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--> 1 A Review of the Physiology and Nutrition in Cold and in High-Altitude Environments by the Committee on Military Nutrition Research CONTENTS     PROJECT OVERVIEW   4     THE COMMITTEE'S TASK   4     MILITARY RESEARCH, COMMAND ISSUES, AND RATIONS FOR COLD AND FOR HIGH-ALTITUDE ENVIRONMENTS   6     THE COLD ENVIRONMENT   9     PHYSIOLOGICAL CHANGES IN THE COLD   9     Basic Physiology of Cold Exposure   9     Central Nervous System Function and Sleep   14     Thermoregulation and Physical Performance   15     Drug-Induced Delay of Hypothermia   16     CHANGES IN NUTRIENT REQUIREMENTS FOR COLD ENVIRONMENTS   17     Fluid Balance   17     Macronutrients   19     Vitamins   25     Minerals   26     APPETITE AND BEHAVIOR CHANGES IN THE COLD   26     THE HIGH-ALTITUDE ENVIRONMENT   27     PHYSIOLOGICAL CHANGES AT HIGH ALTITUDES   27     Basic Physiology of High-Altitude Exposure   27     Biophysical Realities of High Altitudes   28     Physiological Responses at High Altitudes   30     Water Balance at High Altitudes   31     Acclimatization to High Altitudes   32     Altitude-Induced Illness   33

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-->     Weight Loss at High Altitudes   35     Effects of Age and Gender on Response to Altitude   36     CHANGES IN NUTRIENT REQUIREMENTS AT HIGH ALTITUDES   37     Macronutrients   37     Vitamins   40     Minerals   41     APPETITE AND BEHAVIOR CHANGES AT HIGH ALTITUDES   42     Mental Response to High Altitudes   42     The Effect of Altitude on Cognitive Performance and Mood States   42     Food Components that May Enhance Mental Performance at High Altitude and in the Cold   43     Military Considerations   44     INTERACTIONS OF COLD AND HIGH ALTITUDES   46     SUMMARY   46     REFERENCES   47 PROJECT OVERVIEW Military operations are frequently conducted in locations where soldiers are exposed to desert, arctic, and high-altitude environmental extremes. Gradual adaptation to these environments aids physiological acclimatization. However, military missions rarely can be planned to allow lengthy acclimatization periods. The recent Desert Storm operation is an example of an operation conducted under adverse conditions with little time initially for preparation or acclimatization. Recreational mountain climbers, individuals whose professions involve working outdoors in seasonally cold weather, and people who live in cold or high-altitude environments have the opportunity to plan for their activities in these extreme environments. Individuals who are accustomed to the cold or high altitude learn how to adjust their apparel and activities to maintain an acceptable lifestyle in spite of the external environment. Regardless of climatic conditions, troops must be supplied with food, weapons, housing, and other support facilities that will enable the immediate performance of their mission. THE COMMITTEE'S TASK For many years the Military Nutrition Division (MND) at the U.S. Army Research Institute of Environmental Medicine (USARIEM) has been reviewing the nutritional needs of soldiers in environmental extremes and conducting extensive experimentation both in experimental chambers and in the field to ascertain the changing demands placed on soldiers. The Committee on Military

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--> Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), Institute of Medicine (IOM) previously has been requested to provide reviews and recommendations through workshops and reports (IOM, 1991, 1993, 1994) on nutritional needs of soldiers in environmental extremes. These included fluid replacement and nutrient requirements in hot environments. In 1993, the CMNR was asked by the MND to review research pertaining to nutrient requirements for working in cold and in high-altitude terrestrial environments. In addition, the committee was asked to make recommendations regarding the application of this information to military operational rations. The committee was thus asked to provide a thorough review of the literature in this area and to interpret these diverse data in terms of military applications. The CMNR was asked to address the increased energy demands of such environments and to consider whether these environments elicit an increased requirement for other specific nutrients. The MND also asked the CMNR to include in their response the answers to the questions listed in Table 1-1. This TABLE 1-1 Questions Pertaining to Nutritional Needs in Cold and in High-Altitude Environments Posed by the MND to the CMNR Performance • What is the effect of cold/altitude exposure on muscle strength and endurance? • Can diet influence these changes? • How does cold/altitude exposure influence appetite? Health and Medical Aspects • Is there concern for increased cardiovascular risk when a high fat diet is consumed for intermittent (7- to 14-d) time periods in the cold? • What nutrients prevent or lessen the signs and symptoms of acute altitude exposure? • Is free radical formation a concern for prolonged (10- to 30-d) military operations at 10,000-15,000 ft (3,048-4,572 m) elevation? Thermoregulation and Acclimatization • Is cold/altitude acclimatization facilitated by prior satisfactory nutritional status or supplemental nutrients? • What nutrients influence thermoregulation? • Does the timing of food ingestion influence cold tolerance? • What is the relationship between fluid intake and thermoregulation in the cold and at altitude? Nutritional Requirements • What are typical energy requirements for work in cold and high-altitude environments? • What is the effect of cold and altitude exposure (at rest) on basal energy requirements? • Does cold or altitude exposure alter the requirement for nutrients other than energy? • What is the sodium requirement for hard physical work in a cold environment? • What is the relationship between fluid intake and food intake in the cold/altitude?

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--> report thus provides a parallel review to the previous CMNR report on the nutritional needs of individuals actively working in hot climates (IOM, 1993). These specific issues were summarized by COL Eldon W. Askew (program officer designee) into two overriding questions: Aside from increased energy demands, do cold or high-altitude environments elicit an increased demand or requirement for specific nutrients? Can performance be enhanced in cold or high-altitude environments by the provision of increased amounts of specific nutrients? To assist the CMNR in responding to these questions, a workshop was convened on January 31–February 1, 1994 that included presentations from individuals familiar with or having expertise in cold and in high-altitude physiology, energetics, macronutrient and micronutrient requirements, ingestive behavior, psychology, and military rations. In addition, military commanders familiar with working and training personnel in the cold and at high altitudes gave presentations and actively participated in the discussions. The invited speakers discussed their presentations with committee members at the workshop and submitted the content of their verbal presentations as written reports. The committee met after the workshop to discuss the issues raised and the information provided. The CMNR later reviewed the workshop presentations and drew on its collective expertise and the scientific literature to develop the following summary, conclusions, and recommendations that are found in the two chapters in Part I. In writing the first two chapters of this report, the CMNR has used the operational terminology included in Table 1-2. MILITARY RESEARCH, COMMAND ISSUES, AND RATIONS FOR COLD AND FOR HIGH-ALTITUDE ENVIRONMENTS The initial presentations at the workshop and the resulting chapters (3 though 6) in Part II of this report present a background for understanding military nutrition issues in the cold and at high altitudes. The influence of cold and high altitudes on nutritional needs of the soldier has been a topic of interest to the military for many years. In his introduction COL Askew reviews the previous cold- and high-altitude intramural research activities of the Army, research sponsored by Army grants to academic institutions, and military-sponsored workshops or conferences (see Chapter 3 in this volume). COL Askew indicates that early work on cold and on high-altitude physiology and nutrition was typically a collaborative effort between military and civilian scientists. Since the 1970s, the overall extramural research activity supported by the military has significantly decreased, and specific research on nutritional needs in environmental extremes has been conducted largely within military research facilities.

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--> TABLE 1-2 Terms Used in This Report Acclimation Adaptive changes to an environment under controlled conditions, such as an environmental chamber (indoors/in the laboratory). Acclimatization Adaptive changes that occur due to exposure to a natural environment (outdoors/in the field). Altitude Designations At high altitudes General term to represent altitudes of 5,280 ft (1,609 m) or more above sea level. Moderately high altitudes 8,000 to 11,000 ft (2,438 to 3,353 m). High altitudes 12,000 to 18,000 ft (3,658 to 5,486 m). Extremely high altitudes Over 18,000 ft (5,486 m) (above which acclimatization is difficult). Cold Temperature range within which human body has difficulty functioning. 30°F to -30°F (-1°C to -34°C). Diuresis Excretion of urine; commonly denotes transient production of unusually large volumes of urine. Hypothermia* Core body temperature significantly below 95° F (35°C).   Mild: Body temperature of 89.6°F to 95°F (32°C to 35°C)   Moderate: Body temperature of 82.4°F to 89.6°F (28°C to 32°C).   Severe: Body temperature of less than 82.4°F (28°C). Hypoxia Below normal levels of oxygen in arterial blood or tissue, short of anoxia. Hypohydration Decrease in body fluids equivalent to a loss of 1% body mass or more.   SOURCE: Granberg (1991). Clothing, equipment, state of mind, leadership, physical conditioning, mental attitude, preparation, and nutrition are considered by COL Russell W. Schumacher, Jr. in relation to success in cold and in high-altitude training and operations (see Chapter 4 in this volume). COL Schumacher suggests that the single most significant contributor to successful operations in the cold is a positive attitude. In Chapter 4 he further reviews the necessary components of developing and maintaining positive attitudes in troops in these environmental extremes. He stresses the need for unit commanders to have realistic performance expectations of their troops in the cold and at high altitudes and concludes that daily effort must be put forth to attain and maintain positive troop morale in environmental extremes. Military operational rations are the principal source of nutrients provided for the soldier in military operations in all environments. Therefore as

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--> background for the report, a review of current rations specified for use in cold environments and the systems for preparation and use of field rations are summarized by LTC Nancy King and CW4 Thomas J. Lange (see Chapters 5 and 6 in this volume; see also IOM, 1995a). A modified table from Chapter 5 listing the nutrient contents of rations for cold-weather use has been reproduced here for clarity (Table 1-3). The principal ration for group feeding in military field operations currently is the Tray Pack (T Ration). The T Ration is ready-to-heat and -serve, and is provided in low-profile, rectangular metal cans that can be heated quickly in hot water baths. This ration is described in more detail in Chapter 5. The standard T Ration is augmented with a cold-weather supplement module to provide 1,000 kcal per meal extra energy for cold environments. This Arctic T (T Ration supplemented with the cold-weather module) provides approximately 2,400 kcal per meal. Frequently military missions do not permit group feeding, and individually packaged rations must be provided. The basic individually packaged ration is the Meal, Ready-to-Eat (MRE). The general composition of this ration is discussed in Chapter 5. In cold environments the basic three-ration per day provision is augmented with an additional fourth MRE or an energy supplement providing extra kcal. While the MRE can be consumed cold, individual ration heaters are provided since hot rations are more acceptable to soldiers in a cold environment. The Ration, Cold Weather (RCW) is dehydrated and can be reconstituted with hot or cold water, or consumed dry. This ration was developed to meet some of the special needs for operating in arctic conditions. The specifics of the ration are discussed in Chapter 5, along with those of another more specialized food packet, the Long-Range Patrol, Improved (LRP I). CW4 Lange (see Chapter 6 in this volume) summarizes some of the problems of feeding soldiers in the cold. He also discusses the issues of specialized equipment design that have been used to address the arctic and high-altitude conditions that present a very harsh environment for feeding the individual soldier. Problems of sheltering people and equipment as well as food preparation in severely cold and windy conditions are unique. These problems have required the development or improvement of mobile equipment that can function properly in such environments. Examples of these include the Mobile Kitchen Trailer and Kitchen Company Level Field Feeding equipment. These developments are important in providing food to sustain the military effectiveness of the soldier and the unit. Chapters 3 through 6 indicate the need for close coordination between the ration developer and troop support activities to ensure continued improvement in the quality and delivery of nutritionally adequate foods to soldiers operating in these environmental extremes.

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--> THE COLD ENVIRONMENT PHYSIOLOGICAL CHANGES IN THE COLD Basic Physiology of Cold Exposure When exposed to cold environments, the body loses heat through both convective and conductive heat transfer mechanisms. Heat losses are greater if the body is exposed to cold water than to cold air due to the greater heat transfer capacity of water (Gonzalez, 1988). As detailed by Andrew J. Young and colleagues (see Chapter 7 in this volume), the body possesses mechanisms to help maintain core temperature during cold exposure and to reduce heat loss, as well as to restore heat that has been lost. The mechanisms collectively are called thermoregulation. Peripheral Vasoconstriction and Vasodilation The principal mechanism to reduce heat loss is the neurologically induced constriction of vessels in the skin and extremities. This response diminishes heat transfer from the body core to the surfaces. As a result, body surface temperatures fall rapidly upon exposure to cold (Veicsteinas et al., 1982). These low skin and extremity temperatures can result in cold injuries, especially to the hands and fingers. A second mechanism, cold-induced vasodilation (CIVD), somewhat offsets the harmful effects of falling skin temperatures. With exposure to cold, vasoconstriction reduces skin temperatures, but then CIVD allows the temperatures to rise within about 10 minutes (Lewis, 1930). Over time the alternation of these two vascular responses results in a rhythmic (or cyclic) rise and fall of skin temperatures (Lewis, 1930). Metabolic Heat Production Heat production occurs as the result of voluntary muscular work, by involuntary (central nervous system [CNS]-induced) shivering, or by a combination of both mechanisms. Humans have no unique nonshivering, thermogenic mechanisms for responding to cold (Toner and McArdle, 1988). Nevertheless, as pointed out by Ira Jacobs (see Chapter 10 in this volume), every cellular metabolic process within the body has, as its byproduct, the production of heat. Even the vasoconstrictive activity of vessel walls produces some heat.

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--> TABLE 1-3 Approximate Nutritional Content of Rations Used in Cold-Weather Operations   MRDA T Ration* (3 meals) MRE† (4 meals) RCW (1 ration) LRP I (3 meals) Nutrient Men Women Energy, kcal 4,500 3,500 4,323‡ 5,392 4,567 4,668 Protein, g 100 80 181 197 94 179 Carbohydrate, g _§ _§ 582 669 682 586 Fat, g _|| _|| 141 215 163 179 Vitamin A, IU 5,000 4,000 15,153 16,880 8,022 8,133# Vitamin E, mg TE 10 8 15# 22# 21 13# Vitamin C, mg 60 60 208 408 329 183 Thiamin, mg 1.6 1.2 3.5 10.8 5.7 3.7 Riboflavin, mg 1.9 1.4 3.5 4.3 2.6 2.8 Niacin, mg NE 21 16 42 52 31 541 Vitamin B6, mg 2.2 2.0 2.2 7.6 3.9# 2.7 Folacin, µg 400 400 339 292# 141# 132# Vitamin B12, µg 3 3.0 5.3# 3.5# 0.8# 1.8# Calcium, mg 800–1,200 800–1,200 1,687 2,052 1,379 1,149 Phosphorus, mg 800–1,200 800–1,200 2,761 3,184 2,168 2,352

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-->   MRDA T Ration* (3 meals) MRE† (4 meals) RCW (1 ration) LRP I (3 meals) Nutrient Men Women Iron, mg 10–18 18 29 24 19 24 Sodium, mg –** –** 7,374 7,292 4,720 7,740 Potassium, mg _†† _†† 5,626 5,424 4,084 4,419 Magnesium, mg 350–400 300 523 556 592 489 Zinc, mg 15 15 20 13# 11# 9# Cholesterol, mg _§ _§ 484# 476# 183# 174# NOTE: MRDA, Military Recommended Dietary Allowances for moderately active military personnel ages 17 to 50 years old operating in cold weather; T Ration, Tray Pack Ration without cold-weather supplement (FY1992); MRE, Meal, Ready-to-Eat (version XII); RCW, Ration, Cold Weather; LRP I, Long-Range Patrol, Improved. * The T Ration cold-weather supplement provides 148 g carbohydrate (53 percent), 29 g protein (11 percent), and 45 g fat (36 percent of total kcal) for a total of 1,110 kcal (Personal communication, M. S. Harrington, U.S. Army Research Institute of Environmental Medicine, Natick, Mass., February 1996). † The MRE is reformulated annually. Values provided are for version XII. The version in current use is XVI. The relative proportions of energy provided by protein, carbohydrate, and fat vary by no more than 1 percent from year to year (Personal communication, L. D. Sherman, U.S. Army Research Institute of Environmental Medicine, Natick, Mass., February 1996). ‡ Cold-weather supplement adds approximately 1,000 kcal. § No MRDA established. || Should not exceed 35 percent of total energy intake. # Data missing (more than 50 percent) or inaccurate. ** No MRDA established. The safe and adequate levels published in the RDA are considered to be unattainable within military foodservice systems. An average of 5,500 mg for men and 4,100 mg for women is the target. †† NO MRDA established. The safe range is 1,875–5,625 mg, based on AR 40–25 (1985). SOURCE: Adapted from AR 40–25 (1985). Record of nutritive values for each ration.

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--> Skeletal muscle contractions, either during voluntary exercise or involuntary shivering, are the major source of the metabolic heat produced to protect against cold stress (Horvath, 1981). Heat production parallels an increase in oxygen uptake, the magnitude of which depends on the proportion of the muscle mass engaged in shivering or work and the duration and severity of work being done (Young et al., 1986a). Shivering alone can cause only a fourfold increase over basal rates of heat production, and even the greatest increases in heat production because of shivering alone are less than one quarter of a muscle's maximum contractile activity (Horvath, 1981). The thermogenic response to voluntary exercise differs with the form of exercise (Toner and McArdle, 1988). Arm-only exercise causes a greater loss of body heat than does leg-only exercise (when both yield the same magnitude of heat production per unit). As a result, leg-only exercise is more efficient in maintaining body core temperatures (Toner et al., 1984). If voluntary exercise does not maintain body core temperatures during cold exposure, involuntary shivering responses are initiated, and heat production then may result from both forms of muscular work. Maximal energy expenditure by skeletal muscles may be reduced by cold exposure, if temperatures decline in muscle, body core, and/or blood. A fall in the temperature of blood reduces its delivery of oxygen to body tissues, because of temperature effects on the oxyhemoglobin dissociation curve (Young, 1990). Cardiac Responses The increase in oxygen uptake during shivering thermogenesis is also accompanied by an increase in cardiac output (Muza et al., 1988). This increase is due almost entirely to an increase in stroke volume, which appears to be the result of the increased central blood volume that is associated with cold-induced peripheral vasoconstriction. Resting heart rate remains unchanged (Muza et al., 1988). Effect of Gender Almost all studies of physiological responses to cold stress have been conducted in men. However, there is no evidence to suggest that basic mechanisms for peripheral vasoconstriction, cardiovascular responsiveness, and metabolic heat production in the cold are different in men and women. Metabolic changes during the menstrual cycle have not been studied during cold exposure, but basal body temperature is known to vary in response to hormone secretions (Stephenson and Kolka, 1993). Differences in body composition also may play a role, with the higher content of body fat in women and their smaller body surface areas providing some degree of

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--> protection from heat loss. Current knowledge of physiological responses to cold is largely based on studies of healthy young adult males. With the growing numbers of women in the military, they should not be neglected in future studies (IOM, 1995b). Effect of Age As reviewed by Young et al. (see Chapter 7 in this volume), general medical knowledge, backed by older physiological studies, suggests that older individuals may respond poorly to severe cold stress. The typical loss of muscle mass that accompanies the aging process undoubtedly plays a role by reducing the capacity for production of heat from metabolic processes. On the other hand, the accumulation of body fat with aging may provide additional protection against heat loss in mid- to late mid-life, but this protection is most likely lost or may change as aging continues. Extremely old individuals are often characterized by a gradual loss of body fat, especially subcutaneous fat. The increase in body surface area in comparison to body mass combines to reduce the mechanisms used to protect against heat loss (Young, 1991). Similar problems would arise in malnourished subjects who have lost both body fat and muscle mass. Other Factors Cold acclimatization can occur in humans but it is minimal. Probably the most important modifying factor on the thermoregulatory response to cold is the individual's endowment of subcutaneous fat since fat reduces thermal conductance from the core to body surfaces (Toner and McArdle, 1988). Physical fitness has mixed effects: the fittest individuals show the greatest heat production, but they are also the leanest, and that combined with their higher skin temperatures (from increased heat production) causes them to lose heat more quickly. Older individuals tend to maintain lower body temperatures (Mathew et al., 1986) and have less efficient vasoconstrictive mechanisms, so they are at greater risk for heat loss in cold environments. Generalized malnutrition may also impair thermoregulation. Severe losses of body weight associated with the complex stresses of prolonged military operations could also complicate the normal physiological responses to cold. Emphasis on maintaining an adequate intake of operational rations to prevent excessive weight loss in severe operational environments is important to sustain normal physiological responses to cold (IOM, 1995a). A discussion of nutrient requirements in the cold begins on page 15. The most important modifying factors for thermoregulation, however, are the behavioral strategies employed in cold environments. Humans don warm,

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--> Baker-Fulco, C.J. 1995 An overview of dietary intakes during military exercises. Pp. 121–149 in Not Eating Enough, Overcoming Underconsumption of Military Operational Rations, B.M. Marriott, ed. A report of the Committee on Military Nutrition Research, Food and Nutrition Board, Institute of Medicine. Washington, D.C.: National Academy Press. Banderet, L.E., and H.K. Lieberman 1989 Treatment with tyrosine, a neurotransmitter precursor, reduces environmental stress in humans. Brain Res. Bull. 22:759–762. Bärtsch, P., M. Maggiorini, W. Schobersberger, S. Shaw, W. Rascher, J. Girard, P. Weidmann, and O. Oelz 1991 Enhanced exercise-induced rise of aldosterone and vasopressin preceding mountain sickness. J. Appl. Physiol. 71:136–143. Beard, J.L., J.D. Haas, D. Tufts, H. Spielvogel, E. Vargas, and C. Rodriguez 1988 Iron deficiency anemia and steady-state work performance at high altitude. J. Appl. Physiol. 64:1878–1884. Bender, P.R., R.E. McCullough, R.G. McCullough, S.Y. Huang, P.D. Wagner, A. Cymerman, A.J. Hamilton, and J.T. Reeves 1989 Increased exercise SaO2 independent of ventilatory acclimatization at 4,300 m. J. Appl. Physiol. 66:2733–2738. Bouissou, P., J-P. Richalet, F. Galen, M. Lartigue, P. Larmignat, F. Devaux, C. Dubray, and A. Keromes 1989 Effect of β-adrenoceptor blockade on renin-aldosterone and a-ANF during exercise at altitude. J. Appl. Physiol. 67:141–146. Boutwell, J.H., J.H. Cilley, L.R. Kransno, A.C. Ivy, and C.J. Farmer 1950 Effect of repeated exposure of human subjects to hypoxia on glucose tolerance, excretion of ascorbic acid, and phenylalanine tolerance. J. Appl. Physiol. 2:388–392. Brebbia, D.R., R.F. Goldman, and E.R. Buskirk 1957 Water vapor loss from the respiratory tract during outdoor exercise in the cold. J. Appl. Physiol. 11:219–222. Brooks, G.A., G.E. Butterfield, R.R. Wolfe, B.M. Groves, R.S. Mazzeo, J.R. Sutton, E.E. Wolfel, and J.T. Reeves 1991 Decreased reliance on lactate during exercise after acclimatization to 4,300 m. J. Appl. Physiol. 71:333–341. Buskirk, E.R., and J. Mendez 1967 Nutrition, environment and work performance with special reference to altitude. Fed. Proc. 26:1760–1767. Butterfield, G.E., J. Gates, S. Fleming, G.A. Brooks, J.R. Sutton, and J.T. Reeves 1992 Increased energy intake minimizes weight loss in men at high altitude. J. Appl. Physiol. 72:1741–1748. Calloway, D.H., and M.S. Kurzer 1982 Menstrual cycle and protein requirements of women. J. Nutr. 112:98–108. Carson, R.P., W.O. Evans, J.L. Shields, and J.P. Hannon 1969 Symptomatology, pathophysiology, and treatment of acute mountain sickness. Fed. Proc. 28:1085–1091. CDC (Centers for Disease Control and Prevention) 1994 Daily dietary fat and total food energy intakes—Third National Health and Nutrition Examination Survey. Phase 1, 1989–91. Morbid. Mortal. Weekly Rep. 43(7):116–125. Colice, G., and G. Ramirez 1985 Effect of hypoxemia on the renin-angiotensin-aldosterone system in humans. J. Appl. Physiol. 58:724–730. 1986 Aldosterone response to angiotensin II during hypoxemia. J. Appl. Physiol. 61:150–154.

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