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3 Mineral Recommendations for Military Performance This chapter presents the available scientific evidence to support the com- mittee's recommendations on minerals and their required intake levels for mili- tary personnel during garrison training. Garrison training is defined for the pur- pose of this report as situations during which military personnel living on a garrison base are either training or carrying out combat simulations or conduct- ing one-day convoy-type operations. A specific group of known essential miner- als was selected based on the minerals' importance to physical and cognitive performance and maintaining health status. The minerals group was developed after committee deliberations and was founded on results from literature reviews and from information provided by the Department of Defense. Furthermore, in- depth literature reviews on calcium, copper, iron, magnesium, selenium, and zinc were conducted. Following the approach described in this chapter, the com- mittee makes recommendations for soldiers, both men and women, during garri- son training. Also, the committee comments on the adequacy of the estimated levels of those minerals in the current meals, ready to eat (MREs) and first strike rations (FSRs), which are consumed typically during garrison training and sus- tained operations, respectively. Further, the committee comments on the recent Institute of Medicine (IOM) (2006) mineral level recommendations for sustained operations (i.e., FSRs). Finally, a list of priority research questions for each mineral are included. (The research questions are expanded in Chapter 4 to in- clude descriptions of study designs.) THE COMMITTEE'S APPROACH The committee's task was to review and, if necessary, to recommend new levels of dietary intakes for minerals that are of the greatest interest to the mili- 58

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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 59 tary because (1) risk factors during military operations might result in marginal deficiencies among military personnel or (2) higher intakes might be beneficial for optimizing military performance. Based on these two criteria, the committee discussed the relevance of all minerals and decided to focus its task on calcium, copper, iron, magnesium, selenium, and zinc. An in-depth literature review was conducted to gauge the relevance of studies and to evaluate using the studies' results as a basis for recommending mineral intake levels or priority research needs, or both, to answer information gaps related to the committee's task. Subsequently, the committee was able to make recommendations for the fu- ture establishment of new military standards for the specific minerals; specifically, the committee recommended new Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) or Adequate Intake (AIs) for military garrison training (MGT). The new values are referred to as EARMGT, RDAMGT, and AIMGT. Based on the outcomes of importance to the military, that is, to either maintain or improve both physical or cognitive performance under garrison train- ing, two general types of studies were considered: (1) studies designed to examine requirement increases due to exercise, stress, or other conditions encountered dur- ing military life (e.g., sweat losses or changes in bone resorption rates) and (2) studies designed to evaluate the potential benefits of increasing mineral intakes for cognitive or performance functions. When potential nutrient losses or low intake could put soldiers at risk for deficiencies, the recommended level for a given nutrient was increased--as long as the new level did not exceed the Tolerable Upper Intake Level (UL)--based on data from peer-reviewed scientific literature. However, when making a rec- ommendation based on potential benefits of supplementation, the committee erred on the side of caution and only considered those effects if there was enough clear supporting evidence of the benefits to military performance. The commit- tee cautions that most of the studies were conducted on civilians and under circumstances that might not be able to be extrapolated to military circumstances and garrison training. An effort was made to consider gender differences where the data were available. In addition to the other assumptions formulated by the committee, they considered as worst-case scenario the loss of sweat volumes of up to 10 L/day due to heat and exercise. The committee evaluated the adequacy of the mineral content of rations. Adequacy can be evaluated for the population or for the individual. Because the committee does not know of data on mineral distribution intakes for military garrison training, the mineral content of menus for the population could not be evaluated. Instead, the calculated RDAMGT and AIMGT were used as benchmarks to evaluate mineral content adequacy of various rations for individuals. The mineral compositions of three different MREs and three different FSRs were provided by the United States Army Research Institute of Environmental Medi- cine and used to evaluate the rations' adequacy (see Table 3-1 and Tables C-2 through C-7 in Appendix C).

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60 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL TABLE 3-1 Summary Table of the Institute of Medicine Dietary Reference Intakes and Military Dietary Reference Intakes for Garrison Training and Combat Operations for 1950 Year Olds and the Mineral Levels in Current Rations IOM Mineral Intake IOM Dietary Reference Recommendations Intakes (civilian population, (military population, ages 1950 years) ages 1950 years) IOM RDA RDAMGT or Nutrient or AI IOM UL MDRI AIMGT FSRs Calcium (mg) M 1,000 2,500 1,000 1,000 750850 F 1,000 2,500 1,000 1,000 Copper (g) M 900 10,000 ND 1,800 9001,600 F 900 10,000 ND 1,500 Iron (mg) M 8 45 10 14 818 F 18 45 15 22 Magnesium (mg) M 400420* 350 420 420 400550 F 310320* 350 320 320 Selenium (g) M 55 400 55 55 55230 F 55 400 55 55 Zinc (mg) M 11 40 15 15 1125 F 8 40 12 11 NOTE: AI = Adequate Intake; F = female; FSR = first strike ration; IOM = Institute of Medicine; M = male; MDRI = Military Dietary Reference Intake; MGT = military garrison training; MRE = meals, ready to eat; ND = not determined; RDA = Recommended Dietary Allowance; SUSOPS = sustained operations; UL = Tolerable Upper Intake Level. * Lower requirement for 1930 year olds and higher requirement for 3150 year olds. SOURCE: Baker-Fulco (2005); IOM (1997, 2000, 2001, 2006); U.S. Departments of the Army, Navy, and Air Force (2001).

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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 61 Mineral Levels in Current Military Rations MRE XXII MRE XXIV MRE XXIII FSR 2691051 272949 269950 643697 Average: 511 Average: 557.4 Average: 526 Average: 673 (3 rations = 1,533) (3 rations = 1,672) (3 rations = 1,578) ND ND ND ND 519 618 5.7818.39 1518.4 Average: 7.9 Average: 9 Average: 8.6 Average: 17 (3 rations = 24) (3 rations = 27) (3 rations = 26) 60195 78227 69299 375403 Average: 114 Average: 140.5 Average: 177 Average: 86 (3 rations = 342) (3 rations= 421) (3 rations = 531) 0.1234 0.6838 1.3428.3 63160 Average: 9.6 Average: 12.5 Average: 7.8 Average: 100 (3 rations = 30) (3 rations = 37) (3 rations = 23) 1.88.5 28 0.968.14 11.412.2 Average: 4.2 Average: 4.7 Average: 4.2 Average: 11 (3 rations = 13) (3 rations = 14) (3 rations = 13)

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62 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL The committee provided comments on the recent mineral recommendations in the IOM report Nutrient Composition of Rations for Short-Term, High- Intensity Combat Operations (2006; see Table 3-1). The comments reflected all of the report's supportive evidence, including factors related to food technology and nutrient interactions as well as those related to the diets, consumption behav- iors, and nature of the operations. NUTRITIONAL AND ENVIRONMENTAL FACTORS FACING SOLDIERS IN THE FIELD The need for specific nutrients is influenced by the health status and specific scenarios and environmental conditions into which soldiers are deployed. Thus, two military scenarios were considered: (1) garrison training and (2) sustained operations. In order to delineate such scenarios, the committee made a series of assumptions regarding health, environmental conditions, and the soldiers' diets (described in the following section); the scenarios are based on the committee's deliberations, open sessions with sponsor representatives and other military per- sonnel, information from field surveys conducted in Iraq and Afghanistan, and available literature. Specifically, the garrison training information was collected through a personal communication (Personal communication, J. Kent and S. Corum, U.S. Army, August 24, 2005). Garrison Training Environment Soldiers (men and women 1950 years old) are generally in a region of operations for 12 months, although they can be there for up to 18 months, espe- cially if serving in the National Guard or Reserves. Most military sites are large garrison bases with many facilities, however, some are small with a reduced number of facilities. The majority of Iraqi military sites are in hot, desert climates. Soldiers are typically exposed to temperatures above 100F for 810 hours per day. During 1218-month deployments, soldiers (e.g., combat arms soldiers and soldiers performing convoy-type operations in Iraq) are typically away from base camp for 12 hours per day accomplishing a mission or training. They generally re- turn to the camp daily, eat in a dining facility, and sleep in tents or build- ings. Under high temperatures and when prescribed restwork cycles can be followed, soldiers engage in heavy work for about 10 minutes and take long rests periods of about 50 minutes. As they become acclimated, the rest cycles often are shortened. Under combat conditions, rest cycles obviously are not possible.

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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 63 Exercise and Energy Expenditure There are no data on exercise schedules, and they may vary significantly. There are also no metabolic data and no data on the soldiers' energy expenditure in garrison training. However, past studies reported that male soldiers who en- gaged in various activities expended energy in amounts that ranged from 3,500 kcal/day for combat support and combat service support soldiers involved in moderate exercise while in garrison to 4,500 kcal/day for Ranger training under intense exercise. For female soldiers, energy expenditures may range from 2,300 kcal/day when in basic training to 3,000 kcal/day when running medical opera- tions in the field. The committee assumes that the energy expenditures will be an average of 4,000 and 2,500 kcal/day for men and women, respectively. Diet While in base camp, soldiers have free access to dining facilities, and they typically eat three times a day. There are no recorded data on energy intake. When soldiers go on missions off the base camp they eat MREs during the day (sometimes for several days) as well as personal food items (snack foods) re- ceived through the mail or purchased at local Army and Air Force Exchange Service operations. For the purpose of evaluating the adequacy of rations' min- eral content, the committee assumes that male soldiers will consume three MREs per day and that female soldiers will consume two MREs per day. If consump- tion differs from this assumption (e.g., if male soldiers eat two MREs per day and female soldiers eat one MRE per day, and both sets supplement the MREs with snack foods), then the conclusions regarding mineral adequacy of the ra- tions might be different. Soldiers have access to supplemental food and drink from the local economy, but they are highly discouraged from consuming such products. It is unknown to what extent they eat outside of the base camp. Because weight gain can be a problem, weight-loss diets are as popular as they are with the civilian population. Soldiers have access to supplements, especially weight-loss supplements, pro- tein supplements, creatine, or energy drinks. Soldiers also might ingest calcium supplements. However, there are not enough data on supplement use in the field to make definitive conclusions. Water Consumption In Iraq, soldiers consume up to 3 L/day of mineral water that is produced at eight different sites. Since bottled water is considered a food product, members of the Veterinary Corps from Fort Dietrich, Maryland, inspect it for bacteria, contaminants, and mineral content. In order for the water to be shipped to the soldiers, the mineral content has to be as low as what is found in commercially

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64 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL available mineral water in the United States. Commercially purchased bottled water from the United States is used as an internal standard. Often minerals, such as calcium, are added to improve the taste. Soldiers also have access to water that has been filtered through reverse osmosis (reverse osmosis purification unit); this water is essentially mineral free. The filtered water typically is not consumed by soldiers unless bottled water is unavailable; instead, it is used when large amounts of water are required (e.g., in hospitals, cooking, cleaning, washing). Health There is not a particular single health issue that stands out with currently de- ployed soldiers in garrison training. Diarrhea is fairly common, due to antimalarial drugs as well as to occasional outbreaks from consuming unapproved foods (e.g., food from the local economy). Some minor outbreaks of food-borne diseases have occurred (2030 cases per outbreak, possibly due to consumption of local foods). The incidence of iron deficiency among military women is unknown. Typi- cally, they are not tested for iron status, except for when they visit the hospital with other medical problems; during these hospital visits, iron deficiencies have been observed among women in the military. Dehydration is infrequent, and if it does occur, it happens more commonly when soldiers first arrive at base camp, mainly due to emotional issues and lack of acclimation to the heat and daily routines. Soldiers quickly learn to avoid dehydration by drinking fluids. Anecdotal data that indicate weight gain as a problem are being studied currently. To meet military specifications weight loss diets are popular among military personnel, which might have adverse health consequences if intakes of essential nutrients are inadequate. Sleep deprivation does not seem to be a generalized problem, although it may happen occasionally. Soldiers typically sleep for 8 h/day, but sometimes sleep time can be reduced to only 46 h/day. Sustained Operations In the recent IOM report (2006), Nutrient Composition of Rations for Short- Term, High-Intensity Combat Operations, the assumptions related to the charac- teristics of the soldiers' diets and health, the missions, and other issues for soldiers deployed to sustained operations (assault missions) were described at length. The following list summarizes the assumptions: Soldiers deployed on assault missions are male, relatively fit, with an average body weight of 80 kg and approximately 16 percent body fat, and within an age range of 1845 years (average < 25 years).

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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 65 Soldiers may be on a mission for as many as 24 out of 30 days, with each mission lasting three to seven days. There may be as much as 20 h/day of physical activity, with an average of 4 h/day of sleep. Total daily energy expenditure will be approximately 4,500 kcal. Soldiers are likely to have an average energy intake of 2,400 kcal/day. Soldiers are likely to have access to 45 L/day of chlorinated water. Some soldiers may experience diarrhea, constipation, or kidney stones during assault missions. The daily ration must fit within 0.12 cubic feet and weigh three pounds (1.4 kg) or less. It will be approximately 1217 percent water (varying greatly from one item to the other); most items will be energy dense and intermediate in moisture. There will be no liquid foods in the rations, although gels and powders may be provided. The food available during recovery periods will provide, at a minimum, the nutritional standards for operational rations. The recommended rations (see Table C-1 and Box C-1 in Appendix C) do not meet the MDRIs in AR 40-25 (U.S. Departments of the Army, Navy, and Air Force, 2001), nor do they meet the recommended nutrient intakes for civilians (IOM, 1997, 1998a, 2000, 2001, 2002/2005, 2004a). The assault rations (i.e., FSRs) are meant to be used only for repetitive three- to seven-day missions that last for a maximum total period of one month and that include recovery periods of 2472 hours between missions. With the expected energy expenditures of 4,500 kcal/day during the missions and the possibility of as much as a 10-percent body weight loss, it was recommended that weight loss be measured after one month of use. If weight loss of a soldier is higher than 10 percent for a soldier, he should not be sent on assault missions until weight is regained to within 5 per- cent of the initial weight. CALCIUM RECOMMENDATIONS Calcium is an essential mineral that plays a range of biological roles, from being a major constituent of bones and teeth to affecting nerve conduction, muscle contraction, heartbeat regulation, blood coagulation, energy production, glandular secretion, and the maintenance of immune function. Although many minerals are essential for bone health and function, the risk of calcium inad- equacy in the diet is higher than risks of other deficiencies; moreover, calcium is more abundant in the bone than other minerals. Calcium in the diet offsets obligatory calcium losses, protecting skeletal reserves and maintaining structural integrity. Bone loss might occur from inad- equate caloric intake to meet energy expenditure and calcium dermal losses dur-

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66 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL ing exercise and will be exaggerated in females with loss of menstrual function or eating disorders. Micro-fracture repair is also dependent on calcium intake. Thus, ingested calcium prevents the net efflux of calcium from bone and by doing so may help to prevent osteoporosis and stress fractures as a result of military training and combat action (Burr, 1997; IOM, 1997). Basic training appears to first lead to increased resorption (perhaps to compensate for calcium loss due to sweat or negative energy balance), but this is followed by increased formation (stimulated by intense training) and the window between increments in these two processes may be the period of greatest risk of stress fractures. To counteract any excess in bone turnover and meet the demands of the skeleton during intense activity calcium levels higher than current AI of 1,000 mg may be needed with intense exercise. Data on the prevention of stress fractures by cal- cium are limited and not conclusive yet but there is ongoing research that should soon shed more light. More data are clearly needed to understand the role of nutrition in stress fracture occurrence (see Nieves and Hayes in Appendix B). Remarkable changes in bone mineral content (BMC) have been observed in male army infantry recruits 1821 years old who were subjected to very strenu- ous physical training. After 14 weeks of walking, jogging with and without weights, and calisthenics for at least 8 hours a day, 6 days a week, the average bone mineral content of the subjects increased 11 percent in the left leg and 5.2 percent in the right leg (Margulies et al., 1986). Of the 268 recruits, 110 did not complete the training, largely because of incurring stress fractures in the lower limbs. The relationship of calcium intake to bone health and fracture prevention is discussed in more detail in Appendix B (Nieves and Hayes). Monitoring Calcium Status, Its Metabolism, and Related Bone Health Methods for evaluating calcium metabolism and bone health are advanced. Yet simple, inexpensive methods for assessing calcium metabolism and bone health for large numbers of people are still lacking. No biochemical measure can assess calcium status, unless calcium metabolism is grossly abnormal. Measur- ing calcium intake, therefore, is the only approach to evaluating current calcium status in healthy individuals. Approaches for calculating dietary calcium intakes and their limitations have been reviewed by Boushey (2006). A rapid assessment method specific for dietary calcium is given in Weaver and Heaney (2006). However, a dietary assessment tool to evaluate several key nutrients likely to be deficient in diets of military personnel would have broader utility. A detailed description of research methods to measure all parameters of calcium metabolism is given by Weaver (2006). Isotopic calcium tracer method- ology, typically in conjunction with metabolic balance studies, is the gold stan- dard for quantifying complete calcium kinetics including calcium absorption, endogenous secretion, urinary and fecal excretion, bone formation rates, and bone resorption rates. Serum and urinary calcium and serum parathyroid hor-

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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 67 mone (PTH) levels are the best, most readily available assessment tools for evaluating disturbances in calcium metabolism [e.g., those related to premen- strual syndrome (PMS)]. Strategies for monitoring bone health are given in an IOM report (2004b), Monitoring Metabolic Status. Predicting Decrements in Physiological and Cog- nitive Performance. Total body calcium can be determined from total body BMC using bone density, because calcium is a constant fraction of BMC, and repre- sents net cumulative calcium rather than recent dietary calcium intakes. Bone mineral density (BMD), measured by bone densitometry, quantitative computed tomography (QCT), or ultrasound, is a useful measure of bone health because of the strong inverse relationship between BMD and fracture risk (Melton et al., 1993). The large normative databases used by manufacturers of dual energy x-ray absorptiometers (DXA) allow BMD of individuals to be compared to age- matched reference values and fracture risk to be assessed as z-scores. Newer imaging methodologies (e.g., QCT) for assessing bone quality can provide addi- tional useful information about bone geometry. Evaluating interventions by DXA or QCT require years to analyze small changes in bone; however, some interven- tions produce large changes in bone that can be observed in periods as short as six months. Bone is a dynamic tissue that constantly turns over through a remodeling process, during which fatigued bone is resorbed and new bone is formed. In young adults, the two processes are typically coupled to achieve net bone bal- ance. A number of commercial kits are available to estimate bone formation and bone resorption rates. They lack specificity because they do not measure calcium or bone, but rather protein fragments that are released during bone turnover. Moreover, the biochemical markers of bone turnover are typically too variable to reliably predict small changes in bone. Therefore, their use as a primary outcome measure to gauge the effect of stress on bone turnover or to evaluate the effec- tiveness of interventions is not recommended. However, under conditions that have a large impact on bone (e.g., microgravity associated with space flight), biochemical markers have provided useful insights to mechanisms of action (Smith et al., 1999). Calcium Intake Effects on Health and Performance Stress Fractures The rate of stress fractures during basic training has varied depending on the branch of service, methods of detection, and training methods. Navy and Air Force programs consistently report a lower incidence of stress fractures than the Army and Marine Corps programs (Beck et al., 1996; Jones et al., 1989; Kelly et al., 2000; Shaffer, 2001; Shaffer et al., 1999). The fracture rates for females are consistently higher than for males (Almeida et al., 1999; Shaffer, 2001). Pre-

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68 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL 1989 studies of the U.S. military indicate male stress fracture rates from 0.9 percent to 3.0 percent and female rates from 2.7 to 8.2 percent (Jones et al., 1989). Since 1995, stress fracture incidence in female Marine recruits and officer cadets has ranged from 5.7 percent to 11.5 percent (Shaffer et al., 1999; Winfield et al., 1997). The female recruit stress fracture rate at the Naval Recruit Training Center Great Lakes in 1995 was reported as 3.9 percent (Shaffer et al., 1999). Stress fractures rates ascertained at the Fort Leonard Wood Army training center between October 2003 and June 2004 were 9.1 percent for males and 17.5 per- cent for females (Personal communication, J. Lappe and R. Ellyson, U.S. Army Training and Doctrine Command, February, 2003). Research on the benefits of calcium supplements in preventing stress fractures in females is currently being conducted and the results from these studies should be considered when devel- oping calcium requirements for the military. See also Nieves and Hayes in Ap- pendix B. Mood and Psychological Performance There is evidence in the literature that inadequate dietary calcium is associ- ated with negative emotional and mental health, which could have implications for performance. The most rigorously studied type of these conditions is PMS. Approximately 5 percent of North American women have PMS symptoms so severe that health and performance are affected (Thys-Jacobs, 2006). The symp- toms--irritability, depression, anxiety, social withdrawal, headache, and abdomi- nal cramps--can be alleviated in most women with increased dietary calcium or calcium supplementation. The supporting evidence consists of two small, single- site trials (Penland and Johnson, 1993; Thys-Jacob et al., 1989) followed by a multisite randomized, controlled trial (Thys-Jacobs et al., 1998). The study by Penland and Johnson (1993) controlled dietary calcium at 587 or 1,336 mg/day by supplementing with calcium lactate after a 13-day equilibra- tion diet containing calcium of 800 mg/day. Higher calcium intakes were associ- ated with improved mood, concentration, and behavior symptoms, as well as with decreased pain. The multisite trial (Thys-Jacobs et al., 1998) randomly provided 720 women who were 1845 years old and suffering from PMS with a placebo or with 1,200 mg/day of calcium as calcium carbonate for a duration of three menstrual cycles. A daily rating scale and diary were used to measure 17 core symptoms and 4 symptom factors (negative affect, water retention, food cravings, and pain). By the third menstrual cycle, an overall 48-percent reduc- tion in total symptom scores was observed. All 4 symptom factors and 15 core symptoms, but not fatigue and insomnia, were reduced significantly by the cal- cium treatment as compared to placebo. Negative affect was reduced by 45 percent. Results from observation studies add more evidence to the effects of cal- cium intake in alleviating PMS symptoms. In the Nurses' Health Study II cohort,

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