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--> 1 A Review of the Role of Nutrition in Immune Function The infectious disease threats facing soldiers are multiple and vary with geography. In fact, during major wars, infectious diseases usually have accounted for more noneffective days than combat wounds or nonbattle injuries. Combined stressors may reduce the normal ability of soldiers to resist pathogens, may increase their susceptibility to biological agents employed against them, and may reduce the effectiveness of vaccines intended to protect them. Military studies in multistressor environments have demonstrated that higher energy intakes will better sustain the indices of immune status. Troops must be supplied with foods of high biological quality that will enable them to sustain performance and that will counter an array of immunological impairments caused by a myriad of unknown stressors.
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--> The Committee's Task As part of its responsibility to the Military Nutrition Division (currently the Military Nutrition and Biochemical Division) at the U.S. Army Research Institute of Environmental Medicine (USARIEM), the Committee on Military Nutrition Research (CMNR) has, on many occasions, evaluated both research plans and ongoing research efforts funded by U.S. Department of Defense appropriations. Examples include a 1996 review of research activities at the Louisiana State University's Pennington Biomedical Research Center, a 1995 review of issues related to the iron status of women enrolled in U.S. Army Basic Combat Training, and a review of the results of a nutrition intervention project conducted during a 1992 U.S. Army Ranger training class. On May 20–21, 1996, the CMNR convened a workshop in response to a request from Army representatives to provide information on the impact of nutritional status on immune function (see Appendix E for agenda). The purpose of the workshop was to assess the current state of knowledge about how military stresses (including food deprivation) could unfavorably influence immune function and to evaluate ongoing research efforts by USARIEM scientists to study immune status in Special Forces troops. Army representatives asked the CMNR to include in its response the answers to the following five questions: What methods for assessment of immune function are most appropriate in military nutrition laboratory research, and what methods are most appropriate for field research? What are the significant military hazards or operational settings most likely to compromise immune function in soldiers? The proinflammatory cytokines have been proposed to decrease lean body mass, mediate thermoregulatory mechanisms, and increase resistance to infectious disease by reducing metabolic activity in a way that is similar to the reduction seen in malnutrition and other catabolic conditions. Interventions to sustain immune function can alter the actions, nutritional costs, and potential changes in the levels of proinflammatory cytokines. What are the benefits and risks to soldiers of such interventions? What are the important safety and regulatory considerations in the testing and use of nutrients or dietary supplements to sustain immune function under field conditions? Are there areas of investigation for the military nutrition research program that are likely to be fruitful in the sustainment of immune function in stressful conditions? Specifically, is there likely to be enough value added to justify adding to operational rations or including an additional component?
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--> To assist the CMNR in responding to these questions, the workshop included presentations from individuals with expertise in immune function. As a background to these presentations, an Army representative provided an overview of why the Army is interested in nutrition and immune function. In preparing their presentations, the invited speakers were asked to address the questions posed by the Army. The speakers discussed their presentations with committee members at the workshop and submitted written reports based on their verbal presentations. The committee met after the workshop on May 22, 1996, to discuss the proceedings and the information provided. Later, the CMNR reviewed the workshop presentations and drew on its collective expertise and the scientific literature to summarize the information pertinent to nutrition and immune function, and to evaluate the potential contribution of military nutrition research to the maintenance or enhancement of the ability of the immune system to protect soldiers engaged in military operations. The committee's responses to the five questions posed by the Army appear in Chapter 2; while its conclusions and recommendations are contained in Chapter 3. The final report was reviewed and approved by the entire committee. Stage Setting: The Military Situation The opportunities to study the effects of multiple stressors on the immune system occur infrequently, intermittently, and largely in uncontrolled environments. As described by LTC Karl E. Friedl in Chapter 4, studies in multistressor environments, such as basic training and the Special Forces' Assessment and Selection Course (SFAS), demonstrated that higher energy intakes were better able to sustain the indices of immune status. As nutritional studies conducted with Ranger trainees (Ranger I: Moore et al., 1992; Ranger II: Shippee et al., 1994) demonstrated, troops must be supplied with high-quality foods that will enable them to sustain performance and counter an array of immunological impairments caused by a myriad of unknown stressors. Studies of immunocompetence conducted under field conditions, where inadequate energy intake, strenuous exercise, adverse environmental and physical conditions, and psychological stress interact to create an extremely complex stimulus, are markedly different from those conducted in the laboratory. Under laboratory conditions, confounding variables can be controlled and only the variables of interest investigated. In Chapters 5 and 6 respectively, LTC Ronald L. Shippee and Pål Wiik present data describing the effect on the immune system of various training regimens imposed on elite military troops.
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--> The Army's Interest in Nutrition and Immune Function The primary goal of the Army Operational Medicine Program is to develop physiological strategies (including nutritional, pharmacological, and diagnostic strategies) to protect and sustain deployed soldiers, thereby enhancing readiness by maintaining their ability to accomplish assigned missions. One program with a critical need to enhance and maintain readiness is the U.S. Army Special Operations Training Program. Both the U.S. Army Ranger Training and the SFAS are physically and psychologically demanding programs used by the U.S. Army to screen male officers and enlisted soldiers for entry into Special Operations units. Since the summer of 1992, a number of studies have been conducted with these Special Operations schools through collaborative research between the U.S. Army Medical Research and Materiel Command (USAMRMC), the Soldier System Command (SSCOM), the U.S. Department of Agriculture, and industry. Currently, U.S. Ranger training consists of three 3-week phases conducted at widely varying sites with differing physical demands: military base training, mountain training, and swamp training. A desert phase originally was included in Ranger training but recently was omitted from the training program. The last 10 d of each phase were conducted entirely in stressful field situations. An overview of studies conducted by the Army Operational Medicine Program with Special Operations training courses and clinical assessment procedures employed during these studies is presented in Table 1-1. Ranger I, the first joint USAMRMC–SSCOM study (Moore et al., 1992), was conducted from July 1991 through October 1991. Baseline assessments were performed on 190 soldiers, and this group was followed throughout the course, although attrition from the course left a final sample size of 55. Ranger II (a nutritional intervention study; Shippee et al., 1994) was conducted from August through October 1992, and provided for increased rations to mitigate the weight loss and immune dysfunctions that occurred in Ranger I. The primary objective of the Ranger II study was to test the effect of increasing the daily caloric intake by approximately 15 percent (above that documented in the Ranger I study) on body weight loss and on the status indicators for body composition and immune function. It was hoped that the number of infections documented during previous U.S. Ranger studies would be decreased by nutritional intervention. In Ranger II, there was an overall decrease in the incidence of infections (for example, cellulitis, conjunctivitis, acute gastroenteritis, otitis, upper respiratory tract infection, and sore throat) documented in the medical records. Reports of abrasions, injuries, and knee problems also were more common during the earlier training classes. Baseline and periodic assessments were performed on 175 soldiers. Attrition during Ranger II left a final sample size of 53. The Ranger II training course was
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--> composed of four phases that included training exercises in different environmental conditions at four geographically diverse locations. In the summer of 1993, the first nutritional and immune study of SFAS entrants was conducted using a research design and methodology similar to that in the Ranger studies. The SFAS is a physically and psychologically demanding 21-day course. In this course, unlike the Ranger studies, food deprivation was not used as an overt training stressor. Research conducted at the U.S. Army Medical Research Institute of Infectious Diseases by William R. Beisel demonstrated that febrile infections induce a state of hypermetabolism with subsequent losses of protein, minerals, and vitamins, leading to a wasting of muscle mass (Beisel, 1977; Beisel and Sobocinski, 1980; Beisel et al., 1967). These effects were later found to be mediated through the cytokines. Current military research focuses on the effects of nutrition on the sustainment and enhancement of immune status in healthy individuals, rather than on the nutritional consequences of infection and their causal relationship to cytokine responses. During World War II, diseases such as the diarrheal disease encountered by Rommel's troops in North Africa and the malaria suffered by units such as Merrill's Marauders in the China—Burma theater were of major concern to the military. Today, these diseases are still part of the military's high-priority research because of their common and widespread occurrence and the Army's limited ability to provide specific protections. In Chapter 4, LTC Karl E. Friedl hypothesizes that the soldier's defense against biological threat agents may depend on physiological enhancement of the immune system, possibly through various nutritional strategies. Knowledge arising from civilian (that is, academic, governmental, private, and industrial) medical research may not be applicable to troops who are exposed to the stress of a variety of combat—work conditions. This lack of relationship between military immunological data and data from civilian hospital records exists because of the differences in the two populations. Members of the military are initially normal, nutritionally intact, physically fit, and relatively young. In contrast, nonmilitary medical patients are generally older, often demonstrate altered nutritional status (obesity, undernutrition), are rarely physically fit, and often have chronic confounding disease processes (for example, diabetes, atherosclerosis, and cancer) or undesirable life-style habits (for example, drugs, alcohol, and tobacco) that greatly modify their immunological baseline and limit their ability to respond to subsequent stimuli. The stressors faced by military personnel include altered environments (heat or cold, varying altitudes and terrains), excessive work loads, alterations in nutrient intake, and possible exposure to new pathogens and/or chemical toxins. The stress experienced by the military patient may include an emergency or elective
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--> TABLE 1-1 Overview of Army Operational Medicine Program Studies with Special Forces Training Courses: Demographics and Clinical Assessments Ranger I Class 91-11 Ranger II Class 92-11 Fort Jackson BCT SFAS-1 Class 07-93 Dates 7/91–10/91 8/92–10/92 5/93–6/93 6/93 Days in training 63 63 63 21 No. of subjects at start 190 (male) 175 (male) 174 (female) 100 (male) No. of subjects to finish 55 50 158 37 Procedures Dietary assessment Energy intakes X (estimation of food provided) X (estimation of food provided) X (visual estimation) X (diet logs, visual estimation) Energy expenditure (DLW) X X – X Survey of food knowledge and attitudes – – X – Activity monitor TDEE – X – X Body composition Circumference and skinfolds X X X X Body fat (DXA) X X (and BIA) X (and BIA) X Bone mineral X X X –
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--> Ranger I Class 91-11 Ranger II Class 92-11 Fort Jackson BCT SFAS-1 Class 07-93 Strength testing X X X X Biochemistry Clinical X X X X Nutritional* X X X (no copper, zinc) X Hormones X† X X‡ – Immune assessment (N) 49 41 48 37 Leukocytes§ X X X X Lymphocyte proliferation studies X X X X Cytockines|| IL-2 cellular production X X X X IL-2 receptor X X X X IL-6 cellular production and plasma X X X X DTH X – – – CD – 3,4,8,19,4/8 – – Throat and nasal cultures X – – –
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--> Ranger I Class 91-11 Ranger II Class 92-11 Fort Jackson BCT SFAS-1 Class 07-93 Clinical (No. of cases) Injuries 17 10 110 – Infections 42 22 94 – Cognitive function – X – X NOTE: X, measured; –, not measured; BCT, basic combat training; BIA, bioelectrical impedance; CD, cell determinant factors; DLW, doubly labeled water; DTH, delayed-type hypersensitivity; DXA, dual-energy x-ray absorptiometry; IL, interleukin; TDEE, total daily energy expenditure. * Nutritional battery: iron status; vitamins A, D, B6, B12, thiamine, riboflavin, folate, ascorbic acid; minerals, calcium, phosphorus, magnesium, sodium, potassium, and chloride. † Hormone battery for Ranger Studies: triiodothyronine, thyroxine, thyroid binding globulin, testosterone, cortisol, insulin-like growth factor; luteinizing hormone, growth hormone. ‡ Hormone battery for BCT included only serum estradiol, progesterone, 17 α-hydroxyprogesterone, sex hormone binding globulin, and osteocalcin. § Laboratory tests done at local facilities. || All done in U.S. Department of Agriculture Laboratories by T. R. Kramer. SOURCE: Ranger I: Moore et al. (1992); Ranger II: Shippee et al. (1994); Fort Jackson BCT: Westphal et al. (1995); SFAS-I: Fairbrother et al. (1993).
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--> operation, severe infection, or possibly acute hemorrhage. Thus, it may be difficult to compare the immune defects described in civilian patients with those observed in military personnel under combat conditions. The ability to carry out research on the impact of these operational stressors presents many challenges. Ethical considerations limit the ability to design experiments that incorporate many of these stressors and employ human experimental models. Therefore, many experiments have evolved as opportunistic field studies in which investigators do not impose the stressors but are able to study the consequences. From these field studies, recommendations often are made to correct the problem associated with the stressors evaluated, which in turn limits the ability to study this problem further through the field model. For example, the increase in food intake recommended to Ranger II program participants appeared to reduce the high incidence of infections that had been observed in Ranger I (Shippee et al., 1994). The Ranger training studies have provided a unique opportunity to evaluate some of these stressors because of the rigors of the program and the duration of the course, permitting the investigator an evaluation period beyond what may be the manifestation of an initial acute-phase response. A number of investigations have grown out of the use of the Ranger training model. These studies established a relationship between energy deficit (as rate of weight loss) and the suppression of lymphocyte response (see Table 1-2, which is taken from Friedl, Chapter 4). The most important feature of Table 1-2 is the relationship it shows between increasing energy deficit (as a rate of weight loss) and suppression of the lymphocyte response. The lowest levels of interleukin-6 (IL-6) were found in soldiers with the highest stress conditions. Additionally, the very lowest level of IL-6 was demonstrated in the individual soldier with the greatest relative weight loss. Since soldiers do not maintain adequate energy intakes while participating in various simulated combat programs, the intake of protein, vitamins, minerals, and trace elements may be reduced proportionally, thus limiting the supply of cofactors necessary for optimal host defense. Moreover, stress could hypothetically increase the need for antioxidant vitamins and minerals that also serve as cofactors to enhance immunological functions. If this is the case, immunological responses could be attenuated by the lack of adequate nutrients. The potential of specific dietary supplements (pills, foods, or liquid formulas given, in addition to meals, to increase nutrient intakes above the RDA [Recommended Dietary Allowance] to sustain immune function, or even offer superimmunity (a state of enhanced function of the immune system), has not been evaluated fully. There are currently few military studies evaluating the potential for nutritional supplements or whole foods to provide sustained benefits. One such pilot study (Kramer et al., 1997) did report a markedly enhanced mitogen-stimulated lymphocyte proliferation response (a measure of
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--> TABLE 1-2 Energy Deficit and Its Relation to Stress Indices and PHA-Stimulated T-Lymphocyte Proliferation Study N Weeks % BW % FFM % IL-6 % PHA-T % T RGR-I 49 4 -9.2 — -17 -52 -69 8 -15.9 -6.9 -63 -21 -74 RGR-II 41 4 -7.0 — +15 -32 -60 8 -12.8 -6.1 -84 -5 -83 SFAS 37 3 -4.0 -1.0 -46 -20 -15 BCT 48 4 0.8 2.0 -37 +165 — 8 -1.4 +5.0 +220 +144 — NOTE: Values represent percent change from baseline measurements. BW, body weight; FFM, fat-free mass; IL-6, interleukin-6; PHA-T, phytohemagglutinin-stimulated T-cell proliferation; T, testosterone. SOURCE: Adapted from RGR-I, 1991 Ranger course (Kramer et al., 1997); RGR-II, 1992 Ranger course (Kramer et al., 1997); SFAS, 1993 Special Forces Assessment and Selection Course (B. Fairbrother and T.R. Kramer, Unpublished data, USARIEM, Natick, Mass., 1993); BCT, 1993 Army Basic Combat Training (Westphal et al., 1995). T-cell activity) in unstressed individuals given a whole-food supplement that consisted of kale, sweet potato, and tomato juice and thus was high in antioxidants. There is a concern with the inappropriate use of dietary supplements by individual soldiers, particularly in elite units. These soldiers are susceptible to the claims of many manufacturers regarding enhanced performance following use of such products. Since these products are readily available in post exchanges and commissaries, there is, in the view of many, an implied military endorsement of their use. However, the use of these supplements may carry some risk (Herbert, 1997; Rock et al., 1996) and may impair rather than enhance readiness, because enhanced responsiveness of the immune system may not always be desirable. An example of a large-scale epidemic of severe inflammatory illness and mortality associated with a food supplement was the 1-tryptophan eosinophilia myalgia syndrome epidemic of 1989 (Crofford et al., 1990; Silver et al., 1990). At that time, 1-tryptophan was freely available over the counter and was taken for insomnia, muscle building, depression, and premenstrual syndrome. Although the major etiologic factor in the cause of the epidemic was impure 1-tryptophan manufactured by a Japanese petrochemical
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--> company (Showa Denko K.K.), further testing in animals showed that pure 1-tryptophan in doses comparable to the large doses consumed by the patients was associated with related deleterious risks, such as pancreatic acinar hyperplasia (Love et al., 1993). Thus, without adequate research, it cannot be assumed that ''natural products'' are safe, even if manufactured according to Good Manufacturing Practices. Clearly there is a need for studies to evaluate the benefits, risks, and safety limits, if any, associated with intakes of dietary supplements. U.S. Army Training Courses In Chapter 5, Shippee describes four years of studies with the U.S. Army Ranger Training Brigade and SFAS. These studies were designed to test proposed guidelines for sleep deprivation, food restriction, and environmental exposure, with immune response as one of the variables of concern. Shippee points out that in modern warfare, nonbattle injury and infection account for more casualties than actual military action. Currently, U.S. Ranger training consists of three 3-week phases conducted at widely varying sites with differing physical demands: military base field training, mountain training, and swamp training. The last 10 d of each 21-day phase involve a field training period. Changes to the training course have occurred over the years in response to infections, accidents, and death (Consolazio et al., 1966; Johnson et al., 1976), as well as in response to findings from independent research studies (IOM, 1993; Moore et al., 1992; Shippee et al., 1994) that evaluated the effects of training and possible strategies for improved outcome. Typically, data collection occurred pre-course and at the end of each phase before refeeding, sleep, or hygiene (except for dual-energy x-ray absorptiometry determinations, measurement of muscle strength, and particular anthropometric assessments, samples were collected in a fasted state [IOM, 1992]). Blood samples were obtained 3–6 h after individuals returned to the training camp site. Energy was provided initially in these studies by one Meal, Ready-to-Eat (MRE) per day, and in Ranger I, a negative energy balance was reported (-1,203 kcal/d [Moore et al., 1992]). Consequently, mean weight loss over the 62 d of training was significant (15.9 percent), with a large proportion of this loss resulting from the depletion of fat stores, from 14.6 to 5.8 percent. Changes in endocrine function (especially decreases in blood testosterone and triiodothyronine [T3] concentrations) compromised the individual's ability to adapt to environmental stress. Assessment of immune function using an in vitro T-lymphocyte proliferation assay showed that the immune system was significantly suppressed by training. These results explain, in part, the high
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--> Hrushesky, W.J.M., and W.J. Marz. 1994. Chronochemotherapy of malignant tumors: Temporal aspects of antineoplastic drug toxicity. Pp. 611-634 in Biologic Rhythms in Clinical and Laboratory Medicine, 2nd ed., Y. Touitou and E. Haus, eds. Heidelberg: Springer-Verlag. Hughes D.A., A.C. Pinder, Z. Piper, I.T. Johnson, and E.K. Lund. 1996. Fish oil supplementation inhibits the expression of major histocompatibility complex class II molecules and adhesion molecules on human monocytes. Am. J. Clin. Nutr. 63:267-272. IOM (Institute of Medicine). 1992. A Nutritional Assessment of U.S. Army Ranger Training Class 11/91. A brief report of the Committee on Military Nutrition Research, Food and Nutrition Board. March 23. Washington, D.C.: National Academy Press. IOM (Institute of Medicine). 1993b. Review of the Results of Nutritional Intervention, Ranger Training Class 11/92 (Ranger II), B.M. Marriott, ed. A report of the Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM (Institute of Medicine). 1995a. 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. Washington, D.C.: National Academy Press. Johnson, H.L., H.J. Krzywicki, J.E. Canham, J.H. Skala, T.A. Daws, R.A. Nelson, C.F. Consolazio, and P.P. Waring. 1976. Evaluation of calorie requirements for Ranger training at Fort Benning, Georgia. Technical Report No. 34. Presidio of San Francisco, Calif.: Letterman Army Institute of Research. Juretic, A., G.C. Spagnoli, H. Hörig, R. Babst, K. von Bremen, F. Harder , and M. Heberer. 1994. Glutamine requirements in the generation of lymphokine-activated killer cells. Clin. Nutr. 13:42-49. Kakuscska, I., L.I. Romero, B.D. Clark, J.M. Rondeel, Y. Qi, S. Alex, C.H. Emerson, and R.M. Lechan. 1994. Suppression of thyrotropin-releasing hormone gene expression by interleukin-1β in the rat: Implications for nonthyroidal illness. Neuroendocrinology 59(2):129-137. Kanter, M.M., L.A. Nolte, and J.O. Holloszy. 1993. Effects of an antioxidant vitamin mixture on lipid peroxidation at rest and postexercise. J. Appl. Physiol. 74:965-969. Kapcala, L.P., T. Chautard, and R.L. Eskay. 1995. The protective role of the hypothalamic-pituitary-adrenal axis against lethality produced by immune, infectious, and inflammatory stress. Ann. N.Y. Acad. Sci. 771:419-437. Kay, J.E., and C.R. Benzie. 1986. The role of the transferrin receptor in lymphocyte activation. Immunol. Lett. 12:55-58. Kelley, D.S., D.B. Branch, and J.M. Iacono. 1989. Nutritional modulation of human status. Nutr. Res. 9:965-975. Kelley, D.S., L.B. Branch, J.E. Love, P.C. Taylor, Y.M. Rivera, and J.M. Iacono. 1991. Dietary α-linolenic acid and immunocompetence in humans. Am. J. Clin. Nutr. 53:40-46. Kelley, D.S., P.A. Daudu, L.B. Branch, H.L. Johnson, P.C. Taylor, and B. Mackey. 1994. Energy restriction decreases number of circulating natural killer cells and serum levels of immunoglobulins in overweight women. Eur. J. Clin. Nutr. 48(1):9-18. Kelley, D.S., R.M. Dougherthy, L.B. Branch, P.C. Taylor, and J.M. Iacono. 1992a. Concentration of dietary n-6 polyunsaturated fatty acids and human status. Clin. Immunol. Immunopath. 62:240-244.
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