Research clearly indicates that malnourished patients have longer hospitalizations and poorer surgical outcomes than well-nourished patients (Garrouste-Orgeas et al., 2004; O’Brien et al., 2006; Tremblay and Bandi, 2003). However, research also indicates that in a generally adequately nourished population, short-term reduction of protein and energy intake prior to surgery is not significantly related to outcomes. This is relevant to discussion of military service members because they sometimes undergo short periods of time during special missions when dietary intakes may be less than the MDRIs, but these short-term deficits apparently do not affect their health status or performance. Based on the Department of Defense (DoD) testimony, the committee assumed that the nutrition status of active-duty military personnel is similar to that of the general population of the United States. Even with the presumption that their nutrition status is adequate, there may still be opportunities to target intake of specific nutrients having the potential to maximize resilience to an injury such as TBI.
The question of how to maximize the use of nutrition to optimize resilience to TBI should address the overall nutritional status of military personnel, but it should also identify particular nutrients that may be more important than others in a generally well-nourished population. In order to plan menus and rations to ensure adequate diets for military personnel, military nutrition standards and menu-planning procedures have been established and implemented. In the future, these standards and procedures might consider specific nutrition approaches if there is evidence that they would benefit those at higher risk of experiencing TBI.
Historically, the military has reviewed the nutrition standards (DRIs) for the general U.S. population and determined whether adjustments were necessary for military personnel, specifically for those experiencing situations unique to the military, such as being deployed in extreme environments and under high levels of physical and mental stress. Previous reports concluded that service members may have nutritional requirements that differ from those of the general U.S. population. Previous committees of the Institute of Medicine (IOM) also have recognized that the dietary intake of military personnel might be different from that of the general U.S. population and have recommended evaluation of nutritional status throughout the military services (e.g., IOM, 2006, Mineral Requirements for Military Personnel). The MDRIs were last updated in 2001 in a tri-service regulation (Baker-Fulco et al., 2001; U.S. Departments of the Army, 2001). This regulation established nutritional standards for military feeding as well as nutritional standards for operational rations (NSORs). The Army, the lead agency, is tasked with the responsibility to “establish nutritional standards of meals served to military personnel subsisting under normal operating conditions and while under simulated or actual combat conditions” and “establish nutritional standards for operational rations and restricted rations.” Each military service is responsible for ensuring there are mechanisms in place to meet nutritional standards in menus, including compliance requirements in contracts with food service operations. The current MDRIs, shown in Table 5-1, were adapted from the 1989 Recommended Dietary Allowances (RDA, 10th revised edition) and thereafter from the DRIs for the following nutrients: calcium, phosphorus, magnesium, vitamin D, fluoride, thiamine, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, choline, vitamin C, vitamin E, selenium, and carotenoids (Baker-Fulco et al., 2001). The regulation acknowledged that DRIs for some nutrients (i.e., vitamins A and K,