Use of Dietary Supplements by Military Personnel (2008)

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3 Vitamins and Essential Minerals for Military Personnel INTRODUCTION Vitamins and minerals, whether taken in combination or individually, are the most frequently consumed dietary supplements among military personnel in all surveys reviewed (Chapter 2). Although levels for spe- cific military subpopulations have been recommended in other Institute of Medicine (IOM) reports (IOM, 2005, 2006a), potential concerns with high levels of use were not addressed. This chapter includes a summary of recommendations provided in those reports and discusses safety concerns associated with the use of vitamin and mineral supplements. Unlike other dietary supplement ingredients, vitamins and certain min- erals are considered essential nutrients for which standards of adequacy are needed. These standards are developed to ensure that the nutrient needs of different populations are met. In the United States, the nutrient standards or Dietary Reference Intakes (DRIs) are compiled in various IOM reports (IOM, 1997, 1998a, 2000a,b, 2002/2005, 2004) (Table 3-1). The DRIs comprise the following four nutrient-based reference values established by gender and age group: the Estimated Average Requirement (EAR), the R ­ ecommended Dietary Allowance (RDA), the Adequate Intake (AI), and the Tolerable Upper Intake Level (UL). The IOM EARs and RDAs are the average intake levels that meet respectively the requirements of 50 and 97–98 percent of the healthy individuals in a population in a particular life stage and gender group. An RDA is the reference value—derived math- ematically from the EAR population distribution—for planning individual intakes. An AI (estimated intake by a population, based on observed or 72 

VITAMINS AND ESSENTIAL MINERALS 73 TABLE 3-1  Military Recommended Intakes for Men in Garrison Feeding, Operational, and Restricted Rations Compared to Recommended Intakes for Men Ages 19–30 Years in the General Population RDA, AI, or Tolerable AMDR Military Daily Upper Nutrient or Energy (per day) Recommended Intake Level Energy intake (kcal) 3,600 3,250 Protein (for an 80-kg male) (g) 56 g 91 (10–15%) (% of kcal) (10–35%) Fat (% of kcal) 20–35% ≤35% PUFA (% kcal) n-3 as α-linolenic 0.6–1.2% n-6 as linoleic acid 5–10% Carbohydrate (g) 130 ND (% of kcal) (45–65%) Vitamin A (µg) 900 RAE 1,000 µg RE 3,000 Vitamin C (mg) 90 90 2,000 Vitamin D (µg) 5 5 50 Vitamin E (mg) 15 15 1,000 Vitamin K (µg) 120 80 ND Thiamin (mg) 1.2 1.2 ND Riboflavin (mg) 1.3 1.3 ND Niacin (mg NE) 16 16 35 Vitamin B6 (mg) 1.3 1.3 100 Folate (µg DFE) 400 400 1,000 Vitamin B12 (µg) 2.4 2.4 ND Biotin (µg) 30 ND ND Pantothenic acid (mg) 5 ND ND Calcium (mg) 1,000 1,000 2,500 Choline (mg) 550 ND 3,500 Chromium (µg) 35 ND ND Copper (µg) 900 ND 10,000 Fluoride (mg) 4 4 10 Iodine (µg) 150 150 1,100 Iron (mg) 8 15 45 Magnesium (mg) 400 420 350 Manganese (mg) 2.3 ND 11 Molybdenum (µg) 45 ND 2,000 Phosphorus (mg) 700 700 4,000 Potassium (mg) 4,700 3,200 ND Selenium (µg) 55 55 400 Sodium (mg) 1,500 ≤ 2,300 5,000 (4,550–5,525) 2,300 Zinc (mg) 11 15 40 NOTE: AI = Adequate Intake; AMDR = Acceptable Macronutrient Distribution Ranges; DFE = Dietary Folate Equivalents; ND = Not Determined; NE = Niacin Equivalents; PUFA = ­ Polyunsaturated Fatty Acids; RAE = Retinol Activity Equivalent; RDA = Recom- mended ­Dietary Allowance; RE = Retinol Equivalents. SOURCES: IOM, 2004; U.S. Departments of the Army, Navy, and Air Force, 2001. 

74 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL experimentally determined approximations of nutrient intakes) can also be used for planning individual intakes. The IOM UL is the highest intake level likely to pose no reported risk of an adverse health effect to almost all individuals. Because vitamins and minerals are required to maintain health and therefore supplementation might be needed if deficiencies occur, deliberations about their safety and benefits are fundamentally different from those about nonessential dietary supplements, which are discussed in Chapter 4. For nonessential dietary supplements, any discussion on preven- tion of nutrient deficiencies with dietary supplements would not apply. The 2006 IOM report Mineral Requirements for Military Personnel indicates that compared to the general population, some groups in the military may require higher intakes of specific nutrients to maintain health because of sweat losses during high-intensity physical activities (IOM, 2006a). Higher nutrient intakes might also be needed to optimize military performance. Nutrient standards distinct from those for the general popula- tion have been developed for the military population: the Military Dietary Reference Intakes (MDRIs) and the nutritional standards for operational rations, which are based on MDRIs (U.S. Departments of the Army, Navy, and Air Force, 2001). The MDRIs are based on the IOM DRIs; the 2006 IOM report recommends that the MDRIs continue to reflect the IOM DRIs and that they be updated periodically by considering scientific evi- dence from studies on the benefits of specific nutrients (e.g., for improved cognitive function) or from studies revealing altered nutrient metabolism due to military performance (e.g., increased sweat losses) (IOM, 2006a). The committee made specific recommendations for a systematic approach to develop MDRIs for all nutrients and how to apply them. In every case, it recommended that the intake level should be lower than the UL for the age range. The safety of vitamins and minerals therefore needs to be determined with consideration of both risks from toxicity and risks from deficiency. This chapter comments on recent recommendations made by other IOM committees on the establishment of requirements for nutrients, including vitamins and minerals, for military personnel performing high-intensity physical tasks. This committee concurs with those recommendations and provides a list of research needs. SAFETY OF VITAMINS AND MINERALS Risks of Vitamin and Mineral Deficiencies Some military subpopulations engage in high-intensity physical activi- ties while they consume low-calorie diets. Their diets might therefore be 

VITAMINS AND ESSENTIAL MINERALS 75 deficient in vitamins and minerals, and increasing intake might be nec- essary to meet nutritional requirements and maintain health. There are four basic strategies that can be applied to improve nutrient intake and nutritional status of military personnel: food-based approaches, fortifica- tion, supplementation, and complementary public health control measures (IOM, 1998b). The uses, advantages, and disadvantages of each strategy were described in the 2006 IOM report, and this section provides a sum- mary on using supplementation as a strategy to increase intake of essential nutrients in the military. In the 1994 Dietary Supplement Health and Education Act (Dietary Supplement Health and Education Act of 1994, Public Law 103-417, 108 Stat 4325, 103rd Congress, October 25, 1994), Congress defines a dietary supplement as a product (other than tobacco) that is intended to supplement the diet; that contains one or more dietary ingredients (defined as vitamins; minerals; herbs or other botanicals; amino acids; other dietary substances for use by man to supplement the diet by increasing the total dietary intake; or concentrates, constituents, metabolites, extracts, or combinations of any of the aforementioned dietary ingredients); that is intended to be taken by mouth as a pill, capsule, tablet, or liquid; and that is labeled on the front panel as being a dietary supplement. In general, the scientific community agrees that selecting a balanced diet of foods providing sufficient amounts of vitamins and minerals should be encouraged, and supplements should be used only in cases where food does not provide sufficient vitamins and minerals. If levels higher than the RDAs are necessary to achieve opti- mal health benefits or because of greater needs in the military subpopula- tions, supplementation may be the only recourse. For example, the 2006 IOM report showed that the average mineral composition of three different Meals, Ready-to-Eat rations and three different First Strike Ration menus provided by the U.S. Army Research Institute of Environmental Medicine (USARIEM) did not meet the iron requirements for women and the zinc requirements for both men and women. Since iron supplementation can be a highly effective approach to treating iron deficiency but can also be toxic, it is important to find the best means to protect women who participate in heavy training from a decrease in iron status, such as supplementation, iron fortification, dietary adjustments, or other means. When mineral sweat losses cannot be balanced with dietary intake or when there is evidence to suggest that a higher intake might benefit physical or mental function, supplementation should be considered. Supplementation might also be ad- visable when individuals are relying on a low-calorie diet that does not meet the RDAs or if research shows that a low-calorie diet increases micronutri- ent needs to higher than the RDA. For example, although confirmatory research is needed, the Committee on Mineral Requirements for Military 

76 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL Personnel recommended calcium intakes of at least 1,000 mg/day and as much as 1,500–1,700 mg/day to minimize bone loss during weight-loss regimes (IOM, 2006a). In all cases, providing such high levels of nutrients must be justified; even among the general population, the relationship between high intake levels and associated benefits or additional needs is, for many nutrients, still unclear (IOM, 2006a; Lichtenstein and Russell, 2005; Perelson and Ellenbogen, 2002), and intervention studies are needed to demonstrate conclusive nutrient–health benefit links before high levels of nutrients can be recommended. When there are deficiencies, supplementation can generate changes in micronutrient status relatively quickly, although compared with forti- fication or dietary diversification, it reaches relatively small numbers of consumers and requires action on the part of many individuals. Another advantage is that, unlike other strategies mentioned, dietary supplements do not require major changes in the food supply, food processing, or dis- tribution. Still, in general, the IOM reports have endorsed supplementation with specific nutrients only for situations in which there is clear evidence of potential harm due to dietary inadequacy. For the military, the following factors need to be considered when se- lecting a strategy to increase nutrient intakes: • The prevalence and severity of a population’s nutritional inadequacy • The consequences of failing to raise intakes to RDAs or other nutri- ent standard levels • The number of nutrients in which a population is deficient • The amount of time required to affect the health outcomes linked to the nutrient in question • The phase, appropriateness, and feasibility of the intervention • Other characteristics unique to the particular setting • Other characteristics of the nutrient under consideration In contrast, the proposition that taking a multivitamin or multimin- eral (MV/MM) supplement each day should be recommended is debat- able, because the efficacy of using dietary supplements to alter the risk of chronic disease is not well established (Caballero, 2003), and this practice presents public health concerns if intake regularly exceeds the UL. In addi- tion, when supplementary doses of nutrients are high, nutrient interactions tend to be accelerated. There might be harmful consequences from shifting the emphasis away from intake of nutrients from food and toward use of nutrient supplements (Caballero, 2003; Lichtenstein and Russell, 2005), in 

VITAMINS AND ESSENTIAL MINERALS 77 that changes in nutrient profiles might lead to alteration in absorption or metabolism of other constituents. Upper Limits as Safety Levels for Vitamins and Minerals As mentioned above the unique demands of some military situations suggest that nutrient requirements for the military might differ from those for the general population; however, there is no scientific basis to estab- lish different military ULs (for chronic intake). Establishment of the DRIs (and the UL in particular) is an area of nutrition undergoing considerable changes and attracting much attention both nationally and internationally. As with previous IOM committees that have addressed questions related to the nutrient needs of military personnel, this committee recommends that the military defer to the standards established by the IOM when it evaluates the safety of vitamins and minerals (IOM, 1997, 1998a, 2000a, 2002/2005, 2004). The premises and thought process that precede the establishment of ULs are being reconsidered; as recently recognized in the IOM workshop summary Dietary Reference Intakes Research Synthesis, experts recognize the need for improved ULs. Much progress is needed not only in collection of data to determine ULs, but also in the establishment of clear objectives; for instance, for each particular nutrient it is critical to define the adverse effects or health end points to be used in establishing the UL. The IOM workshop summary identified data on dose–response; measures of expo- sure; exposure in subpopulations, especially for the upper percentiles; and long-term exposure as both critical and lacking. Finally, understanding the interactions of multiple nutrients and identifying approaches to deal with the challenges associated with human intervention studies (e.g., approaches for extrapolating conclusions from animal data) were highlighted as areas of research requiring attention (IOM, 2006b). Efforts are being made to enhance the approaches used to establish the DRIs, including models for ULs. The military leadership responsible for setting nutrition policy should closely follow current and future developments in this area. One question that might arise during performance of military tasks is the appropriate acute intake of a mineral or vitamin. The ULs are based on chronic intakes, not acute intakes. The safety of vitamins or minerals when a large amount is consumed over a short period of time is unknown. For example, in case of injury, a patient’s acute intake of doses of vitamin E lower than the UL might still be lethal because of its antithrombotic effect. On the other hand, short-term consumption of other nutrients in amounts that exceed the UL might not present a significant risk. This is an issue of concern for military personnel in combat. 

78 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL Are There Safety Concerns for Vitamin and Mineral Use Among Military Populations? Survey Data Chapter 2 summarizes unpublished survey data on dietary supplement use that was collected during the past several years and presented during the 2007 workshop Dietary Supplement Use by Military Personnel and data from a small number of published surveys (Appendix C). The most recent unpublished surveys indicated that products with a combination of vita- mins and minerals (MV/MM) are among the most frequently used dietary supplements in both the general active duty population (Corum, 2007; Marriott, 2007; Thomasos, 2007) and special military subpopulations (ap- proximately 23 percent, 32 percent, and 39 percent of U.S. Army Rangers, Special Forces, and Army War College students, respectively) (Lieberman et al., 2007). The published literature also concurs with a high frequency of use of multivitamin or multimineral products or both compared to other dietary supplements among military personnel (Arsenault and Kennedy, 1999; Bovill et al., 2000; Brasfield, 2004; McGraw et al., 2000; Sheppard et al., 2000). In addition to MV/MM supplements, individual minerals or vitamins were also frequently used. A high percentage of the subjects reported “improvement of health” or “to supplement diet” as the reasons for their use of MV/MM supplements (76 percent) or individual vitamins or minerals (65 percent) (Marriott, 2007) (Chapter 2). Data Limitations The limitations of survey designs are presented in Chapter 2. One ma- jor limitation is that although surveys have collected partial information on frequency of use, none of the questions addressed the specific dosages or amounts of a supplement consumed, which is a critical piece of infor- mation when evaluating safety. Even with the assumption that consumers ingest one pill or tablet per day, the broad range of levels in commercially available brands would hamper any accurate estimation of consumption level. In fact, from the data available to the committee, it is not possible to determine whether the current uses of specific minerals or vitamins might be cause for concern. This state of affairs was eloquently and extensively de- scribed in the 30th National Nutrient Database Conference Report Progress in Developing Analytical and Label-Based Dietary Supplement Databases at NIH’s Office of Dietary Supplements (Dwyer et al., 2007). This report concluded that the widespread use of dietary supplements increases the need for better data on dietary supplement composition and possible health effects. These data are critical for an accurate estimate of total intake of 

VITAMINS AND ESSENTIAL MINERALS 79 vitamins and minerals, including dietary. Recognizing this, the government has led several initiatives such as the development of a validated MV/MM supplement ingredient database and the update of the National Health and Nutrition Examination Survey (NHANES) dietary supplement label data- base as well as a study to assess the feasibility of a label database for all dietary supplements marketed in the United States. The panel at the 30th National Nutrient Database Conference concluded that the evidence was insufficient to either recommend or discourage the use of MV/MM supple- ments (Dwyer et al., 2007). One factor that hinders the availability of total intake data is the lack of information on vitamin and mineral intake from food sources. For ex- ample, the 2006 IOM report Mineral Requirements for Military Personnel stated that the few studies available on mineral intake suggest that military servicemen’s dietary intake of some minerals (i.e., magnesium and zinc) might be marginal, but the latter does not provide a clear picture of the mineral and vitamin intake from food among service members (Baker- Fulco, 2005; personal communication, Carol J. Baker-Fulco, USARIEM, April 23, 2007). This committee concurs with other IOM committees that there is an important need to collect intake data on essential minerals and vitamins from both dietary supplements and the diet. Interactions with Other Dietary Components or Medications Data from only two of the available surveys were analyzed to answer questions related to concomitant consumption of various dietary supple- ments; for example, what is the proportion of users of mineral or vitamin supplements who also consume other dietary supplements? Are some sup- plements taken frequently in combination? The analysis of the data from the Army-wide survey found that among multivitamin users, 21 percent take one other supplement, 22 percent take three or four other supplements, and 31 percent take five or more other supplements (Lieberman et al., 2007). The most popular “other” supplements were protein powder (taken by 29 percent of respondents), sports drinks (24 percent), vitamin C (21 percent), calcium (15 percent), other vitamins (vitamins E, D, or A) (30 percent), cre- atine (9 percent), or other antioxidants (9 percent). Likewise, the analysis of data from the army survey administered to active duty personnel deployed in Germany showed that among those taking multivitamins, multiminerals, or both, many also used other vitamins or minerals such as vitamin C (43 percent), calcium (38 percent), vitamin E (32 percent), or iron (30 percent); a smaller proportion were also taking performance enhancers such as cre- atine (13 percent), sports drinks (11 percent), and arginine; others were also taking herbal supplements such as ginseng (11 percent), garlic (8 percent), Ginkgo biloba (7 percent), or echinacea (6 percent); and others were also 

80 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL taking caffeine (5 percent) (personal communication, Sonya Corum, U.S. Army Training and Doctrine Command, April 10, 2007). In addition to consumption of a combination of dietary supplements, there are concerns related to the use of dietary supplements while using prescription medications. Yetley (2007) briefly reviewed potential undesir- able effects that may result. For instance, intake of calcium, frequently used among military personnel, may reduce absorption of some medications and reduce their efficacy. Other reported interactions include vitamin E and as- pirin, with the potential for an antithrombotic effect (Yetley, 2007). Because vitamins and minerals are essential nutrients, this committee recommends that if a dietary supplement compromises the effectiveness of a medication, an alternative medication should be prescribed if possible. Similarly, if doses higher than the RDA of a specific vitamin or mineral are known to reduce the effect of medication, then advising a reduction in intake of the vitamins or minerals to the RDA level would be appropriate. As with other supplements, however, there is little research conducted on the effects of interactions between medications and vitamins or minerals. SUMMARY Two IOM committees have recently addressed the nutrient needs of military personnel and highlighted several areas where research is war- ranted, including mineral losses under high-intensity military situations; iron status and total calcium intake throughout the time served in military service; and potential beneficial effects on performance of supplementation with specific vitamins and minerals, such as iron and zinc, alone or in com- bination. These two IOM committees demonstrate the lack of information regarding nutrient requirements for specific subpopulations in the military as well as the lack of information on mineral or vitamin deficiencies that might result in health or performance decrements. As suggested by the IOM Committee on Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations (IOM, 2005), nutrients should be provided in whole foods, and fortification and the use of supplementation should be limited to the extent possible owing to the potential for nutrient–nutrient interactions. To remedy deficiencies of es- sential vitamins or minerals, the military may find it useful to implement combined strategies that involve typical diets, fortified foods, and dietary supplements. Whether supplement use is institutionally implemented or not, an in- dividual might still decide to use an MV/MM dietary supplement; unfortu- nately, as outlined above, there is very little information on the doses and frequency of current use. In the absence of information on total dietary intake of vitamins and minerals, and assuming that individual users of 

VITAMINS AND ESSENTIAL MINERALS 81 MV/MM dietary supplements take one unit (e.g., pill) per day and that the amounts of essential nutrients per unit are comparable to the military RDA, the committee concluded that the potential for adverse health effects from the use of these dietary supplements would be minimal. Acute intake beyond UL levels of some minerals and vitamins might, however, pose some risks in specific high-intensity military situations that would not be predicted by considering the ULs, which are based on chronic intake levels. Likewise, the acute intake of other minerals and vitamins beyond the UL might not pose significant risks. Thus, the recommendation to use ULs as the upper limit should be based on chronic use, as intended when the ULs were established by the IOM. RESEARCH NEEDS The committee recommends that research efforts for vitamins and minerals be made in the following areas: 1. Gather data on nutrient composition of rations and on total dietary intake of vitamins and minerals by military personnel. To gather these data, the military should do the following: a. Design and conduct surveys on dietary supplement use by mili- tary personnel following the guidance provided in Chapter 2. In par- ticular, more accurate information about dosage and frequency needs to be gathered. b. Continue conducting ration composition analysis, and conduct studies to estimate the dietary intake of minerals and vitamins. 2. Participate in current government-led initiatives to construct a label database and a composition database for vitamin and mineral products. 3. Follow closely the current and future UL developments and include them in their MDRI tables. Consider establishing ULs for the military in special conditions (i.e., during combat when the risk of injury is high, when clotting medications are being used, or during wound healing when vitamin E intake might need to be restricted). 4. If surveys of use reveal that the intake of specific vitamins or miner- als are approaching ULs within short periods of time, then conduct research to determine the safety of acute intakes of those minerals or vitamins under military conditions of concern. Consider establishing upper limits for acute intakes. REFERENCES Arsenault, J., and J. Kennedy. 1999. Dietary supplement use in U.S. Army Special Operations candidates. Mil Med 164(7):495-501. 

82 USE OF DIETARY SUPPLEMENTS BY MILITARY PERSONNEL Baker-Fulco, C. J. 2005. Derivation of the military dietary reference intakes and the mineral content of military rations. Institute of Medicine Workshop on the Mineral Requirements for Cognitive and Physical Performance of Military Personnel, Washington, DC. Bovill, M. E., S. M. McGraw, W. J. Tharion, and H. R. Lieberman. 2000. Supplement use and nutrition knowledge in a Special Forces unit. FASEB J 15(5):A999. Brasfield, K. 2004. Dietary supplement intake in the active duty enlisted population. US Army Med Dept J (Oct-Dec):44-56. Caballero, B. 2003. Fortification, supplementation, and nutrient balance. Eur J Clin Nutr 57(Suppl 1):S76-S78. Corum, S. J. C. 2007. Dietary supplements questionnaire. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel meeting, Washington, DC, February 13. Dwyer, J. T., M. F. Picciano, J. M. Betz, K. D. Fisher, L. G. Saldanha, E. A. Yetley, P. M. Coates, J. A. Milner, J. Whitted, V. Burt, K. Radimer, J. Wilger, K. E. Sharpless, J. Holden, K. Andrews, J. Roseland, C. Zhao, A. Schweitzer, J. Harnly, W. R. Wolf, and C. R. Perry. 2007. 30th National Nutrient Database Conference Report: Progress in developing analytical and label-based dietary supplement databases at NIH’s Office of Dietary Supplements. Honolulu, HI. IOM (Institute of Medicine). 1997. Dietary reference intakes for calcium, phosphorus, mag- nesium, vitamin D, and fluoride. Washington, DC: National Academy Press. IOM. 1998a. Dietary reference intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press. IOM. 1998b. Prevention of micronutrient deficiencies: Tools for policymakers and public health workers. Washington, DC: National Academy Press. IOM. 2000a. Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington, DC: National Academy Press. IOM. 2000b. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Wash- ington, DC: National Academy Press. IOM. 2002/2005. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington, DC: The National Academies Press. IOM. 2004. Dietary reference intakes for water, potassium, sodium, chloride, and sulfate. Washington, DC: The National Academies Press. IOM. 2005. Nutrient composition of rations for short-term, high-intensity combat operations. Washington, DC: The National Academies Press. IOM. 2006a. Mineral requirements for military personnel: Levels needed for cognitive and physical performance during garrison training. Washington, DC: The National Acad- emies Press. IOM. 2006b. Dietary reference intakes research synthesis: Workshop summary. Washington, DC: The National Academies Press. Lichtenstein, A. H., and R. M. Russell. 2005. Essential nutrients: Food or supplements? Where should the emphasis be? JAMA 294(3):351-358. Lieberman, H. R., T. Stavinoha, S. McGraw, and L. Sigrist. 2007. Use of dietary supplements in U.S. Army populations. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel meeting, Washington, DC, February 13. Marriott, B. M. 2007. Dietary supplement use by active duty military personnel: A worldwide sample. Institute of Medicine Committee on Dietary Supplement Use by Military Person- nel meeting, Washington, DC, February 13. McGraw, S. M., W. J. Tharion, and H. R. Lieberman. 2000. Use of nutritional supplements by U.S. Army Rangers. FASEB J 14(4):A742. 

VITAMINS AND ESSENTIAL MINERALS 83 Perelson, A. M., and L. Ellenbogen. 2002. Rationale for use of vitamin and mineral supple- ments. In Handbook of nutrition and food, edited by C. M. Berdanier, E. B. Feldman, W. P. Flatt, and S. T. St. Jeor. Boca Raton, FL: CRC Press. Pp. 1333-1361. Sheppard, H. L., S. M. Raichada, K. M. Kouri, L. Stenson Bar Maor, and J. D. Branch. 2000. Use of creatine and other supplements by members of civilian and military health clubs: A cross-sectional survey. Int J Sport Nutr Exerc Metab 10(3):245-259. Thomasos, C. 2007. Assessment of Air Force dietary supplement usage by major commands. Institute of Medicine Committee on Dietary Supplement Use by Military Personnel meet- ing, Washington, DC, February 13. U.S. Departments of the Army, Navy, and Air Force. 2001. Nutrition standards and educa- tion. AR 40-25/BUMEDINST 10110.6/AFI 44-141. Washington, DC: U.S. Department of Defense Headquarters. Yetley, E. A. 2007. Multivitamin and multimineral dietary supplements: Definitions, character- ization, bioavailability, and drug interactions. Amer J Clin Nutr 85(Suppl):269S-276S.