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Appendix D Letter Report: Review of the Revision of the Medical Services Nutrition Allowances, Standards, and Education (AR 40-25, 1985) Submitted October 1995



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--> Appendix D Letter Report: Review of the Revision of the Medical Services Nutrition Allowances, Standards, and Education (AR 40-25, 1985) Submitted October 1995

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--> INSTITUTE OF MEDICINE NATIONAL ACADEMY OF SCIENCES 2101 CONSTITUTION AVENUE WASHINGTON, D.C. 20418 FOOD AND NUTRITION BOARD COMMITTEE ON MILITARY NUTRITION RESEARCH (202) 334-1737 FAX (202) 334-2316 October 26, 1995 Brig. General R. Zajtchuk Commanding General U.S. Army Medical Research and Materiel Command (SGRD-ZA) Fort Detrick Frederick, MD 21702-5012 Dear General Zajtchuk: At the specific request of the COL Eldon W. Askew, Ph.D., (former) Chief, Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine (USARIEM) and Grant Officer Representative of the U.S. Army Medical Research and Materiel Command (USAMRMC, the Command) for Grant No. DAMD17-92-J-2003 to the National Academy of Sciences for support of the Food and Nutrition Board's (FNB) Committee on Military Nutrition Research (CMNR), members of the CMNR met in Washington, D.C. on February 1, 1994. A partial purpose of this meeting was to provide additional scientific guidance to the staff of the Office of the Surgeon General, Department of the Army (OTSG, DA) in reviewing their latest revision of the Medical Services Nutrition Allowances, Standards, and Education (AR 40-25, 1985). This document is a Joint Army, Navy and Air Force Regulation for which the OTSG, DA is identified as the DoD Executive Agent for Nutrition and has responsibility for drafting revisions and coordinating changes with the responsible offices in the other Services. The CMNR was requested to perform this review as part of its task to provide scientific support to USARIEM, which has the mission to perform military nutrition and related research. Prior to the meeting, the CMNR reviewed (1) Army Regulation 40-25/Naval Command Medical Instruction 10110.1/Air Force Regulation 160-95, "Nutrition Allowances, Standards, and Education," (AR 40-25, 1985); and (2) the proposed revision submitted by COL Karen Fridlund (see Attachment

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--> II-henceforth called AR 40-25REV), (former) Chief Dietitian, Office of the Surgeon General, Department of the Army. The Committee on Military Nutrition Research's role at the meeting was to evaluate, comment upon, and make specific recommendations for changes in the entire revised document with special attention to Chapter 2, "Nutritional Allowances and Standards," that includes the Military Recommended Dietary Allowances (MRDAs), Estimated Safe and Adequate Daily Dietary Intakes, and Nutrient Standards for Operational and Restricted Rations as they reflect changes in the latest version of the Recommended Dietary Allowances (RDAs), published by the Food and Nutrition Board (NRC, 1989b) and other relevant national policy statements on nutrition and health such as the Surgeon General's Report on Nutrition and Health (DHHS, 1988) and the Diet and Health report (NRC, 1989a). This task was not in the original plan of work for the committee as part of Grant DAMD17-92-J-2003 from the U.S. Army, which ended on May 31, 1994. The CMNR has made completion of this report its highest priority under its new grant DAMD17-94-J-4046 which was initiated on November 1, 1994. A list of committee members present at the initial meeting and the current committee membership roster are included as Attachment A. This report of the CMNR has been reviewed in accordance with National Research Council (NRC) guidelines by a separate anonymous scientific review panel. This report is thus based on executive session discussions by the committee and is a thoughtfully developed presentation incorporating the scientific opinion of the CMNR and comments of the anonymous peer review panel of the NRC. This letter contains a summary of the Committee on Military Nutrition Research's evaluation of AR 40-25REV and the Committee recommendations. There are three attachments with this letter: Attachment I lists the members of the Committee on Military Nutrition Research (CMNR) who participated in this review; Attachment II is AR 40-25REV as presented to the Committee for review; and Attachment III contains an elaboration of the recommendations and comments in this letter. Attachment III is organized into four sections. First, there are more detailed explanations of the recommendations and comments that pertain to the MRDAs in general that are included here. Second, there is a listing of general comments regarding the text of AR 40-25REV that was reviewed by the CMNR. Third, there are specific comments directed to questions or concerns that the CMNR believe need to be addressed before publication of the revision. To assist with clear interpretation of the specific comments, a reference version of AR 40-25REV has been included in Attachment III (henceforth called AR 40-25REF). The line numbers cited in the specific comments below refer to AR 40-25REF. Fourth, the CMNR and the anonymous reviewers of this report have suggested wording changes for the text of AR 40-25REV. These have been made directly in the text of AR 40-25REF. The suggested wording for removal has been

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--> indicated by cross out and the recommended new wording indicated by highlighting; these suggested changes are not discussed in any detail in the text of the report. Recommendations and Comments Regarding AR 40-25REV On the basis of past reviews of AR 40-25, recent reviews of military rations and ration developments, recent workshops on nutrient requirements for military personnel in environmental extremes, and committee deliberations regarding the present version of AR 40-25REV, the CMNR presents the following recommendations to the U.S. Army Medical Research and Materiel Command (USAMRMC) regarding AR 40-25REV. The CMNR believes that the comments and recommendations in this report are also of significance to those responsible for establishing nutritional policy for the DoD in the Office of The Surgeon General, Department of the Army, as well as those responsible for the planning and procurement of military rations. The Committee particularly wants to call the attention of those individuals to Sections B and C in Attachment III. The staffs of OTSG, DA and USAMRMC are urged to review whether there continues to be a need to maintain separate MRDAs (specifically sections 2.1, 2.2, 2.4, and 2.5, which are derived from the RDAs), in light of existing information that has been developed by the IOM, DHHS, and other organizations for the general population. The CMNR recommends that Table 2-3 on nutritional standards for operational and restricted rations be retained and that the narrative accompanying the table values (section 2.3) explain clearly how the reference values were derived. If it is determined by the OTSG, DA that the military version of the RDAs (sections 2.1, 2.2, 2.4, and 2.5) is to be maintained, the CMNR recommends that serious consideration be given to the future mechanism for development of these sections as well as the nutrient standards for operational or restricted rations (section 2.3). The CMNR cannot identify a group within the existing DoD structure with a sufficient depth and breadth of expertise to develop these recommendations. There is a critical need for a group of individuals who are familiar with the development of RDAs to assist in the derivation of the MRDAs as well as the nutritional standards. The CMNR further recommends that, if it continues to be the view of the OTSG, DA that the MRDAS and nutritional standards for operational and restricted rations are needed, then:

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--> the scientific expertise at USARIEM should be involved in the future in the development of such standards to assure consideration of the findings of research conducted by the Military Nutrition Division at USARIEM; a joint review by nutritionists/dietitians from each of the Services is desirable to assure consideration of issues of special concern to each of the branches of the military, in the development of these MRDAs and standards since they are applicable to the Army, Air Force, and Navy; and timely consideration by the military of dietary recommendations developed by the Food and Nutrition Board should occur as new versions are released. Conclusions It is the view of the CMNR that there does not appear to be a scientific basis to have distinct military recommended dietary allowances for individuals performing duties in normal peacetime military operations and non-field conditions. However, since the MIRDAs have an extensive history of use by the military in areas such as menu planning and procurement of military rations, the Committee recognizes that they may serve an essential purpose beyond that usually identified with the RDAs. In addition, nutritional standards for the development and procurement of operational and restricted rations are necessary to assure that the issued rations meet the needs of service men and women whose entire diet while under simulated or actual combat conditions may consist of the issued rations for extended periods of time, such as experienced during Operation Desert Shield/Storm and during peace-keeping operations in Somalia and Haiti. The CMNR is pleased to provide this review as part of its continuing response to the U.S. Army Medical Research and Materiel Command. The Committee always welcomes comments and suggestions from you or your staff regarding how these reports can better serve the purpose of the Army. Sincerely, Robert O. Nesheim, Ph.D. Chairman, Committee on Military Nutrition Research Enclosures cc: F. Hagge H. Lieberman

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--> K. Shine K. Hein A. Yates B. Marriott References AR 40-25. 1985. See U.S. Departments of the Army, the Navy, and the Air Force. NRC (National Research Council). 1989a. Diet and Health: Implication for Reducing Chronic Disease Risk. A report of the Committee on Diet and Health, Food and Nutrition Board, Commission on Life Sciences. Washington, D.C.: National Academy Press. NRC. 1989b. Recommended Dietary Allowances, 10th ed. A report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. Washington, D.C.: National Academy Press. U.S. Departments of the Army, the Navy, and the Air Force. 1985. Army Regulation 40-25/Naval Command Medical Instruction 10110.1/Air Force Regulation 160-95. "Nutrition Allowances, Standards, and Education." May 15. Washington, D.C.

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--> Attachment I Committee on Military Nutrition Research Roster Robert O. Nesheim, Ph.D. (Chair) 28009 Mesa de Tierra Salinas, CA 93908 (408) 484-9296 FAX (408) 484-1903 William R. Beisel, M.D. Adjunct Professor, Department of Immunology and Infectious Diseases Johns Hopkins School of Hygiene and Public Health Baltimore, MD 21205 Mailing address: 8210 Ridgelea Frederick, MD 21702 (301) 662-2745 Gail E. Butterfield, Ph.D. Director, Nutrition Studies Palo Alto Veterans Affairs Health Care System(GRECC/182-B) Visiting Associate Professor, Program in Human Biology, Stanford University 3801 Miranda Avenue Palo Alto, CA 94304 (415) 493-5000 Ex 64577 or 63289 FAX (415) 855-9437 John D. Fernstrom, Ph.D. Professor of Psychiatry, Pharmacology and Neuroscience University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic 3811 O'Hara Street, Room 1620 Pittsburgh, PA 15213 (412) 624-2032 FAX (412) 624-3696 FERNSTRO+@PITT.EDU G. Richard Jansen, Ph.D. Professor Emeritus, Department of Food Science and Human Nutrition Colorado State University Gifford Bldg., Room 205 Fort Collins, CO 80523 (970) 484-3212 FAX (970) 491-7252 Robin B. Kanarek, Ph.D. Professor of Psychology Department of Psychology Tufts University 490 Boston Avenue Medford, MA 02155 (617) 628-5000 Ext. 5902 FAX (617) 627-3178 RKANAREK@PEARL.TUFTS.EDU Orville A. Levander, Ph.D. Research Leader Nutrient Requirements and Functions Laboratory U.S. Department of Agriculture ARS, BHNRC, Building 307, Room 117 Beltsville, MD 20705 (301) 504-8351 FAX (301) 504-9062 Gilbert A. Leveille, Ph.D. Vice President Research and Technical Services Nabisco Foods Group 200 DeForest Avenue, P.O. Box 1944 East Hanover, NJ 07936-1944 (201) 503-4770 FAX (201) 515-9229 John E. Vanderveen, Ph.D. Director, Office of Plant and Dairy Foods and Beverages Food and Drug Administration 200 C Street, SW Washington, DC 20204 (202) 205-4064 FAX (202) 205-4422 Douglas W. Wilmore, M.D. Frank Sawyer Professor Department of Surgery Brigham and Women's Hospital Boston, MA 02115 (617) 732-5280 FAX (617) 732-5506

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--> Food and Nutrition Board Liaison to Committee: Johanna T. Dwyer, D.Sc., R.D. Director, Frances Stern Nutrition Center Professor, Department of Medicine Tufts Medical School and New England Medical Center 750 Washington Street, Box #783 Boston, MA 02111 (617) 636-5273 FAX (617) 636-8325 U.S. Army Grant Officer Representative: Harris R. Lieberman, Ph.D. Chief, Military Nutrition Division Occupational Heath and Performance Directorate USARIEM ATTN: MCMR-UE-OPN Natick, MA 01760-5007 (508) 233-4856 FAX (508) 651-4195 (508) 233-4859 (Secretary) NRC Staff: Bernadette M. Marriott, Ph.D. Study Director Sydne J. Carlson, Ph.D. Program Officer Susan M. Knasiak Research Assistant Donna F. Allen Project Assistant (202) 334-1737 FAX (202) 334-2316

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--> Committee on Military Nutrition Research Roster (former committee, January 1994) Robert O. Nesheim, Ph.D. (Chair) 28009 Mesa de Tierra Salinas, CA 93908 (408) 484-9296 FAX (408) 484-1903 Richard L. Atkinson, M.D. Professor of Medicine and Nutritional Sciences University of Wisconsin-Madison 1415 Linden Drive, Nutritional Sciences Bldg. Madison, WI 53706 (608) 262-2727 FAX (608) 262-5860 William R. Beisel, M.D. Adjunct Professor, Department of Immunology and Infectious Diseases Johns Hopkins School of Hygiene and Public Health Baltimore, MD 21205 Mailing address: 8210 Ridgelea Frederick, MD 21702 (301) 662-2745 Gail E. Butterfield, Ph.D. Stanford University School of Medicine Division of Endocrinology, Gerontology, and Metabolism Geriatric Research, Education, and Clinical Center VA Medical Center (GRECC/182-B) 3801 Miranda Avenue Palo Alto, CA 94304 (415) 493-5000 FAX (415) 855-9437 John D. Fernstrom, Ph.D. Professor of Psychiatry, Pharmacology and Neuroscience University of Pittsburgh School of Medicine Western Psychiatric Institute and Clinic 3811 O'Hari Street, Room 1620 Pittsburgh, PA 15213 (412) 624-2032 FAX (412) 624-3696 Joël A. Grinker, Ph.D. Professor, Pediatrics and Communicable Diseases Program in Human Nutrition School of Public Health University of Michigan 1420 Washington Heights-M5170 Ann Arbor, MI 48109 (313) 764-5270 FAX (313) 763-5455 G. Richard Jansen, Ph.D. Professor Emeritus, Department of Food Science and Human Nutrition Colorado State University Gifford Bldg., Room 205 Fort Collins, CO 80523 (303) 494-3212 FAX (303) 491-7252 Orville A. Levander, Ph.D. Vitamin and Mineral Nutrition Laboratory USDA, ARS, BHNRC Building 307, Room 117 Beltsville, MD 20705 (301) 504-8351 FAX (301) 504-9062 Gilbert A. Leveille, Ph.D. Vice President Research and Technical Services Nabisco Foods Group 200 DeForest Avenue P.O. Box 1944 East Hanover, NJ 07936-1944 (201) 503-4770 FAX (201) 515-9229 John E. Vanderveen, Ph.D. Director, Office of Plant and Dairy Foods and Beverages Food and Drug Administration 200 C Street, SW Washington, DC 20204 (202) 205-4064 FAX (202) 205-4594

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--> Food and Nutrition Board Liaison to Committee: Johanna T. Dwyer, D.Sc., R.D. Professor, Department of Medicine, Tufts Medical School and New England Medical Center Director, Frances Stern Nutrition Center 750 Washington Street, Box #783 Boston, MA 02111 (617) 956-5273 FAX (617) 524-1252 U.S. Army Grant Officer Representative: Dr. James A. Vogel Director, Occupational Health and Performance Directorate USARIEM ATTN: SGRD-UE-OPN Natick, MA 01760-5007 (508) 651-4800 FAX (508) 651-5833 FAX AV 256-5298 NRC Staff. Bernadette M. Marriott, Ph.D. Program Director Donna F. Allen Project Assistant (202) 334-1737 FAX (202) 334-2316

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--> sweetened beverages, etc." It appears that the point trying to be communicated is that foods containing complex carbohydrates are typically more nutrient dense than those containing simple carbohydrates. Complex carbohydrates may also be a source of dietary fiber. Special attention needs to be placed on reviewing the document for this problem. The reference format is inconsistent throughout the document. Text references should either include authors and year or title, author, and year, or be cited numerically. All references should be as complete as possible. All references cited in the text must be cross checked and included in the reference list. Many references that are currently in the text are not included in the reference list. The entire draft regulation requires thorough proofreading and the use of a professional copy editor to address general editing problems of this nature as well as the use of correct English, spelling (dietitian should replace dietician) and scientific abbreviations; for example "calorie" should be replaced with kcal as a measurement of energy throughout the text. C. Specific Comments Regarding AR 40-25REV The comments below are indicated by Section, and where appropriate, by line number in AR 40-25REF that follows. Chapter 1 1-1. No comments. 1-2. References. The CMNR recommends that the following references be added as related references: Nutrition During Pregnancy (IOM, 1990); Nutrition During Lactation (IOM, 1991c); Nutrition During Pregnancy and Lactation: An Implementation Guide ((IOM, 1992c); Body Composition and Physical Performance (IOM, 1992a); Military Nutrition Initiatives (IOM, 1991a); and Nutritional Needs in Hot Environments (IOM, 1993). In addition it is not clear what is meant by "required publications". Rationale should be provided to indicate by whom and for what these references are required. 1-3. See suggested changes in glossary of AR 40-25REF. 1-4a. The CMNR concurs with the inclusion of simulated combat conditions as a situation under which MRDAs must be met. 1-4a. The CMNR strongly supports the maintenance of military nutrition research capability through the U.S. Army Medical Research and Materiel

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--> Command, particularly through utilizing the combined support available at the U.S. Army Research Institute of Environmental Medicine (USARIEM) facilities located in Natick, Massachusetts. 1.4a. See suggested wording changes in AR 40-25REF. 1-4b. No comments. Chapter 2 2-1a. The wording throughout this section was not clear. See suggested changes in AR 40-25REF. Line 111. After stating that the MRDAs are listed in Table 2-1, it would be helpful to add that the values are expressed in terms of "reference individuals" for each gender. See the text pertaining to reference individuals in the National Research Council's Recommended Dietary Allowances, 10th Edition (pp. 14–15). The RDA values are the actual medians of height and weight for the U.S. population of the designated age and gender, as reported in the second National Health and Nutrition Examination Survey (NHANES II). 2-1b. No comments. 2-1c. Lines 121–126. This statement does not match the calculated values in Table 2-1 because the energy values in the table assume moderate to heavy physical activity. Please consider revising text or table values for consistency. 2-1d. No comments. 2-2. See suggested wording changes in AR 40-25REF. 2-3a–b. See suggested wording changes in AR 40-25REF. 2-3d. The CMNR is unable to comment on this section since it has not reviewed the Food Packet, Survival, Abandon Ship Survival Ration, or the Aircraft/Life Raft Ration. 2-3d. See suggested wording changes in AR 40-25REF. 2-4. It is suggested that the current section 2-4c. Physical Activity would be more appropriately placed as section 2-4b; with the present section 2-4b. Body Size moved to become section 2-4c. 2-4a. See suggested wording changes in AR 40-25REF. 2-4b. See suggested wording changes in AR 40-25REF. Lines 193–196. These last sentences need to be changed as shown in the text or a longer rationale needs to be provided. 2-4c. See suggested wording changes in AR 40-25REF. The values here contradict those described in Section 2-1c. In addition, there appears to be confusion within the table and between the table and text regarding energy recommendations. There is considerable inconsistency. Many of the values in

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--> Table 2-1 were calculated using the average MRDA value for energy, which pertains to those who engage, by the table definitions, in moderate to heavy activity. All MRDA values need to be recalculated based on consistent energy recommendations. Table 2-1, would be more readily understood if a supporting table was generated that provided a listing of typical military activities and classified them as light, moderate, heavy and very heavy physical activity. 2-4d. See suggested wording changes in AR 40-25REF. 2-4d. (1) See suggested wording changes in AR 40-25REF. 2-4d. (2) See suggested wording changes in AR 40-25REF. Line 232. The sentence that begins "Beyond 30 degrees . . . " is very specific. To include this level of specificity in the text requires that a solid scientific reference be cited. Line 236. It is suggested that the following sentence be added at the end of this paragraph and the implications considered carefully: "This requirement, when computed, results in 4,370 kcal/day for the reference moderately active military man; 3,415 kcal/day for the military woman." 2-4d. (3) The CMNR suggests that this section be replaced by the following: "Altitude: Energy requirements for high-altitude operations, greater than 10,000 ft (3,050 m) are increased due to: (1) 15% elevation in basal metabolism, (2) performance of physical activities over rugged terrain, and (3) physiological response to cold. Total energy requirements for individuals performing strenuous work at altitude may reach 6,000 kcal/d. The loss of appetite that occurs at high altitude coupled with this increased need makes obtaining sufficient energy to maintain lean body mass very difficult to attain without conscious effort and may require a disciplined food and water intake program." (Keep last sentence in this section. There is little evidence that chronic altitude exposure increases the requirement for any specific nutrients other than carbohydrate and water.) 2-4d. (4) See suggested wording changes in AR 40-25REF. 2-5a. See suggested wording changes in AR 40-25REF. 2-5b. The CMNR wishes to congratulate the Army on its education programs that were successful in reducing fat intake in garrison from a range of 41.8 to 48.6% to 34.0 to 38.4% (IOM, 1991a, p. 95) and suggests additional studies that would similarly measure the impact of nutrition education initiatives. The statement in AR 40-25REV regarding saturated fats in the diet is modeled after the statement in the 1989 edition of the RDAs, but the CMNR cautions that this approach may warrant consideration in light of recent changes in the Dietary Guidelines for Americans and pending changes in the RDAs. Lines 264–269. Does this refer to shipboard and garrison only? Please clarify.

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--> 2-5c. "Complex carbohydrates are more nutrient dense . . . " with regard to what? relative to vitamins and minerals? This section is not clear. Also see suggested wording changes in AR 40-25REF. 2-5d. See suggested wording changes in AR 40-25REF. Although low fat dairy products are healthier, their calcium content is not dramatically different. 2-5e. Lines 296–299. The CMNR suggests that the last two sentences of section 2-5e be removed because the current RDAs do not indicate a need for supplementation for lower energy intake levels in women. 2-5f. This statement focuses entirely on salt as a source of iodine. Other sources should be mentioned so there will not be contradictions with other sections of AR 40-25REV where a reduction in salt intake is recommended. 2-5g. See suggested wording changes in AR 40-25REF. 2-5h. (1) See suggested wording changes in AR 40-25REF. It is suggested for clarity that the following be added after line 315: "The MRDAs for sodium are based on an average level of energy expenditure (3,600 kcal/day for men; 2,500 kcal/day for women). The table values, 5,600 mg/day for men and 3,900 mg/day for women, are the average values that were calculated using the range 1,400–1,700 mg sodium/1,000 kcal (rounded to the nearest 50 mg increment)." The CMNR further notes that there is no scientific reference provided for the basis of the MRDA value for sodium. 2-5h. (2) See suggested wording changes in AR 40-25REF. The CMNR advises that both "discretionary" and "non-discretionary" sodium intake should be defined in the glossary. Also note that the citation of the CMNR Activity Report as a reference is inaccurate. There is no identifiable reference in this report to salt tablets. In addition, the CMNR Activity Reports are summaries of previous reports and the correct citation would be the original report. 2-5i. Water. See suggested wording changes in AR 40-25REF. Lines 330–333. This statement is referenced erroneously to the CMNR report, Nutritional Needs in Hot Environments (IOM, 1993). Perhaps this statement could be supported through a derivation from Carl Gisolfi's chapter in that report, but this does not appear to be the case. For CMNR reports, the authored chapters must be cited by the author's name and year and referenced as a titled chapter in the report. The CMNR report can only be cited as a reference if the material is based on chapters 1 and 2 that were written by the committee. This fact is clearly stated in each CMNR report. NOTE: There is something wrong with the assumptions with respect to water. See calculations below for what recommendations under "water" appear to suggest. Assume 1 ml water/kcal as a reasonable basis.

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--> Assume average energy expenditures as indicated in Table 2-1. Therefore: for men 3.6 L and for women 2.5 L. Assume in hot climates water need increases by 1.5–2 times, then 5.4–7.2 L for men 3.75–5.0 L for women Assume in addition, if heavy work is done fluid needs increase 3 fold so, 3.6 × 3 = or 2.5 × 3 = 10.8 L for men 7.5 L for women Assume if all of the above are true, and the soldier arrives at high altitude, that 3–4 liters additional are suggested, plus 200–300 g of carbohydrate 13.8–17.8 L for men 10.5–11.5 L for women  Assume an additional 4 liters over the 3–4 liters additional in step 5. if the individual is in an engine room or MOPP4 garments 14.8 L for men 11.5 L for women NOTE: These recommendations result in different levels, e.g., 3.6 L and 2.5 L, for temperate climates than the 6 L suggested at the end of the AR 40-25REV text in section 2-5i. Water; using average energy intakes as stated in the regulation. Also, the rationale or derivation of values for Arctic climates of 8 L at line 346 is not provided at all and needs to be. Basically, increased fluid intake for active personnel in the cold is dependent on sweating plus excessive respiratory water loss because of the low ambient vapor pressure. The committee has deleted this section in AR 40-25REF since there is no reference cited. The calculations for water needs for hot environments to arrive at the value of 12 L on line 346 also are not clear. If we took assumption 3 above and added assumption 6, the result would be 9.4–11.2 L for men and 7.75–9.0 L for women, not 12 L. Finally, it is not clear to what base figure a 4 L per day increment for working in a hot engine room or MOPP4 suit should be added? Is it 1 ml/kcal plus adjustments for hot climate of 1.5–2 times, or 3 times for hot climate plus work? The MOPP4 garments should be included in this discussion as well as a definition of this term. Please note again that the method of citing scientific references is inconsistent and scientifically inaccurate. Nutrition in Exercise and Sport is an edited volume. Any reference to material from this book needs to be cited by the names of the authors of the chapter in which the material is found and the publication year. The CMNR did not read this book to try to verify this information in lines 333 to 339 and therefore cannot make any comment on this high altitude recommendation for additional fluid and carbohydrate. Rewording has been suggested for readability. 2-5j. Supplemental beverages. See suggested wording changes in AR 40-25REF.

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--> Lines 362–364. "With normal fluid and food intake, carbohydrate and electrolyte balance losses due to stress may be restored . . . " This is not clear; restored by what? Lines 364–366. Inaccurate reference citation to the CMNR Activity Report, 1986–1992. This is a summary report of activities. Citations must be attributed to the original report or authored chapters in original reports. Lines 368–371. This is an inaccurate reference citation to the report, Nutritional Needs in Hot Environments. The correct report has been cited in the text. Lines 373–376. See comment above regarding the use of the title of an edited volume as a reference and revise to provide a specific scientifically accurate reference. Specific Comments on Table 2-1 See suggested wording changes in AR 40-25REF. Please state the reference weight standard in the table (e.g., 78 kg, 61 kg). Energy: Use a standard figure for all calculations. The committee found it confusing to have it stated that moderate activity levels were selected, when, in fact, many of the values in AR 40-25REV were calculated using the higher AVG Energy. Thus, 3,150 and 2,250 are not the base (e.g., moderate activity for men and women). All AR 40-25REV values should be calculated using the same energy needs. Footnotes are needed to explain many values in the table. Below are the calculations attempted by the CMNR to derive the table values. This type of information must be added to the text and footnoted in Table 2-1 for clarity. Protein: The recommended allowance for reference protein is 0.75 g/kg and 0.8 g/kg is the recommended dietary allowance for U.S. Dietary Protein (RDAs, NRC, 1989b). A value that takes into account newer studies suggesting higher values with physical activity is 1.5 g/kg. The mid-point of this range is used to calculate a reference weight for men of 78 kg and reference weight for women of 61 kg. Thiamin (B1 ): This calculation is based on 0.5 mg/1,000 kcal. (RDAs, NRC, 1989b) assuming AVG Energy values, therefore 1.8 mg (men), and 1.25 mg or 1.3 mg, (women). Riboflavin: The MRDA value is based on 0.6 mg per 1,000 kcal (RDAs, NRC, 1989a) using AVG Energy values, therefore 2.16 or 2.2 mg (men) and 1.3 mg (women). Niacin: The RDA appears to be different from the value in AR 40-25REV. Why? Possible calculation is 6.6 NE/1,000 kcal; therefore 16.5 or 17 mg.

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--> Vitamin B6 : Typographical error—It should read B6 9 not B-9. In footnote #9, explicitly state the equation from the 1989 RDA to show how the AR 40-25REV value is calculated. Folic Acid: The folic acid value was calculated using 78 kg reference weight for men and 3 μg/kg body weight (RDAs, NRC, 1989b). The value for women correctly differs from the RDA because of a more recent directive from the U.S. Public Health Service; this directive should be cited. Sodium: See previous comments. It is unclear how the values 5,600 and 3,900 mg were derived if the value of 1.0 mg/kcal was used as the basis for the calculation. Please recalculate these values and present clear rationales for their calculation. Clearly the footnote is incorrect. In addition, these are not sodium requirements but rather recommendations. NOTE: It is not clear how the sodium recommendation was derived. The 1989 RDAs only provide a minimum recommendation. On the basis of AVG Energy, sodium recommendation would be: Men 3,600 mg Women 2,500 mg If 1,400–1,700 mg Na/1,000 kcal, then Men = 5,040–6,120 mg for 3,600 kcal AVG Energy Women = 3,500–4,250 mg for 2,500 kcal AVG Energy or a midpoint of 3,875. These do not agree with the RDAs. Line 436. The reference is cited incorrectly. The author and year of publication should be cited in the text. Then the full citation should be included in the reference list. This reference citation cannot be understood as it presently is written. Line 443. This reference is inaccurate. This statement was made in another CMNR report as shown. See suggested wording changes in AR 40-25REF. Table 2-2. See suggested wording changes in AR 40-25REF. Also note that because of the inclusion of minimum requirements for potassium and chloride, the title for this table becomes incorrect and inappropriate. It is questionable if the values for potassium and chloride should even be included or presented as part of this table. The RDA table (Table II-1) includes a footnote indicating that desirable intakes of potassium may considerably exceed the minimum requirements (approx. 3,500 mg for adults) and there is further explanation/discussion in the text. The chloride value is not compatible with other statements regarding Na or NaCl.

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--> Table 2-3. See suggested wording changes in AR 40-25REF. NOTE: See Specific Statements earlier. This entire table needs accompanying text that indicates clearly how the values were derived. Chapter 3 Nutrition Education 3-1. Introduction a–c. See suggested wording changes in AR 40-25REF. 3-2. Table 3-2 The CMNR suggests replacing the food guide pyramid (a copy of which we have added to C). Alternatively an additional new pyramid could be developed to become Table 3-3. In this new table, the suggested servings in the pyramid could be derived from values for energy in AR 40-25REV (2,250 kcal for women; 3,150 kcal for men). Line 605. We have added the text from the USDA and DHHS brochure (1990) that we assume you will include here in AR 40-25REF. The revision of the Dietary Guidelines is in progress (USDA, 1995), and new Dietary Guidelines are anticipated. These recommendations should also be considered in this section. In addition, there is a need to indicate the servings for higher caloric levels. As an example, these are the sample diets for a day at what are designated as Moderate and High calorie intakes in supporting documentation that accompanied the Food Pyramid. These would have to be modified further for inclusion in the revised text:   MODERATE 2,200 Kcal HIGH 3,150 Kcal Bread Group Servings 9 11 Vegetable Group Servings 4 5 Fruit Group Servings 3 4 Milk Group Servings 2–3 2–3 Meat Group (ounces) 6 7 Total fat (g) 73 93 Total added sugars (tsp) 12 18 3-2b Sections (1) through (7) are direct extracts from the Dietary Guidelines (1990). No comments are warranted. The Army must consider the newly issued Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 1995 (USDA, 1995) in revisions to this section.

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--> Appendix A References-A reference section needs to be added that includes all articles cited in the text in a consistent, scientific format. Required and Recommended Reading See previous comments. Appendix B Justification for Protein Recommendations Note: The word ''requirement'' needs to be changed to "recommendation" throughout Appendix B. See suggested wording changes in AR 40-25REF. g. Line 776: These values conflict with the values in Table 2-1: 3,600 for men; 2,500 for women. Which are the ones to be used? Line 777: Table 2-1 values are 88 and 69 grams respectively. These are in conflict, which are correct? Appendix C Nutrient Density Index The CMNR was not provided with the necessary background material to review this Appendix. No detailed review or recommendations could therefore be provided here. There are several points worth noting about errors/confusion in Table C-1. Footnotes 1, 2 and 3 apply only to the values for the reduced calorie menu; thus the placement of the footnote numbers in the table is completely confusing. The values for minimum recommended allowance also are incorrect/confusing. The minimums are based on the minimums indicated in the RDAs for energy intakes <2,000 kcal, which are not the values listed in the footnotes. Glossary Abbreviations. Add B Rations and T Rations and others from text. Terms. See suggested wording changes in AR 40-25REF. After definition for congregate feeding, please add definition for discretionary sodium such as, "Sodium which is added to foods by the cook or by the individual when food is eaten." As an alternative, the terms "discretionary" and "nondiscretionary" could be listed under the term sodium as separate items. In addition, the entire Terms section may need additional review to be sure that all terms are actually used in the text, for example, is cholecalciferol still cited in the text?

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--> References AR 45-20. 1985. See U.S. Departments of the Army, the Navy, and the Air Force. DHHS (U.S. Department of Health and Human Services). 1988. The Surgeon General's Report on Nutrition and Health. DHHS (PHS) Publ. No. 88-50210. Public Health Service, U.S. Department of Health and Human Services. Washington, D.C.: U.S. Government Printing Office. IOM (Institute of Medicine). 1990. Nutrition During Pregnancy. Subcommittee on Nutritional Status and Weight Gain During Pregnancy, Subcommittee on Dietary Intake and Nutrient Supplements During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1991a. Military Nutrition Initiatives. A Brief Report of the Committee on Military Nutrition Research, Food and Nutrition Board. February 25, 1991. Washington, D.C.: National Academy Press. IOM. 1991b. Fluid Replacement and Heat Stress. Proceedings of a Workshop of the Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1991c. Nutrition During Lactation. Subcommittee on Nutrition During Pregnancy, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board . Washington, D.C.: National Academy Press. IOM. 1992a. Body Composition and Physical Performance, Applications for the Military Services. Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1992b. Fluid Replacement and Heat Stress, 2nd printing. Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1992c. Nutrition During Pregnancy and Lactation: An Implementation Guide. Subcommittee for a Clinical Application Guide, Committee on Nutritional Status During Pregnancy and Lactation, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1993. Nutritional Needs in Hot Environments, Applications for Military Personnel in Field Operations. Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1994a. Fluid Replacement and Heat Stress, 3rd printing. Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press. IOM. 1994b. How Should the Recommended Dietary Allowances Be Revised? Food and Nutrition Board. Washington, D.C.: National Academy Press. NRC (National Research Council). 1989a. Diet and Health: Implications for Reducing Chronic Disease Risk. Committee on Diet and Health, Food and Nutrition Board, Commission on Life Sciences . Washington, D.C.: National Academy Press. NRC. 1989b. Recommended Dietary Allowances, 10th ed. Report of the Subcommittee on the Tenth Edition of the RDAs, food and Nutrition Board, Commission on Life Sciences. Washington, D.C.: National Academy Press. USDA (U.S. Department of Agriculture). 1995. Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 1995. Washington, D.C.: U.S. Government Printing Office.

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--> USDA and DHHS (U.S. Department of Agriculture and U.S. Department of Health and Human Services). 1990. Dietary Guidelines for Americans, 3rd ed. Washington, D.C.: U.S. Government Printing Office. U.S. Departments of the Army, the Navy, and the Air Force. 1985. Army Regulation 40-25/Naval Command Medical Instruction 10110.1/Air Force Regulation 160-95. "Nutrition Allowances, Standards, and Education." May 15. Washington, D.C.