Reducing Stress Fracture in Physically Active Military Women (1998)

Headquarters

Departments of the Army, the Navy, and the Air Force

Washington, D.C.

15 May 1985

* Army Regulation 40-25/Naval Command Medical Instruction 10110.1/Air Force Regulation 160-95

Medical Services

Nutrition Allowances, Standards, and Education

Summary. This joint regulation on nutrition allowances, standards, and education has been revised. It defines the nutrition responsibilities of The Surgeons General of the Army, the Navy, and the Air Force. This regulation—

1. Provides a current statement of the military recommended dietary allowances.

2. Sets nutrient standards for packaged rations.

3. Provides a standardized nutrient density index for normal and reduced calorie menu planning.

4. Provides nutrition education guidance to assist the military in promoting a healthful diet.

Applicability. This regulation applies to all active elements of the Army, Navy, and Air Force. It also applies to the Reserve Components of these Services.

Impact on New Manning System. This regulation does not contain information that affects the New Manning System.

Supplementation. Supplementation of and exceptions to this regulation are prohibited without prior approval from HQDA (DASG-PSP), WASH DC 20310-2300; Department of the Navy, Naval Medical Command, WASH DC 20732; or HQ USAF/SGB, Bolling AFB, WASH DC 20332-6188, for each respective Service. Nutrient standards prescribed in table 2-3 for operational and restricted rations are not subject to exception.

Interim changes. Interim changes to this regulation are not official unless they are authenticated by The Adjutant General, Headquarters, Department of the Army (HQDA). Users will destroy interim changes on their expiration dates unless sooner superseded or rescinded.

Suggested improvements. The Army office of primary interest in this regulation is the Office of The Surgeon General, HQDA. Army users are invited to send comments and suggested improvements on DA Form 2028 (Recommended Changes to Publications and Blank Forms) directly to HQDA (DASG-PSP),

WASH DC 20310-2300. Other users may send comments and recommendations through normal channels to their respective Surgeons General: Naval Medical Command, ATTN: MEDCOM-312, Navy Department, WASH DC 20372, for the NAVY; and HQ USAF/SGB, WASH DC 20332-6188, for the Air Force.

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This regulation defines the nutrition responsibilities of The Surgeons General of the Army, Navy, and Air Force by—

1. Establishing dietary allowances for military feeding.

2. Prescribing nutrient standards for packaged rations.

3. Providing, basic guidelines for nutrition education as prescribed in DOD 1338.10-M.

1. Required Publications.

   1. DOD Manual 1338.10-M, Manual for the Department of Defense Food Service Program. (Cited in para 1-1.)

   2. TB MED 507/NAVMED P-5052-5/AFP 160-1, Occupational and Environmental Health: Prevention, Treatment, and Control of Heat Injury. (Cited in para 2-5i.)

2. Related publications. (A related publication is merely a source of additional information. The user does not have to read it to understand this regulation.)

   1. Recommended Dietary Allowances, ninth revised edition, 1980. (Copies may be obtained from the Office of Publications, National Academy of Sciences, 2101 Constitution Avenue, WASH DC 20418.)

   2. United States Department of Agriculture Handbook 8 Series, Composition of Foods, Raw, Processed, and Prepared. (Copies may be obtained from the Superintendent of Documents, US Government Printing Office, WASH DC 20402.)

Abbreviations and special terms used in this regulation are explained in the glossary.

1. The Surgeon General, Department of the Army (TSG, DA). TSG, DA, will act as the Department of Defense (DOD) Executive Agent for Nutrition and will—

   1. Establish dietary allowances for military personnel subsisting under normal operating conditions.

   2. Establish nutrient standards for packaged rations.

   3. Adjust dietary allowances and nutrient standards to meet variations in age, sex, body size, physical activity, climate, or other conditions that may influence nutritional requirements.

   4. Evaluate current and proposed operational rations. Recommend adjustments and other actions to ensure that the nutrient composition of the

rations as offered for consumption meets the nutritional requirements of personnel in all operational environments.

5. Coordinate the development of nutrition education programs for all Services.

6. Provide qualified representatives to advise committees which support the DOD Food Service Program in matters that affect the nutritional quality of the military diet.

2. The Surgeons General of the Army, Navy, and Air Force. TSGs will—

   1. Review requests and make appropriate recommendations for deviations from established nutritional standards.

   2. Evaluate adjustments to planned diets (menus). Make recommendations to ensure that the nutrient composition of the diet as offered will promote and maintain health.

   3. Evaluate the nutritional status of personnel and report nutritional deficiencies or excesses.

   4. Recommend standard methods to assess body composition.

   5. Provide nutritional guidance to the Services' weight control and physical fitness programs.

   6. Develop and implement a Service-wide nutrition education program for military personnel and their dependents. Provide information to motivate the consumption of a nutritionally adequate diet that contains all of the macronutrients and micronutrients needed to promote health and to maintain desirable body weight.

   7. Assist in providing food service personnel with knowledge and skills of proper food preparation that will maintain the nutritional value of foods.

   8. Provide qualified representatives to—

      1. Advise local food service organizations, such as menu boards, on matters that affect the nutritional quality of meals prepared and consumed.

      2. Serve as consultants to installation commanders on the development and evaluation of nutritional aspects of the Services' weight control and physical fitness programs.

1. Table 2-1 prescribes military recommended dietary allowances (MRDA) for military personnel. These allowances are adapted from the National Academy of Sciences/National Research Council publication Recommended

Dietary Allowances (RDA), ninth revised edition, 1980. MRDA are the daily essential nutrient intake levels presently considered to meet the known nutritional needs of practically all 17- to 50-year old, moderately active military personnel.

2. MRDA are intended for use by professional personnel involved in menu planning, dietary evaluation on a population basis, nutrition education, nutrition research, and food research and development. MRDA are based on estimated nutritional requirements. They provide broad dietary guidelines for healthy military personnel.

3. MRDA represent recommended daily nutrient intake levels, which should meet the physiological requirements of nearly all healthy military personnel. The energy allowances shown in table 2-1 represent ranges of caloric intake reflecting wide variations in energy requirements among individuals at similar levels of activity. These energy allowances are designed to maintain desirable body weight for healthy service members under conditions of moderate physical activity in an environment compatible with thermal comfort. The allowances are not to be interpreted as individual requirements. Also, they may not apply to personnel requiring special dietary treatment for conditions such as infection, chronic disease, trauma, unusual stress, pregnancy, lactation, or weight reduction. The allowances are subject to adjustments as outlined in paragraphs 2-3 and 2-4.

4. MRDA refer to the nutrient concentrations of edible portions of food offered for consumption. Nutrient losses may occur during food processing and preparation. These nutrient losses must be considered when nutrient composition tables are used to compare menus or food products with these allowances. The most recent edition of the United States Department of Agriculture Handbook 8 series, Composition of Foods, Raw, Processed, and Prepared, will be used as the standard reference nutrient composition data base.

Table 2-2 is based on the RDA and provides estimated safe and adequate adult dietary intake ranges for selected nutrients, which are known to be essential in the diet, but for which recommended levels of intake have not been established.

Table 2-3 prescribes nutrient standards, which are the criteria for evaluating the nutritional adequacy of operational and restricted rations. Operational rations include the individual combat ration such as the meal, combat, individual (MCI); the meal, ready-to-eat (MRE); and other rations (A, B, or T) used to support operations in the field. A level of 3600 kilocalories (kcal) is required for operational rations to meet energy demands associated with extended field operations. (See para 2-4.) Total fat calories should not exceed 40 percent of

the energy value of the operational ration or 160 grams (gm). It is essential that ration planners compensate for losses of nutrients, such as ascorbic acid, thiamin, riboflavin, niacin, and pyridoxine (vitamin B6), which may occur during storage of operational and restricted rations.

1. Nutritionally complete, individual operational rations such as the MCI and MRE must be formulated so that the nutrient content of each day's ration satisfies these nutrient standards. It is desirable that each combat meal provides one-third of the nutrient standard.

2. Under certain operational scenarios such as long-range patrol, assault and reconnaissance, and other situations where resupply is unavailable, it may be necessary for troops to subsist for periods (up to 10 days) on a restricted ration. To minimize loss of performance, the restricted ration should provide 1100 to 1500 kilocalories, 50 to 70 grams of protein, and a minimum of 100 grams of carbohydrate on a daily basis. Vitamins and minerals should be provided at the levels prescribed in table 2-3. This restricted ration is not appropriate for use under extreme, cold climates.

3. The survival food packet is a packaged food bar of approximately 400 kilocalories derived from carbohydrates. The low protein content spares body water by reducing the obligatory water demand caused by consuming high protein foods. The nutrient standards for operational and restricted rations do not apply to the survival food packet. This packet is designed to be consumed for periods of less than 4 consecutive days.

The following factors affect individual energy requirements:

1. Age. MRDA are intended for men and women 17 to 50 years of age. Upon completion of growth, energy requirements for adults gradually decline with age due to a reduced resting metabolic rate and curtailment in physical activity. Within the 17 to 50 year military age range, age-related differences in caloric allowances appear to be minimal under conditions of similar physical activity.

2. Body size. The energy allowances are established for average sized personnel, which represent approximately 70 percent of the military personnel between the ages of 17 and 50 years. (See table 2-1.) To maintain desirable body weight, caloric intake must be adjusted for variable energy requirements due to individual differences in lean body mass reflected by body size. Large individuals (such as those with greater height and appropriately higher weight) have slightly higher resting, basal metabolic rates. They, therefore, require more total energy per unit of time for activities that involve moving body mass over distance. Smaller sized individuals require fewer calories.

3. Physical activity. Differences in energy needs are largely due to differences in the amount of time an individual performs moderate and heavy

work tasks in contrast to light or sedentary activities. MRDA for energy in table 2-1 are for military personnel who are moderately active and living in a temperate climate or in a thermally neutral environment. Total energy requirements are influenced by the intensity and duration of physical activity. For example, a day of moderate physical activity may include 8 hours of sleeping, 12 hours of light activity, and 4 hours of moderate to heavy activity. For military personnel doing heavy work or involved in prolonged, vigorous physical training, the recommended caloric allowance should be increased by at least 25 percent (approximately 500 to 900 kilocalories).

4. Climate. MRDA for energy intake are established for personnel in a temperate climate. (See table 2-1). When there is prolonged exposure to cold or heat, energy allowances may need adjustment.

   1. Cold environment. In a cold environment (mean temperature less than 14 °C (57.2 °F), the energy cost of work for garrison troops is approximately 5 percent greater than in a warmer environment. There is an additional 2 to 5 percent increase in energy expenditure associated with carrying the extra weight of heavy, cold weather clothing and footgear (the ''hobbling" effect). Garrison personnel may require an extra 150 to 350 kilocalories per day under these conditions. Energy allowances of 4500 calories for men and 3500 calories for women are required to support adequately clothed troops maneuvering for prolonged periods (several hours) with heavy gear on foot, snowshoes, and skis over snow- or ice-covered terrain. This increased energy allowance does not apply to troops stationed in cold climates who are engaged in moderate activity within a garrison setting.

   2. Hot environment. In a hot climate, loss of appetite may cause a voluntary but undesirable reduction in caloric intake below the level of need. This loss of appetite may be most noticeable after troops have arrived in a hot environment and before the process of acclimatization is completed. When personnel are required to perform the same amount of work in a hot environment as in a temperate environment, the caloric expenditure will be increased. Little adjustment appears to be necessary for a change in environmental temperature between 20 °C (68 °F) and 30 °C (86 °F). It is desirable under conditions of moderate physical activity to increase the caloric allowance by at least 0.7 percent for every degree centigrade rise in average ambient temperature above 30 °C (86 °F). Daily energy requirements under extremely hot conditions (greater than 40 °C (104 °F), may reach 56 kcal/kilogram (kg) of body weight.

   3. Nuclear, biochemical, and chemical environment. Certain conditions will require special guidance and nutrient formulation not described in this regulation. One such condition is when troops are operating in contaminated environments for more than 6 hours while wearing protective clothing.

1. Protein. MRDA for protein are based, in part, on an estimated nutritional requirement of 0.8 gm/day/kg of body weight. (See table 2-1.) For military personnel within the reference weight range, protein recommendations are set between 48 to 63 gm/ day, for males and 37 to 50 gm/day for females. These computed protein levels have been further increased to 100 gm/day for male and 80 gm/day for female personnel. This increase reflects usual intake patterns and helps to maintain a high level of palatability and food acceptance among military personnel. These allowances are based on the consumption of a diet containing mixed proteins of animal and vegetable origin. A total day's protein intake of more than 100 gm/day has not been shown to improve heavy physical performance.

2. Fat. Fats are important in the diet to furnish energy, provide essential fatty acids, transport fat soluble vitamins and aid in their absorption, increase palatability, and give meal satisfaction. It is becoming increasingly clear that excessive amounts to total fat may lead to an increased risk of coronary heart and vascular disease. For this reason, it is recommended that the calories derived from total dietary fat should not exceed 35 percent under garrison feeding conditions. Higher proportions of fat calories are acceptable in combat, arctic, or other operational rations to increase caloric density. Emphasis should be placed on planning the military menu with lower fat concentrations while maintaining acceptability. A reduction of fat calories in the diet can be achieved by lowering added fats during food preparation and replacing foods high in fat with lean meats, fish, poultry, low fat milk, and other low fat dairy products in the military menu. As fat calories are reduced in the diet, it is recommended that the current level of about 7 percent of caloric intake as polyunsaturated fat be maintained to ensure an adequate intake of essential fatty acids.

3. Carbohydrate. Carbohydrates should contribute approximately 50 to 55 percent of the total dietary energy. It is recommended that simple, refined, and other processed sugars provide only about 10 percent of total dietary energy. The remaining carbohydrate calories should come from complex carbohydrates such as starches and naturally occurring sugars found in fruits, vegetables, and milk.

4. Calcium and phosphorus. MRDA are the same for both calcium (Ca) and phosphorus (P), although a wide variation in the Ca:P ratio is tolerated. In the presence of adequate vitamin D nutriture, a ratio of between 1:1 to 1.5:1 is nutritionally desirable.

5. Iron, ascorbic acid, and animal protein. The absorption of iron, a nutrient involved in maintaining optimal aerobic fitness, can be significantly affected by the composition of foods in a particular meal. Heme iron from animal protein sources is better absorbed (approximately 23 percent) than nonheme

iron (approximately 3 to 8 percent) which is found in both animal and in many plant food sources. Certain cereal and legume proteins are known to reduce the bioavailability of nonheme iron. The nonheme iron absorption rate can be more than doubled when nonheme iron is consumed with a modest serving of meat, fish, poultry, or a source of ascorbic acid (vitamin C) at the same meal. The dietary iron allowance for females and 17- to 18-year old males is 18 milligrams (mg)/day, or 7.5 and 5.6 mg/1000 calories respectively. Moderately active female personnel consuming an average of 2400 calories per day may require supplemental iron to meet the recommended 18 mg/day. Issuing supplemental iron should be done on an individualized basis after a medical evaluation.

6. Iodine. Wide variation occurs in the amount of iodine present in food and water. All table and cooking salt used should be iodized to ensure an adequate intake of 150 micrograms (mcg) of iodine per day.

7. Fluoride. Fluoride is an essential nutrient which is found in the enamel of teeth and bone. This nutrient is an important factor in preventing tooth decay. Fluoride may confer some protection against certain degenerative bone diseases. Fluoride is found in varying amounts in most foods and water supplies. Maintaining a fluoride concentration of about 1 mg/liter (1 part per million) in water supplies has proven to be safe, economical, and efficient in reducing the incidence of dental caries.

8. Sodium. Sodium is the principal cation involved in maintaining osmotic equilibrium and extracellular fluid volume in the body.

   1. Under conditions of normal ambient temperature and humidity, the healthy adult can maintain sodium balance with an intake of as little as 150 mg/day (381 milligrams of salt). While daily intake below 2000 milligrams of sodium are generally considered unpalatable, 3300 milligrams of sodium/day represents a lower acceptable limit to which the American population can adapt. The average young civilian male consumes approximately 5500 milligrams of sodium/day in food plus an additional 20 percent (1000 milligrams) as added salt. Although dietary levels of sodium for the military population are unknown, the average intake may well exceed the civilian level. The goal for the sodium content in foods as served within military dining facilities is 1700 milligrams of sodium/1000 kcal. (See table 3-1).

   2. Hard physical work in a high ambient temperature greatly increases the amount of sodium lost in sweat. Sodium losses may reach levels as high as 8000 mg/day (20 grams of salt). Whenever more than 3 liters of water per day are required to replace sweat losses, extra salt intake may be required. The need for extra salt depends on the severity of sweat losses and the degree of acclimatization. Sodium should be replaced through food in both nondiscretionary form and as added salt.

9. Water. As caloric requirements are increased, water needs are also increased. During periods of light to moderate activity in a temperate climate, I milliliter of water per calorie expended is a reasonable intake goal. Water requirements may increase from 50 to 100 percent for personnel living in a hot climate expending similar energy levels. Water requirements may increase threefold above normal under conditions of heavy work in a hot environment. Even in cold climates sweat rates and, consequently, water needs may be quite high due to the hot microclimate that can develop under insulated clothing during heavy physical activity. Inadequate water intakes can be accompanied by a disturbance in electrolyte balance with a resultant performance decrement. (See TB MED 507/NAVMED P-5052-5/AFP 160-I.) Under conditions of normal dietary intake, the preferred fluid to replace losses is cool water. Electrolyte- and sugar-containing solutions are not necessary since glucose and electrolytes are adequately replenished in the normal diet. Under certain conditions, electrolyte and sugar solutions may actually impair rather than enhance performance.