Military nutrition: maintaining health and rebuilding injured tissue

Nutrition Knowledge Is Associated With Diet Quality Among US Army Soldiers

OBJECTIVE

Examine the relationship between nutrition knowledge, diet quality, and eating behavior among active-duty US Army Soldiers.

METHODS

Cross-sectional study with data collection in February 2018 via paper surveys during the validation of the Military Eating Behavior Survey.

RESULTS

Among 440 US Army Soldiers, nutrition knowledge was positively and significantly associated with diet quality (b = 0.29, P < 0.001). For every 1-point increase in nutrition knowledge, the Healthy Eating Index-2015 score was expected to increase by 0.29 points. Nutrition knowledge was not significantly associated with skipping breakfast (odds ratio, 1.01; 95% confidence interval, 0.98-1.04) or dining out (odds ratio, 1.01; 95% confidence interval, 0.98-1.03).

CONCLUSIONS AND IMPLICATIONS

The outcomes of this study warrant further investigation to determine what interventions provide the strongest outcomes for improving nutrition knowledge and diet quality, as well as create and support an environment that enhances healthy behaviors regarding nutrition that lead to improved diet quality among active-duty Soldiers.

Military Food Supply Chain during the COVID-19 Pandemic

The outbreak of the COVID-19 pandemic in Wuhan, China, disrupted international trade and changed the global food supply chain. Disruptions affected all food supply chains, including those critical to national security. To the best of our knowledge, this study is the first to reveal the impact of the pandemic on the military food supply chain in Poland. In the analysed single case study, we used process mapping to show the diversity of the types of military food supply chains operating in military units. The attention was focused on the internal and external food supply chains in the context of the disruptions and dysfunctions that appeared in the sphere of management. The contribution of the article is twofold. First, we used a situational crisis management approach to isolate four types of internal military food supply chains. Practical guidance concerns showing actions influencing the modification of system solutions in the military sphere in peacetime in connection with the pandemic. As a member of the North Atlantic Treaty Organization (NATO), Poland applies system solutions similar to those in place in other allied countries. The results of our research can be used as recommendations for solving problems in the military food supply chain in other countries within NATO.

Effectiveness of nutrition interventions on improving diet quality and nutrition knowledge in military populations: a systematic review

CONTEXT

Optimizing nutrition in military groups through improved diet quality and nutrition knowledge is key in supporting the high physical and cognitive demands.

OBJECTIVE

The objective of this investigation was to systematically review the effectiveness of nutrition interventions among military personnel in improving diet quality and/or nutrition knowledge.

DATA SOURCES

Medline, Embase, CINAHL, and Scopus were searched from the earliest records to May 2020.

DATA EXTRACTION

Data were extracted by 2 reviewers. The primary outcomes were diet quality and/or nutrition knowledge.

DATA ANALYSIS

Twenty studies were included. The main intervention approaches identified were nutrition education of individuals (i.e., education-based studies; EB) (n = 12), and manipulation of the food service environment (i.e., dining facility studies; DFACs) (n = 8). The most common strategies were face-to-face lectures (n = 8) for EB, and healthier menus (n = 7) and education of catering staff (n = 6) for DFAC interventions. Most studies (18/20) demonstrated favorable within-group effects; however, dietary changes were inconsistent. Five of 10 studies using a comparator group demonstrated positive between-group differences.

CONCLUSION

Although potential exists for improving diet quality and nutrition knowledge in military populations, the heterogeneity of the studies to date limits conclusions on the most efficacious strategies.

An Alternate Approach to Military Rations for Optimal Health and Performance

INTRODUCTION

Operational ration packs are the sole source of nutrition when military personnel cannot access fresh food and field kitchens due to deployment and training in remote and hostile locations. They should be light, durable, nutrient rich, and contain sufficient energy to ensure that the personnel can carry out the expected duties. The macronutrient composition of rations has remained relatively unchanged despite escalating concerns related to the health and operational readiness of personnel globally. Currently, the New Zealand Defence Force (NZDF) provides the personnel with a 24-hour ration pack. The aims of this study were to (1) analyse the nutrient content, cost, and weight of the NZDF-supplied ration pack and (2) develop and analyse an alternate ration pack. The alternate ration pack was designed with the intention of improving overall quality and macronutrient distribution ratio, to align with optimal health and performance outcomes.

MATERIALS AND METHODS

Nutrient and weight analyses of the NZDF and alternate ration packs were conducted using nutrition analysis software Foodworks V. 10 (Xyris software). The ration packs were costed using information from the NZDF and from commercial online shopping websites (particularly Countdown supermarket and an online shop, iHerb). Data from nutrition panels were entered into Foodworks V. 10 (Xyris software). The data underlying this article will be shared on reasonable request to the corresponding author.

RESULTS

The NZDF-supplied ration pack cost 37.00 NZD and contained an excessive amount of sugar (636 g or 46% total energy) and marginally insufficient protein (118.7 g or 9% total energy) to sustain physically active military personnel. Comparatively, the alternate ration pack was more costly (63.55 NZD) and contained significantly less sugar (74.6 g or 7.2% total energy) and exceeded protein (263.1 g or 26% total energy) requirements for physically active military personnel. Furthermore, the alternate ration pack was significantly lighter (0.71 kg) than the NZDF ration pack (1.4 kg). In summary, the alternate ration was nutritionally superior and lighter when compared to the currently supplied NZDF ration, but more expensive when purchased as a one-off.

CONCLUSIONS

This work highlights the shortcomings of currently supplied military rations packs (i.e., excessive sugar and marginally inadequate protein) and proposes a novel alternate approach to ration pack formulation. This approach would significantly reduce sugar and increase protein and fat content in military rations. Although this work indicates that the alternate approach (which would produce lighter and nutritionally superior rations) is more costly, this cost could be reduced significantly through bulk purchasing and purpose-built rations and food items. Considering these findings, field user-testing of the alternate ration pack is recommended and subsequent reformulation of guidelines for ration pack development, as appropriate.

Can Social Cognitive Theory Influence Breakfast Frequency in an Institutional Context: A Qualitative Study

Breakfast is considered an important meal, especially for people who are about to commence a long or demanding workday, and for roles that may involve physical tasks and a requirement to remain alert and vigilant in potentially high-risk situations. This study looks at breakfast consumption influences within two workplace institutional settings, namely military and mining. Semi-structured interviews were conducted with military personnel (n = 12) and mining employees (n = 12) to understand their breakfast consumption behaviour at work and at home, and the associated behavioural influences. The interview questions were framed by social cognitive theory. Overall, cognitive and environmental influences were the most prominent influences on breakfast consumption, less evident were behavioural influences. A negative stereotype of workplace institutional food services emerged as one of the most significant barriers to breakfast consumption for those already at work. Considerations of environmental influences on behaviour may need to be broadened beyond physical barriers and social influences, to include perceptions of the behavioural environment. Programs that aim to increase breakfast consumption must create areas where their employees want to go. Food systems need to ensure nutritious, quality, and appealing food is available. Interventions need to increase participants’ knowledge, improve their attitudes, and create positive expectations for breakfast.

Free-Living Dietary Intake in Tactical Personnel and Implications for Nutrition Practice: A Systematic Review

Tactical personnel (including military, law enforcement, and fire and rescue) are responsible for ensuring national and public safety. Dietary intake is an important consideration to support optimal health and performance. The aims of this systematic review were to: (1) describe the reported free-living dietary intake (energy and macronutrients) of tactical personnel, and (2) describe the practical implications of reported dietary intakes to support the physical and dietary requirements of tactical personnel. A systematic search of databases (MEDLINE, EMBASE, CINAHL and Web of Science) was conducted following the PRISMA guidelines. English and full text research articles were identified and screened against inclusion and exclusion criteria. Demographic and dietary intake data were extracted, tabulated, and synthesized narratively. The quality of the studies was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Twenty-two studies (15 military, 4 law enforcement, and 2 fire and rescue) were eligible to inform this review. The volume of evidence suggested that tactical personnel met dietary protein and exceeded dietary fat recommendations but failed to meet energy and carbohydrate recommendations. Therefore, practical approaches to support optimized energy, fat and carbohydrate intake in tactical personnel is important.

The effect of food ration bar enriched with β-alanine, L-arginine, and Nigella sativa on performance and inflammation following intense military training: A double-blind randomized clinical trial

BACKGROUND

There are growing interests in using dietary supplements to improve athletic performance. This study aimed to evaluate the effect of the food ration bar enriched with β-alanine, L-arginine, and Nigella sativa on athletic performance and inflammation following intense military training.

METHODS

This double-blind, randomized, controlled clinical trial was conducted on 54 new cadets. Eligible participants were randomly assigned in a 1:1 ratio to receive food ration bars enriched with arginine (2 g/day), β-alanine (2 g/day), and Nigella sativa (2 g/day) or nonenriched food ration bars during a 2-week military training. Aerobic and anaerobic performances were evaluated by the Cooper and RAST tests, respectively.

RESULTS

A significant increase in anaerobic powers (min, mean, and max) and a significant reduction in fatigue index were observed in the intervention group as compared to the control group, even after the adjustment for confounding factors. Also, increased levels of hs-CRP and TNF-α following military training were significantly lower in the intervention group as compared to the control group (hs-CRP: 0.55 ± 0.1 versus 2.43 ± 0.1 mg/L; p-value: 0.01; TNF-α: 0.12 ± 0.04 versus 0.62 ± 0.04 pg/ml; p-value: 0.03). No significant changes were observed in VO2 max in both groups.

CONCLUSIONS

Our results showed that the combination of β-alanine, L-arginine, and Nigella sativa can improve anaerobic performance and reduce inflammation following intense physical activities. Further studies with long-term duration are needed to confirm the cumulative/synergic effects of these ingredients in trained and nontrained subjects.

Dietary Assessment Methods in Military and Veteran Populations: A Scoping Review

Optimal dietary intake is important for the health and physical performance of military personnel. For military veterans, the complex nature of transition into civilian life and sub-optimal dietary intake is a leading contributor to the increased burden of disease. A scoping review was undertaken to determine what is known about the assessment and reporting of dietary intakes within both military and veteran populations. In addition, this review determines if studies reporting on the dietary intake of military personnel or veterans include comparisons with dietary guidelines. Six databases were searched to identify papers published from the database inception to April 2019. Observational and intervention studies were searched to identify if they assessed and reported whole dietary intake data, reported data exclusively for a military or veteran population, and included only healthy populations. A total of 89 studies were included. The majority of studies used one dietary assessment method (n = 76, 85%) with fewer using multiple methods (n = 13, 15%). The most frequent methodology used was food frequency questionnaires (FFQ) (n = 40, 45%) followed by 24-hour recalls (n = 8, 9%) and food records (n = 8, 9%). The main dietary outcomes reported were macronutrients: carbohydrate, protein, fat, and alcohol (n = 66, 74%) with total energy intake reported in n = 59 (66%). Fifty four (61%) studies reported a comparison with country-specific dietary guidelines and 14 (16%) reported a comparison with the country-specific military guidelines. In conclusion, dietary intake in military settings is most commonly assessed via FFQs and 24-hour recalls. Dietary intake reporting is mainly focused around intakes of energy and macronutrients. Most studies compare against dietary guidelines, however, comparison to specific military dietary guidelines is minimal.

Comparison of dietary intakes of Canadian Armed Forces personnel consuming field rations in acute hot, cold, and temperate conditions with standardized infantry activities

BACKGROUND

Dietary Reference Intakes are used to guide the energy intake of the Canadian Armed Forces (CAF) field rations provided to military personnel deployed for training or operations. However, the high energy expenditures likely to occur under harsh environmental/metabolically challenging deployment conditions may not be adequately considered. This study examined the Ad libitum energy and nutrient intakes of CAF personnel (n = 18) consuming field rations in a resting thermoneutral environment and during a day of standardized strenuous infantry activities at varying environmental temperatures.

METHODS

Dietary intake was assessed using a measured food intake/food waste method during the experimental treatment and for 6 h after treatment. Four treatments were administered in a randomized counterbalanced design: exercise (as standardized infantry activities) in the heat (30 °C), exercise in the cold (- 10 °C), exercise in temperate thermoneutral (21 °C) air temperatures and a resting (sedentary) trial (21 °C).

RESULTS

The average Ad libitum consumption of field rations was 70% of the provided total energy (2776 ± 99 kcal/8 h) during all treatments. Even with an acute challenge of increased energy expenditure and temperature stress in the simulated field conditions, participants' energy intakes (1985 ± 747 kcal/8 h) under hot, cold and temperate treatments did not differ from energy intake during the sedentary condition (1920 ± 640 kcal/8 h). Participants' energy intakes (1009 ± 527 kcal/6 h) did not increase during the 6 h posttreatment period when the stresses of the strenuous physical activities and the harsh environmental temperatures had subsided.

CONCLUSION

These results should be considered when planning the provision of field rations for CAF personnel expected to be engaged in strenuous physical activities with prolonged exposure to temperature extremes.

Behavioral and Health Outcomes Associated With Deployment and Nondeployment Acquisition of Traumatic Brain Injury in Iraq and Afghanistan Veterans

OBJECTIVE

To characterize behavioral and health outcomes in veterans with traumatic brain injury (TBI) acquired in nondeployment and deployment settings.

DESIGN

Cross-sectional assessment evaluating TBI acquired during and outside of deployment, mental and behavioral health symptoms, and diagnoses.

SETTING

Veterans Affairs Medical Centers.

PARTICIPANTS

Iraq and Afghanistan veterans who were deployed to a warzone (N=1399).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Comprehensive lifetime TBI interview, Structured Clinical Interview for DSM-IV Disorders, Combat Exposure Scale, and behavioral and health measures.

RESULTS

There was a main effect of deployment TBI on depressive symptoms, posttraumatic stress symptoms, poor sleep quality, substance use, and pain. Veterans with deployment TBI were also more likely to have a diagnosis of bipolar, major depressive, alcohol use, and posttraumatic stress disorders than those who did not have a deployment TBI.

CONCLUSIONS

TBIs acquired during deployment are associated with different behavioral and health outcomes than TBI acquired in nondeployment environments. The presence of TBI during deployment is associated with poorer behavioral outcomes, as well as a greater lifetime prevalence of behavioral and health problems in contrast to veterans without deployment TBI. These results indicate that problems may persist chronically after a deployment TBI and should be considered when providing care for veterans. Veterans with deployment TBI may require treatment alterations to improve engagement and outcomes.

Relationship between general nutrition knowledge and diet quality in Australian military personnel

A balanced diet informed by sound nutrition knowledge is key for operational readiness and the health of military personnel. Unfortunately, research suggests that military personnel have inadequate dietary intakes. This study assessed general nutrition knowledge, diet quality and their association in Australian military personnel. A convenience sample of male military personnel (n 211) including Army soldiers and officers completed a validated general nutrition knowledge questionnaire (GNKQ) and FFQ. The GNKQ assessed knowledge of dietary guidelines (Section A), sources of nutrients (Section B), choosing everyday foods (Section C) and diet–disease relationships (Section D). The Australian Recommended Food Score (ARFS) was used to assess diet quality from FFQ data. Statistical analyses included the χ2 test, Spearman’s correlation test, t test, median test, ANCOVA and ordinal logistic regression. The mean total GNKQ score was 52·7 %. Participants performed best on Section A (58·5 %) followed by Sections B (57·3 %) and C (57·0 %) and worst on Section D (31·0 %). Overall, officers scored significantly higher than soldiers (58·7 v. 51·9 %, P=0·001). Age was weakly but positively correlated with GNKQ total scores (r 0·307; P<0·0005), with no significant effects seen for level of education (P=0·463) or living arrangement (P=0·167). Overall ARFS was 37·6 (sd 7·7) (50·8 %) with officers scoring significantly higher than soldiers (54·7 v. 50·3 %, P=0·040). No demographic variables influenced total ARFS. The total GNKQ score had a significant, positive but weak relationship with total ARFS (r 0·179; P=0·009). Given the importance of nutrition to personnel health and operational readiness, initiatives to improve nutrition knowledge and diet quality are recommended in this population, especially in soldiers.

Energy expenditure, nutritional status, body composition and physical fitness of Royal Marines during a 6-month operational deployment in Afghanistan

Understanding the nutritional demands on serving military personnel is critical to inform training schedules and dietary provision. Troops deployed to Afghanistan face austere living and working environments. Observations from the military and those reported in the British and US media indicated possible physical degradation of personnel deployed to Afghanistan. Therefore, the present study aimed to investigate the changes in body composition and nutritional status of military personnel deployed to Afghanistan and how these were related to physical fitness. In a cohort of British Royal Marines (n 249) deployed to Afghanistan for 6 months, body size and body composition were estimated from body mass, height, girth and skinfold measurements. Energy intake (EI) was estimated from food diaries and energy expenditure measured using the doubly labelled water method in a representative subgroup. Strength and aerobic fitness were assessed. The mean body mass of volunteers decreased over the first half of the deployment ( − 4·6 (sd 3·7) %), predominately reflecting fat loss. Body mass partially recovered (mean +2·2 (sd 2·9) %) between the mid- and post-deployment periods (P< 0·05). Daily EI (mean 10 590 (sd 3339) kJ) was significantly lower than the estimated daily energy expenditure (mean 15 167 (sd 1883) kJ) measured in a subgroup of volunteers. However, despite the body mass loss, aerobic fitness and strength were well maintained. Nutritional provision for British military personnel in Afghanistan appeared sufficient to maintain physical capability and micronutrient status, but providing appropriate nutrition in harsh operational environments must remain a priority.

Considerations for protein supplementation in warfighters

Ingestion of dietary protein stimulates the synthesis of numerous body proteins. This effect is manifest via hyperaminoacidemia with insulin as a permissive factor. In a sedentary person in energy balance, it is possible to maintain nitrogen balance while consuming protein at an intake of 0.8 g protein · kg(-1) · d(-1). What is unclear is whether being in nitrogen balance is optimal for protein synthesis and not merely adequate and representative of adaptive strategies that could lead to accommodation in "stressed" physiological states. It is clear that being in negative energy balance results in reductions in lean mass and reduced rates of protein synthesis, which can be mitigated by consumption of higher (i.e., 2-3 times the RDA) dietary protein. That long-term practice of inadequate protein intake leads to reduced metabolic, physiological, and physical function provides the basic rationale for the consumption of more than merely adequate protein to prevent not only adaptation but accommodation. Warfighters engaged in combat have been shown to have high daily physical activity energy expenditure, engage in voluntary energy restriction, and are under high metabolic and mental stress. Thus, as a group warfighters would be at risk of consuming suboptimal protein intakes and therefore may benefit from higher amounts of dietary protein intake. Balanced against the potential risk of consuming higher protein, the scientific documentation for which is lacking, there is a strong rationale for the recommendation of higher protein intakes in warfighters who are engaged in field operations.

Sepsis management in the deployed field hospital

Sepsis, a syndrome caused by severe infection, affects a small proportion of military casualties but has a significant effect in increasing morbidity and mortality, including causing some preventable deaths. Casualties with abdominal trauma and those with significant tissue loss appear to be at a greater risk of sepsis. In this article, the diagnosis and management of sepsis in military casualties with reference to the Surviving Sepsis Campaign guidelines are examined. We discuss the management considerations specific to military casualties in the deployed setting and also discuss factors affecting evacuation by the UK Royal Air Force Critical Care Air Support Team.

Nutritional management of critically ill trauma patients in the deployed military setting

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.