some alcohol may be available from the local environment; alcohol use was not reported as a problem. It is estimated that 20–30 percent of the soldiers smoke and as many as 60 percent chew or dip tobacco. The committee assumes that immediately prior to a mission soldiers are well hydrated, often use tobacco products, and do not abuse alcohol. Scenario During Assault Mission Duration of Mission The worst-case scenario is depicted as three- to seven-day missions that will be repeated several times with little rehabilitation in between missions, leading to increased physiological stress. Based on experiences in Afghanistan, in a 30-day period soldiers might be in assault operations as many as 24 days. The committee assumes that a soldier is in an assault mission 24 out of 30 days, with each mission lasting three to seven days. Physical Activity and Energy Expenditure The energy expenditure of soldiers while on an assault mission is reported to be approximately 4,500 kcal/day due to intermittent periods of high energy expenditure (> 50 percent VO2max) and periods of low-intensity, sustained movement. According to the experiences in Afghanistan, during a mission many soldiers sleep about five to six hours per day; the average sleep time, however, was four hours. The committee assumes that a soldier is physically active for a total of 20 hours per day, gets four hours per day of sleep, and expends about 4,500 kcal/day. Consumption of Ration Food Items Observational data from testing First Strike Rations (FSRs), a lightweight ration prototype being developed for assault missions by the US Department of

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations Defense Combat Feeding Directorate in Natick, Massachusetts, showed little wastage at approximately 2,400 kcal when used in military training. Some reports, however, suggest that with other higher-calorie rations, soldiers trade and selectively discard items (stripping) according to individual preferences. It appears that there is less stripping of the FSR than was the case in Desert Storm using MREs in the early 1990s (personal communication, S. Montain, US Army Research Institute of Environmental Medicine [USARIEM], August 9, 2004). When stripping of rations does occur, the carbohydrate-rich (e.g., candies) and protein-rich (or those entrees that are perceived as high in protein) meal items are the ones most frequently preserved. Items stripped depend on the environment; some items are favored in hot climates and others in cold climates. Relevant to these discussions is the fact that during Ranger Training in which one MRE per day plus a bread item (1,600 kcal/day) was provided, the rangers did not discard but rather ate 100 percent of the ration; however, their daily energy expenditure averaged 4,000 kcal and the period of training in the field was twice as long (56 days) as the time being considered in this report (Shippee et al., 1994). Other observations indicate that during recent Iraq missions troops discarded food items from MREs to carry more ammunition and then became hungry. It is not known what or how much was thrown away. The committee assumes that, if palatable, when provided with an assault ration of 2,400 kcal or less per day, soldiers expending 4,500 kcal per day will consume virtually 100 percent of the ration. Accessibility to Water It is assumed that soldiers have four to five liters of chlorinated water (i.e., 2-5 ppm chlorine) available during the mission. Water will be resupplied or obtained from other sources during the mission. Health Issues Little specific information is available on prevalence of diarrhea during recent assault missions in Afghanistan. Cases of diarrhea were reported as being a problem when soldiers ate local foods. Very few of the cases of diarrhea resulted in dehydration so severe that personnel had to be evacuated from the theatre of operation, although many more cases were probably treated medically in the field. Constipation in the field appears not to be of concern, according to interviews and information available to the committee. There is little information on the prevalence of kidney stones in the field, but it was mentioned as a concern in anecdotal reports. Some cases of kidney stones, though, were thought to be not the result of the rations consumed but of some preexisting condition previous to deployment (personal communication, C. Koenig, USARIEM, November 19, 2004). It is assumed that cases of diarrhea and kidney stones

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations occur during missions and are an important consideration when making recommendations on nutritional composition of assault rations. Environmental Conditions The climatic conditions and geographical sites in which combat can take place vary from hot, dry deserts to cold, high-altitude mountain terrains. Deployment to these varying environments can affect the nutrient requirements of soldiers due to differences in fluid intake as well as in sweat and excretory losses of nutrients. Even more unknown are the effects of these varied environments on food preferences, acceptability, and eating behavior. Although there was no attempt to consider all the possible environmental conditions, two environmental temperatures (20 and 30°C) were assumed in cases in which losses of a particular nutrient through sweat could be significant. In line with the committee’s philosophy of assuming the worst-case scenario, when sweat losses of minerals are significant (i.e., could lead to adverse health effects), an extra amount of the nutrient was included to cover the losses endured by soldiers engaged in significant energy expenditure (4,500 kcal) in warm temperatures. Physiological Compensation for Changes in Electrolyte Intake Electrolyte, especially sodium, intake in garrison and on mission may be very different. Adaptation to a lower level of intake is fairly rapid as reequilibrium of serum levels occurs quickly (e.g., within a few days for potassium and sodium; Luft et al., 1979; Ruppert et al., 1994). It is assumed that soldiers have different electrolyte intakes before a mission than during a mission but that the period of biological adjustment to these changes will be relatively short and thus of little consequence. Assault Ration Size and Weight Limits The daily assault ration for sustained operations could be distributed in various components but must fit in 0.12 cubic feet (e.g., a 6-inch cube) and weigh no more than 3 lb (1.36 kg). Packaging material constitutes 0.181 kg of the 1.36 kg. It is assumed that the ration is on average approximately 12–17 percent water, varying greatly from one item to the other; most items are energy dense, intermediate moisture food products with negligible packaging material weight. Form of Food In addition to food products of intermediate moisture, gels or powders high in carbohydrate and/or electrolytes that can be added to water and candy are

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations possible food forms that can be used in an assault ration. The committee assumed that there will be no liquid foods in the rations, and that gels, powders, or candy are alternate forms of food. Micronutrients Electrolytes may be supplemented as candy, gels, or powders to be added to fluid. It is assumed that all other required micronutrients, however, are provided within the food items making up the basic ration. Food Consumption During Recovery After Deployment on Assault Missions It is difficult to determine whether soldiers consciously attempt to gain weight during recovery or rehabilitation after missions. Anecdotal information indicates that after an assault mission and during recovery, soldiers generally eat to appetite if food is readily available, and most do not attempt to gain or lose weight. A complete reversal of the deficits incurred during the assault mission may not occur during the 1–3-day recovery period of time. For example, a report from recent operations in Afghanistan suggests that personnel are re-deployed on repeated assault missions with little time for recovery between missions. Thus, soldiers would rarely have adequate time to build up bodily stores for the next assault exercise. The committee assumes that food consumption after return from an assault mission will not allow for complete rehabilitation. However, it is also assumed that the food available during recovery will provide at a minimum the nutritional standards for operational rations as delineated in AR 40-25 (US Departments of Army, Navy, and Air Force, 2001). QUESTION A Should the energy content of the ration (energy density) be maximized so as to minimize the energy debt, or is there a more optimal mix of macronutrients and micronutrients, not necessarily producing maximal energy density? RECOMMENDATION: The basic ration’s energy content should be approximately 2,400 kcal/day. While this level does not maximize energy density, this is the average daily energy intake that has frequently been reported for soldiers during training. Choosing this caloric level minimizes the possibility of discarding food items that might result in inadequate intakes of necessary micronutrients; however, in case ration items are discarded, micronutrients should be distributed as evenly as possible throughout the food items in the ration (rather than clustering them in a few items) to prevent significant amounts of individual micronutrients from

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations being discarded. It should also be emphasized that rations should only be used over intermittent short terms (three to seven days) that, together, may last for a total of no more than a month. Options for the Energy Content of the Ration The committee discussed options that provide different macronutrient profiles and caloric content to meet the needs of soldiers on assault missions. Given the weight and size constraints of the ration (0.12 cubic feet, 1.36 kg) and unique circumstances encountered in the assault scenario, three options that represent the spectrum of possibilities were developed, and the most feasible option based on review of expected benefits and drawbacks was identified. The first option was to design a ration that would provide enough energy (i.e., 4,500 kcal) to meet the expected needs during the mission. The advantage of such a ration, if it were eaten completely, would be that soldiers would maintain energy equilibrium and avoid the adverse consequences of a periodic hypocaloric diet. The major disadvantage of this first option would be that when food items are discarded, as is often the case when higher-calorie rations are provided, nutrients would be discarded as well, potentially resulting in inadequate intakes of essential nutrients. Therfore, a major challenge with this scenario is to design a ration of sufficient palatability so that it is eaten in its entirety. When soldiers in the field do not consume all of their ration items when they are provided with enough MREs to meet their energy needs (personal communication, C. Koenig, USARIEM, November 19, 2004), then the risk of soldiers discarding foods containing rich sources of essential nutrients and increased risk for nutrient deficiency cannot be dismissed. Although it might be possible to design a ration in which nutrients are equally distributed among items, the acceptability of such a ration would be low compared to a ration that included foods that offer variety and familiarity (see Chapter 3, Food Matrix Considerations). Given the routine practice of stripping based on food preferences, providing a ration with a variety of highly acceptable products that ensures 100 percent consumption is more important than providing a ration with a high caloric value that may result in important components being discarded. A second option was to design a ration that would provide the usual energy needs of soldiers when not on assault operations; such energy needs are assumed to be approximately 3,500 kcal/day. The major advantage of this second option is that it would create a comparatively small energy deficit when energy expenditure is at the level of 4,500 kcal/day. However, this option design presents the same challenges as the one above, namely to design a ration that is fully eaten when the caloric content is higher than what they would normally eat. Given the challenge of designing a highly acceptable ration that is fully eaten by soldiers under stress in an assault operation, and due to concerns about selective discarding of some items in the ration, this is also not a viable design.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations The third energy level option would provide as a basic ration 2,400 kcal/day, with a supplemental source of energy. Observations in the field indicate that during training and with 3,600 kcal (3 MREs), a soldier’s voluntary energy intake is approximately 2,400 kcal/day, even when the energy expenditure is high (>7,000 kcal for marines at high altitudes and cold temperatures or ~ 6,000 kcal for Army rangers in warm temperatures) (see Montain, 2004 in Appendix B); therefore, 2,400 kcal/day represents an energy level at which virtually all of the ration should be consumed (personal communication, A. Young, USARIEM, August 9, 2004). The ration would include 100 to 120 g of protein, 350 g of carbohydrate, and the remainder as fat (approximately 22–25 percent) (see questions B and C and Box 2-1) for a total of 2,400 kcal, as well as the micronutrient recommendations which follow (see questions D and E). BOX 2-1 General Design of the Recommended Assault Ration Basic Ration: Protein 100–120 g (400–480 kcal; 17–20% kcal) Carbohydrate 350 g (1,400 kcal; 58% kcal) Fat 58–67 g (520–600 kcal; 22–25% kcal) Water 105 g (assuming an average of 17% moisture) Total weight (kcal) 613–642 g (2,400 kcal) Carbohydrate (and Electrolyte) Supplement: Carbohydrate 100 g (400 kcal) Water 17 g (assuming an average of 17% moisture) Sodium up to 12 g (based on palatability) Potassium up to 3.3–4.7 g (based on palatability) Total Weight (kcal) 117 g (400 kcal) Salt Tablets (Available Through Medical Personnel): Sodium up to 12 g Potassium up to 4.7 g Total Weight 16.7 g Packaging: 181 g Total Weight 0.95 kg Total Energy Content 2,800 kcal NOTE: This ration is intended for use over three- to seven-day missions for up to a month. Prolonged and continuous use of these rations as a sole source of sustenance may lead to substantial weight loss. Constraints: weight of 3 lb (1.36 kg) and volume of 0.12 cubic feet.

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations To provide an energy level closer to the level of energy expended, 400 additional kcal should be supplemented to the basic ration, increasing the total energy content of the ration to 2,800 kcal/day. This can be accomplished with the addition of supplements in individual, small packages with a total amount of up to 100 g (400 kcal) of carbohydrate in four forms: as a powder to be dissolved in a liquid, as a gel, as candy, or as some combination of these depending on the delivery system. Although soldiers would still be in a negative energy balance, little evidence exists to suggest that a periodic hypocaloric diet, if otherwise adequate in protein and other essential nutrients as specified in the following sections, is likely to be harmful when consumed over brief periods of time (repetitive three to seven days, up to a month), even if some weight loss occurs (< 10 percent of body weight). However, with the expected energy expenditures of 4,500 kcal/day during the missions, it is possible that some soldiers might lose as much as 10 percent body weight before the end of the month, even with refeeding between missions; this degree of weight loss could result in adverse, but mild, performance decrements. However, this level of weight loss is not likely to be of any serious consequences for health. Therefore, it is recommended that weight loss be measured after one month of use, and if weight loss is higher than 10 percent for a soldier, he should not be sent on assault missions until weight is regained to within 5 percent of initial weight. Rationale for Energy Content Energy expenditures of soldiers during combat assault missions have been reported to be high (about 4,500 kcal/day). The committee based its recommendation for energy level on the premise that, to maintain health and performance, it is critical that soldiers have adequate nutrient intakes and that, based on experience, in this type of military operations voluntary daily energy intakes approximates 2,400 kcal. While it is possible to construct a ration with up to 4,500 kcal within the constraints of weight and size, given the research reviewed and anecdotal information, soldiers would most likely selectively discard unwanted items (“cherry pick”) and, in this way, would likely consume less of essential nutrients. A strategy to avoid nutrient inadequacies due to stripping would be to design a ration with nutrients equally distributed among items. While this might appear ideal and highly desirable from the nutritional standpoint, it is unlikely that a ration can be designed that, in addition to having nutrients equally distributed, is also palatable and acceptable, two key requirements to enhancing intake. Typically, nutrients in palatable, commercially available products are not equally distributed. To maximize acceptability and encourage consumption, the ration should contain a variety of foods that are similar to those commercially available rather than relying on the “bar” type of product fortified to contain the recommended levels of all nutrients. Moreover, given the fact that water needs increase

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Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations with caloric intake, a lower calorie ration may be advantageous. Providing a ration with a variety of highly acceptable products that ensure 100 percent consumption is more important than providing a ration with a high caloric value that may result in important components being discarded. Given the weight and volume restrictions and considerations described above, a 2,400 kcal basic ration is the most nutritionally appropriate choice among the three options discussed above (i.e., energy content of 4,500, 3,600, and 2,400 kcal). Recent experience with prototype FSRs at approximately similar levels of energy content (approximately 2,400 kcal) indicates that selective discarding of menu items in the rations was not widely practiced (personal communication, A. Young, USARIEM, August 9, 2004). A ration of 2,400 kcal, although hypocaloric, will be above the basal level necessary for covering resting metabolism in all individuals in the military. Since the caloric deficit is not likely to be sustained for more than three to seven days at a time during the assault mission, the concern about the potential inadequate intake of important nutrients when stripping a higher caloric ration outweighs the concern about the effects of multiple hypocaloric periods. In addition to the enery content of the basic ration of 2,400 kcal, an additional 100 g (400 kcal) of carbohydrate would be a readily available source of carbohydrate. This supplemental energy source could be consumed on a periodic basis in bolus doses to keep energy (and electrolytes) at more satisfactory levels or as a supplement of energy for individuals with even greater caloric expenditure. Also, such energy-dense snacks appear to be particularly popular among the troops (personal communication, C. Koenig, USARIEM, November 19, 2004). Even with such a low-caloric ration, specific items containing concentrated sources of a particular nutrient may be selectively discarded, leading to an increased risk of nutrient deficits. This is particularly true for items other than high-carbohydrate foods. Therefore, to further ensure the maximum consumption of all essential nutrients in the ration, the micronutrients and macronutrients should be distributed as evenly as possible; this should be accomplished without compromising acceptability across menu items in the ration. Research Needs Related to Energy Content Test the acceptability of the prototype assault ration under field conditions and determine the actual amounts eaten. The extent of discarding ration items under combat conditions needs to be evaluated in field surveys, and the findings must be taken into account in ration development and refinement.

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