Assessing Readiness in Military Women

The Relationship of Body Composition, Nutrition, and Health

Committee on Body Composition, Nutrition, and Health of Military Women

Committee on Military Nutrition Research

Food and Nutrition Board

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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--> Assessing Readiness in Military Women The Relationship of Body Composition, Nutrition, and Health Committee on Body Composition, Nutrition, and Health of Military Women Committee on Military Nutrition Research Food and Nutrition Board INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1998

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--> NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W.Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was established in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. Support for this project was provided by the U.S. Army Medical Research and Materiel Command through contract no. DAMD17-95-1-5037. The views presented in this publication are those of the Committee on Body Composition, Nutrition and Health of Military Women and are not necessarily those of the sponsor. Library of Congress Catalog Card No. 98-65788 International Standard Book Number 0-309-06075-3 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Lock Box 285 Washington, D.C. 20055 Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at http://www.nap.edu. For more information about the Institute of Medicine and the Food and Nutrition Board, visit the IOM's and FNB's home pages at http://www2.nas.edu/iom/ and http://www2.nas.edu/fnb/. Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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--> COMMITTEE ON BODY COMPOSITION, NUTRITION, AND HEALTH OF MILITARY WOMEN BARBARA O. SCHNEEMAN (Chair), College of Agricultural and Environmental Sciences, University of California, Davis ROBERT O. NESHEIM (Vice Chair), Salinas, California NANCY F. BUTTE, Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas JOAN M. CONWAY, Diet and Human Performance Laboratory, U.S. Department of Agriculture Beltsville Human Nutrition Research Center, Beltsville, Maryland STEVEN B. HEYMSFIELD, Human Body Composition Laboratory, Weight Control Unit, and Obesity Research Center, St. Luke's-Roosevelt Hospital Center, New York, New York ANNE LOOKER, Division of Health Examination Statistics, National Center for Health Statistics, Hyattsville, Maryland MARY Z. MAYS, Eagle Creek Research Services, San Antonio, Texas MARITZA RUBIO-STIPEC, Department of Economics, University of Puerto Rico, San Juan Committee on Military Nutrition Research Liaison GAIL E. BUTTERFIELD, Nutrition Studies, Palo Alto Veterans Affairs Health Care System and Program in Human Biology, Stanford University, Palo Alto, California Food and Nutrition Board Liaison JANET C. KING, U.S. Department of Agriculture Western Human Nutrition Research Center, San Francisco and University of California, Berkeley Military Liaison Panel CAROL J. BAKER-FULCO, Military Nutrition and Biochemistry Division, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts LTC SUE CHIANG, USA, Office of the Surgeon General, Falls Church, Virginia LTC ALANA D. CLINE (through April 1997), U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts LT LESLIE COX, USN, Bureau of Naval Personnel, Washington, D.C. MAJ BETH FOLEY, USA, Health Promotion Policy, Department of the Army, Washington, D.C. LTC DALE HILL (through November 1996), USA, Office of the Surgeon General, Falls Church, Virginia JAMES A. HODGDON, Human Performance Department, Naval Health Research Center, San Diego, California MAJ JOANNE M. SPAHN, USAF, Nutritional Medicine Service, 3rd Medical Group/SGSD, Elmendorf AFB, Alaska CDR FAYTHE M. WEBER, USN, Medical Service Corps, Bureau Medicine and Surgery, Washington, D.C.

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--> U.S. Army Grant Representative LTC KARL E. FRIEDL, USA, Army Operational Medicine Research Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland Staff REBECCA B. COSTELLO (from July 15, 1996), Project Director SYDNE J. CARLSON-NEWBERRY, Program Officer SUSAN M. KNASIAK-RALEY, Research Assistant DONNA F. ALLEN (through September 5, 1997), Senior Project Assistant MELISSA L. VAN DOREN (from September 22, 1997), Project Assistant

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--> COMMITTEE ON MILITARY NUTRITION RESEARCH ROBERT O. NESHEIM (Chair), Salinas, California WILLIAM R. BEISEL, Department of Molecular Microbiology and Immunology, The Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland GAIL E. BUTTERFIELD, Nutrition Studies, Palo Alto Veterans Affairs Health Care System and Program in Human Biology, Stanford University, Palo Alto, California WANDA L. CHENOWETH, Department of Food Science and Human Nutrition, Michigan State University, East Lansing JOHN D. FERNSTROM, Department of Psychiatry, Pharmacology, and Neuroscience, University of Pittsburgh School of Medicine, Pennsylvania G. RICHARD JANSEN (through August 31, 1997), Department of Food Science and Human Nutrition, Colorado State University, Fort Collins ROBIN B. KANAREK, Department of Psychology, Tufts University, Boston, Massachusetts ORVILLE A. LEVANDER, Nutrient Requirements and Functions Laboratory, U.S. Department of Agriculture Beltsville Human Nutrition Research Center, Beltsville, Maryland JOHN E. VANDERVEEN, Office of Plant and Dairy Foods and Beverages, Food and Drug Administration, Washington, D.C. DOUGLAS W. WILMORE, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts Food and Nutrition Board Liaison JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Departments of Medicine and Community Health, Tufts Medical School and School of Nutrition Science and Policy, Boston, Massachusetts U.S. Army Grant Representative HARRIS R. LIEBERMAN, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts Staff REBECCA B. COSTELLO (from July 15, 1996), Project Director SYDNE J. CARLSON-NEWBERRY, Program Officer SUSAN M. KNASIAK-RALEY, Research Assistant DONNA F. ALLEN (through September 5, 1997), Senior Project Assistant MELISSA L. VAN DOREN (from September 22, 1997), Project Assistant

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--> FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutrition, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois at Urbana-Champaign LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis BENJAMIN CABALLERO, Center for Human Nutrition, The Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland FERGUS M. CLYDESDALE, Department of Food Science, University of Massachusetts, Amherst ROBERT J. COUSINS, Center for Nutritional Sciences, University of Florida, Gainesville MICHAEL P. DOYLE, Center for Food Safety and Quality Enhancement, Department of Food Science and Technology, The University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Departments of Medicine and Community Health, Tufts Medical School and School of Nutrition Science and Policy, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas CHARLES H. HENNEKENS, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts JANET C. KING, University of California, Berkeley, and U.S. Department of Agriculture Western Human Nutrition Research Center, San Francisco SANFORD A. MILLER, Graduate School of Biomedical Sciences, University of Texas Health Science Center, San Antonio ROSS L. PRENTICE, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington A. CATHARINE ROSS, Department of Nutrition, Pennsylvania State University, University Park ROBERT E. SMITH, R. E. Smith Consulting, Inc., Newport, Vermont VIRGINIA A. STALLINGS, Division of Gastroenterology and Nutrition, The Children's Hospital of Philadelphia, Pennsylvania VERNON R. YOUNG, Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge Ex-Officio Member STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln Institute of Medicine Council Liaison HARVEY R. COLTEN, Northwestern University Medical School, Chicago, Illinois

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--> Staff ALLISON A. YATES, Director CAROL W. SUITOR (April–July 1997), Acting Director GAIL SPEARS, Administrative Assistant

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--> Preface U.S. military personnel are required to adhere to standards of body composition, fitness, and appearance for the purpose of achieving and maintaining readiness. Military readiness, while encompassing many factors, can be defined briefly as maintenance of optimum health and performance so that deployment can occur at any moment. In 1992, the Committee on Military Nutrition Research (CMNR) was asked to review existing policies pertaining to the body composition, fitness and appearance standards imposed for recruitment and retention in the armed forces to consider whether these standards are mutually supportive and whether they collectively support the health and performance of military personnel, or whether the standards actually oppose each other and negatively affect health and performance (IOM, 1992). Among the report's conclusions were that the standards of body composition required for women to achieve an appearance goal seemed to conflict with those necessary for performance of many types of military tasks. The committee recommended that body composition standards be based on considerations of task performance and health and be validated with regard to the ethnic diversity of the military. In addition, they recommended that task-specific performance tests be developed and that the wide disparity between recruitment and retention body composition standards for women be adjusted (to reflect those for men, thus rejecting fewer women at recruitment); the latter change was enacted by the Army prior to release of the report.

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--> In 1994, as part of the Defense Women's Health Research Program, the CMNR was asked again to review existing military policies governing body composition and fitness, as well as postpartum return-to-duty standards, Military Recommended Dietary Allowances, and physical activity and nutritional practices of military women to determine their individual and collective impact on the health, fitness, and readiness of active-duty women. In particular, the committee was asked to evaluate whether existing body composition and appearance standards for women were in conflict with body composition requirements for task performance, and whether these same standards might interfere with readiness by encouraging chronic dieting and inadequate nutrient intake. In addition, the committee was asked to examine such policies and practices in comparable civilian services and to make recommendations regarding the body composition, physical performance, and postpartum return-to-duty standards that would best optimize the nutritional status, fitness, and health of active-duty women. A subcommittee of the CMNR was established to review these topics. In addition to several members of the parent committee, individuals were included who have expertise in body composition assessment, physical fitness and performance, pregnancy and lactation, women's nutrition, weight management, epidemiology and survey design, and cognitive performance. This subcommittee was designated the Committee on Body Composition, Nutrition, and Health of Military Women (BCNH committee). In addition, a group of individuals representing the body composition, fitness, and nutrition research and policy making bodies of the Army, Navy, and Air Force were invited by the sponsor to form a liaison panel to advise the BCNH committee. A small preliminary meeting was held in November 1995, including staff, the two committee chairs, and the sponsor's staff officer (LTC Karl E. Friedl). In April 1996, the full committee met with the liaison panel to define more clearly the focus of the task. A workshop was held in September 1996 to help gather information and impressions from other military representatives as well as several civilian researchers working in areas believed to be critical to the questions posed by the sponsor. Participants in the workshop were identified by committee and staff. A workshop summary was drafted and finalized at a meeting in January 1997, and based on the questions originally posed and those that were raised by the workshop, a comprehensive literature search was conducted by the staff and National Academy of Sciences librarians. The results of this literature search, as well as the expertise of the committee, the information gathered by staff attendance at conferences and discussion with representatives of civilian police and fire-fighting services (and with representatives of the Marine Corps and Coast Guard and other Army, Navy, and Air Force personnel) form the basis of this report, drafted at a meeting in June 1997 and served to help the committee to answer the sponsor's questions and formulate a set of recommendations. Chapter 1 of the report provides a brief discussion of the methods used by the subcommittee to formulate recommendations in response to the questions posed by the military, as well as a demographic profile of active-duty women. Chapter 2 presents a discussion of the military body composition standards in light of what is known about the associations among body composition and health, fitness and performance, and appearance. Currently used methods of assessment, which form an integral aspect of the policy, are discussed along with research on newer techniques. Chapter 3 discusses the military fitness standards, their adequacy to ensure maintenance of fitness and avoidance of injury, the association between fitness and physical task

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--> performance, recent efforts by the military to ensure that personnel can perform tasks requiring physical strength, and task performance tests used by civilian services. Chapter 4 discusses the military weight management programs, weight management methods used by military personnel and comparable civilian populations, and some of the risks of chronic dieting behavior. Chapter 5 further elucidates dieting risks from a nutritional standpoint and assesses the contribution of military operational rations and dining hall meals to the nutritional status of active-duty women. Chapter 6 discusses military pregnancy policies and their implications for health and fitness, and Chapter 7 provides the subcommittee's conclusions, recommendations, and suggestions for future research. The committee wishes to acknowledge the help of Institute of Medicine president Kenneth I. Shine, Food and Nutrition Board division director Allison A. Yates and former acting director Carol Suitor, and the staff of the BCNH committee: former study director Bernadette M. Marriott, current study director Rebecca B. Costello; staff officer Sydne J. Carlson-Newberry; research assistants Susan M. Knasiak-Raley and Sheila A. Moats, former senior project assistant Donna F. Allen, project assistant Melissa L. Van Doren, Reports and Information Office director Michael A. Edington and associate Claudia M. Carl, National Academy of Sciences librarians Susan Fourt and Julie Walko. Additionally, the committee would like to thank editor Judith Grumstrup-Scott, members of the military liaison panel, and the individuals and organizations who provided information and materials. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The BCNH committee wishes to thank the following individuals for their participation in the review of this report: Elsworth R. Buskirk, Gilbert Burnett Forbes, Robert L. Goldenberg, Helen Lane, Sally A. Lederman, Roseann M. Lyle, David D. Schnakenberg, Marta Van Loan, and Richard J. Wood. While the individuals listed above have provided many constructive comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the Institute of Medicine. Reference IOM (Institute of Medicine). 1992. Body Composition and Physical Performance, Applications for the Military Services, B.M. Marriott and J. Grumstrup-Scott, eds. Committee on Military Nutrition Research, Food and Nutrition Board, Institute of Medicine. Washington, D.C.: National Academy Press.

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--> Contents     Executive Summary   1 1   Introduction   25 2   Body Composition   33 3   Physical Fitness Policies and Programs   61 4   Weight Management   87 5   Nutritional Concerns of Military Women   109 6   Pregnancy and Lactation and Postpartum Return-to-duty Fitness   127 7   Conclusions and Recommendations   157

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-->     Appendixes         A Workshop Summary, Agenda, Participants, and Abstracts   173     B Practices and Policies Tables   253     C Military Occupational Specialty Classification Tables   263     D Search Strategy for Literature Review   281     E Civilian Inquiry Letter and Table of Responses   285     F Abbreviations   291     G Bibliography   295     H Biographical Sketches   335     Index   339

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