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3
Mineral Recommendations for
Military Performance
This chapter presents the available scientific evidence to support the com-
mittee's recommendations on minerals and their required intake levels for mili-
tary personnel during garrison training. Garrison training is defined for the pur-
pose of this report as situations during which military personnel living on a
garrison base are either training or carrying out combat simulations or conduct-
ing one-day convoy-type operations. A specific group of known essential miner-
als was selected based on the minerals' importance to physical and cognitive
performance and maintaining health status. The minerals group was developed
after committee deliberations and was founded on results from literature reviews
and from information provided by the Department of Defense. Furthermore, in-
depth literature reviews on calcium, copper, iron, magnesium, selenium, and
zinc were conducted. Following the approach described in this chapter, the com-
mittee makes recommendations for soldiers, both men and women, during garri-
son training. Also, the committee comments on the adequacy of the estimated
levels of those minerals in the current meals, ready to eat (MREs) and first strike
rations (FSRs), which are consumed typically during garrison training and sus-
tained operations, respectively. Further, the committee comments on the recent
Institute of Medicine (IOM) (2006) mineral level recommendations for sustained
operations (i.e., FSRs). Finally, a list of priority research questions for each
mineral are included. (The research questions are expanded in Chapter 4 to in-
clude descriptions of study designs.)
THE COMMITTEE'S APPROACH
The committee's task was to review and, if necessary, to recommend new
levels of dietary intakes for minerals that are of the greatest interest to the mili-
58
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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 59
tary because (1) risk factors during military operations might result in marginal
deficiencies among military personnel or (2) higher intakes might be beneficial
for optimizing military performance. Based on these two criteria, the committee
discussed the relevance of all minerals and decided to focus its task on calcium,
copper, iron, magnesium, selenium, and zinc. An in-depth literature review was
conducted to gauge the relevance of studies and to evaluate using the studies'
results as a basis for recommending mineral intake levels or priority research
needs, or both, to answer information gaps related to the committee's task.
Subsequently, the committee was able to make recommendations for the fu-
ture establishment of new military standards for the specific minerals; specifically,
the committee recommended new Estimated Average Requirements (EARs) and
Recommended Dietary Allowances (RDAs) or Adequate Intake (AIs) for military
garrison training (MGT). The new values are referred to as EARMGT, RDAMGT,
and AIMGT. Based on the outcomes of importance to the military, that is, to either
maintain or improve both physical or cognitive performance under garrison train-
ing, two general types of studies were considered: (1) studies designed to examine
requirement increases due to exercise, stress, or other conditions encountered dur-
ing military life (e.g., sweat losses or changes in bone resorption rates) and (2)
studies designed to evaluate the potential benefits of increasing mineral intakes for
cognitive or performance functions.
When potential nutrient losses or low intake could put soldiers at risk for
deficiencies, the recommended level for a given nutrient was increased--as long
as the new level did not exceed the Tolerable Upper Intake Level (UL)--based
on data from peer-reviewed scientific literature. However, when making a rec-
ommendation based on potential benefits of supplementation, the committee
erred on the side of caution and only considered those effects if there was enough
clear supporting evidence of the benefits to military performance. The commit-
tee cautions that most of the studies were conducted on civilians and under
circumstances that might not be able to be extrapolated to military circumstances
and garrison training. An effort was made to consider gender differences where
the data were available. In addition to the other assumptions formulated by the
committee, they considered as worst-case scenario the loss of sweat volumes of
up to 10 L/day due to heat and exercise.
The committee evaluated the adequacy of the mineral content of rations.
Adequacy can be evaluated for the population or for the individual. Because the
committee does not know of data on mineral distribution intakes for military
garrison training, the mineral content of menus for the population could not be
evaluated. Instead, the calculated RDAMGT and AIMGT were used as benchmarks
to evaluate mineral content adequacy of various rations for individuals. The
mineral compositions of three different MREs and three different FSRs were
provided by the United States Army Research Institute of Environmental Medi-
cine and used to evaluate the rations' adequacy (see Table 3-1 and Tables C-2
through C-7 in Appendix C).
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60 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
TABLE 3-1 Summary Table of the Institute of Medicine Dietary
Reference Intakes and Military Dietary Reference Intakes for Garrison
Training and Combat Operations for 1950 Year Olds and the Mineral
Levels in Current Rations
IOM Mineral Intake
IOM Dietary Reference Recommendations
Intakes (civilian population, (military population,
ages 1950 years) ages 1950 years)
IOM RDA RDAMGT or
Nutrient or AI IOM UL MDRI AIMGT FSRs
Calcium (mg)
M 1,000 2,500 1,000 1,000 750850
F 1,000 2,500 1,000 1,000
Copper (µg)
M 900 10,000 ND 1,800 9001,600
F 900 10,000 ND 1,500
Iron (mg)
M 8 45 10 14 818
F 18 45 15 22
Magnesium (mg)
M 400420* 350 420 420 400550
F 310320* 350 320 320
Selenium (µg)
M 55 400 55 55 55230
F 55 400 55 55
Zinc (mg)
M 11 40 15 15 1125
F 8 40 12 11
NOTE: AI = Adequate Intake; F = female; FSR = first strike ration; IOM = Institute of Medicine;
M = male; MDRI = Military Dietary Reference Intake; MGT = military garrison training;
MRE = meals, ready to eat; ND = not determined; RDA = Recommended Dietary Allowance;
SUSOPS = sustained operations; UL = Tolerable Upper Intake Level.
* Lower requirement for 1930 year olds and higher requirement for 3150 year olds.
SOURCE: Baker-Fulco (2005); IOM (1997, 2000, 2001, 2006); U.S. Departments of the Army,
Navy, and Air Force (2001).
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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 61
Mineral Levels in Current Military Rations
MRE XXII MRE XXIV MRE XXIII FSR
2691051 272949 269950 643697
Average: 511 Average: 557.4 Average: 526 Average: 673
(3 rations = 1,533) (3 rations = 1,672) (3 rations = 1,578)
ND ND ND ND
519 618 5.7818.39 1518.4
Average: 7.9 Average: 9 Average: 8.6 Average: 17
(3 rations = 24) (3 rations = 27) (3 rations = 26)
60195 78227 69299 375403
Average: 114 Average: 140.5 Average: 177 Average: 86
(3 rations = 342) (3 rations= 421) (3 rations = 531)
0.1234 0.6838 1.3428.3 63160
Average: 9.6 Average: 12.5 Average: 7.8 Average: 100
(3 rations = 30) (3 rations = 37) (3 rations = 23)
1.88.5 28 0.968.14 11.412.2
Average: 4.2 Average: 4.7 Average: 4.2 Average: 11
(3 rations = 13) (3 rations = 14) (3 rations = 13)
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62 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
The committee provided comments on the recent mineral recommendations
in the IOM report Nutrient Composition of Rations for Short-Term, High-
Intensity Combat Operations (2006; see Table 3-1). The comments reflected all
of the report's supportive evidence, including factors related to food technology
and nutrient interactions as well as those related to the diets, consumption behav-
iors, and nature of the operations.
NUTRITIONAL AND ENVIRONMENTAL FACTORS
FACING SOLDIERS IN THE FIELD
The need for specific nutrients is influenced by the health status and specific
scenarios and environmental conditions into which soldiers are deployed. Thus,
two military scenarios were considered: (1) garrison training and (2) sustained
operations. In order to delineate such scenarios, the committee made a series of
assumptions regarding health, environmental conditions, and the soldiers' diets
(described in the following section); the scenarios are based on the committee's
deliberations, open sessions with sponsor representatives and other military per-
sonnel, information from field surveys conducted in Iraq and Afghanistan, and
available literature. Specifically, the garrison training information was collected
through a personal communication (Personal communication, J. Kent and S.
Corum, U.S. Army, August 24, 2005).
Garrison Training
Environment
Soldiers (men and women 1950 years old) are generally in a region of
operations for 12 months, although they can be there for up to 18 months, espe-
cially if serving in the National Guard or Reserves. Most military sites are large
garrison bases with many facilities, however, some are small with a reduced
number of facilities.
The majority of Iraqi military sites are in hot, desert climates. Soldiers are
typically exposed to temperatures above 100°F for 810 hours per day. During
1218-month deployments, soldiers (e.g., combat arms soldiers and soldiers
performing convoy-type operations in Iraq) are typically away from base camp
for 12 hours per day accomplishing a mission or training. They generally re-
turn to the camp daily, eat in a dining facility, and sleep in tents or build-
ings. Under high temperatures and when prescribed restwork cycles can be
followed, soldiers engage in heavy work for about 10 minutes and take long
rests periods of about 50 minutes. As they become acclimated, the rest cycles
often are shortened. Under combat conditions, rest cycles obviously are not
possible.
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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 63
Exercise and Energy Expenditure
There are no data on exercise schedules, and they may vary significantly.
There are also no metabolic data and no data on the soldiers' energy expenditure
in garrison training. However, past studies reported that male soldiers who en-
gaged in various activities expended energy in amounts that ranged from 3,500
kcal/day for combat support and combat service support soldiers involved in
moderate exercise while in garrison to 4,500 kcal/day for Ranger training under
intense exercise. For female soldiers, energy expenditures may range from 2,300
kcal/day when in basic training to 3,000 kcal/day when running medical opera-
tions in the field. The committee assumes that the energy expenditures will be an
average of 4,000 and 2,500 kcal/day for men and women, respectively.
Diet
While in base camp, soldiers have free access to dining facilities, and they
typically eat three times a day. There are no recorded data on energy intake.
When soldiers go on missions off the base camp they eat MREs during the day
(sometimes for several days) as well as personal food items (snack foods) re-
ceived through the mail or purchased at local Army and Air Force Exchange
Service operations. For the purpose of evaluating the adequacy of rations' min-
eral content, the committee assumes that male soldiers will consume three MREs
per day and that female soldiers will consume two MREs per day. If consump-
tion differs from this assumption (e.g., if male soldiers eat two MREs per day
and female soldiers eat one MRE per day, and both sets supplement the MREs
with snack foods), then the conclusions regarding mineral adequacy of the ra-
tions might be different.
Soldiers have access to supplemental food and drink from the local economy,
but they are highly discouraged from consuming such products. It is unknown to
what extent they eat outside of the base camp. Because weight gain can be a
problem, weight-loss diets are as popular as they are with the civilian population.
Soldiers have access to supplements, especially weight-loss supplements, pro-
tein supplements, creatine, or energy drinks. Soldiers also might ingest calcium
supplements. However, there are not enough data on supplement use in the field
to make definitive conclusions.
Water Consumption
In Iraq, soldiers consume up to 3 L/day of mineral water that is produced at
eight different sites. Since bottled water is considered a food product, members
of the Veterinary Corps from Fort Dietrich, Maryland, inspect it for bacteria,
contaminants, and mineral content. In order for the water to be shipped to the
soldiers, the mineral content has to be as low as what is found in commercially
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64 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
available mineral water in the United States. Commercially purchased bottled
water from the United States is used as an internal standard. Often minerals, such
as calcium, are added to improve the taste.
Soldiers also have access to water that has been filtered through reverse
osmosis (reverse osmosis purification unit); this water is essentially mineral free.
The filtered water typically is not consumed by soldiers unless bottled water is
unavailable; instead, it is used when large amounts of water are required (e.g., in
hospitals, cooking, cleaning, washing).
Health
There is not a particular single health issue that stands out with currently de-
ployed soldiers in garrison training. Diarrhea is fairly common, due to antimalarial
drugs as well as to occasional outbreaks from consuming unapproved foods (e.g.,
food from the local economy). Some minor outbreaks of food-borne diseases have
occurred (2030 cases per outbreak, possibly due to consumption of local foods).
The incidence of iron deficiency among military women is unknown. Typi-
cally, they are not tested for iron status, except for when they visit the hospital
with other medical problems; during these hospital visits, iron deficiencies have
been observed among women in the military.
Dehydration is infrequent, and if it does occur, it happens more commonly
when soldiers first arrive at base camp, mainly due to emotional issues and lack
of acclimation to the heat and daily routines. Soldiers quickly learn to avoid
dehydration by drinking fluids.
Anecdotal data that indicate weight gain as a problem are being studied
currently. To meet military specifications weight loss diets are popular among
military personnel, which might have adverse health consequences if intakes of
essential nutrients are inadequate.
Sleep deprivation does not seem to be a generalized problem, although it
may happen occasionally. Soldiers typically sleep for 8 h/day, but sometimes
sleep time can be reduced to only 46 h/day.
Sustained Operations
In the recent IOM report (2006), Nutrient Composition of Rations for Short-
Term, High-Intensity Combat Operations, the assumptions related to the charac-
teristics of the soldiers' diets and health, the missions, and other issues for
soldiers deployed to sustained operations (assault missions) were described at
length. The following list summarizes the assumptions:
· Soldiers deployed on assault missions are male, relatively fit, with an
average body weight of 80 kg and approximately 16 percent body fat, and within
an age range of 1845 years (average < 25 years).
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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 65
· Soldiers may be on a mission for as many as 24 out of 30 days, with each
mission lasting three to seven days.
· There may be as much as 20 h/day of physical activity, with an average
of 4 h/day of sleep. Total daily energy expenditure will be approximately 4,500
kcal.
· Soldiers are likely to have an average energy intake of 2,400 kcal/day.
· Soldiers are likely to have access to 45 L/day of chlorinated water.
· Some soldiers may experience diarrhea, constipation, or kidney stones
during assault missions.
· The daily ration must fit within 0.12 cubic feet and weigh three pounds
(1.4 kg) or less. It will be approximately 1217 percent water (varying greatly
from one item to the other); most items will be energy dense and intermediate in
moisture.
· There will be no liquid foods in the rations, although gels and powders
may be provided.
· The food available during recovery periods will provide, at a minimum,
the nutritional standards for operational rations.
The recommended rations (see Table C-1 and Box C-1 in Appendix C) do
not meet the MDRIs in AR 40-25 (U.S. Departments of the Army, Navy, and Air
Force, 2001), nor do they meet the recommended nutrient intakes for civilians
(IOM, 1997, 1998a, 2000, 2001, 2002/2005, 2004a). The assault rations (i.e.,
FSRs) are meant to be used only for repetitive three- to seven-day missions that
last for a maximum total period of one month and that include recovery periods
of 2472 hours between missions. With the expected energy expenditures of
4,500 kcal/day during the missions and the possibility of as much as a 10-percent
body weight loss, it was recommended that weight loss be measured after one
month of use. If weight loss of a soldier is higher than 10 percent for a soldier, he
should not be sent on assault missions until weight is regained to within 5 per-
cent of the initial weight.
CALCIUM RECOMMENDATIONS
Calcium is an essential mineral that plays a range of biological roles, from
being a major constituent of bones and teeth to affecting nerve conduction,
muscle contraction, heartbeat regulation, blood coagulation, energy production,
glandular secretion, and the maintenance of immune function. Although many
minerals are essential for bone health and function, the risk of calcium inad-
equacy in the diet is higher than risks of other deficiencies; moreover, calcium is
more abundant in the bone than other minerals.
Calcium in the diet offsets obligatory calcium losses, protecting skeletal
reserves and maintaining structural integrity. Bone loss might occur from inad-
equate caloric intake to meet energy expenditure and calcium dermal losses dur-
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66 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
ing exercise and will be exaggerated in females with loss of menstrual function
or eating disorders. Micro-fracture repair is also dependent on calcium intake.
Thus, ingested calcium prevents the net efflux of calcium from bone and by
doing so may help to prevent osteoporosis and stress fractures as a result of
military training and combat action (Burr, 1997; IOM, 1997). Basic training
appears to first lead to increased resorption (perhaps to compensate for calcium
loss due to sweat or negative energy balance), but this is followed by increased
formation (stimulated by intense training) and the window between increments
in these two processes may be the period of greatest risk of stress fractures. To
counteract any excess in bone turnover and meet the demands of the skeleton
during intense activity calcium levels higher than current AI of 1,000 mg may be
needed with intense exercise. Data on the prevention of stress fractures by cal-
cium are limited and not conclusive yet but there is ongoing research that should
soon shed more light. More data are clearly needed to understand the role of
nutrition in stress fracture occurrence (see Nieves and Hayes in Appendix B).
Remarkable changes in bone mineral content (BMC) have been observed in
male army infantry recruits 1821 years old who were subjected to very strenu-
ous physical training. After 14 weeks of walking, jogging with and without
weights, and calisthenics for at least 8 hours a day, 6 days a week, the average
bone mineral content of the subjects increased 11 percent in the left leg and 5.2
percent in the right leg (Margulies et al., 1986). Of the 268 recruits, 110 did not
complete the training, largely because of incurring stress fractures in the lower
limbs. The relationship of calcium intake to bone health and fracture prevention
is discussed in more detail in Appendix B (Nieves and Hayes).
Monitoring Calcium Status, Its Metabolism, and Related Bone Health
Methods for evaluating calcium metabolism and bone health are advanced.
Yet simple, inexpensive methods for assessing calcium metabolism and bone
health for large numbers of people are still lacking. No biochemical measure can
assess calcium status, unless calcium metabolism is grossly abnormal. Measur-
ing calcium intake, therefore, is the only approach to evaluating current calcium
status in healthy individuals. Approaches for calculating dietary calcium intakes
and their limitations have been reviewed by Boushey (2006). A rapid assessment
method specific for dietary calcium is given in Weaver and Heaney (2006).
However, a dietary assessment tool to evaluate several key nutrients likely to be
deficient in diets of military personnel would have broader utility.
A detailed description of research methods to measure all parameters of
calcium metabolism is given by Weaver (2006). Isotopic calcium tracer method-
ology, typically in conjunction with metabolic balance studies, is the gold stan-
dard for quantifying complete calcium kinetics including calcium absorption,
endogenous secretion, urinary and fecal excretion, bone formation rates, and
bone resorption rates. Serum and urinary calcium and serum parathyroid hor-
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MINERAL RECOMMENDATIONS FOR MILITARY PERFORMANCE 67
mone (PTH) levels are the best, most readily available assessment tools for
evaluating disturbances in calcium metabolism [e.g., those related to premen-
strual syndrome (PMS)].
Strategies for monitoring bone health are given in an IOM report (2004b),
Monitoring Metabolic Status. Predicting Decrements in Physiological and Cog-
nitive Performance. Total body calcium can be determined from total body BMC
using bone density, because calcium is a constant fraction of BMC, and repre-
sents net cumulative calcium rather than recent dietary calcium intakes. Bone
mineral density (BMD), measured by bone densitometry, quantitative computed
tomography (QCT), or ultrasound, is a useful measure of bone health because of
the strong inverse relationship between BMD and fracture risk (Melton et al.,
1993). The large normative databases used by manufacturers of dual energy
x-ray absorptiometers (DXA) allow BMD of individuals to be compared to age-
matched reference values and fracture risk to be assessed as z-scores. Newer
imaging methodologies (e.g., QCT) for assessing bone quality can provide addi-
tional useful information about bone geometry. Evaluating interventions by DXA
or QCT require years to analyze small changes in bone; however, some interven-
tions produce large changes in bone that can be observed in periods as short as
six months.
Bone is a dynamic tissue that constantly turns over through a remodeling
process, during which fatigued bone is resorbed and new bone is formed. In
young adults, the two processes are typically coupled to achieve net bone bal-
ance. A number of commercial kits are available to estimate bone formation and
bone resorption rates. They lack specificity because they do not measure calcium
or bone, but rather protein fragments that are released during bone turnover.
Moreover, the biochemical markers of bone turnover are typically too variable to
reliably predict small changes in bone. Therefore, their use as a primary outcome
measure to gauge the effect of stress on bone turnover or to evaluate the effec-
tiveness of interventions is not recommended. However, under conditions that
have a large impact on bone (e.g., microgravity associated with space flight),
biochemical markers have provided useful insights to mechanisms of action
(Smith et al., 1999).
Calcium Intake Effects on Health and Performance
Stress Fractures
The rate of stress fractures during basic training has varied depending on the
branch of service, methods of detection, and training methods. Navy and Air
Force programs consistently report a lower incidence of stress fractures than the
Army and Marine Corps programs (Beck et al., 1996; Jones et al., 1989; Kelly et
al., 2000; Shaffer, 2001; Shaffer et al., 1999). The fracture rates for females are
consistently higher than for males (Almeida et al., 1999; Shaffer, 2001). Pre-
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68 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
1989 studies of the U.S. military indicate male stress fracture rates from 0.9
percent to 3.0 percent and female rates from 2.7 to 8.2 percent (Jones et al.,
1989). Since 1995, stress fracture incidence in female Marine recruits and officer
cadets has ranged from 5.7 percent to 11.5 percent (Shaffer et al., 1999; Winfield
et al., 1997). The female recruit stress fracture rate at the Naval Recruit Training
Center Great Lakes in 1995 was reported as 3.9 percent (Shaffer et al., 1999).
Stress fractures rates ascertained at the Fort Leonard Wood Army training center
between October 2003 and June 2004 were 9.1 percent for males and 17.5 per-
cent for females (Personal communication, J. Lappe and R. Ellyson, U.S. Army
Training and Doctrine Command, February, 2003). Research on the benefits of
calcium supplements in preventing stress fractures in females is currently being
conducted and the results from these studies should be considered when devel-
oping calcium requirements for the military. See also Nieves and Hayes in Ap-
pendix B.
Mood and Psychological Performance
There is evidence in the literature that inadequate dietary calcium is associ-
ated with negative emotional and mental health, which could have implications
for performance. The most rigorously studied type of these conditions is PMS.
Approximately 5 percent of North American women have PMS symptoms so
severe that health and performance are affected (Thys-Jacobs, 2006). The symp-
toms--irritability, depression, anxiety, social withdrawal, headache, and abdomi-
nal cramps--can be alleviated in most women with increased dietary calcium or
calcium supplementation. The supporting evidence consists of two small, single-
site trials (Penland and Johnson, 1993; Thys-Jacob et al., 1989) followed by a
multisite randomized, controlled trial (Thys-Jacobs et al., 1998).
The study by Penland and Johnson (1993) controlled dietary calcium at 587
or 1,336 mg/day by supplementing with calcium lactate after a 13-day equilibra-
tion diet containing calcium of 800 mg/day. Higher calcium intakes were associ-
ated with improved mood, concentration, and behavior symptoms, as well as
with decreased pain. The multisite trial (Thys-Jacobs et al., 1998) randomly
provided 720 women who were 1845 years old and suffering from PMS with a
placebo or with 1,200 mg/day of calcium as calcium carbonate for a duration of
three menstrual cycles. A daily rating scale and diary were used to measure 17
core symptoms and 4 symptom factors (negative affect, water retention, food
cravings, and pain). By the third menstrual cycle, an overall 48-percent reduc-
tion in total symptom scores was observed. All 4 symptom factors and 15 core
symptoms, but not fatigue and insomnia, were reduced significantly by the cal-
cium treatment as compared to placebo. Negative affect was reduced by 45
percent.
Results from observation studies add more evidence to the effects of cal-
cium intake in alleviating PMS symptoms. In the Nurses' Health Study II cohort,
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180 MINERAL REQUIREMENTS FOR MILITARY PERSONNEL
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Representative terms from entire chapter:
weight loss
