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Mineral Requirements for Military Personnel Levels Needed for Cognitive and Physical Performance During Garrison Training Committee on Mineral Requirements for Cognitive and Physical Performance of Military Personnel Committee on Military Nutrition Research Food and Nutrition Board THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by contract number DAMD17-99-1-9478 between the National Academy of Sciences and the United States Army. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the sponsoring agency that provided support for the project. International Standard Book Number: 0-309-10126-3 (book) International Standard Book Number: 0-309-65790-3 (PDF) Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the re- sponsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the Na- tional Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON MINERAL REQUIREMENTS FOR COGNITIVE AND PHYSICAL PERFORMANCE OF MILITARY PERSONNEL ROBERT M. RUSSELL, (Chair) Human Nutrition Research Center on Aging, Tufts University, Boston, MA JOHN L. BEARD, Department of Nutrition, Pennsylvania State University, University Park MELINDA BECK, School of Public Health and Medicine, University of North Carolina, Chapel Hill BRUCE R. BISTRIAN, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA JOSEPH G. CANNON, Medical College of Georgia, Augusta GERALD F. COMBS, JR., Grand Forks Human Nutrition Research Center, Grand Forks, ND JOHANNA T. DWYER, Office of Dietary Supplements, National Institutes of Health, Baltimore, MD JOHN W. ERDMAN, Department of Food Science and Human Nutrition, University of Illinois, Urbana-Champaign EMILY M. HAYMES, Department of Nutrition, Food and Exercise Sciences, Florida State University, Tallahassee JANET R. HUNT, Grand Forks Human Nutrition Research Center, Grand Forks, ND HELEN W. LANE, Johnson Space Center, National Aeronautics and Space Administration, Houston, TX JAMES G. PENLAND, Grand Forks Human Nutrition Research Center, Grand Forks, ND SUSAN S. PERCIVAL, Department of Food Science and Human Nutrition, University of Florida, Gainesville CONNIE M. WEAVER, Department of Food Science and Nutrition, Purdue University, West Lafayette, IN Staff MARIA P. ORIA, Study Director LESLIE J. SIM, Research Associate JON Q. SANDERS, Senior Program Assistant v

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FOOD AND NUTRITION BOARD* ROBERT M. RUSSELL (Chair), Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin MICHAEL P. DOYLE, Center for Food Safety, University of Georgia, Griffin SUSAN FERENC, Food Products Association, Washington, DC NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver REYNALDO MARTORELL, Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA J. GLENN MORRIS, JR., Department of Epidemiology and Preventive Medicine, School of Medicine and School of Public Health, University of Maryland, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging, Tufts University, Boston, MA LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Harvard University, Boston, MA BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON BANDY, Financial Associate *IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution. vi

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures ap- proved by the National Research Council's Report Review Committee. The pur- pose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manu- script remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Mary R. L'Abb, Bureau of Nutritional Sciences Food Directorate, Health Canada, Ottawa Ronni Chernoff, University of Arkansas Medical School, Little Rock Felicia Cosman, Columbia-Presbyterian Medical Center, New York Susanna Cunningham-Rundles, Cornell University Weill Medical College, Ithaca, NY Marc K. Hellerstein, University of California, Berkeley Orville Levander, USDA Human Nutrition Research Center, Beltsville, MD Joan Lyon, USDA Center for Nutritional Policy and Promotion, Alexandria, VA Stacey L. Mobley, Purdue University, Lafayette, IN Harold H. Sandstead, The University of Texas Medical Branch, Galveston Richard J. Wood, Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, Boston, MA Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the conclusions or recom- mendations nor did they see the final draft of the report before its release. The vii

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viii REVIEWERS review of this report was overseen by Michael P. Doyle, University of Georgia. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully con- sidered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface The Committee on Military Nutrition Research (CMNR) was established in October 1982 following a request by the Assistant Surgeon General of the Army that the Board on Military Supplies of the National Academy of Sciences (NAS) set up a special committee to advise the U.S. Department of Defense (DoD) on the need for and conduct of nutrition research and related issues. The CMNR, a standing committee, was eventually transferred to the Food and Nutrition Board of the Institute of Medicine, National Academies. The standing committee's primary tasks are to identify factors that may critically influence the physical and mental performance of combat military personnel under all environmental ex- tremes, to identify knowledge gaps, to recommend research that would remedy these deficiencies, to identify approaches for studying the relationship of diet to physical and mental performance, and to review and advise on military feeding standards. It is customary that for each specific task, an ad hoc committee com- posed with the appropriate expertise is formed. For example, under the oversight of the CMNR, an ad hoc committee of experts provided recommendations for nutrient composition of assault rations for short-term, high intensity sustained operations in a recent report. This report entitled, Mineral Requirements for Military Personnel results from the work of an ad hoc Committee on Mineral Requirements for Cognitive and Physical Performance of Military Personnel under the auspices of the CMNR. This report was produced in response to the request by the Commander, U.S. Army Medical Research and Materiel Command (USAMRMC) to the Insti- tute of Medicine (IOM) to convene a committee to review and recommend the mineral requirements for military personnel on military garrison training, not only by considering excess losses due to physical and environmental stress, but also by considering potential enhancements of performance (e.g., mental, physical, immune). These are the personnel that, while living at military bases, engage in military training or in daily operations that entail high physical and mental demands. The specific questions posed to the committee evolved from discussions ix

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x PREFACE between the standing CMNR, and the Military Nutrition Division of the U.S. Army Research Institute of Environmental Medicine (USARIEM) in Natick, Massachusetts. The CMNR also provided input during the initial stages of expert selection for potential ad hoc committee members and workshop speakers. A 14-member committee was formed with expertise on calcium, copper, iron, magnesium, selenium, and zinc, and with specific attention to areas of nutrient absorption, metabolism and functions particularly important to the mili- tary, such as immune function, physical and cognitive performance. Experts on food technology, clinical nutrition, dietetics, and psychology were also included in the committee. The committee's task was to assess the current Military Refer- ence Dietary Intakes (MDRIs) and if needed, recommend, new mineral intakes for soldiers in garrison training. The committee was also asked to review the mineral levels of the current operational rations i.e., Meals, Ready to-Eat and First Strike Rations and determine if they are adequate. Because the committee's expertise was strong in the area of essential minerals, it was also requested that they comment on the recommendations for mineral levels in assault rations. The committee discussed the limitations of the data, regarding minerals. First, even though there is a reasonable amount of data on mineral levels of rations, data on mineral intake by military personnel is scanty. In order to assess the adequacy of mineral levels in rations, the committee had to assume that the complete rations were consumed, which might not be the case. It is therefore a challenge to assess whether or not the intakes of military personnel are adequate. Second, there is a lack of information regarding changes in metabolism or re- quirements due to the unique demands arising from physical or mental stressors during military operations. The committee based its recommendations on the best available data from studies done on civilians under circumstances that paral- leled the military situation as closely as possible. For example, higher mineral requirements due to sweat losses in soldiers were based on studies in exercising civilians. The committee also reviewed studies which suggested that a higher intake of minerals might improve immune function, the ability to perform physi- cal or mental tasks, or mood states. In this case, the data were suggestive only, and no definitive conclusions were reached. Although the committee was able to recommend intakes for certain selected minerals of importance, additional data from studies performed under the circumstances encountered by soldiers in gar- rison training are needed, so that requirements are updated with new, more ap- propriate data, including data on potential improvements of functions of military importance. Undoubtedly, the committee's important recommendations relate to specific research need priorities. The committee carried out its work over 12 months and met twice. The first meeting of the committee was held in conjunction with a two-day workshop. This workshop, designed to address this task, was hosted by The National Acad- emies in Washington DC, June 1315, 2004. Speakers addressed the issues brought to the committee by the USARIEM. These presentations formed the

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PREFACE xi basis for the committee's deliberations and recommendations, and are included in this report as individually authored papers in Appendix B.1 One additional meeting of the committee was held on August 2425, 2005. Prior to this second meeting, the committee took part in a series of conference calls to deliberate the scientific basis for the recommendations for each of the minerals. Further, additional conference calls were held to discuss and finalize recommendations. Finally, a research agenda was set forth through numerous face to face and phone interactions by committee members. The committee wishes to express its special thanks to Andrew J. Young, Chief Nutritionist of the Nutrition Division and representative from the Department of Defense for this report, for generously giving his time and help and for being available to clarify the task of the committee. Special thanks are extended to Angus G. Scrimgeour, Research Physiologist, and James P. McClung, Nutritional Biochemist at the Nutrition Division of USARIEM. Their assistance was invalu- able during the committee's work in that they helped delineate the task and pro- vided numerous reports and other data to the committee in a timely manner. The committee wants to express its deepest appreciation to Carol J. Baker-Fulco, nutri- tionist at USARIEM, who offered her valuable help on numerous occasions to address the multiple questions regarding the nature of the military food and min- eral intake and ration composition data. The committee wishes to extend thanks also to LTC John E. Kent, Chief, Nutrition Care Division at Darnall Army Com- munity Hospital and LTC Sonya J.C. Corum, TRADOC Dietitian at Fort Jackson, South Carolina for their assistance in describing nutritional and environmental factors in the field. Thanks also go to COL Maria A. Worley, Nutrition Program Director and Chief Dietitian of the U.S. Army, for her frank description of practi- cal uses of MDRIs for rations by the military. Finally, the committee wishes to thank COL Karl E. Friedl who tirelessly supports the work of the CMNR in so many different ways, from his participation in workshops to provision of appropri- ate contacts. On behalf of the committee, I wish to sincerely thank the workshop partici- pants and speakers for addressing topics critical to the completion of the com- mittee's work. Each speaker not only provided an excellent presentation, but was available for multiple interactions during and after the workshop, and prepared a manuscript of their presentations (see Appendix B), working with IOM staff throughout the revision process. These presentations were important reference sources for the committee and, as already mentioned, were used as the scientific basis throughout the report. The committee owes a strong debt of gratitude to the FNB staff for its professionalism and effectiveness in ensuring that our committee adhered to its task statement, for providing discipline and experience in helping to assemble 1The authored papers have undergone limited editorial changes, have not been reviewed by the report reviewers, and represent the views of the individual authors.

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xii PREFACE the report, for providing background research support, and for organizing our meetings. In particular, we would like to thank Senior Program Officer Maria P. Oria of the FNB, who worked tirelessly on numerous drafts and revisions. Ably assisting Maria in her efforts were Senior Program Assistant Jon Q. Sanders and Research Associate Leslie J. Sim. The committee is also grateful to the overall guidance and continuous support of Linda D. Meyers, Director of the FNB. I also extend my deep gratitude to my fellow committee members, who participated in our discussions in this study in a professional and collegial man- ner, and who approached their task statement with great seriousness and intellec- tual curiosity. Robert M. Russell, M.D., Chair

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Contents SUMMARY 1 1 INTRODUCTION 13 2 MILITARY DIETARY REFERENCE INTAKES: 36 PROCESS TO ESTABLISH, USES, AND DELIVERY METHODS 3 MINERAL RECOMMENDATIONS FOR MILITARY 58 PERFORMANCE 4 RESEARCH NEEDS 191 5 ANSWERS TO THE MILITARY'S QUESTIONS 219 APPENDIXES A WORKSHOP AGENDA 235 B WORKSHOP PAPERS 240 Introduction to Combat Rations Concerns About the Effects of Military Environments on Mineral 240 Metabolism and Consequences of Marginal Deficiencies to Performance Karl E. Friedl Derivation of the Military Dietary Reference Intakes and the 249 Mineral Content of Military Rations Carol J. Baker-Fulco xiii

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xiv CONTENTS Mineral Metabolism Bioavailability of Iron, Zinc, and Copper as Influenced by Host 265 and Dietary Factors Janet R. Hunt Functional Metabolism of Copper, Zinc, and Iron 277 Cathy W. Levenson Absorption Mechanisms, Bioavailability, and Metabolism of 285 Calcium and Magnesium Connie M. Weaver Drinking Water as a Source of Mineral Nutrition 295 Gerald F. Combs, Jr. Assessment of Zinc, Copper, and Magnesium Status: Current Approaches and Promising New Directions 304 Carl L. Keen and Janet Y. Uriu-Adams Stress Factors Affect Homeostasis Environmental Stressors During Military Operations 315 Robert Carter III, Samuel Cheuvront, Andrew J. Young, and Michael N. Sawka Mineral Sweat Losses During Exercise 323 Emily M. Haymes Stress Factors Affecting Homeostasis: Weight Loss and Mineral Status 329 Steven B. Heymsfield Protein Turnover and Mineral Metabolism 338 Henry C. Lukaski Minerals and the Immune System Physical Activity and Tyrosine Supplementation: Two Effective 343 Interventions Against Stress-Induced Immunosuppression Monika Fleshner Mineral Intake Needs and Infectious Diseases 357 Davidson H. Hamer Copper, Zinc, and Immunity 370 Susan S. Percival Impact of Nutritional Deficiencies and Psychological Stress 378 on the Innate Immune Response and Viral Pathogenesis John F. Sheridan, Patricia A. Sheridan, and Melinda A. Beck Injury and Optimization of Recovery The Influence of Minerals on Muscle Injury and Recovery 384 Joseph G. Cannon Physical Activity and Nutrition: Effects on Bone Turnover, 390 Bone Mass, and Stress Fracture Jeri W. Nieves

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CONTENTS xv Minerals and Cognition and Behavior Evaluating Nutritional Effects on Cognitive Function in 398 Warfighters: Lessons Learned Harris R. Lieberman Iron and Cognitive Performance 410 John L. Beard and Laura E. Murray-Kolb Zinc and Other Mineral Nutrients Required for Cognitive 419 Function and Behavior in Military Personnel James G. Penland Minerals and Physical Performance Zinc, Magnesium, and Copper Requirements and Exercise 436 Henry C. Lukaski The Effects of Iron Deficiency on Physical Performance 451 Jere D. Haas C TABLES 462 D BIOGRAPHICAL SKETCHES OF WORKSHOP SPEAKERS 470 E BIOGRAPHICAL SKETCHES OF COMMITTEE 479 MEMBERS AND STAFF F ACRONYMS AND ABBREVIATIONS 486 G GLOSSARY 493

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