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2
Military Dietary Reference Intakes:
Process to Establish, Uses,
and Delivery Methods
Nutrient standards are developed to ensure that different populations' (indi-
viduals or groups) nutrients needs are met--they serve as criteria for dietary
nutrient adequacy. In the United States, the Dietary Reference Intakes (DRIs)
recommended in various Institute of Medicine (IOM) reports (IOM, 1997, 1998a,
2000b, 2001, 2002/2005, 2005) are used as the nutrient standards to ensure a
healthy U.S. population (see Table 1-1). The DRIs are comprised of the follow-
ing four nutrient-based reference values established by gender and age group--
the Estimated Average Requirement (EAR), the Recommended Dietary Allow-
ance (RDA), the Adequate Intake (AI), and the Tolerable Upper Intake Level
(UL).
The IOM EARs and RDAs are the average intake levels that meet respec-
tively the requirements of 50 and 9798 percent of the healthy individuals in a
population in a particular life stage and gender group. An RDA is the reference
value--derived mathematically from the EAR population distribution--for plan-
ning individual intakes. If an EAR cannot be determined because of a lack of
experimental data (e.g., balance studies), then the AI (estimated intake by a
population, based on observed or experimentally determined approximations of
nutrient intakes) is used for planning individual intakes. The IOM UL is the
highest intake level likely to pose no risk of an adverse health effect to almost all
individuals. As mentioned previously, changes in the DRIs are the prerogative of
the IOM DRI committee and will be considered and applied as new relevant
information becomes available.
Military personnel engage in activities that may require higher intakes of
specific nutrients to maintain health. If the objective is not only to maintain
health, like with the IOM DRIs but also to optimize performance, then the nutri-
36
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MILITARY DIETARY REFERENCE INTAKES 37
ent needs might change even more. The establishment of standards specific to
the military population requires not only expertise in nutrient metabolism but
also in-depth knowledge of the military scenarios and factors that need to be
considered thereof. Such standards--the Military Dietary Reference Intakes
(MDRIs) and the nutritional standards for operational rations (NSORs)--were
last published in 2001 Army Regulation (AR) 40-25 (U.S. Departments of the
Army, Navy, and Air Force, 2001) before the publication of numerous IOM
reports, including those that have provided revised IOM DRI values for some
minerals (IOM, 2001). Table 1-1 in Chapter 1 shows the MDRIs, the NSORs,
and the IOM RDAs (or AIs) for men and women.
MDRIs are intended to serve menu developers and other nutritional special-
ists with ensuring adequate nutrition of military personnel during garrison activi-
ties, that is, when the personnel are eating primarily from cafeteria-style menus
in dining facilities, not from operational rations. In contrast, the NSORs have
been established to represent the minimal levels of nutrients that operational
rations should contain; these levels would provide adequate nutrition for most
military personnel doing moderate or intense physical activity and are based on
the MDRIs (see Chapter 1). AR 40-25 (U.S. Departments of the Army, Navy,
and Air Force, 2001)--the 2001 regulation stating the MDRIs and NSORs--will
be revised soon (Baker-Fulco, 2005; see Appendix B) to possibly reflect updated
DRI values that take into account new EARs (e.g., for iron and zinc) or nutrients
previously without MDRIs (e.g., copper and manganese). The 2001 MDRIs were
based entirely on the DRIs but were applied to the military population, which in
general tends to be a little heavier and more active than the U.S. population
(Baker-Fulco, 2005; see Appendix B). Many of the MDRI values are similar to
the DRIs, with the notable exception of sodium. Although the following discus-
sion on the process of establishing mineral standards for the military might be
applicable to other nutrients, the Committee on Mineral Requirements for Cog-
nitive and Physical Performance of Military Personnel has focused its delibera-
tions on standards for minerals, therefore, these recommendations apply mainly
to the establishment of mineral standards.
There are two main types of feeding schedules in the military: garrison and
operational rations. Garrison feeding refers to food consumption by military
personnel who are under a variety of scenarios that range from administrative
duties (e.g., office workers completing physically inactive tasks) to support tasks
performed by personnel (e.g., hospital personnel involved in moderate levels of
activity) to soldiers training for or performing missions while living on a military
base (e.g., Rangers training at high levels of physical activity).
Operational feeding refers to the consumption of either full- or restricted-
calorie rations while engaged in military operations (e.g., sustained operations as
defined in Chapter 3) or training. The MDRIs are used to establish the NSORs
for full-calorie, standard operational rations as well as for restricted-calorie ra-
tions. There is an expectation that operational rations will be used by men and
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38 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
woman who undergo much more rigorous physical activity than the average
person in the same age range in the U.S. general population.
This report is concerned with soldiers in garrison who perform a moderate-
to high-level of physical activity (referred to throughout the report as "garrison
training" and defined in Chapter 3) and with soldiers in sustained operations
while eating operational rations [i.e., first strike rations (FSRs)].
MILITARY NUTRIENT STANDARDS
Is There a Need for Specific Military Nutrient Standards?
Because of the different environmental and physiological circumstances of-
ten encountered by the Armed Forces, the MDRIs (traditionally variants of the
IOM DRIs) have been developed to plan appropriate intakes and rations for
enlisted personnel. There are several good reasons to establish the MDRIs, dis-
tinct from the IOM DRIs for the U.S. general population.
First, the reference anthropometric standards for the military are different
from those for civilians. The reference military person is slightly different in
height, weight, and body fat and lean mass compared to the civilian person.
Second, the MDRIs are targeted to individuals who are 1750 years old, the age
range of the vast majority of enlisted men and women (for those who are 1718
years old, AR 40-25 includes exceptions to the MDRI levels, indicated as foot-
notes to the MDRI tables) (U.S. Departments of the Army, Navy, and Air Force,
2001). The MDRIs are stated as a single value for men and women when they
are used to establish NSOR, that is, the highest gender-specific reference value
for 1750 year olds is used. The MDRIs could be adapted for specifying differ-
ent recommendations for males and females, should that be necessary. There are
no ULs specifically for the military, because the UL values are judged to be the
same as those for civilians.
Second, the process of developing the MDRIs involves examination and
deliberation about the specific requirements of the military, not taken into ac-
count when establishing the DRI for the general population. For example, MDRIs
specify appropriate nutrient intakes in especially stressful environments (e.g.,
those with extremes in weather) or under different levels of activity. Other groups
within the military that might need special nutrient requirements are those con-
suming calorie-reduction diets or suffering from illnesses, such as infections or
those performing tasks that demand appropriate maintenance of cognitive func-
tions (e.g., attention or alertness). Hence, it would be possible to specify condi-
tions for various special circumstances, such as garrison training and sustained
operations, each with its own idiosyncrasies that might result in different nutri-
ent recommendations. In fact, although the MDRIs are based generally on the
IOM DRIs, there are already some exceptions to them based on unique situa-
tions; the rationale for these exceptions is stated explicitly in an accompanying
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MILITARY DIETARY REFERENCE INTAKES 39
document (Baker-Fulco et al., 2001), which is updated periodically by the U.S.
Department of Defense. As the science addressing the unique nutrient needs of
the military personnel emerges, additional exceptions will have to be made, as
illustrated in the mineral level recommendations listed in Chapter 3.
The importance of establishing military-specific nutrient standards lies in
the fact that the MDRIs serve as a useful basis for devising menus for the troops.
The MDRIs are used as a sort of minimum standard to be supplied in developing
rations for which the military provides most or all of the food. This is a critical
and practical application of the MDRIs. It may be that some rations' nutrient
levels would be inadequate--especially when soldiers face extreme environmen-
tal or stressful situations--if the IOM DRIs for the general population were
used.
The third reason for establishing and periodically revising the MDRIs is to
demonstrate that the Armed Forces have duly noted and carefully considered and
updated recommendations for feeding enlisted men and women. Maintaining
and promoting the health of the military who are serving public interests should
be among the utmost priorities and deserve the highest consideration.
RECOMMENDATION: The MDRIs should continue to reflect the
IOM DRIs. Modifications should be made to specific nutrient re-
quirements if there is sufficient scientific evidence that circum-
stances call for different requirements and intakes, whether to
maintain nutrient or health status or to improve performance. In
particular, some recommended values for minerals should reflect
enhanced mineral losses caused by high performance activity. Also,
the MDRIs can be used for rations development for the individual
soldier.
Establishment of Nutrient Military Standards
The MDRIs have not been established using the more systematic approach
followed for deriving the IOM DRIs because critical experimental studies to
develop them were lacking. The foundation for setting RDAs is the EAR for a
given gender and life stage within a population. As mentioned previously the
EAR is the nutrient intake level for a population group that would meet the needs
for 50 percent of that population and should be based on appropriate experimen-
tal data that allow an estimate of average requirements. The RDA then can be set
by adding two standard deviations (SDs) of the EAR to the EAR if the require-
ment is normally distributed. Thus, the RDA = EAR + (2 × SDEAR). Often the
SD of the EAR's distribution is unknown, and a coefficient of variation of 10
percent around the EAR is used. In any case, it follows that establishing an EAR
is necessary for setting an RDA. Although, ideally, one should collect new data
under the special circumstances that occur in the military (e.g., higher energy
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40 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
expenditures and excessive sweating) to establish a new military EAR, it is
unlikely that such data will be collected specifically for military personnel. In
the absence of these data, adjustment of the existing EAR for appropriate age
and sex groups may be necessary to set an RDA for military personnel. If an
IOM EAR for the U.S. population does not exist, then the U.S. population's AI
(which allows estimating an intake level that will be adequate for practically
everyone in a particular life stage and gender) could be used as a guide to ensure
adequacy. There is less confidence, however, in using an AI as a nutrient stan-
dard than there is in using an RDA. Moreover, using an AI as a criterion for
planning rations and menus as well as for assessing intake adequacy presents
special challenges (IOM, 2000a, 2003).
Thus, the committee urges that research studies be designed to determine
the EAR adjustments needed for those nutrients whose requirements will most
likely change under the environmental conditions of higher energy expenditure
and stress that accompany garrison training and other unique military situations.
In addition, the standard deviation of such experimental data should be derived
in order to calculate an RDA for military personnel. For example, sweat losses of
minerals during garrison training should be measured and factored into a new
garrison-training EAR; in other words, to calculate the military standard, the
IOM EAR should be modified accordingly (see the following section, Factors
Affecting Nutrient Needs for Military Personnel, for other considerations). Using
an approach that is similar to the derivation of IOM RDAs, the new military
RDA for garrison training for each nutrient could be calculated by using the new
EAR's standard deviation. Such an approach will result in a new level estimated
to be adequate to fulfill the needs of 9798 percent of the military personnel in
garrison training. The committee concluded that the new RDAs could not appro-
priately be called military RDAs, because they are meant to meet the unique
needs of those in garrison training, not all military personnel. For the purpose of
this report, the committee will refer to these new RDAs as RDAs for military
garrison training or RDAMGT (also EARMGT or AIMGT). The following two-part
equation--using the example of mineral losses during garrison training--
demonstrates how the new standard will be calculated:
1. Current IOM EAR + additional mineral sweat losses = EARMGT
2. EARMGT + 2 × SD (EARMGT) = RDAMGT
RECOMMENDATION: Nutrient standards for the military in gar-
rison training should be derived as follows:
1. EARMGT = Modify the current IOM EAR by adjusting for
the variable of interest (e.g., level of sweat losses)
2. RDAMGT = Add 2 × SD of the EARMGT, to ensure 9798
percent of soldiers will have adequate intake
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MILITARY DIETARY REFERENCE INTAKES 41
Factors Affecting Nutrient Needs for Military Personnel
There are at least five different ways in which nutrients deficiencies may
develop: (1) reduced intake, (2) impaired intake due to disease or trauma, (3)
increased losses, (4) impaired utilization, and (5) increased requirements. One or
more of these factors may be involved in increasing an individual's vulnerability
toward nutrient deficiency. Except for those individuals in the military who are
responsible solely for administrative tasks, military life encompasses unique cir-
cumstances that, for some nutrients, may result in nutrient requirements different
from those of the general population. For example, soldiers are involved rou-
tinely in training, combat, and support operations; these activities carry with
them a number of stresses that are extremely demanding, both physically and
mentally, for each individual. It is important to periodically examine the nutrient
needs of various groups within the military and to adjust or develop new MDRIs
accordingly.
In addition to any altered nutrient requirements that emerge as a result of the
unique situations in military life, it is necessary to distinguish between the nutri-
ent requirements as defined in previous IOM reports and the nutrient require-
ments that will be recommended in this report, which are referred to as standards
for individuals for various military situations (e.g., RDAMGT). An underlying
principle of the RDAs set by the IOM is that the desired outcome was to main-
tain health in already healthy people; improving performance was not relevant.
Following this principle, the IOM levels are based on calculations of the amounts
that must be provided to meet physiological needs under relatively normal con-
ditions. In contrast, the task given to this committee was to determine mineral
requirements that sustain but also improve military performance, including physi-
cal and cognitive performance. Accordingly, the RDAMGT or AIMGT recom-
mended by this committee have taken into account not only requirements to
meet physiological needs, but also any scientific evidence that would support
potential benefits of a particular nutrient level on military performance. Out-
comes that have been considered by this committee are mostly those included in
the cognitive and behavioral systems, immune and endocrine systems, and mus-
culoskeletal system.
Currently the MDRIs-based NSOR are meant for the healthy military popu-
lation; they are supposed to cover the needs of military personnel under operat-
ing conditions, whether simulated or actual combat. The major feature that cur-
rently distinguishes the MDRIs from the IOM DRIs is a need for additional
sodium for individuals who do hard physical work. Future reiterations of the
Army Regulations should reflect other unique requirements of military per-
sonnel undergoing physical exercise under stress and extreme environmental
conditions.
Variables such as nutrients' bioavailability, interactions with other nutrients,
and nutrient degradation due to long-term storage should be factored in when
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42 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
designing rations. The rations should contain at least the level of nutrients
required, plus an amount of nutrient that reflects nutrients' bioavailability or
losses during food processing or storage.
RECOMMENDATION: As more evidence becomes available, the
committee recommends that military nutrient standards for unique
circumstances in the military (e.g., soldiers engaging in sustained
operations or in garrison training) be updated periodically by con-
sidering scientific evidence from studies on the benefits of specific
nutrients (e.g., for improved cognitive function) or from studies re-
vealing altered nutrient metabolism due to military performance
(e.g., increased sweat losses).
Use of Nutrient Military Standards
To recommend levels for mineral nutrient standards that are scientifically-
based as well as practical, it is important to consider the intended use of such
standards. With this in mind, the committee asked for guidance from military
personnel with experience in implementing the military nutrient standards, both
the 2001 MDRIs and the previous standards, the 1985 MRDAs. In addition, the
committee requested opinions from military professionals (including physicians,
dietitians, and Quartermaster Corps) regarding the need for distinction between
the MDRIs and the IOM DRIs. The requests revealed that the MDRIs were used
as basis for the NSORs, which are used for rations planning and assessment;
consequently, they affect the Combat Feeding Program for both training and
combat (e.g., sustained operations) more directly than they affect the menu de-
signs or dietary counseling activities in garrison situations. In summary, there is
a place for the MDRIs as nutrient standards in the context of military operations,
but they are not as useful as a basis for the garrison training situations during
which cafeteria-style food is offered ad libitum.
As with other dietitians, those in the military rely on the DRIs for counsel-
ing clients or for planning garrison menus. The major goal for garrison menus is
to provide variety of healthy options to military personnel who eat in the dining
facilities, especially for those who are trying to lose weight. Dietitians use basic
and flexible menu standards; devising menus primarily by using food-based
guidelines, such as the Department of the Army Pamphlet 30-22, Operating
Procedures for the Army Food Program (U.S. Department of the Army, 2002),
rather than the nutrients standard in AR 40-25 (U.S. Departments of the Army,
Navy, and Air Force, 2001). Although installation commanders are told to pro-
mote a comprehensive nutrition program for all operational dining facilities
through AR 30-22, The Army Food Program (U.S. Department of the Army,
2005), respondents to the committee's queries indicated that implementation and
oversight varied greatly by commander. Food Operations Sergeants (FOS) are
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MILITARY DIETARY REFERENCE INTAKES 43
asked to consider nutritional adequacy in accordance with the Nutrition Stan-
dards and Education, AR 40-25 (U.S Department of the Army, 2002) when they
make adjustments to the dining facility menus--AR 40-25 regulations are cited
in various places in Department of the Army Pamphlet 30-22.
The most practical use of the IOM DRIs is in the dietary planning and
assessment for populations and individuals; these uses have been described in
two reports (IOM, 2000a, 2003) that illustrate the processes with practical ex-
amples. Generally, the IOM DRIs are used for planning to ensure a low preva-
lence of inadequate nutrient intakes. For example, the IOM DRIs can be used by
an individual to plan his or her diet and food purchases or by a food service
manager to plan menus for an institution. To plan menus or rations for a large
group, the EAR (the average intake for nutrients by the target population) or AI
and its distribution should be known. To plan diets for individuals, however, it is
appropriate and sufficient to use only the RDAs. Both the group and individual
planning also use the UL as well. Similar to the IOM DRIs, the MDRIs could be
used to plan and assess menus for military personnel.
The difficulty in assessing the nutritional adequacy--whether nutrient com-
position satisfactorily will meet nutrient needs--of menus for soldiers in garri-
son training is the lack of data on the intake distribution. The distribution is
likely to be broad when individuals are sometimes eating cafeteria food ad libi-
tum, as soldiers do when in garrison training. This lack of data is a limitation that
partially explains the fact that the MDRIs are not typically used to plan or assess
menus for soldiers with free access to cafeteria food. This committee speculates
that the MDRIs could be used by cafeteria menu planners as a useful benchmark
for what levels of nutrients are needed in foods on the menu. However, that task
is beyond the scope of this report. The IOM report Applications in Dietary Plan-
ning (IOM, 2003) should serve as a guide on using MDRIs for dietary planning
for populations. For the present, managers should make sure that cafeteria food
is nutritionally diverse and adequate and that it contains all of the food groups so
as to meet an individual's MDRIs. Food service managers should include dieti-
tians and nutritionists who also are capable of applying nutrition guides, such as
the Dietary Guidelines for Americans (http://www.healthierus.gov/dietaryguide
lines/) and MyPyramid (http://www.mypyramid.gov/), to the design of cafeteria
food choices. The committee encourages studies by the military on nutrient in-
take distribution data that would assist the military in using the MDRIs to plan
menus.
Conversely, although the nutrient intake levels for those eating rations is not
known, it can be assumed safely that such levels will not vary too much if all of
the rations issued are fully consumed. Under such circumstances, group-
planning methods are not needed. Instead, the goal will be that each individual
eating the rations gets the recommended intake, which can be expected since
each individual within the group will be provided the same level of nutrient
(mineral). In particular, to plan the levels of minerals in operational rations for
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44 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
garrison training, rations should meet the new military RDAs (e.g., RDAMGT) for
minerals, which should be established specifically depending on the operation
and environment (e.g., garrison training versus sustained operations).
In this report, the assumption is made that most soldiers in military opera-
tions will consume their complete rations. Since males and females may differ in
requirements, and given that the Army cannot particularize its rations, the rec-
ommended mineral amounts in the rations for groups with gender differences
should be set at the highest standards. In every case, this recommended level
should be lower than the UL for the age range. Accordingly, the current NSOR
are established to represent the minimal levels (or those that are maximums) of
nutrients in operational rations and, when adjusted as described (where the aver-
age menu meets one-third of the NSOR and no single menu is 20 percent below
set minimums or above set maximums of one-third the NSOR limits [Baker-
Fulco et al., 2001]), would provide adequate levels for military personnel under
specific military situations.
RECOMMENDATION: The committee supports the use of NSORs
as minimum levels of minerals in operational ration; NSORs should
be established based on new military RDAs (e.g., RDAMGT), devel-
oped as new scientific data become available. The NSORs might be
different for specific military situations; for example, NSORs for
military garrison training and those for sustained operations might
differ.
THREE STRATEGIES TO INCREASE NUTRIENT INTAKE
The following three basic strategies can be used to improve intake and nutri-
tional status of enlisted personnel: food-based approaches, fortification, supple-
mentation (IOM, 1998b). The uses, advantages, and disadvantages of each strat-
egy are described in the following sections.
Typical Food-Based Approaches
The most common food-based strategies to raise nutrient intake are those
that encourage dietary diversification and frequent consumption of particularly
nutrient-rich food sources.
Uses and Advantages
The advantages of these strategies include greater acceptability by the target
population, the ability to provide many nutrients simultaneously, and the rela-
tively low cost. Also, concentrated doses of nutrients that may be problematic or
associated with toxicities are avoided. Finally, there are potentially beneficial
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MILITARY DIETARY REFERENCE INTAKES 45
bioactive food components that, because they are not nutrients, are not added to
foods as fortificants or supplements. Food-based strategies are relatively long-
term strategies if changing diets or food habits is necessary, but they can be
combined with shorter-term strategies to achieve needed results. In an ideal
situation--if food access, availability, and diversity were optimal--the nutrient
needs of the general population would be met solely from food sources, since
there are many different food combinations in diets that sustain good health. The
optimal food combinations depend on the food characteristics and the larger
environments, economics, and other factors (e.g., accessibility) that may apply
only to the military.
There is a general perception that nutrients from food are healthier than
those that come from supplements. Although it is true that some forms of vita-
mins and minerals are different or more bioavailable in foods than in supple-
ments, this is not true in all cases; bioavailability varies from nutrient to nutrient.
In fact, some nutrients (e.g., various forms of calcium) are more bioavailable in
fortificants and supplements than they are in food form. Many constituents that
exist in a food matrix may influence not only nutrient bioavailability but also
their functions in the body. In general, if the diet is complete and balanced, no
supplement is needed to meet the DRI. For these reasons, most nutrition science
experts favor food-based strategies and dietary patterns instead of ones that em-
phasize dietary supplements (Lichtenstein and Russell, 2005). Also, even though
it has not been possible to show a decreased incidence of cardiovascular disease
or other chronic degenerative diseases with simple single-nutrient supplementa-
tion or fortification programs, total dietary patterns do seem to make a greater
difference. For example, the Dietary Approaches to Stop Hypertension (DASH)
diet--which uses regular food items to provide a moderate- to low-fat diet high
in calcium, potassium, and magnesium (elements that have been associated with
a decreased risk of heart disease)--does seem, in fact, to have a beneficial effect
on blood pressure, especially when dietary sodium is also lower (Appel et al.,
1997; Harsha et al., 1999).
Disadvantages
One of the disadvantages associated with food-based strategies is that it is a
long-term strategy; thus, when more immediate results are necessary, they may
not be achievable in a short time period. A second disadvantage is that dietary
strategies involving ordinary foods are rarely helpful therapeutically. Once dis-
ease is present more radical measures, including diet therapy and supplementa-
tion, are likely to be needed. Third, educators need to be involved extensively,
and, if the food is not already available, then the agricultural sector must become
involved to produce it. Also, long-held food beliefs, cultures, and behaviors may
need to be changed. Some advocates of supplements claim that although most
Americans consume enough nutrients in their diets to prevent dietary deficiency
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46 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
diseases, they consume less than the amount necessary for good health. While
this is an interesting hypothesis, it has yet to be tested, and at present cannot be
used as a justification for supplementation. Finally, it may not be possible to
obtain the necessary nutrient amounts from food sources alone, so other mea-
sures may then be taken.
Fortification
Fortification describes adding to a food nutrient levels that are above the
naturally-occurring levels; in some cases, it means adding a nutrient to a food in
which it normally would not be present. Restoration is a form of fortification that
involves the replacement (either partial or full) of nutrients that were lost during
a stage of food production or distribution. In theory, it should be possible to add
pure forms of nutrients present in minimally processed foods to highly processed
foods to obtain nutritional equivalency. The original food should be an important
source of one or more nutrients, especially if there is nutrient inadequacy in the
population group. One standard for this is that the food that provides at least 10
percent of the Daily Value for a specific nutrient (U.S. FDA, 1999).
Nutritionally improving widely consumed foods by fortification (also called
enrichment), without trying to change food habits, is a common way of ensuring
and improving the food supply's nutritional adequacy. This strategy also is use-
ful when food choices are limited or when available foods are not nutritionally
complete or acceptable. Other cases exist, too, when fortification may be neces-
sary (e.g., to meet certain nutrient standards). The term fortification is used to
refer to the addition of nutrients not only to food but also to water and salt.
Key conditions for successful fortification include the following:
· Fortification should focus as narrowly as possible on a target population.
For example, when the benefits from higher nutrient intakes extend across the
population, the entire population is the target, and appropriate fortification of
staple foods ensures reaching the targeted population. On the other hand, when
only a subgroup of the population is deficient in a nutrient, then fortification of
specific foods eaten by those at risk is more appropriate. Dietary surveys may be
needed to describe the amounts and distributions of nutrient intakes in the popu-
lation and to identify the most suitable food vehicle.
· Fortificants must be bioavailable.
· Fortification must be acceptable from the standpoint of final food prod-
uct taste and appearance, as some fortificants, such as iron salts, change food
quality.
· The food vehicle used to carry a fortificant must be easily accessible and
eaten regularly in portions that are large enough to provide the appropriate dose.
· The production capacity, instructions, and monitoring of fortification
must be in place.
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MILITARY DIETARY REFERENCE INTAKES 47
Fortification increases costs to food manufacturers because of the cost of
mixing the fortificants, quality control procedures, and the cost of acquiring
particular fortificants at selected levels. Foods fortified solely for the military are
more costly than foods already fortified for the civilian menu because of losses
in economies of scale. In the United States, most ready-to-eat breakfast cereals
have been fortified voluntarily--with a range of vitamins and iron at levels of 17
to 50 percent of the RDAs--for many years (e.g., iron levels see Johnson et al.,
1998). Bread and flour have been fortified not only for iron but also, in the
United Kingdom, for calcium; these fortifications appear to be acceptable even
at fairly high levels. Orange juice, meal-replacement products, and sport drinks
are examples of other calcium-fortified foods.
Uses and Advantages of Fortification
Fortification is best used as a preventive strategy or to decrease the risk of
nutrient inadequacy. Its time course of effect is between that of the supplement,
which is relatively rapid in achieving the change in micronutrient status (owing
to the high specificity and relatively high doses), and the less rapid effects ob-
served from eating usual diets. The fortification strategy is sustainable under
most conditions, and it is often cost effective as well.
Fortification is defined by statute for certain nutrients but not for others. For
example fortification is used in the United States for restoring certain nutrients to
flour. Enriched products in the United States have a standard of identity that
requires nutrients to be added in accordance with U.S. Food and Drug Adminis-
tration (FDA) regulations, for example folic acid (U.S. FDA, 1996). The FDA
also specifies enrichment and fortification levels for nutrients that are known to
be essential such as minerals and it is recommended that they are fortified at
levels proportional to the caloric content of the food they are added to. In the
majority of cases, these specifications are FDA guidelines and are not mandated.
Thus, public health measures--specified by law or regulation--that rely on for-
tification and enrichment have clear guidelines that must be followed. No spe-
cific fortification levels are set as regulations for other nutrients (e.g., chromium,
selenium, potassium) as well as for some nutrients in other foods (e.g., for cal-
cium in orange juice).
Disadvantages
One of the disadvantages of fortification is that it is rarely used for more
than a few nutrients. However, some nutrients occurring in foods may function
better together with or only in the presence of other nutrients. For example, the
B-complex vitamins have closely interrelated metabolic functions. Failure to
provide sufficient dietary amounts of one or more of those nutrients that work
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48 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
together may impair the functions of other B vitamins. This scenario also might
be true for some combinations of minerals.
The risk of excessive intakes of specific nutrients due to voluntary, market-
driven food fortification or overconsumption of the fortified food is of concern,
especially when the IOM UL is relatively close to the RDA. Also, there are
concerns about the potential for public confusion about nutrition education mes-
sages. For example, fortifying candies and carbonated beverages is not sup-
ported fully among nutritionists because it might be perceived as sending an
inconsistent message.
Another disadvantage of providing nutrients, especially minerals, in large
amounts from single sources is that bioavailability may decrease when nutrient
interactions are favored by the high nutrient concentrations.
Supplementation
The FDA defines a dietary supplement as a product (other than tobacco)
that adds to the diet and contains one or more of the following dietary ingredi-
ents: a vitamin; a mineral; an herb or other botanical; an amino acid; a dietary
substance that supplements the diet by increasing the total daily intake; or a
concentrate, metabolite, constituent, extract; or combinations of these ingredi-
ents (U.S. FDA, 1995). Dietary supplements that provide nutrients or non-
nutrients by oral means come in various forms (e.g., pills and powders) other
than food and beverages.
Uses
International bodies, such as the Codex Alimentarius (FAO, 2005), re-
cently have released guidelines for the use of supplements. The guidelines
state that individuals should be encouraged to select a balanced diet from which
sufficient amounts of the vitamins and minerals can be obtained. Hence, supple-
ments should be used only in cases where food does not provide sufficient
vitamins and minerals. The Scientists from an International Conference on
Nutrition suggests that supplementation be restricted to vulnerable groups that
cannot meet their nutrient needs through food alone. Such groups include
women of childbearing age, infants and young children, the elderly and the
poor, those who are displaced, refugees, and those in other emergency situa-
tions (FAO and WHO, 1992).
Factors to consider when choosing supplementation as a strategy include the
following:
· The intake amounts that can be obtained normally from food relative to
the amounts that are needed.
· The target group or population.
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MILITARY DIETARY REFERENCE INTAKES 49
· The targeted individuals' willingness to consume supplements.
· The inability to use another strategy (e.g., nutrient-rich food sources or
fortified foods).
Advantages
Supplementation is suitable for nutrient deficiency prevention in healthy
individuals, but it is especially appropriate for therapeutic purposes. However,
the efficacy of using dietary supplements to provide high levels of nutrients for
altering chronic disease risk is less well established (Caballero, 2003). Criteria
for recommending mineral supplementation vary among expert groups.
Supplementation can generate changes in micronutrient status relatively
quickly. However, when compared with fortification or dietary diversification,
the approach reaches relatively small numbers of consumers and requires action
on the part of many individuals to comply. For some nutrients to reach the
targeted individuals in sufficient amounts supplementation is justified (Perelson
and Ellenbogen, 2002).
Unlike the other strategies mentioned, dietary supplements do not require
major changes in the food supply, food processing, or distribution. Moreover, in
a heterogeneous population, only those who are in certain age, gender, or lifestyle
groups may require dietary supplements. Within these groups, further tailoring
may be possible and desirable. For example, in the past there has been a one-
size-fits-all recommendation that pregnant women should use iron supplements;
however, it has been suggested more recently that only pregnant women who
exhibit certain hematological parameters indicative of deficits should use iron
supplements (IOM, 1998b). In general, the IOM reports have endorsed supple-
mentation with specific nutrients (including the minerals) only for situations in
which there is clear evidence of potential harm due to their inadequacy.
If very high levels of mineral intakes are necessary to achieve optimal health
benefits, supplementation may be the only recourse. Nonetheless, the advisabil-
ity of providing such high levels of nutrients must be justified, and for many
nutrients (including some of the minerals) the relationship between high-nutrient
levels and associated benefits is still unclear. While there is little disagreement
about the usefulness of dietary supplements in boosting nutrient intake shortfalls
and thus achieving IOM RDA levels (for example, in situations of weight loss or
illness), the value of consuming nutrient levels higher than the IOM RDAs con-
tinues to be debated (Lichtenstein and Russell, 2005; Perelson and Ellenbogen,
2002). There is a strong consensus that intervention studies are needed to dem-
onstrate conclusive nutrienthealth benefit links before high levels of nutrients
can be recommended to the general population. The proposition that taking a
multivitamin mineral supplement each day is advisable to decrease the risk of
chronic degenerative disease in adults is also debatable. It presents economic as
well as public health concerns if the intake is beyond the UL.
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50 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
Disadvantages
The efficacy of most supplements in preventing chronic degenerative dis-
eases has not been demonstrated; however, they are helpful in preventing nutri-
ent deficiency diseases (e.g., folic acid helps fight neural tube defects) and
chronic degenerative disease (e.g., vitamins A, D, C, iron). Attempts at using
supplements to prevent cardiovascular disease and lung cancer have been disap-
pointing, and the evidence to date is stronger for the association between dietary
patterns and decreased chronic disease risk than it is for individual nutrients.
There are other disadvantages in using supplements. When supplementary
doses of nutrients are high, nutrient interactions tend to be accelerated. There
might be unknown consequences from shifting the emphasis away from food
and toward nutrient supplements (Caballero, 2003; Lichtenstein and Russell,
2005), in which unusual nutrient profiles could be created and lead to alteration
in absorption or metabolism of other constituents. Finally, genetic polymor-
phisms in the population might lead not only to increased requirements and
needs for nutrients but also to lower thresholds for adverse effects from large
doses of nutrients.
Combined Strategies
The Armed Forces may find it useful to consider combined strategies that
involve usual diets, fortified foods, and dietary supplements--the combination
could work toward a long-term goal while rapidly remedying immediate prob-
lems. In fact, a comprehensive approach could be implemented to provide pre-
ventive measures with nutrients at normal levels for the general population of
soldiers and therapeutic treatment with nutrients at pharmacological levels for
those with proven deficiencies.
Complementary Public Health Measures
Regardless of the strategy adopted, complementary public health measures
are also essential. For example, to prevent anemia in regions where malaria
parasites (Plasmodium falciparum) are present in the environment, de-worming
and taking antimalarial measures are vital, as is consuming iron in adequate
amounts. Sanitary water and food are indispensable since intestinal disease will
cause excessive malabsorption or excretion of most nutrients.
Choosing the Best Strategies
The best choice among these strategies for raising nutrient intakes depends
on several factors and varies from one nutrient to another. Considerations in-
clude the following:
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MILITARY DIETARY REFERENCE INTAKES 51
· The prevalence and severity of a population's nutritional inadequacy.
· The consequences of failing to raise intakes to RDAs or other nutrient
standard levels.
· The number of nutrients that require intervention.
· The time required to affect the health outcomes linked to the nutrient in
question.
· The phase, appropriateness, and feasibility of the intervention.
· Other characteristics that are unique to the particular setting (e.g., the
military).
· Other characteristics of the mineral under consideration.
The recent report Nutrient Composition of Rations for Short-Term, High-
Intensity Combat Operations (IOM, 2006) offered recommendations and sug-
gestions that address providing the appropriate amounts of nutrients to the mili-
tary personnel. The three main points made by that report's committee are the
following:
· Macronutrients should be provided in whole foods, and fortification and
the use of supplementation should be limited to the extent possible due to the
potential for nutrient interactions. The committee acknowledges the need for
fortification in some cases due to the type of foods included in some rations, for
example, those rations where shelf-stability is a priority.
· Fortification with labile nutrients presents unique challenges because of
potential interaction with other compounds and decreased bioavailability with
storage. Shelf-life should be a factor to consider when calculating the level of
fortificant in the food, and encapsulation for some nutrients may be necessary.
· Because taste is an important factor in soldiers' food preferences and
operational rations should be eaten entirely, providing a variety of acceptable
and palatable products becomes a primary concern. Zinc, calcium, magnesium,
and other nutrients have objectionable tastes to some individuals at the levels
used in fortificants. Use of appropriate chemicals with better taste or encapsula-
tion or other means to mask objectionable tastes should be given high priority for
food developers.
WATER AS A MATRIX TO INCREASE INTAKE OF MINERALS
Background
The military promotes consumption of water during periods of heavy exer-
cise and elevated ambient temperatures. In addition to being a potential vehicle
for nutrients and hydration, water can be a feasible vehicle for providing miner-
als that help meet mineral requirements as long as soldiers are consuming daily
210 L of water. The changes in drinking water sources that occur during mili-
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52 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
tary deployment could affect the balance of the essential dietary minerals that are
provided. The amounts of minerals in the U.S. public water supplies, in bottled
water, and in field purification water may vary.
The U.S. Environmental Protection Agency (EPA) administers the tap water
(drinking water) quality standards as well as those for local and state water (U.S.
EPA, 2005). The EPA standards recognize that some minerals--such as heavy
metals, copper, and iron--need to be regulated for high levels. In addition to
enforced levels, quality factors are considered when changing the levels of min-
erals in water. For instance, elevated levels of calcium make most water unpalat-
able and difficult to use because of associated brine qualities (WHO, 2004).
Mineral levels in U.S. tap water vary in quantity depending on the origin of
the freshwater supply (See Table 2-1; NRC, 1980). For example, from the Na-
tional Health and Nutrition Examination Survey III (NHANES III) data on water
intake, it can be calculated that individuals consuming hard water (water with
high calcium and magnesium levels) can supplement their mineral intake with
tap water (median intake between 9001,000 ml/day) (IOM, 2005). Generally,
this is considered advantageous if dietary sources do not provide adequate in-
takes (see Combs, 2005 in Appendix B; NRC, 1980). Hard water generally con-
tains 10500 mg/L of calcium carbonate and traces of magnesium as compared
with soft water, which contains lower levels of calcium (< 10 mg/L) (WHO,
2003). This high level of calcium can be altered with water treatments, and
sodium levels may be exchanged for calcium, thus providing soft water with
elevated levels of sodium (NRC, 1980; WHO, 2004).
Water Treatment
Ground or well water is treated by various methods, including filtration and
chlorination. The final mineral levels depend on the source water, for example,
ground water is hard water and rain water is soft water. Combination methods
like filtration, reverse osmosis, and distillation are used in some parts of the
world because the local water is high in salt and debris. Desalination is used to
TABLE 2-1 U.S. Tap Water Mineral Levels
Mineral Typical levels (mg/L) Higher levels (mg/L)
Calcium 26.00 145.00
Magnesium 6.25 120.00
Iron 0.24 2.20
Copper 0.10 0.45
Zinc 0.20 1.50
Selenium 0.00 0.01
Sodium 28.00 220.00
SOURCE: NRC (1980).
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MILITARY DIETARY REFERENCE INTAKES 53
treat water that is high in salt content, (e.g., some lakes and the ocean). Treat-
ments such as distillation, deionization using membranes, electrodialysis, re-
verse osmosis, and other technologies, significantly reduce the mineral content.
Bottled water can be obtained from tap water, treated water, and other ground
water sources. In the United States, bottled water standards are under the admin-
istration of the FDA (Bullers, 2002). In general, the FDA's standards for bottled
water are the same as the EPA's standards for tap water. If the bottled water is
labeled purified water, then it is manufactured by distillation, reverse osmosis,
or other suitable processes that meets the definition set by the U.S. Pharma-
copeia (http://www.usp.org/). Purified water has a low mineral content unless
the manufacturer adds minerals especially to improve taste. There are no known
health advantages from consuming bottled water except in areas where local
drinking water does not meet health standards. Table 2-2 lists an example of the
mineral content from bottled water prepared for the military operations in Iraq.
Minerals and Taste
Most sensory evaluation studies indicate that low-salt waters have poor taste
for most people. The addition of calcium (at least 4 meq/L of CaSO4), sodium
(1.5 meq/L NaHCO3), and magnesium (3 meq/L of Mg[HCO3]) enhanced posi-
tive taste results (Zoeteman, 1980). On the other hand, overly high levels of
calcium and sodium can decrease taste acceptability. Results vary, but in general
levels of calcium that are above 100 mg/L and of sodium that are above 200 mg/L
(WHO, 2004; Zoeteman, 1980) are unacceptable.
In fact, when water treatment results in low mineral content, calcium and
magnesium may be added back to improve taste and to prevent the leaching of
TABLE 2-2 Mineral Content of Bottled Water in Iraq
(Danone Hayat, Product of Istanbul)
Compound Content (mg/L)
Calcium 25.650
Magnesium 7.050
Fluoride 0.030
Chloride 4,900
Chlorine --
NH3 --
Sulphate 2.560
NO2 --
Nitrate 1.236
Silica 1.000
pH 7.480
SOURCE: Personal communication, J. Kent, Darnall Army Community
Hospital U.S. Army, August 25 (2005).
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54 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
minerals from pipes (Cotruvo, 2005; Kozisek, 2005; Monarca et al., 2005; WHO,
2004; Zoeteman, 1980). The process results in the provision of calcium and
magnesium as dietary sources. The addition of dissolved salts and calcium may
be around 100 mg/L and 30 mg/L, respectively (Kozisek, 2005). Another factor
that might change mineral content of water is the leaching of minerals (espe-
cially of cadmium and lead depending on nature of pipe) from pipes that occurs
with desalted water (Cotruvo, 2005). Finally, water might be blended, that is,
some salt water is added to increase the overall salt levels after the desalination
treatment. This results in an increase primarily of sodium (Cotruvo, 2005).
Minerals in Water and Cardiovascular Disease
Many epidemiological studies have been conducted to determine if consum-
ing hard water decreases the risk of cardiovascular diseases (Altura and Altura,
1995; Hopps and Feder, 1986; Kousa et al., 2004; Maheswaran et al., 1999; Pocock
et al., 1980; Rubenowitz et al., 2000). Studies suggest an inverse relationship
between calcium and magnesium concentrations in tap water and cardiovascular
mortality in the United States (Hopps and Feder, 1986), England (Pocock et al.,
1980), Europe (Sonneborn et al., 1983), and Finland (Kousa et al., 2004). Re-
cently, Monarca et al. (2005) reviewed the literature between 1979 and 2003 re-
garding the role of calcium and magnesium content of water on prevention of
cardiovascular diseases. These studies were conducted in many geographical loca-
tions and report case-studies and correlation studies between both naturally occur-
ring hard water and water treated to reduce hardness; this entailed replacement of
calcium and magnesium with sodium, an electrolyte that at high dietary levels may
be related to hypertension, which might have confounded the results. Aside from
this limitation, most case-control studies show and inverse relationship between
mortality (but not incidence) from cardiovascular disease and magnesium levels
but not calcium levels. Most studies show an inverse correlation between water
hardness and mortality from cardiovascular disease, but not all. Although many of
these studies have large sample sizes and include longitudinal data to document
the efficacy of hard water, government agencies (Combs, 2005; see Appendix B)
do not support adding calcium and magnesium to drinking water to prevent cardio-
vascular diseases. There are indications that reducing hard water by the substitu-
tion of calcium and magnesium with sodium replaces valuable dietary calcium and
magnesium; also, high-sodium diets may be related to hypertension for some
people. Apart from the studies suggesting the benefits of consuming hard water,
there are no data that show increased cardiovascular disease in communities where
rain water (soft water) is the primary source of drinking water (Hopps and Feder,
1986; Maheswaran et al., 1999; Pocock et al., 1980). Also, the consumption of
purified water (e.g., bottled water) showed no enhancement of health except in
cases where local water cannot meet U.S. EPA standards for chemical and micro-
biological contaminents (Bullers, 2002).
In summary, chronic consumption of soft water has been related to cardio-
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MILITARY DIETARY REFERENCE INTAKES 55
vascular disease in some studies but not all. Altogether, these studies were not
deemed strong enough for the WHO to recommend the addition of calcium and
magnesium to drinking water, but they do indicate potential importance of water
as a nutrient source of calcium and magnesium.
Bioavailability
The bioavailability of each mineral from water will vary with the salt form
(Hopps and Feder, 1986; Sonneborn et al., 1983). Except for some epidemiologi-
cal research (see section on Epidemiological Cardiovascular Disease Studies),
there has been little evidence showing that adding calcium and magnesium to
drinking water enhances mineral nutritional status. However, calcium and magne-
sium in hard water are well absorbed and can provide additional sources of these
nutrients to meet dietary requirements (Kozisek, 2005). This additional source
may be important when other food sources of calcium and magnesium are low.
Water Quality During Military Operations
The military's primary concern is to provide water that meets U.S. EPA
standards for chemicals and microbiological levels. During foreign deploy-
ments, drinking water may come from local water supplies and undergo addi-
tional treatments, such as chlorination for bacterial control and filtration for
the removal of dissolved solids. The mineral levels with this type of treated
water depend on the mineral levels of the source water, that is, hard water,
which is high in minerals--primarily calcium and magnesium--would retain
its minerals after treatment.
In some situations, water may be treated by reverse osmosis or distillation,
both of which remove minerals. Thus, as mentioned previously, most treatment
plants add minerals, especially calcium and magnesium, to prevent metal leach-
ing and to improve the water's palatability. Bottled water generally has low
concentrations of minerals.
Typical levels of minerals in tap water are similar to those in bottle water
used in Iraq (Table 2-1 and 2-2). Based on these typical levels, on the known
treatment processes applied to water, and on the typical consumption of 3 L of
water/day the committee concluded that, differences in mineral content of water
would not be such that will affect the total intake levels of minerals by military
personnel. The committee also concluded that the addition of calcium and mag-
nesium to water consumed by military personnel is warranted only when im-
proving the taste is the desirable outcome. There is no evidence to suggest that
the addition of substantial levels of calcium and magnesium would be an effi-
cient strategy to meet nutritional standards; in addition, there is little research
on bioavailability of minerals from water. Additional cost evaluation of using
water as a vehicle for minerals should be conducted if it is to be considered for
implementation.
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56 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
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Representative terms from entire chapter:
garrison training
