August 2008 Issue

Nutrition in Action
By Sharon Palmer, RD
Today’s Dietitian
Vol. 10 No. 8 P. 48

Eating to maximize troops’ performance and wellness is one of the armed forces’ most important military tactics.

If you haven’t served your country as a member of the U.S. Armed Forces, there’s a good chance you’re unfamiliar with what’s happening on the military nutrition front. But the news flashes of U.S. troops in Iraq that appear on your television screen may prompt you to consider the special nutritional needs of military personnel. And as the scientific base of military nutrition knowledge widens, it is fascinating to observe how nutrition has become an important ally for the Armed Forces.

Nutrition Powers Up Military Performance
Although many nutritional issues have surfaced in the military over the years, one stands out above the rest: eating for performance. With evidence linking nutrition and hydration to athletic performance, mental alertness, and endurance, it’s no wonder the U.S. Department of Defense (DoD) considers nutrition an important tool for strengthening the body, mind, and spirit in preparation for combat.

“There’s a culture of exercise and fitness. The members need to be strong and in shape,” says Lori Tubbs, MS, RD, CDE, CSSD, LCDR, MSC, USN, human performance nutritionist for Naval Special Warfare Group TWO, who works with the Navy SEALs. “My work is very similar to that of a professional sports nutritionist. I have had the opportunity to train physically and operationally at different sites to understand needs of members of SEAL teams. This gives me a good perspective on how to provide the best methods to feeding these men at remote sites and while they are operational,” says Tubbs, who has run 38 marathons and is competing in her second Ironman triathlon this year.

The U.S. Army Center for Health Promotion and Preventative Medicine (CHPPM) has developed tools such as the reports “How Nutrition Can Help You Become a Road Marching Machine!” which outlines specific steps for fueling up for a road march, and “Meeting Performance Energy Needs,” which contains specific guidelines for energy and hydration during performance and criteria for selecting sports bars and beverages. Military personnel are also instructed to identify and shop for “power foods” by focusing on high carb, low fat, moderate protein, and a variety of foods available at grocery stores and commissaries.

Military Nutrition Research: Hard at Work
Per a request from the assistant surgeon general of the Army, the Food and Nutrition Board of the National Academy of Sciences set up the Committee on Military Nutrition Research (CMNR) to advise the DoD on the need for nutrition research. The committee identifies nutritional factors that may influence the physical and mental performance of military personnel under environmental extremes, identifies gaps concerning the relationship between diet and performance, recommends research initiatives to fill those gaps, suggests research strategies to study the links between diet and performance, and advises on current nutritional guidelines for military feeding. Committee members represent the fields of human nutrition, nutritional biochemistry, performance physiology, food science, and psychology, and several research reports have been published in recent years.

In the April 2004 Institute of Medicine report “Monitoring Metabolic Status: Predicting Decrements in Physiological and Cognitive Performance During Military Operations,” the CMNR identified that commanders may be able to monitor the status of combat service members in the field to avoid performance degradation in high-stress situations. The report identified promising biomarkers such as the use of odors and human tears for predicting health deteriorations and tools for monitoring metabolic status in the field.

According to the June 6, 2005, report “Nutrient Composition of Rations for Short-Term, High-Intensity Combat Operations,” the physical and mental status of military personnel can largely affect the success of military operations. Nutritional status can play a big role in maximizing performance during short-term, high-stress, high-intensity assault missions. Attaining optimal nutritional status during assault missions can be challenging due to decreased appetite from stress and factors such as individual preference and climate. Soldiers generally consume about one half of the calories they require, leaving them in negative energy balance, which can result in weight loss, fatigue, and mental impairments during strenuous circumstances. Developing lightweight rations that contain all essential nutrients and food components to sustain performance has become a high priority.

The DoD has funded Donna H. Ryan, MD, associate executive director of clinical research at Pennington Biomedical Research Center (PBRC) in Baton Rouge, La., in conducting military nutrition research for 20 years. She reports that this research relationship is with the Army Research Institute for Environmental Medicine (ARIEM), which is responsible for all nutrition research in the military. She also works with two projects that address weight control in the Army: one in the 94th Battalion and one at Fort Bragg, N.C. In addition, she has helped develop an Internet and environmental intervention to help soldiers meet their Army physical fitness tests (APFT).

Ryan authored the October 2005 report “Military Nutrition Research: Eight Tasks to Address Medical Factors Limiting Soldier Effectiveness.” These tasks were performed to assess, maintain, or improve a soldier’s physical, physiological, and psychological capability to function effectively under environmental and operational stress and keep adverse effects of stress on health, safety, and performance to a minimum. Research accomplishments at PBRC include a stable isotope laboratory that measures energy expenditure and body water in free-ranging personnel field training in extreme climates. The lab found that soldiers at work expend 4,000 calories per day, and men in specialized training expend as high as 8,000 calories per day. Researchers also measured body water changes in high altitude studies in relationship to acute mountain sickness and discovered that hydration status decreased within one day at altitude, with a retained effect for at least six days after returning to sea level.

The lab also developed a nutritional assessment panel for metabolic markers; worked to identify nutritional interventions for stress-induced behavior; investigated nutrition, stress, and work performance; analyzed food intake; devised strategies for improved garrison intake using behavior modification techniques; evaluated stress-induced immune modulation; and investigated issues such as alertness and performance associated with caffeine in its metabolic unit project.

A Weighty Issue
Weight has also become a big component of the military’s nutritional strategy. Weight loss in the field is undesirable, as it is linked with fatigue and loss of strength. Those in the field may need twice the average calories. Troops are encouraged to eat at least a snack every three or four hours, eat all of the rations or at least some of each item to get the balance of nutrients they need, consume high-carbohydrate foods when on the move to keep muscles stocked with glycogen and blood sugar moving to the brain, and drink adequate amounts of fluid.

But overweight can be just as pressing in the military. “Despite the availability of multiple resources to our sailors and Marines, a healthy weight is something that some members still struggle to achieve. We are continually working to identify barriers to success and develop programs and resources to address them,” says Kim Zuzelski, MS, RD, CDE, CSSD, LCDR, MSC, USN, specialty leader for Navy Dietetics who serves as a subject matter expert for the dietetic community and makes recommendations regarding staffing, distribution of resources, planning, and operational requirements. Zuzelski also serves on the DoD Nutrition Committee, which makes policy recommendations regarding nutritional programs. 

Ryan says, “Recently, our work has focused on the problem of overweight and obesity. There are about 5% of Army personnel and similar percentages for other services who are released each year for failure to meet the APFT standards, chiefly because of overweight.”

The 2005 “DoD Survey of Health Related Behaviors Among Active Duty Military Personnel” found that obesity in the total DoD population was lower compared with the U.S. civilian population, but overweight and preobesity in military personnel was higher than in the civilian population and increased with age. Among men in the military, the rate for those aged 35 and older for all services was notably high (Navy: 80.1%; Army and Air Force: 77.1%; Marine Corps: 75.6%). Overweight was lower among military women but exceeded 50% for women aged 35 or older for the Navy (57.8%), Army (54.5%), and Air Force (52.3%). It is important to note that defining weight status using body mass index does not distinguish between weight due to muscle and fat. Some personnel classified as overweight may still have percentage body fat measurements that are within acceptable ranges for their services.

According to an August 1, 2003, report, “Weight Management: State of the Science and Opportunities for Military Programs,” the main purpose of fitness and body composition standards in the Armed Forces has been to find individuals best suited for the physical demands of service based on the position that appropriate body weight and composition support good health, physical fitness, and positive military appearance. The current epidemic of overweight and obesity in the country has not escaped the military services.

The pool of available recruits is lower because they fail to meet body composition standards for entry into the services, and a high percentage of individuals exceeding military weight-for-height standards at the time of entry leave the military before completing their term of enlistment. The report reviewed the scientific evidence regarding factors that play into body weight and made recommendations to the DoD on strategies for preventing weight gain, creating weight and fat loss programs in the military, and standardizing programs across the different branches of service.

The Nutritional Wellness Strategy
Fortunately, in addition to nutrition for performance, attention is also being given to nutrition for wellness. “Without a doubt, all branches of the military are attuned to the issue of nutrition and health promotion and are growing more so. The military invests heavily in time, effort, and money in training its personnel. There is a growing awareness of the need to keep that workforce healthy and in optimal functioning. I have seen increasing awareness and concern over my 20 years of working with the military,” says Ryan.

“Navy dietitians look at the whole patient and where they are in the military life cycle. We want to provide optimal nutrition to all of our beneficiaries, regardless of whether they are a new 18-year-old recruit or a retired family member. Education is geared to the population being addressed in order to meet the unique needs that some may have. Dietitians actively collaborate with healthcare providers and health promotion program coordinators in disease prevention efforts, with the overarching goal to reduce our beneficiaries’ risk of chronic conditions and diseases such as obesity, diabetes, cardiovascular disease, cancer, etc, to improve quality of life,” says Zuzelski.

In addition to overweight, the 2005 DoD survey reported findings on other nutritional areas of concern. According to the survey, less than 10% of military personnel eat three or more servings of fruits and vegetables per day and fewer than 12% meet recommendations for intake of whole grains and low-fat milk products, with roughly 25% and 30% reporting that they consume whole grains and low-fat milk, respectively, fewer than three times per week.

Approximately 10% of military personnel reported eating lean protein sources three or more times per day, with 30% stating that they consume higher fat protein fewer than three times per week. One third of personnel stated that they eat sweets and snacks fewer than three times per week, and about 50% stated that they consume fast food fewer than three times per week. Military dining facilities were reported as the source of 15% to 30% of meals, with lunch being the clear favorite for military dining choice, highlighting that it could be the opportune time to promote healthy eating. In addition, 12.1% of all active-duty military personnel were told they had high blood pressure.

According to Tubbs, some of the primary concerns about military personnel include lack of sleep, belly fat, lipidemia, and stress factors. “There is a dietary component that is lacking. We have the best gyms, but the food component has never been at the same level. I would like to see more nutrition education and health promotion at the recruitment level, where someone comes in and talks to them about tobacco, safe sex, and healthy eating to protect the entire body. As these guys get older, they have to deal with heart disease and other chronic conditions,” she says.

With so much emphasis on performance and exercise, Tubbs reports that many members are drawn to supplements marketed for muscle development. In the 2005 DoD survey, 60.3% of military personnel reported having taken dietary supplements, and nearly one in four males in the total DoD reported taking a body-building supplement at least once per week during the previous year. Approximately 8.5% of the total force used both joint health/arthritis and performance-enhancing supplements regularly during the previous year. Ryan reports, “We did a study of nutritional supplements in Rangers who were replicating the high-endurance activities of their missions. This study showed that it was not necessary to have an individually specified supplement, but a general supplement would suffice for all Rangers.”

The CHPPM’s goal is to impact the physical, mental, spiritual, emotional, and social health of the force by assimilating health promotion into the Army environment. Health promotion is believed to maximize health, fitness, readiness, efficiency, and productivity. Evidence-based health promotion and wellness programs and tools are developed in collaboration with other military and civilian organizations. Ryan reports that the CHPPM has oversight for an officer at each base who directs health promotion. Reserve components of the Army are also targeted for health and wellness via their own Web site, Hooah4Health.com, with the goal of living a healthier, less stressful life as citizen soldiers.

Tubbs, who works with members through a medical team, as well as during individual consultations, says, “When these guys become older, job responsibilities, stress, and poor eating often lead to such conditions as weight creep and hyperlipidemia. At my job, I have a great opportunity to talk to them early in their career about nutrition and health conditions that could lead to being nonoperational. When I tell them that 60% of performance is nutrition related, I get to them.”

Tubbs also includes the members’ spouses in the nutrition link so that the entire SEAL family is engaged in good nutrition. As she travels with the SEALs, Tubbs develops meal plans with local restaurants, working to promote good nutrition throughout the community. Another ongoing task has been providing nutritional guidance to sailors who are already in the Navy and getting ready to begin basic SEAL training.

Better Rations
Thanks to the Field and Garrison Nutrition Program, rations and feeding systems are evaluated for nutritional adequacy and their influence on medical markers. Dietitians, nutritionists, behavioral scientists, and statisticians from the Military Nutrition and Biochemistry Division conduct most of the field and garrison nutrition studies to develop better ration components, menus, and supplements.

The program conducted the largest nutritional evaluation of Army field feeding in U.S. history, thus creating an improved system. Accomplishments include subsistence recommendations to enhance performance at altitude, demonstrating how lightweight 2,000-calorie rations are capable of supporting U.S. Special Operations Forces for up to 30 days, evaluating the Army field feeding system in Arctic environments, confirming the adequacy of the ready-to-eat meals to meet the nutritional standards for up to 21 days, and demonstrating how intense training scenarios may compromise immune capacity.

“The issue is to develop, on a population level, guidelines for meals for a variety of environments,” says Ryan. “For example, we helped the Army study the intake of cold weather rations in a study of soldiers in an Arctic exercise. We demonstrated some of the highest energy requirements ever measured—over 5,000 calories per day for these soldiers. We used the doubly labeled water technology to assess energy needs in the soldiers. The cold weather rations contained only 3,500 calories and, after the study, the food was increased in the rations.” 

One particular avenue that Tubbs has found successful is the creation of recovery meals, specially formulated meals available for members after hard exercise. In designing these 1,200-calorie meals intended to be consumed over three hours following exercise, Tubbs incorporated findings from the 2005 DoD survey, including low intakes of fruits and vegetables, and nine years of Navy SEAL logs collected by Tubbs that indicated low intakes of calcium and healthy fats and irregularity of meals. The recovery meals include high-glycemic juice, a snack bar with a 4 to 1 ratio of carbohydrates to protein, low-fat yogurt, almonds, tuna, fresh fruit, and tomato juice. “We’ve received great testimonies from the members. The recovery meals are selling like crazy,” notes Tubbs.

Dietitians at Work in the Military
Dietitians are involved in numerous military settings as active duty, reserve, civil service, and contract employees in multiple roles. According to Zuzelski, military dietitians work in settings such as the following:

• foodservice administration in the academies, recruit training centers, hospitals, and on hospital ships;

• clinical nutrition in hospitals with inpatient and outpatient care;

• operational roles around the globe, including those on hospital ships; deployments to the Middle East; feeding the troops and detainees in Guantanamo Bay, Cuba; and providing support to Special Operations Forces (A dietitian approves all menus for the fleet and collaborates with the Navy’s Food Management Team to provide training to military cooks.);

• health promotion activities for service members and all beneficiaries, including commissary tours, health fairs, and nutrition education classes (A dietitian also travels to teach nutrition and weight management principles to the command fitness leaders that oversee the physical readiness programs at various locations.);

• humanitarian efforts in which dietitians deploy on hospital ships and other missions and oversee food services on the ship (They often conduct nutrition screenings, assessments, and medical nutrition therapy for the populations served. A dietitian is currently deployed now on a humanitarian mission with the USNS Hospital Ship Mercy in the Pacific.);

• research and policy development; and

• healthcare administration and/or executive medicine because of the versatility, interoperability, and diverse experiences that dietitians have, often with large numbers of personnel and significant budgets. Navy dietitians are also selected to fill positions as hospital directors, executive and commanding officers, and in key roles within Navy medicine. 

Nutrition is becoming more widely embraced as a key player in optimal military performance and endurance, as well as in disease prevention and wellness. It looks like there will be plenty of opportunities for dietitians to work within the U.S. Armed Forces to help bring these goals to fruition. And civilian dietitians peering into the military nutrition front can learn a thing or two as well.
 
— Sharon Palmer, RD, is a contributing editor at Today’s Dietitian and a freelance food and nutrition writer in southern California.

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