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NOT EATING ENOUGH

Overcoming Underconsumption of Military Operational Rations

Committee on Military Nutrition Research

Food and Nutrition Board

Institute of Medicine

Bernadette M. Marriott, Editor

National Academy Press
Washington, D.C. 1995



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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations NOT EATING ENOUGH Overcoming Underconsumption of Military Operational Rations Committee on Military Nutrition Research Food and Nutrition Board Institute of Medicine Bernadette M. Marriott, Editor National Academy Press Washington, D.C. 1995

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 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 competencies and with regard for appropriate balance. Part I of this report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was established in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This report was produced under grants DAMD17-92-J-2003 and DAMD17-94-J-4046 between the National Academy of Sciences and the U.S. Army Medical Research and Materiel Command. The views, opinions, and/or findings contained in chapters in Parts II through V that are authored by U.S. Army personnel are those of the authors and should not be construed as official Department of the Army positions, policies, or decisions, unless so designated by other official documentation. Human subjects who participated in studies described in those chapters gave their free and informed voluntary consent. Investigators adhered to U.S. Army regulation 70-25 and United States Army Medical Research and Development Command regulation 70-25 on use of volunteers in research. Citations of commercial organizations and trade names in this report do not constitute an official Department of the Army endorsement or approval of the products or services of these organizations. The chapters are approved for public release; distribution is unlimited. Library of Congress Catalog Card No. 95-70892 International Standard Book Number 0-309-05341-2 Additional copies of this report are available from: National Academy Press 2101 Constitution Avenue, N.W. Box 285 Washington, DC 20055 Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). Copyright 1995 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 image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations COMMITTEE ON MILITARY NUTRITION RESEARCH ROBERT O. NESHEIM (Chair), Salinas, California WILLIAM R. BEISEL, Department of Immunology and Infectious Diseases, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland GAIL E. BUTTERFIELD, Nutrition Studies, Palo Alto Veterans Affairs Medical Center, and Program in Human Biology, Stanford University, Palo Alto, California JOHN D. FERNSTROM, Department of Psychiatry, Pharmacology, and Neuroscience, University of Pittsburgh School of Medicine, Pennsylvania G. RICHARD JANSEN, Department of Food Science and Human Nutrition, Colorado State University, Fort Collins ROBIN B. KANAREK, Department of Psychology, Tufts University, Boston, Massachusetts ORVILLE A. LEVANDER, Nutrient Requirements and Functions Laboratory, U.S. Department of Agriculture, Beltsville, Maryland GILBERT A. LEVEILLE, Nabisco Foods Group, East Hanover, New Jersey JOHN E. VANDERVEEN, Office of Plant and Dairy Foods and Beverages, Food and Drug Administration, Washington, D.C. DOUGLAS W. WILMORE, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts ALLISON A. YATES, College of Health and Human Sciences, University of Southern Mississippi, Hattiesburg (through June 30, 1994) Food and Nutrition Board Liaison JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center Hospital and Tufts University School of Medicine, Boston, Massachusetts Committee on Military Nutrition Research U.S. Army Grant Officer Representative JAMES A. VOGEL, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts COL ELDON W. ASKEW, U.S. Army Research Institute of Environmental Medicine, Natick, Massachusetts (through February 21, 1994) Staff BERNADETTE M. MARRIOTT, Program Director SUSAN M. KNASIAK, Research Assistant VALERIE BREEN, Research Assistant (through July 31, 1994) DONNA F. ALLEN, Project Assistant

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations FOOD AND NUTRITION BOARD CUTBERTO GARZA (Chair), Division of Nutritional Sciences, Cornell University, Ithaca, New York JOHN W. ERDMAN, JR. (Vice Chair), Division of Nutritional Sciences, College of Agriculture, University of Illinois at Urbana-Champaign PERRY L. ADKISSON, Department of Entomology, Texas A&M University, College Station LINDSAY H. ALLEN, Department of Nutrition, University of California, Davis DENNIS M. BIER, Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas FERGUS M. CLYDESDALE, Department of Food Science and Nutrition, University of Massachusetts, Amherst MICHAEL P. DOYLE, Center for Food Safety and Quality Enhancement, Department of Food Science and Technology, The University of Georgia, Griffin JOHANNA T. DWYER, Frances Stern Nutrition Center, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts SCOTT M. GRUNDY, Center for Human Nutrition, University of Texas Southwestern Medical Center at Dallas K. MICHAEL HAMBIDGE, Center for Human Nutrition, University of Colorado Health Sciences Center, Denver JANET C. KING, University of California, Berkeley, and U.S. Department of Agriculture Western Human Nutrition Research Center, Presidio of San Francisco SANFORD A. MILLER, Graduate School of Biomedical Sciences, University of Texas, Health Science Center, San Antonio ALFRED SOMMER, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, Maryland VERNON R. YOUNG, Laboratory of Human Nutrition, School of Science, Massachusetts Institute of Technology, Cambridge STEVE L. TAYLOR (Ex-Officio Member), Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln Staff ALLISON A. YATES, Director BERNADETTE M. MARRIOTT, Associate Director; Interim Director (December 23, 1993 through June 30, 1994) CATHERINE E. WOTEKI, Director (through December 22, 1993) GAIL SPEARS, Administrative Assistant MARCIA S. LEWIS, Administrative Assistant (through June 30, 1994)

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations Preface This publication, Not Eating Enough, Overcoming Underconsumption of Military Operational Rations, is another in a series of reports based on workshops sponsored by the Committee on Military Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), Institute of Medicine, National Academy of Sciences. Other workshops or symposia have included such topics as food components to enhance performance, nutritional needs in hot environments, body composition and physical performance, nutrition and physical performance, cognitive testing methodology, and fluid replacement and heat stress. These workshops form a part of the response that the CMNR provides to the Commander, U.S. Army Medical Research and Materiel Command (USAMRMC), regarding issues brought to the committee through the Military Nutrition Division of the U.S. Army Research Institute of Environmental Medicine (USARIEM) at Natick, Massachusetts. FOCUS OF THE REPORT Eating enough food and thereby meeting nutritional needs to maintain good health and perform well in all aspects of life—both on the job and during

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations relaxation—is important for all individuals throughout their lives. Food is provided for military personnel on the military bases through garrison dining facilities and during field operations through a variety of military operational rations. In garrison, soldiers can choose to eat in the military dining halls, eat at home with their families, or eat in restaurants similar to the American civilian population. In the field, food selection is limited to the operational ration available during the mission. The nutrient level in military food—whether offered in military dining halls or packaged in military operational rations—is guided by the joint Tri-Services Regulation, AR 40-25 (1985). This regulation includes nutritional allowances and standards for active military personnel (the Military Recommended Dietary Allowances [MRDAs]), nutrient standards for operational and restricted rations (for example, survival rations), military menu guidance, and a chapter on nutrition education. The MRDAs are based on the Recommended Dietary Allowances (RDAs) developed by the FNB to provide for the basic nutritional needs of all healthy Americans (NRC, 1989). The military operational rations are thus designed to provide a healthy diet for military personnel that includes additional energy and nutrients as may be needed to perform heavy work or meet the demands of environmental extremes. Unfortunately, in training and field operations, military personnel often do not eat their rations in amounts adequate to meet energy expenditures. Consequently, they lose weight and potentially risk loss of effectiveness both in physical and cognitive performance. The U.S. Army's concern about potential performance degradation has led to a consideration of the cause of this underconsumption in the field. Why do soldiers eat less and lose weight in the field? Can the drop in food intake be linked to stress in the field setting, the food itself, or the eating situation? Is the underconsumption serious enough to affect performance? The CMNR was asked to assist a collaborative program between scientists at USARIEM and the U.S. Army Natick Research, Development and Engineering Center (NRDEC) by reviewing recent research in military settings that addresses these issues, coupled with more general research on the effects of the following on food intake: physiology (hydrations status, biological rhythms), the food itself (quality, quantity, variety, learned preferences, food expectations), food packaging and marketing, and social factors (the eating situation, food appropriateness, social facilitation and inhibition). The purpose was to (1) evaluate whether the consistent energy deficit recorded in military personnel in field settings could significantly affect performance and (2) discuss potential strategies that could be used by the military to reduce underconsumption. The CMNR was asked to consider the results from military research and from the other studies and also to address five questions posed by the Army about soldier underconsumption. The questions that were posed to the committee are included in Chapter 1 of this report.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations The views of military and nonmilitary scientists from the fields of food science, food marketing, food engineering, nutrition, physiology, various medical specialties, and psychology on the most recent research concerning factors that influence food intake in stressful conditions are included in this report. Although described within a context of military tasks, the conclusions and recommendations presented in Chapters 1 and 2 of this report have wide-reaching implications for individuals who find that job stress changes their eating habits. HISTORY OF THE COMMITTEE The CMNR was established in October 1982 following a request by the Assistant Surgeon General of the Army that the FNB of the National Academy of Sciences set up a committee to advise the U.S. Department of Defense on the need for and conduct of nutrition research and related issues. The committee's tasks are to identify nutritional factors that may critically influence the physical and mental performance of military personnel under all environmental extremes, to identify deficiencies in the existing data base, to recommend research that would remedy these deficiencies and approaches for studying the relationship of diet to physical and mental performance, and to review and advise on standards for military feeding systems. Within this context, the CMNR was asked to focus on nutrient requirements for performance during combat missions rather than requirements for military personnel in garrison (the latter were judged to be not significantly different from those of the civilian population). Although the membership of the committee has changed periodically, the disciplines represented have consistently included human nutrition, nutritional biochemistry, performance physiology, food science, and psychology. For issues that require broader expertise than exists within the committee, the CMNR has convened workshops. These workshops provide additional state-of-the-art scientific information and informed opinion for the consideration of the committee. COMMITTEE TASK AND PROCEDURES In March 1993, personnel from the USARIEM requested that the CMNR review research conducted by the U.S. Army and examine the current state of knowledge concerning the consistent underconsumption of military operational rations. This request originated from joint concerns of scientists at the NRDEC, who developed food products and tested their acceptability, and scientists in the Division of Nutrition at USARIEM. It also arose from a Science and Technology Objective (STO) to prevent performance degradation of the soldier under the stress of sustained field operations as part of an overall

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations initiative, "The Soldier as a System." This initiative recognizes the importance of all aspects of the soldier's equipment and person for enhanced capabilities necessary for the future (Army Science Board, 1991). The committee was aware of the complexity of the issue, in particular the question of when a reduction in intake of rations becomes detrimental and can be labeled underconsumption, and at what point undernutrition leads to a decrement in performance. The CMNR decided that the best way to review the state of knowledge in this disparate area was through a workshop at which knowledgeable researchers could review published research with the committee. Such a workshop would enable the CMNR to review the adequacy of the current research and to identify gaps in the knowledge base that might be filled by future research. A subgroup of the committee met in April 1993, with assistance from Herbert L. Meiselman from NRDEC, to determine the key topics for review, to identify speakers with expertise in these topics, and to plan the workshop for November 1993. Invited speakers were asked to prepare a review paper on their assigned topic for presentation and publication and to make specific recommendations in response to several questions posed to them prior to the workshop. The CMNR also believed that it would be beneficial to include a review of earlier and ongoing military research. Scientists at USARIEM and NRDEC participated in the workshop, which resulted in a well-rounded agenda. At the workshop, each speaker gave a formal presentation, which was followed by questions and a brief discussion period. The proceedings were tape recorded and professionally transcribed. At the end of the presentations, a general discussion of the overall topic was held. Immediately after the workshop, the CMNR met in executive session to review the issues, draw some tentative conclusions, and assign the preparation of draft reviews and summaries specific topics to individual committee members. Committee members subsequently met in a series of working sessions and worked separately and together using the authored papers and additional reference material to draft the summary and recommendations. The final report was reviewed and approved by the entire committee. The summary and recommendations of the Committee on Military Nutrition Research constitute Part I of this volume, and Parts II through V include the papers presented at the workshop. Part I has been reviewed anonymously by an outside group with expertise in the topic area and experience in military issues. The authored papers in Parts II through V appear in the order in which they were presented at the workshop. These chapters have undergone limited editorial change, have not been reviewed by the outside group, and represent the views of the individual authors. Selected questions directed toward the speakers and the speakers' responses are included when they provided a flavor of the workshop discussion. This is followed by brief biographical sketches of committee members and chapter authors in Appendix A and a list of abbreviations used in this report in

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations Appendix B. The invited speakers were also requested to submit a brief list of selected background papers prior to the workshop. These recommended readings, relevant citations collected by CMNR staff prior to the workshop, and selected citations from each chapter are included in the Selected Bibliography (Appendix C). ACKNOWLEDGMENTS It is my pleasure as chairman of the CMNR to acknowledge the contributions of the FNB staff, particularly the excellent technical and organizational skills of Bernadette Marriott, Ph.D., associate director of the FNB and the program director for the CMNR. Her assistance in organizing the workshop and her persistence in getting the cooperation of the speakers and the committee in order to produce a timely publication is commendable and greatly appreciated. I wish to acknowledge as well the excellent contributions by the workshop speakers and their commitment to participating and preparing detailed review papers on relatively short notice. The CMNR appreciates the assistance of Herbert L. Meiselmen and F. Matthew Kramer from NRDEC and of COL Eldon W. Askew and LTC Mary Z. Mays from USARIEM for their assistance in identifying issues of concern to the military and obtaining the involvement of the military personnel who participated in the workshop, which was held in the auditorium at the Natick Laboratory, Natick, Massachusetts. The committee expresses their appreciation to the commanders at NRDEC and USARIEM for making their superb conference facility available for this workshop. The CMNR also is appreciative of the support provided by Cliff Murphy and Veronica Panciocco, who were instrumental in making the local arrangements at Natick. The committee is grateful to Ms. Panciocco for her continued support in providing information and assistance with all aspects of CMNR. I want to especially acknowledge the excellent participation of the members of the discussion panel, Robert E. Smith, Howard Moskowitz, Cheryl Achterberg, and Robin B. Kanarek, for taking time from their very busy schedules to listen to the proceedings and to provide insightful comments that helped form the discussion and recommendations of this workshop. The critiques by the anonymous reviewers and by FNB liaison member Johanna T. Dwyer provided helpful insight in the development of this final document. The editorial efforts of Judy Grumstrup-Scott and the assistance of research assistants Valerie Breen and Susan Knasiak are gratefully acknowledged. The effort of Donna Allen, CMNR project assistant, in word processing and preparing the camera-ready copy for this report is greatly appreciated. Finally, I am grateful to the members of the committee who participated significantly in the discussions at the workshop and in the preparation of the summaries of the proceedings. The commitment of committee members, who

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations serve without compensation, to evaluating the information presented and developing recommendations for consideration by the military is commendable. I am personally inspired as I work with this group of dedicated professionals. ROBERT O. NESHEIM, Chair Committee on Military Nutrition Research REFERENCES AR (Army Regulation) 40-25 1985. See U.S. Departments of the Army, the Navy, and the Air Force. Army Science Board 1991. The Soldier as a System. 1991 Summer Study Final Report. Assistant Secretary of the Army Research, Development, and Acquisition. Washington, D.C. : U.S. Department of the Army. NRC (National Research Council) 1989. Recommended Dietary Allowances, 10th ed. A Report of the Subcommittee on the Tenth Edition of the RDAs, Food and Nutrition Board, Commission on Life Sciences. Washington, D.C.: National Academy Press. U.S. Departments of the Army, the Navy, and the Air Force 1985. Army Regulation 40-25/Naval Command Medical Instruction 10110.1/Air Force Regulation 160-95. "Nutritional Allowances, Standards, and Education." May 15. Washington, D.C.

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations Contents     PREFACE   V I   COMMITTEE SUMMARY AND RECOMMENDATIONS   1     1 Introduction and Background   3     2 Conclusions and Recommendations   41 II   BACKGROUND AND INTRODUCTION TO THE TOPIC   55     3 Introduction to the Concepts and Issues: Underlying Underconsumption in Military Settings Herbert L. Meiselman   57     4 Army Field Feeding System-Future Peter Motrynczuk   65     5 Commanders' Perceptions and Attitudes About Their Responsibilities for Feeding Soldiers Celia F. Adolphi   77     6 Nutritional Criteria for Development and Testing of Military Field Rations: An Historical Perspective David D. Schnakenberg   91     7 Evolution of Rations: The Pursuit of Universal Acceptance Gerald A. Darsch and Philip Brandler   109     8 An Overview of Dietary Intakes During Military Exercises Carol J. Baker-Fulco   121     9 The Effects of Ration Modifications on Energy Intake, Body Weight Change, and Food Acceptance Edward Hirsch   151

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations III   FACTORS UNDERLYING FOOD INTAKE AND UNDERCONSUMPTION—FOOD   175     10 The Role of Image, Stereotypes, and Expectations on the Acceptance and Consumption of Rations Armand V. Cardello   177     11 Effects of Food Quality, Quantity, and Variety on Intake Barbara J. Rolls   203     12 Effects of Beverage Consumption and Hydration Status on Caloric Intake Dianne Engell   217     13 Industry Approaches to Food Research Eileen G. Thompson   239 IV   UNDERCONSUMPTION AND PERFORMANCE   251     14 When Does Energy Deficit Affect Soldier Physical Performance? MAJ Karl E. Friedl   253     15 Impact of Underconsumption on Cognitive Performance LTC Mary Z. Mays   285     16 The Functional Effects of Carbohydrate and Energy Underconsumption Stephen Phinney   303 V   FACTORS UNDERLYING FOOD INTAKE AND UNDERCONSUMPTION—THE EATING SITUATION AND SOCIAL ISSUES   317     17 The Physical Eating Situation F. Matthew Kramer   319     18 Eating Situations, Food Appropriateness, and Consumption Howard G. Schutz   341     19 From Biologic Rhythms to Chronomes Relevant to Nutrition Franz Halberg, Erhard Haus, and Germaine Cornélissen   361     20 Social Facilitation and Inhibition of Eating John M. de Castro   373     21 Lessons from Eating Disorders John P. Foreyt, G. Ken Goodrick, and Jean E. Nelson   393     22 A Plan to Overcome Ration Underconsumption Edward Hirsch   411

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Not Eating Enough: Overcoming Underconsumption of Military Operational Rations     APPENDIXES   417     A Biographical Sketches   419     B Abbreviations   433     C Factors Related to Underconsumption—A Selected Bibliography   437     INDEX   465