Injuries and attrition affect military unit readiness rates and missions. Female injuries are significantly higher than male injuries. Injuries/attrition are expensive. http://www.ncbi.nlm.nih.gov/pubmed/20684449 The AF iron anemia trial raised some very important issues. The AF iron anemia/multi vitamin intervention dramatically decreased injury/attrition rates. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4863912/ http://militarymedicine.amsus.org/doi/full/ 10.7205/MILMED-D-14-00258 It is really a game changer because most of the hx injury research focused on mechanical things as do most of the treatment protocols. Overuse injuries are caused by overuse and prevented by decreasing mileage/workload, etc. and casting, etc. Every service has its own process. Each process may have different results. The core question is “why do these folks break and those folks do not?” Realizing BCT injury rates may be undercounted (AIT entry rates are higher).
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Injuries and attrition affect military unit readiness rates and missions. Female injuries are significantly higher than male injuries. Injuries/attrition are expensive.http://www.ncbi.nlm.nih.gov/pubmed/20684449
The AF iron anemia trial raised some very important issues.
The AF iron anemia/multi vitamin intervention dramatically decreased injury/attrition rates.
It is really a game changer because most of the hx injury research focused on mechanical things as do most of the treatment protocols. Overuse injuries are caused by overuse and prevented by decreasing mileage/workload, etc. and casting, etc.
Every service has its own process. Each process may have different results. The core question is “why do these folks break and those folks do not?” Realizing BCT injury rates may be undercounted (AIT entry rates are higher).
There are lots of variables and lots of unknowns. No single variable is THE 100% cause. Any new intervention may decrease many, even most, but not all injuries. It is likely that some have multiple causal variables (under fitness, poor diet, nutrient deficiencies, poor bone status, etc.).
We have basically studied attrition and injuries by subject matter fiefdoms. ARI, RAND, AMSARA, Public Health Command, USARIEM, IOM, PT School, et al have their individual areas of
expertise.
In order to answer these questions:
1. Where are best places to screen for what?
2. What are best screens for what?
3. What are best treatments for what?
We need more information about etiology and interventions.
Although we focus on BCT attrition & injuries, the more important reality is these injury rates continue into the field and affect unit readiness rates.
We can hypothesize that the stress fracture/injury/attrit group has:
a. a poor nutrition hx (calcium, D, iron, Bs, good fats, etc.)
b. a poor exercise hx
c. possible smoking hx
d. poor bone status
e. some combination of above
We know:
1. the adolescent population is changing. Family structure has changed. Schools have changed (busing, diets, less PE). NHANES provides data on various population nutrient deficiencies (e.g. majority are D deficient).
2. roughly 25.4% of women and 8.9% of men may arrive with iron anemia (degree of anemia varies)(Respective prevalence of borderline, moderate, and severe anemia was 12.6, 10.9, and 1.9 % for females and 4.8, 3.8, and 0.3 % for males.)(AF)
3. about 1/5 females may have poor bone status (Lappe et al)
4. under fitness rates are significant and vary by gender and component.
5. micronutrient deficiencies increase in BCT (diet, sweat losses, less sun exposure, etc.). Recruits, for example, may prefer sodas over milk; milk may be difficult to find. Dairy products are generally the only useful calcium source. USARIEM
6. food bars/supplements help reduce injuries. USARIEM
7. multi-vitamins and anemia treatment reduce injuries and attrition. AF
8. Standards of Care/Clinical Practice Guidelines may be dated. Guidance may be dated (e.g. TBMED 592).
9. treatment/rehabilitation doctrine varies or doesn’t exist. Rehab units can have significant morale/behavior issues.
10. early blood donations increase risk of Heat Injury and Iron Deficiency. The Red Cross and service HQ may strenuously object to stopping early donations. Some suggest folks in Reception may not be able to give informed consent.
11. workload progression, marching procedures, PT schedule et al affect injury rates. Scheduling systems may be manual.
12. injuries/attrition vary by gender and component
13. injury rates continue into field units, affecting readiness rates.
14. attrition varies by units and leader’s attitudes.
15. iron anemia affects thinking, learning, and mood.
16. Some potential causes may have no evidence (e.g. rigid boots). Some potential causes may have limited visibility or research (e.g. collagen… collagen makes bones strong. The mineral matrix is brittle.).
"Bone can be imagined as being somewhat like a sponge made of living protein upon which mineral crystals are embedded. By volume, roughly half of bone is comprised of protein. When a fracture occurs, the body is called upon to gather protein building blocks together to synthesize a new structural bone protein matrix. In addition, protein supplementation increases growth factors like insulin‐like growth factor‐1 (IGF‐1), a polypeptide that exerts a positive effect on skeletal integrity, muscle strength, immune response, and bone renewal.4 Protein malnutrition or under‐nutrition leads to a “rubbery” callus, compared to the rigid calluses of those with adequate or high protein intake. Numerous studies document the acceleration of fracture healing with even a modest 10‐ to 20‐gram increase in protein intake. The benefits of supplemental protein are important to everyone and especially important to those with malnutrition or low baseline protein intake. In fact, among elderly hip fracture patients, poor protein status at the time of fracture predicts fracture outcome. Those with low protein status take longer to heal, and have more complications, including death.5 "
Any dialogue about the diet/menu can be complex. The 1995 study says female recruits were malnourished. Which is why TRADOC added food bars. The menu may be good, but recruits may make poor choices. Or eating 2,000 cal (minimum needed to get all nutrients) may be difficult for smaller folks. Traditional nutrients are not the only options (plums, omega 3s, green tea, EVOO, etc. may have positive effects on bone/tissue health)(NASA/others). Most healing takes place at night, yet recruits can be without food for 10-12
hours.
And, resources cannot be ignored. Each recruit may cost $75k to recruit and train, but saving attrits may not give you $75k. The AF has paused its program due to overloading the hospital.
You can develop/validate various tools (when/where TBD) AND significantly improve treatment protocols. For example, how are ACL injuries treated? Sportsmetrics reduced risk by 80% by balancing hams-quads.
Options or option mix
a. Paper & pencil diet/exercise questionnaire (online, computer based, or paper)
b. Best bone assessment device (fast, portable, relatively low cost, non invasive)
c. Fitness screen.
d. Blood tests
e. Best supplement mix/options (maybe a therapeutic food bar)(women have trouble with large pills).
Xxxxxxxx"Osteoporosis is a disease with its roots in childhood, as bone size, strength, and mineralization peak in one's 20s. Since bone mass declines with advancing age and menopause, individuals who attain optimal peak bone mass during their younger years will have an advantage as they get older. Although it is largely genetically predetermined, peak bone mass is not always attained due to inadequate calcium and vitamin D intakes, poor overall nutrition, lack
of physical activity, and other factors such as smoking.1 “
Brown JP et al. Canadian Consensus Conference on osteoporosis, 2006 update. J Ostete Gynaecol Can 2006;28(2 Suppl 1):S95-S112.
xxxxxxxxx"A probable cost-effective screening stratagem would befirst to identify the white nonexercising smokers among femalerecruits and to confine SOS measurement to that subset(14% of the total cohort in this study).
Those with SOS values below 1508 m/s could be shunted into an alternativeBT regimen. This approach eliminates the need to measureQUS in every recruit, reducing the number of SOS measurements"
JL NOTE: And/Or evaluated/treated for iron anemia.
Quantitative Ultrasound: Use in Screening for Susceptibilityto Stress Fractures in Female Army RecruitsJoan Lappe, Kennard Davies, Robert Recker, and Robert Heaney
ABSTRACT: QUS measurements were made on 4,139 female Army recruits at the beginning of basic training(BT). QUS predicted stress fracture in female recruits as well as it predicts hip fracture in elderly women.Recruits with low QUS values and a history of smoking and not exercising had an extremely high risk of stressfracture.
Introduction: Stress fractures during basic military training (BT) cause morbidity for the recruits and expensefor the Military Services. Females have a higher incidence than males. If recruits at high risk for stress fracturecould be accurately identified before they began BT, the military might find it advantageous to provideadaptive training programs for them. Currently no accurate methods of risk identification are available. Wemeasured quantitative ultrasound (QUS) in a population sample of female Army recruits to determine if QUS
is a useful tool for determining soldiers at high risk of stress fracture during BT.
Materials and Methods: We recruited 93% of the population of female recruits entering BT at Fort LeonardWood, MO, during a 10-month period. We measured calcaneal QUS and administered a risk factor questionnaireat baseline and ascertained stress fractures during the 8 weeks of BT. Logistic regression was usedto calculate relative risk (RR) of stress fracture. The area under the receiver-operating characteristic (ROC)curve was also analyzed to determine the sensitivity and specificity of speed of sound (SOS) in predicting stressfracture.
Results: The incidence of stress fracture was 4.7%. SOS was significantly related to the risk of stress fracture.(p < 0.000) The area under the ROC curve was 0.70. The relative risk (RR) of fracture of those in the lowestquintile (Q1) of SOS was 6.7.
The highest risk of stress fracture was found in the subgroup of white womenin Q1 of SOS who smoked and didn’t exercise (RR, 14.4). Over 16% of the fractures occurred in this subgroup,which indicates that about six of these women would need to be assigned to an alternate BT regimen toprevent one stress fracture.
Conclusions: The combination of QUS measurements with evaluation of individual risk factors can identifyrecruits who are at the very highest risk of stress fracture. The military may find these data helpful to determinethe cost-effectiveness of alternate BT regimens.
J Bone Miner Res 2005;20:571–578. Published online on December 6, 2004; doi: 10.1359/JBMR.041208Key words: female, military recruits, BMD, quantitative ultrasound, stress fracture
Clinical Orthopaedics & Related Research:June 1971 - Volume 77 - Issue - ppg 276-283The Effect of Iron Deficiency Anemia on Fracture Healing: PDF Only
https://www.ncbi.nlm.nih.gov/pubmed/5140454
Clin Orthop Relat Res. 1971;77:276-83.The effect of iron deficiency anemia on fracture healing.Rothman RH, Klemek JS, Toton JJ.
Mil Med. 2006 Sep;171(9):866-9.High prevalence of iron deficiency and anemia in female military recruits.Dubnov G1, Foldes AJ, Mann G, Magazanik A, Siderer M, Constantini N.Author information
AbstractIron deficiency anemia has long been known to impair physical and mental performance. Iron deficiency itself, even without anemia, may also cause such an effect. Similar to female athletes, women in active military units may have increased risks for iron deficiency and its detrimental effects. Female recruits were screened for anemia and iron store status, and a questionnaire on lifestyle habits and menstruation was completed. Iron depletion (serum ferritin level of <20 microg/L) was found for 77% of study participants. Iron deficiency (ferritin level of <12 microg/L and transferrin saturation of <15%) was found for 15% of study participants. Anemia was found for 24% of subjects, and iron deficiency anemia was found for 10% of subjects. High prevalence of iron depletion, iron deficiency, anemia, and iron deficiency anemia was found among female recruits intended for active military duty. Therefore, a recommendation can be made to screen such female recruits for anemia and iron stores.
PMID: 17036608
Int J Sport Nutr Exerc Metab. 2004 Feb;14(1):30-7.Prevalence of iron depletion and anemia in top-level basketball players.Dubnov G1, Constantini NW.Author information
AbstractIron depletion, with or without anemia, may have a negative effect on physical and mental performance. Even with current recognition of the problem, its incidence among athletes remains high. Most studies describe iron status in endurance athletes. This study examined the prevalence of iron depletion and anemia among male and female top-level basketball players. Adolescents and adults (N = 103) from 8 national basketball teams were screened for anemia and iron stores status, which included a complete blood count and levels of plasma ferritin, transferrin, and serum iron. Iron depletion, defined by a ferritin level below 20 microg/L, was found among 22% of study participants (15% in males vs. 35% in females, p = .019). Anemia was found among 25% of athletes (18% in males vs. 38% in females, p = .028). Iron deficiency anemia, defined by the presence of anemia, ferritin levels below 12 microg/L, and transferrin saturation below 16%, was found among 7% of players (3% in males vs. 14% in females, p = .043). In summary, a high prevalence of iron depletion, anemia, and iron deficiency anemia was found among basketball players of both genders. We recommend screening ballgame players for blood count and iron store status, and providing nutritional counseling and iron supplementation when necessary.PMID: 15129928
J Am Coll Nutr. 2006 Feb;25(1):64-9.Prevalence of iron deficiency and iron deficiency anemia among three populations of female military personnel in the US Army.McClung JP1, Marchitelli LJ, Friedl KE, Young AJ.Author information
AbstractBACKGROUND: Iron deficiency is the most prevalent micronutrient deficiency disease in the world and occurs in young women in the United States. Female military personnel represent a unique population faced with intense physical and cognitive demands.OBJECTIVE: The objective of this study was to determine the prevalence of iron deficiency and iron deficiency anemia among three populations of female military personnel in the US Army.METHODS: Iron status was assessed in 1216 volunteers. Volunteers were recruited from three groups: immediately following initial entry to the Army (IET), immediately following basic combat training (AIT), or following at least six months of permanent assignment (PP). Iron deficiency was determined using a three variable model, including cut-off values for serum ferritin, transferrin saturation, and red cell distribution width (RDW). Iron deficiency anemia was categorized by iron deficiency and a hemoglobin (Hgb) value of <12 g/dL.RESULTS: The prevalence of iron deficiency was greater in women in the AIT group (32.8%) than in the IET and PP groups (13.4 and 9.6%, respectively). The prevalence of iron deficiency anemia was greater
in the AIT group (20.9%) than in the IET and PP groups (5.8 and 4.8%, respectively). Furthermore, the prevalence of iron deficiency anemia was greater in Hispanic (21.9%) and African-American military personnel (22.9%) than in Caucasian military personnel (10.5%).CONCLUSIONS: These data indicate that female military personnel experience diminished iron status following training, and that iron nutriture is an important issue facing females in the military.PMID: 16522934
Mil Med. 2006 Apr;171(4):298-300.Iron supplementation and the female soldier.Johnson AE1.Author information
AbstractTwenty-two percent of women in the United States are iron deficient. Iron deficiency adversely affects immune function as well as physical and cognitive performance. Although the risk of developing iron deficiency is high for female soldiers, this risk can be minimized with proper nutritional guidance. Recommended dietary modifications include (1) heme iron consumption, (2) ingestion of vitamin C and protein with meals, and (3) discontinued tea and coffee consumption with meals.PMID: 16673742
Nurs Clin North Am. 2010 Jun;45(2):95-108. doi: 10.1016/j.cnur.2010.02.005.Iron deficiency in women and its potential impact on military
effectiveness.Wilson C1, Brothers M.Author information
AbstractIron deficiency is recognized as a significant health concern for women of childbearing age in the civilian population. In the military, most women are of childbearing age. Not only do they carry the normal risks for developing iron deficiency, but they also have the added threats of possible decreased choices of food high in iron content, increased physical activity, and weight loss. This can put these women at risk for decreased energy efficiency and impaired cognitive performance. This article describes the pathophysiology of iron deficiency and iron deficiency anemia, the consequences of each, and the need to routinely screen military women for iron depletion.Published by Elsevier Inc.PMID: 20510697 DOI: 10.1016/j.cnur.2010.02.005[PubMed - indexed for MEDLINE]
Front Pharmacol. 2014; 5: 156. Published online 2014 Jul 10. doi: 10.3389/fphar.2014.00156
PMCID: PMC4091310The role of iron in the skin and cutaneous wound healingJosephine A. Wright,1,* Toby Richards,1 and Surjit K. S. Srai2Author information ► Article notes ► Copyright and License information ► This article has been cited by other articles in PMC.
Go to:AbstractIn this review article we discuss current knowledge about iron in the
skin and the cutaneous wound healing process. Iron plays a key role in both oxidative stress and photo-induced skin damage. The main causes of oxidative stress in the skin include reactive oxygen species (ROS) generated in the skin by ultraviolet (UVA) 320–400 nm portion of the UVA spectrum and biologically available iron. We also discuss the relationships between iron deficiency, anemia and cutaneous wound healing. Studies looking at this fall into two distinct groups. Early studies investigated the effect of anemia on wound healing using a variety of experimental methodology to establish anemia or iron deficiency and focused on wound-strength rather than effect on macroscopic healing or re-epithelialization. More recent animal studies have investigated novel treatments aimed at correcting the effects of systemic iron deficiency and localized iron overload. Iron overload is associated with local cutaneous iron deposition, which has numerous deleterious effects in chronic venous disease and hereditary hemochromatosis. Iron plays a key role in chronic ulceration and conditions such as rheumatoid arthritis (RA) and Lupus Erythematosus are associated with both anemia of chronic disease and dysregulation of local cutaneous iron hemostasis. Iron is a potential therapeutic target in the skin by application of topical iron chelators and novel pharmacological agents, and in delayed cutaneous wound healing by treatment of iron deficiency or underlying systemic inflammation.Keywords: iron, skin, wound-healing, ultraviolet, iron chelating agents
Go to:INTRODUCTIONIron is a vital co-factor for proteins and enzymes involved in energy metabolism, respiration, DNA synthesis, cell cycle arrest and apoptosis. Over the past 10 years, major advances have been made in understanding the genetics of iron metabolism and this has led to identification of a number of new proteins, including hepcidin, an acute phase protein that is the master regulator of iron absorption and utilization, often activated in chronic diseases (Weiss, 2009; Finberg, 2013).Historically, it has long been known that iron is essential for healthy skin, mucous membranes, hair and nails. Clinical features of iron deficiency include skin pallor, pruritus, and predisposition to skin infection (impetigo, boils and candidiasis), angular chelitis, swollen tongue, fragile nails, kolionychia, and dry brittle hair.
Growth Horm IGF Res. 2012 Oct;22(5):151-7. doi: 10.1016/j.ghir.2012.04.007. Epub 2012 Jun 14.Female recruits sustaining stress fractures during military basic training demonstrate differential concentrations of circulating IGF-I system components: a preliminary study.Strohbach CA1, Scofield DE, Nindl BC, Centi AJ, Yanovich R, Evans RK, Moran DS.Author information
AbstractOBJECTIVE: Stress fracture injuries sustained during military basic combat training (BT) are a significant problem and occur at a higher rate in female recruits than male recruits. Insulin-like growth factor-I (IGF-I) is an easily measured biomarker that is involved in bone formation and positively correlated with bone mineral density, especially in women. This study examined the response of the IGF-I system between female soldiers that sustained a stress fracture (SFX, n=13) during BT and female soldiers who did not (NSFX, n=49).DESIGN: Female soldiers (n=62, 18.8 ± 0.6 yr) from 2 companies of a gender-integrated combat battalion in the Israeli Defense Forces participated in this study. Height, weight and blood draws were taken upon entry to BT (preBT) and after a four-month BT program (postBT). Stress fractures were diagnosed by bone scan. Serum was analyzed for total IGF-I, free IGF-I, IGF binding proteins (IGFBP)1-6, BAP, calcium, CTx, IL1β, IL6, PINP, PTH, TNFα, TRAP, and 25(OH)D. Statistical differences between SFX and NSFX groups and time points were assessed by RM ANOVA with Fisher post-hoc (p≤0.05).RESULTS:
The SFX group was significantly taller and had lower BMI than NSFX (p≤0.05). Serum concentrations of total IGF-I, bioavailable IGF-I, other bone biomarkers, and cytokines were not significantly different between SFX and NSFX preBT. Serum IGFBP-2 and IGFBP-5 were significantly higher in the SFX compared to the NSFX preBT (p≤0.05). In both groups, total IGF-I increased pre to postBT (p≤0.05). Additionally, a significant difference was observed in the bioavailable IGF-I response pre to postBT for both groups. The SFX group demonstrated a significant decrease in bioavailable IGF-I pre to postBT (preBT: 0.58 ± 0.58 ng/mL; postBT 0.39 ± 0.48; p≤0.05) whereas the NSFX group demonstrated a significant increase in bioavailable IGF-I pre to postBT (preBT: 0.53 ± 0.37 ng/mL; postBT: 0.63 ± 0.45; p≤0.05).CONCLUSIONS: Our study demonstrated that serum IGF-I changes during basic training and that women sustaining stress fracturesduring BT significantly decreased bioavailable IGF-I, whereas their uninjured counter parts increased bioavailable IGF-I. These results suggest that stress fracture susceptibility may be related to differential IGF-I system concentrations and response to physical training.Published by Elsevier Ltd.PMID: 22704365 DOI: 10.1016/j.ghir.2012.04.007
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J Strength Cond Res. 2011 Dec;25(12):3412-21. doi: 10.1519/JSC.0b013e318215f779.Anemia, iron deficiency, and stress fractures in female combatants during 16 months.Yanovich R1, Merkel D , Israeli E, Evans RK, Erlich T, Moran DS.Author information
AbstractYanovich, R, Merkel, D, Israeli, E, Evans, RK, Erlich, T, and Moran, DS. Anemia, iron deficiency, and stress fractures in female combatants during 16 months. J Strength Cond Res 25(12): 3412-3421, 2011-The purpose of this study is to evaluate the hematological profile of military recruits in different settings and training programs and to investigate the link between anemia and iron deficiency with stress fracture (SF) occurrence. We surveyed 3 groups of recruits for 16 months: 221 women (F) and 78 men (M) from 3 different platoons of a gender-integrated combat battalion and a control group (CF) of 121 female soldiers from a noncombat unit. Data were fully collected upon induction and at 4 and 16 months from 48F, 21M, and 31CF. Blood tests, anthropometry, physical aerobic fitness, and SF occurrence were evaluated. On induction day, 18.0 and 19.0% of F and CF were found to be anemic, and 61.4 and 50.9%, respectively, were found to have iron deficiency, whereas 7.7% of M were found to be anemic and 10.2% iron deficient. During the 4 months of army basic training (ABT), anemia and iron deficiency prevalence did not change significantly in any group. After 16-months, anemia prevalence decreased by 8% among F and CF and abated in M. Iron deficiency was prevalent in 50.0, 59.4, and 18.8% of F, CF, and M, respectively. Stress fractures were diagnosed in 14 F during ABT, and they had a significantly higher prevalence (p < 0.05) of anemia and iron deficiency anemia compared to F without SFs. The observed link between anemia and iron deficiency on recruitment day and SFs suggests the importance of screening female combat recruits for these deficiencies. To minimize the health impact of army service on female soldiers, preventative measures related to anemia and iron deficiency should be administered. Further research is needed for evaluating the influence of low iron in kosher meat as a possible explanation for the high prevalence of iron deficiency among young Israeli recruits.
PMID: 22080308 DOI: 10.1519/JSC.0b013e318215f779
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The association between hematological and inflammatory factors and stress fractures among female military recruits.Merkel D, et al. Med Sci Sports Exerc. 2008.Show full citation
AbstractBACKGROUND: With the growing number of females accepted for
combat-related military duties in the Israeli Defense Forces, their
special needs should be addressed. Previous studies on females in
combat training have found a high prevalence of iron deficiency at
recruitment as well as an increased rate of stress fractures (SF) and
overuse injuries during training when compared with males. The aim
of this study was to assess the correlation between hematological
and inflammatory variables and SF occurrence among military
recruits during basic training.
METHODS: Three gender-integrated light infantry units were followed
prospectively. Female recruits inducted for medic and dental
assistants' courses were followed for comparison. Hemoglobin, iron,
transferrin, ferritin, C-reactive protein, and interleukin-6 levels were
measured for all participants at recruitment and at 2 and 4 months of
training. SF were diagnosed radiographically or scintigraphically
according to the Israeli Defense Forces protocol.
RESULTS: A total of 438 subjects were recruited (female combatants
= 227, male combatants = 83, noncombatant females = 128). At
induction, 18% of female combatants had anemia compared with 8%
of males and 19% of noncombatants. Iron deficiency was noted in
40%, 6%, and 38%, respectively. There were no clinically significant
changes during training. Twelve percent of female combatants
developed SF, whereas none occurred among male combatants or
noncombatants. Subjects sustaining an SF had significantly lower
levels of serum iron and iron saturation.
CONCLUSIONS: A high incidence of anemia as well as iron
deficiency was found in this young asymptomatic cohort, with no
significant change during training. The lower level of iron in female
combatants sustaining SF warrants further investigation.
PMID 18849864 [PubMed - indexed for MEDLINE]
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Prediction model for stress fracture in young female recruits during basic training.Moran DS, et al. Med Sci Sports Exerc. 2008.Show full citation
AbstractPURPOSE: To develop a new prediction model for stress fractures
(SF) in female recruits during basic training (BT) to identify risk
factors and to try to prevent orthopedic injuries.
METHODS: Measurements and data collection were taken from three
companies of gender-integrated recruited units before the BT
program (a total of 227 females and 83 males). Measurements
included anthropometric variables, blood samples for hematology
profile and markers for bone metabolism, fitness tests, bone quality
(peripheral quantitative computed tomography), nutritional and
activity habits, psychological assessment, and medical evaluation. SF
were diagnosed during BT by bone scintigraphy and/or magnetic
resonance imaging.
RESULTS: All collected measurements were used to construct a new
prediction model for the 27 and 192 female soldiers found with and
without stress fracture, respectively. There were no SF in the male
soldiers. The model successfully predicts 76.5% of the female
soldiers with and without stress fractures (SF) as follows:PSF = -
Ferritin,where PSF is the SF prediction according to the log odds(SF);
odds(SF) is the ratio between probability of SF existence and
nonexistence; Ht is the height (cm); BUR is a subjective assessment
of burnout on a scale of 1 to 7; Fe is the iron blood level (microg x
dL); ferritin is the iron storage level (ng x mL); and BMI is the body
mass index (kg x m).
CONCLUSION: A young female recruited to an integrated light
combat unit is at risk for stress fracture if she is tall, lean, feels
"burnout," has iron deficiency, and is at the high end of the normal
ferritin range. However, further evaluation is required in different
populations, conditions, and training programs to evaluate these
results.
PMID 18849871 [PubMed - indexed for MEDLINE]
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Iron deficiency and the role of nutrition among female military
recruits.Israeli E, et al. Med Sci Sports Exerc. 2008.Show full citation
AbstractThe impact of iron deficiency is considerable when enhanced
physical fitness is required. Female military recruits represent a
unique population faced with intense physical and cognitive
demands.
PURPOSE: To examine the prevalence of iron deficiency and the
impact of dietary habits among female recruits in the Israel Defense
Forces.
METHODS: Three hundred and forty-eight recruits completed the
study (188 female combatants, 58 male combatants, and 92
noncombat females). Dietary intake was assessed using a Food
Frequency Questionnaire. Blood samples were collected for complete
blood cell count, iron indices, and vitamin B12. The common
definitions for anemia and iron store deficiency were used as follows:
hemoglobin <12 g x dL for females and <14 g x dL for males; serum
ferritin <12 mg x dL.
RESULTS: The prevalence of iron deficiency and iron deficiency
anemia was 29.8% and 12.8%, respectively, among female
combatants. Similar data were found among noncombat females
(27.2% and 17.4%, respectively) as compared with 5.2% and 0%
among males. No significant difference in iron or total calorie intake
was detected between subjects with iron deficiency (with or without
anemia) when compared with subjects with normal iron status in the
same study group. Plant sources constituted 85% of dietary iron
source for females, in comparison to 73% for males. The contribution
of red meat to the daily iron intake was 2% for females and 20% for
males.
CONCLUSIONS: A high prevalence of iron deficiency was found
among female recruits. Coupled with the iron loss during
menstruation, inadequate iron intake may have a permissive role for
iron deficiency in female recruits and is an important issue facing
females in the military.
PMID 18849865 [PubMed - indexed for MEDLINE]
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High prevalence of iron deficiency and anemia in female military recruits.Dubnov G, et al. Mil Med. 2006.Show full citation
AbstractIron deficiency anemia has long been known to impair physical and
mental performance. Iron deficiency itself, even without anemia, may
also cause such an effect. Similar to female athletes, women in active
military units may have increased risks for iron deficiency and its
detrimental effects. Female recruits were screened for anemia and
iron store status, and a questionnaire on lifestyle habits and
menstruation was completed. Iron depletion (serum ferritin level of
<20 microg/L) was found for 77% of study participants. Iron
deficiency (ferritin level of <12 microg/L and transferrin saturation of
<15%) was found for 15% of study participants. Anemia was found
for 24% of subjects, and iron deficiency anemia was found for 10% of
subjects. High prevalence of iron depletion, iron deficiency, anemia,
and iron deficiency anemia was found among female recruits
intended for active military duty. Therefore, a recommendation can be
made to screen such female recruits for anemia and iron stores.
PMID 17036608 [PubMed - indexed for MEDLINE]xxxxxxx
Bone. 2014 Nov;68:46-56. doi: 10.1016/j.bone.2014.08.002. Epub 2014 Aug 10.Calcium and vitamin D supplementation maintains parathyroid hormone and improves bone density during initial military training: a randomized, double-blind, placebo controlled trial.Gaffney-Stomberg E1, Lutz LJ1, Rood JC2, Cable SJ3, Pasiakos SM1, Young AJ1, McClung JP4.Author information
AbstractCalcium and vitamin D are essential nutrients for bone health. Periods of activity with repetitive mechanical loading, such as militarytraining, may result in increases in parathyroid hormone (PTH), a key regulator of Ca metabolism, and may be linked to the development of stress fractures. Previous studies indicate that consumption of a Ca and vitamin D supplement may reduce stress fracture risk in female military personnel during initial military training, but circulating markers of Ca and bone metabolism and measures of bone density and strength have not been determined. This randomized, double-blind, placebo-controlled trial sought to
determine the effects of providing supplemental Ca and vitamin D (Ca+Vit D, 2000mg and 1000IU/d, respectively), delivered as 2 snack bars per day throughout 9weeks of Army initial military training (or basic combat training, BCT) on PTH, vitamin D status, and measures of bone density and strength in personnel undergoing BCT, as well as independent effects of BCT on bone parameters. A total of 156 men and 87 women enrolled in Army BCT (Fort Sill, OK; 34.7°N latitude) volunteered for this study. Anthropometric, biochemical, and dietary intake data were collected pre- and post-BCT. In addition, peripheral quantitative computed tomography was utilized to assess tibia bone density and strength in a subset of volunteers (n=46). Consumption of supplemental Ca+Vit D increased circulating ionized Ca (group-by-time, P=0.022), maintained PTH (group-by-time, P=0.032), and increased the osteoprotegerin:RANKL ratio (group-by-time, P=0.006). Consistent with the biochemical markers, Ca+Vit D improved vBMD (group-by-time, P=0.024) at the 4% site and cortical BMC (group-by-time, P=0.028) and thickness (group-by-time, P=0.013) at the 14% site compared to placebo. These data demonstrate the benefit of supplemental Ca and vitamin D for maintaining bone health during periods of elevated bone turnover, such as initial military training. This trial was registered with ClincialTrials.gov, NCT01617109. Published by Elsevier Inc.KEYWORDS: Bone; Calcium; Exercise; Nutrition; Peripheral QCT; Vitamin DPMID: 25118085 DOI: 10.1016/j.bone.2014.08.002
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J Trace Elem Med Biol. 2014 Oct;28(4):388-92. doi: 10.1016/j.jtemb.2014.06.022. Epub 2014 Jul 5.Female athletes: a population at risk of vitamin and mineral
deficiencies affecting health and performance.McClung JP1, Gaffney-Stomberg E2, Lee JJ3.Author information
AbstractAdequate vitamin and mineral status is essential for optimal human health and performance. Female athletes could be at risk for vitamin and mineral insufficiency due to inadequate dietary intake, menstruation, and inflammatory responses to heavy physical activity. Recent studies have documented poor iron status and associated declines in both cognitive and physical performance in female athletes. Similarly, insufficient vitamin D and calcium status have been observed in female athletes, and may be associated with injuries, such as stress fracture, which may limit a female athlete's ability to participate in regular physical activity. This review will focus on recent studies detailing the prevalence of poor vitamin and mineral status in female athletes, using iron, vitamin D, and calcium as examples. Factors affecting the dietary requirement for these vitamins and minerals during physical training will be reviewed. Lastly, countermeasures for the prevention of inadequate vitamin and mineral status will be described. Published by Elsevier GmbH.KEYWORDS: Calcium; Exercise; Female athlete; Iron; Vitamin DPMID: 25060302 DOI: 10.1016/j.jtemb.2014.06.022
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BMC Musculoskelet Disord. 2013 Apr 12;14:135. doi: 10.1186/1471-2474-14-135.A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures.Montain SJ1, McGraw SM, Ely MR, Grier TL, Knapik JJ.Author information
AbstractBACKGROUND: Low vitamin D status increases the risk of stress fractures. As ultraviolet (UV) light is required for vitamin D synthesis, low UV light availability is thought to increase the risk of vitamin D insufficiency and poor bone health. The purpose of this investigation was to determine if individuals with low UV intensity at their home of record (HOR) or those with darker complexions are at increased risk of developing stress fractures and lower limb fractures during U.S. Army Basic Combat Training (BCT).METHODS: This was a retrospective cohort study using the Armed Forces Health Surveillance Center data repository. All Basic trainees were identified from January 1997 to January 2007. Cases were recruits diagnosed with stress fractures and lower limb fractures during BCT. The recruit's home of record (HOR) was identified from the Defense Manpower Data Center database. The average annual UV intensity at the recruits' HOR was determined using a U.S National Weather Service database and recruits were stratified into low (≤3.9); moderate (4.0-5.4), and high (≥5.5) UV index regions. Race was determined from self-reports.RESULTS: The dataset had 421,461 men and 90,141 women. Compared to
men, women had greater risk of developing stress fractures(odds ratio (OR) = 4.5, 95% confidence interval (95%CI) = 4.4-4.7, p < 0.01). Contrary to the hypothesized effect, male and female recruits from low UV index areas had a slightly lower risk of stress fractures (male OR (low UV/high UV) = 0.92, 95%CI = 0.87-0.97; females OR = 0.89, 95%CI = 0.84-0.95, p < 0.01) and were at similar risk for lower limb fractures (male OR = 0.98, 95%CI = 0.89-1.07; female OR = 0.93, 95%CI = 0.80-1.09) than recruits from high UV index areas. Blacks had lower risk of stress and lower limb fracturesthan non-blacks, and there was no indication that Blacks from low UV areas were at increased risk for bone injuries.CONCLUSIONS: The UV index at home of record is not associated with stress or lower limb fractures in BCT. These data suggest that UV intensity is not a risk factor for poor bone health in younger American adults.PMID: 23587313 PMCID: PMC3637200 DOI: 10.1186/1471-2474-14-135xxxxxxxxxxx
J Int Soc Sports Nutr. 2012 Aug 6;9(1):38. doi: 10.1186/1550-2783-9-38.Vitamin D status, dietary intake, and bone turnover in female Soldiers during military training: a longitudinal study.Lutz LJ1, Karl JP, Rood JC, Cable SJ, Williams KW, Young AJ, McClung JP.Author information
AbstractBACKGROUND: Vitamin D is an essential nutrient for maintaining bone health, to include protecting against stress fracture during periods of rapid bone
turnover. The objective of this longitudinal, observational study was to assess vitamin D status, biomarkers of bone turnover, and vitamin D and calcium intake in female Soldiers (n = 91) during US Army basic combat training (BCT).METHODS: Anthropometric, biological and dietary intake data were collected at wk 0, 3, 6, and 9 of the 10 wk BCT course. Mixed models repeated measures ANOVAs were used to assess main effects of time, race, and time-by-race interactions.RESULTS: White volunteers experienced a decrease in serum 25(OH)D levels, whereas non-white volunteers experienced an increase during BCT. However, serum 25(OH)D levels were lower in non-whites than whites at all timepoints (P-interaction < 0.05). Group mean PTH levels increased (P < 0.05) during the first 3 wk of training, remained elevated for the duration of BCT, and were higher in non-whites compared to whites (P-race < 0.05). Biomarkers of both bone formation (bone alkaline phosphatase and procollagen I N-terminal peptide) and resorption (tartrate-resistant acid phosphatase and C-terminal telopeptide) increased (P < 0.05) during BCT, indicating increased bone turnover. Estimated daily intakes of vitamin D and calcium were below recommended levels (15 μg and 1000 mg/day, respectively), both before (group mean ± SEM; 3.9 μg/d ± 0.4 and 887 mg/d ± 67) and during BCT (4.1 μg/d ± 0.3 and 882 mg/d ± 51).CONCLUSIONS: These findings demonstrate that female Soldiers experience dynamic changes in vitamin D status coupled with increased bone turnover and potentially inadequate vitamin D and calcium intake during military training.PMID: 22866974 PMCID: PMC3423002 DOI: 10.1186/1550-2783-9-38
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Growth Horm IGF Res. 2012 Oct;22(5):151-7. doi: 10.1016/j.ghir.2012.04.007. Epub 2012 Jun 14.Female recruits sustaining stress fractures during military basic training demonstrate differential concentrations of circulating IGF-I system components: a preliminary study.Strohbach CA1, Scofield DE, Nindl BC, Centi AJ, Yanovich R, Evans RK, Moran DS.Author information
AbstractOBJECTIVE: Stress fracture injuries sustained during military basic combat training (BT) are a significant problem and occur at a higher rate in female recruits than male recruits. Insulin-like growth factor-I (IGF-I) is an easily measured biomarker that is involved in bone formation and positively correlated with bone mineral density, especially in women. This study examined the response of the IGF-I system between female soldiers that sustained a stress fracture (SFX, n=13) during BT and female soldiers who did not (NSFX, n=49).DESIGN: Female soldiers (n=62, 18.8 ± 0.6 yr) from 2 companies of a gender-integrated combat battalion in the Israeli Defense Forces participated in this study. Height, weight and blood draws were taken upon entry to BT (preBT) and after a four-month BT program (postBT). Stress fractures were diagnosed by bone scan. Serum was analyzed for total IGF-I, free IGF-I, IGF binding proteins (IGFBP)1-6, BAP, calcium, CTx, IL1β, IL6, PINP, PTH, TNFα, TRAP, and 25(OH)D. Statistical differences between SFX and NSFX groups and time points were assessed by RM ANOVA with Fisher post-hoc (p≤0.05).RESULTS: The SFX group was significantly taller and had lower BMI than NSFX
(p≤0.05). Serum concentrations of total IGF-I, bioavailable IGF-I, other bone biomarkers, and cytokines were not significantly different between SFX and NSFX preBT. Serum IGFBP-2 and IGFBP-5 were significantly higher in the SFX compared to the NSFX preBT (p≤0.05). In both groups, total IGF-I increased pre to postBT (p≤0.05). Additionally, a significant difference was observed in the bioavailable IGF-I response pre to postBT for both groups. The SFX group demonstrated a significant decrease in bioavailable IGF-I pre to postBT (preBT: 0.58 ± 0.58 ng/mL; postBT 0.39 ± 0.48; p≤0.05) whereas the NSFX group demonstrated a significant increase in bioavailable IGF-I pre to postBT (preBT: 0.53 ± 0.37 ng/mL; postBT: 0.63 ± 0.45; p≤0.05).CONCLUSIONS: Our study demonstrated that serum IGF-I changes during basic training and that women sustaining stress fracturesduring BT significantly decreased bioavailable IGF-I, whereas their uninjured counter parts increased bioavailable IGF-I. These results suggest that stress fracture susceptibility may be related to differential IGF-I system concentrations and response to physical training.Published by Elsevier Ltd.PMID: 22704365 DOI: 10.1016/j.ghir.2012.04.007
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J Strength Cond Res. 2011 Dec;25(12):3412-21. doi: 10.1519/JSC.0b013e318215f779.Anemia, iron deficiency, and stress fractures in female combatants during 16 months.Yanovich R1, Merkel D , Israeli E, Evans RK, Erlich T, Moran DS.Author information
Abstract
Yanovich, R, Merkel, D, Israeli, E, Evans, RK, Erlich, T, and Moran, DS. Anemia, iron deficiency, and stress fractures in female combatants during 16 months. J Strength Cond Res 25(12): 3412-3421, 2011-The purpose of this study is to evaluate the hematological profile of military recruits in different settings and training programs and to investigate the link between anemia and iron deficiency with stress fracture (SF) occurrence. We surveyed 3 groups of recruits for 16 months: 221 women (F) and 78 men (M) from 3 different platoons of a gender-integrated combat battalion and a control group (CF) of 121 female soldiers from a noncombat unit. Data were fully collected upon induction and at 4 and 16 months from 48F, 21M, and 31CF. Blood tests, anthropometry, physical aerobic fitness, and SF occurrence were evaluated. On induction day, 18.0 and 19.0% of F and CF were found to be anemic, and 61.4 and 50.9%, respectively, were found to have iron deficiency, whereas 7.7% of M were found to be anemic and 10.2% iron deficient. During the 4 months of army basic training (ABT), anemia and iron deficiency prevalence did not change significantly in any group. After 16-months, anemia prevalence decreased by 8% among F and CF and abated in M. Iron deficiency was prevalent in 50.0, 59.4, and 18.8% of F, CF, and M, respectively. Stress fractures were diagnosed in 14 F during ABT, and they had a significantly higher prevalence (p < 0.05) of anemia and iron deficiency anemia compared to F without SFs. The observed link between anemia and iron deficiency on recruitment day and SFs suggests the importance of screening female combat recruits for these deficiencies. To minimize the health impact of army service on female soldiers, preventative measures related to anemia and iron deficiency should be administered. Further research is needed for evaluating the influence of low iron in kosher meat as a possible explanation for the high prevalence of iron deficiency among young Israeli recruits.PMID: 22080308 DOI: 10.1519/JSC.0b013e318215f779
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Med Sci Sports Exerc. 2008 Nov;40(11 Suppl):S609-22. doi: 10.1249/MSS.0b013e3181892d53.Stress fracture and military medical readiness: bridging basic and applied research.Friedl KE1, Evans RK, Moran DS.Author information
AbstractPURPOSE: Military recruits and distance runners share a special risk of stress fracture injury. Recent efforts by US and Israeli military-sponsored researchers have uncovered important mechanisms and practical low-cost interventions. This article summarizes key findings relevant to prevention of stress fracture, including simple strategies to identify and to mitigate risk.METHODS: Published research supported through the Bone Health and Military Medical Readiness research program and related military bone research was analyzed for contributions to preventing stress fracture in military recruits and optimizing bone health.RESULTS: Thousands of military recruits helped test hypotheses about predictors of risk, safer exercise regimens, and rest, nutrition, gait training, and technology interventions to reduce stress fracture risk. Concurrent cellular, animal, and human laboratory studies were used to systematically investigate mechanisms of mechanical forces acting on bone and interactions through muscle, hormonal and genetic
influences, and metabolism. The iterative and sometimes simultaneous process of basic discovery and field testing produced new knowledge that will provide safer science-based physical training.DISCUSSION: Human training studies evaluating effects on bone require special commitment from investigators and funders due to volunteer compliance and attrition challenges. The findings from multiple studies indicate that measures of bone elasticity, fragility, and geometry are as important as bone mineral density in predicting fracture risk, with applications for new measurement technologies. Risk may be reduced by high intakes of calcium, vitamin D, and possibly protein (e.g., milk products). Prostaglandin E2, insulin-like growth factor 1, and estrogens are important mediators of osteogenesis, indicating reasons to limit the use of certain drugs (e.g., ibuprofen), to avoid excessive food restriction, and to treat hypogonadism. Abnormal gait may be a correctable risk factor. Brief daily vibration may stimulate bone mineral accretion similar to weight-bearing exercise. Genetic factors contribute importantly to bone quality, affecting fracture susceptibility and providing new insights into fracture healing and tissue reengineering.PMID: 18849874 DOI: 10.1249/MSS.0b013e3181892d53
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Med Sci Sports Exerc. 2008 Nov;40(11 Suppl):S660-70. doi: 10.1249/MSS.0b013e318189422b.Effects of a 4-month recruit training program on markers of bone metabolism.Evans RK1, Antczak AJ, Lester M, Yanovich R, Israeli E, Moran DS.Author information
AbstractStress fracture susceptibility results from accelerated bone remodeling after onset of novel exercise and may be reflected in bone turnover changes. It is unknown if the bone turnover response to exercise is different between sexes.PURPOSE: To assess disparity between sexes in bone metabolism markers during military recruit training and to evaluate relationships between bone turnover markers and factors that may affect bone metabolism.METHODS: Volunteers were age-matched men (n = 58) and women (n = 199), 19 yr old, entering gender-integrated combat training. Blood was collected at 0, 2, and 4 months and anthropometric and fitness measures at 0 and 4 months. Serum was analyzed for biomarkers reflecting bone formation (bone alkaline phosphatase and procollagen I N-terminal peptide), bone resorption (C-telopeptide cross-links of type I collagen and tartrate-resistant acid phosphatase), endocrine regulation (parathyroid hormone, calcium, and 25(OH)D), and inflammation (interleukin 1B, interleukin 6, and tumor necrosis factor alpha). Data were analyzed using ANOVA, correlation, and regression analyses.RESULTS: Bone turnover markers were higher in men (P < 0.01) and increased similarly for both sexes from 0 to 2 months (P < 0.01). Independent of gender, VO2max (R = 0.477) and serum calcium (R = 0.252) predicted bone formation activity (bone alkaline phosphatase) at baseline (P < 0.01). Serum calcium and parathyroid hormone decreased (2.0 and 6.4%, respectively) from 0 to 2 months (P < 0.001), returning to baseline at 4 months for both sexes. Men exhibited a decrease in 25(OH)D from 0 to 4 months (P = 0.007). Changes in endocrine regulators were significantly correlated with
changes in bone turnover markers. Inflammatory markers did not differ between sexes and did not increase.CONCLUSION: Military training increased bone formation and resorption markers in 2 months, suggesting rapid onset of strenuous exercise accelerates bone turnover similarly in men and women. Although bone turnover markers were higher in men than women, bone formation status may be related to aerobic fitness and serum calcium independent of gender and may be affected by small changes in endocrine regulators related to nutrition.PMID: 18849868 DOI: 10.1249/MSS.0b013e318189422b
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J Bone Miner Res. 2008 May;23(5):741-9. doi: 10.1359/jbmr.080102.Calcium and vitamin d supplementation decreases incidence of stress fractures in female navy recruits.Lappe J1, Cullen D , Haynatzki G, Recker R, Ahlf R, Thompson K.Author information
AbstractINTRODUCTION: Stress fractures (SFx) are one of the most common and debilitating overuse injuries seen in military recruits, and they are also problematic for nonmilitary athletic populations. The goal of this randomized double-blind, placebo-controlled study was to determine whether a calcium and vitamin D intervention could reduce the incidence of SFx in female recruits during basic training.MATERIALS AND METHODS: We recruited 5201 female Navy recruit volunteers and randomized them to 2000 mg calcium and 800 IU vitamin D/d or placebo. SFx were ascertained when recruits reported to the Great Lakes clinic
with symptoms. All SFx were confirmed with radiography or technetium scan according to the usual Navy protocol.RESULTS: A total of 309 subjects were diagnosed with a SFx resulting in an incidence of 5.9% per 8 wk. Using intention-to-treat analysis by including all enrolled subjects, we found that the calcium and vitamin D group had a 20% lower incidence of SFx than the control group (5.3% versus 6.6%, respectively, p = 0.0026 for Fisher's exact test). The per protocol analysis, including only the 3700 recruits who completed the study, found a 21% lower incidence of fractures in the supplemented versus the control group (6.8% versus 8.6%, respectively, p = 0.02 for Fisher's exact test).CONCLUSIONS: Generalizing the findings to the population of 14,416 women who entered basic training at the Great Lakes during the 24 mo of recruitment, calcium and vitamin D supplementation for the entire cohort would have prevented approximately 187 persons from fracturing. Such a decrease in SFx would be associated with a significant decrease in morbidity and financial costs.Comment in
How effective is nutritional supplementation for the prevention of stress fractures in female military recruits? [Nat Clin Pract Endocrinol Metab. 2008]
PMID: 18433305 DOI: 10.1359/jbmr.080102
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Orthop Rev. 1992 Mar;21(3):297-303.Stress fractures in the lower extremities of soldiers in basic training.Pester S1, Smith PC.Author information
AbstractIn a 4-year study on stress fractures of the lower extremities in basic-training soldiers at Fort Dix, New Jersey, 1,338 stress fractureswere confirmed in 1,050 soldiers from a total training population of 109,296, for an incidence of 0.96%. There were 691 men with stress fractures from a male training population of 76,237 (0.91%), and 359 women with stress fractures from a female training population of 33,059 (1.09%), with significant sexual differences in the anatomic distribution of fractures as well. Common male stress-fracture sites were the metatarsals (66%), calcaneus (20%), and lower leg (13%). Common female stress-fracture sites were the calcaneus (39%), metatarsals (31%), and lower leg (27%). Female soldiers suffered more than twice the number of bilateral stress fractures than men. The week of onset of stress fractures during basic training varied directly with the sex of the soldier. Modifications in the physical training program aimed at eliminating continuous, high-impact activities during high-risk weeks resulted in a 12.73% drop in stress-fracture incidence (decreases of 7.32% in women and 16.19% in men).PMID: 1565519[PubMed - indexed for MEDLINE]
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Osteoporos Int. 2001;12(1):35-42.The impact of lifestyle factors on stress fractures in female Army recruits.Lappe JM1, Stegman MR, Recker RR.Author information
AbstractEstimates are that stress fractures during basic training (BT) occur in
as many as 14% of US female military recruits. Injuries of this type lead to morbidity ranging from minor pain to serious lifetime disability. Since women are assuming an increasing role in the military, this high risk of stress fracture is of concern. The purpose of this prospective study was to determine factors that predict stress fracture during BT in US Army female recruits. The analysis was part of an investigation using quantitative ultrasound (QUS) to determine risk of stress fracture during BT. Prior to the start of BT, we obtained QUS measurements and asked each subject to complete a risk factor questionnaire. We completed assessments for 3758 recruits who then proceeded to 8 weeks of BT, during which time any diagnosed stress fractures were reported to us by Army clinicians. Stress fractures were confirmed with radiographs. The incidence of stress fracture was 8.5% per 8 weeks. Factors associated with stress fracture include: QUS, age, race, alcohol and tobacco use, weight-bearing exercise, lowest adult weight, corticosteroid use, and, in white women only, use of depo-medroxyprogesterone acetate (DMPA). Women who fractured were older than women who remained fracture-free, and black women were less likely to sustain a fracture than whites and other races. Compared with their non-stress-fracture counterparts, recruits who developed stress fractures were more likely to report current or past smoking, alcoholic drinking of > 10 drinks/week, corticosteroid use and lower adult weight. A history of regular exercise was protective against stress fracture, and a longer history of exercise further decreased the relative risk of fracture. Although current weight was not associated with stress fracture, lowest adult weight was inversely related to the risk of fracture. We conclude that prevention of stress fractures in female military recruits should include a thorough assessment of lifestyle factors such as exercise patterns, alcohol and tobacco habits, and corticosteroid and DMPA use. Assessment of risk factors may be helpful in pinpointing female recruits who should have further evaluation of their bone health or additional preparation, such as gradual increases in physical activity, prior to being exposed to the rigor of BT.PMID: 11305081 DOI: 10.1007/s001980170155
Am J Prev Med. 2012 Jun;42(6):620-4. doi: 10.1016/j.amepre.2012.02.014.Step test performance and risk of stress fractures among female army trainees.Cowan DN1, Bedno SA, Urban N, Lee DS, Niebuhr DW.Author information
Chen, Z., et al. 2003. Habitual tea consumption and risk of osteoporosis: A prospective study in the women’s health initiative observational cohort. Am. J. Epidemiol., 158 (8), 772–781. URL (accessed 11.11.2009).https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754215/
Daniells, S. 2009. Green tea extracts linked to healthier bones: Study. URL: http://www.nutraingredients-usa.com/Research/Green-tea-extracts-linked-to-healthier-bones-Study (accessed 11.10.2009).
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Int J Vitam Nutr Res. 2011 Mar;81(2-3):134-42. doi: 10.1024/0300-9831/a000063.Protein intake and bone health.Bonjour JP1.Author information
AbstractAdequate nutrition plays an important role in the development and maintenance of bone structures resistant to usual mechanical stresses. In addition to calcium in the presence of an adequate supply of vitamin D, dietary proteins represent key nutrients for bone health and thereby function in the prevention of osteoporosis. Several
studies point to a positive effect of high protein intake on bone mineral density or content. This fact is associated with a significant reduction in hip fracture incidence, as recorded in a large prospective study carried out in a homogeneous cohort of postmenopausal women. Low protein intake (< 0.8 g/kg body weight/day) is often observed in patients with hip fractures and an intervention study indicates that following orthopedic management, protein supplementation attenuates post-fracture bone loss, tends to increase muscle strength, and reduces medical complications and rehabilitation hospital stay. There is no evidence that high protein intake per se would be detrimental for bone mass and strength. Nevertheless, it appears reasonable to avoid very high protein diets (i. e. more than 2.0 g/kg body weight/day) when associated with low calcium intake (i. e. less than 600 mg/day). In the elderly, taking into account the attenuated anabolic response to dietary protein with ageing, there is concern that the current dietary protein recommended allowance (RDA), as set at 0.8 g/kg body weight/day, might be too low for the primary and secondary prevention of fragility fractures.PMID: 22139564 DOI: 10.1024/0300-9831/a000063[PubMed - indexed for MEDLINE]
Am J Clin Nutr. 2014 Feb;99(2):400-7. doi: 10.3945/ajcn.113.073809. Epub 2013 Nov 27.Calcium homeostasis and bone metabolic responses to high-protein diets during energy deficit in healthy young adults: a randomized controlled trial.Cao JJ1, Pasiakos SM, Margolis LM, Sauter ER, Whigham LD, McClung JP, Young AJ, Combs GF Jr.Author information
AbstractBACKGROUND: Although consuming dietary protein above current recommendations during energy deficit (ED) preserves lean body mass, concerns have
been raised regarding the effects of high-protein diets on bone health.OBJECTIVE: The objective was to determine whether calcium homeostasis and bone turnover are affected by high-protein diets during weight maintenance (WM) and ED.DESIGN: In a randomized, parallel-design, controlled trial of 32 men and 7 women, volunteers were assigned diets providing protein at 0.8 [Recommended Dietary Allowance (RDA)], 1.6 (2 × RDA), or 2.4 (3 × RDA) g · kg(-1) · d(-1) for 31 d. Ten days of WM preceded 21 d of ED, during which total daily ED was 40%, achieved by reduced dietary energy intake (∼30%) and increased physical activity (∼10%). The macronutrient composition (protein g · kg(-1) · d(-1) and % fat) was held constant from WM to ED. Calcium absorption (ratio of (44)Ca to (42)Ca) and circulating indexes of bone turnover were determined at day 8 (WM) and day 29 (ED).RESULTS: Regardless of energy state, mean (±SEM) urinary pH was lower (P < 0.05) at 2 × RDA (6.28 ± 0.05) and 3 × RDA (6.23 ± 0.06) than at the RDA (6.54 ± 0.06). However, protein had no effect on either urinary calcium excretion (P > 0.05) or the amount of calcium retained (P > 0.05). ED decreased serum insulin-like growth factor I concentrations and increased serum tartrate-resistant acid phosphatase and 25-hydroxyvitamin D concentrations (P < 0.01). Remaining markers of bone turnover and whole-body bone mineral density and content were not affected by either the protein level or ED (P > 0.05).CONCLUSION: These data demonstrate that short-term consumption of high-protein diets does not disrupt calcium homeostasis and is not detrimental to skeletal integrity. This trial was registered at www.clinicaltrials.gov as NCT01292395.PMID: 24284444 DOI: 10.3945/ajcn.113.073809
Nutrition. 2002 Oct;18(10):853-6.Nutritional interventions related to bone turnover in European space missions and simulation models.Heer M1.
Author information
AbstractLow energy intake, low calcium intake, low plasma 25-hydroxy-vitamin D or low calcitriol levels, and high salt intake might support the development of space osteoporosis. Therefore, my colleagues and I monitored the daily energy and calcium intakes in eight astronauts during their respective space missions (Spacelab D2, Euromir 94, Euromir 95). In most of these astronauts, energy intake was reduced by more than 20% compared with their calculated energy expenditure. In all three missions, the average daily calcium intake of the eight astronauts was 25% lower than the German recommended daily allowances of 900 mg/d for healthy people without osteoporosis risk. In some astronauts, the calcium intake was extremely low at 53 and 74 mg/d. Sodium intake in these astronauts varied from 39 mEq/d to a very high intake of 462 mEq/d. As a consequence of these results, we examined in the 21-d Mir 97 mission a preventative dietary approach of high calcium intake of at least 1000 mg/d with vitamin D supplementation (650 IU/d of Ergocalciferol) and constant sodium intake (180 mEq/d). Total serum calcium concentration and urinary calcium excretion significantly increased during this mission. Synthesis of 25-OH-cholecalciferol synthesis was markedly reduced because of inadequate ultraviolet light, whereas total 25-OH-Vitamin D levels were unchanged. However, parathyroid hormone and calcitriol levels decreased significantly. Sodium excretion decreased significantly, resulting in positive sodium balances. Based on these results, dietary calcium and vitamin D do not stabilize bone turnover because markers of bone formation were reduced and markers of bone resorption were increased. We concluded that, in contrast to terrestrial conditions, adequate or even high calcium and vitamin D intakes during microgravity do not efficiently counteract the development of space osteoporosis. Conversely, vitamin K (Konakion) seemed to counteract microgravity-induced reduction of bone formation markers. In the 179-d Euromir 95 mission, investigators administered 10 mg of vitamin K from inflight day 86 to day 136 in one astronaut. During and after supplementation, bone formation markers increased significantly during this part of the mission. Therefore, vitamin K seems to play a significant role in bone turnover during space flight.
PMID: 12361778[PubMed - indexed for MEDLINE]
Keio J Med. 2005 Jun;54(2):55-9.Interventions to prevent bone loss in astronauts during space flight.Iwamoto J1, Takeda T, Sato Y.Author information
AbstractThis paper reviews the interventions to stabilize calcium balance and bone metabolism and prevent bone loss in astronauts during space flight. Weightlessness during space flight results in calcium, vitamin D, and vitamin K deficiency, increases urinary calcium excretion, decreases intestinal calcium absorption, and increases serum calcium level, with decreased levels of serum parathyroid hormone and calcitriol. Bone resorption is increased, whereas bone formation is decreased. The loss of bone mineral density (BMD) in the spine, femoral neck and trochanter, and pelvis is 1.0-1.6% per month. High calcium intake and vitamin D supplementation during space flight does not affect bone metabolism, but prevents an elevation of serum calcium level through increased calcitriol level, while vitamin K counteracts the reduction in bone formation. However, there are no data to show the efficacy of pharmaceutical agents for prevention of development of osteoporosis in astronauts during flight, although the preventative effect of bisphosphonates, testosterone, and vitamin K2 on cancellous bone loss in the tibia or BMD loss in the hindlimb was reported in tail-suspended mature rats. It still remains uncertain whether these agents can prevent cortical bone loss caused by weightlessness in tail-suspended rats. Therefore, in addition to calcium, vitamin D, and vitamin K supplementation, agents that have both potent anti-resorptive and anabolic effects on cancellous and cortical bone may be needed to stabilize calcium balance and bone metabolism and prevent bone loss in astronauts during space flight.PMID: 16077253
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Maturitas. 2014 Sep;79(1):122-32. doi: 10.1016/j.maturitas.2014.07.005. Epub 2014 Jul 17.The role of dietary protein and vitamin D in maintaining musculoskeletal health in postmenopausal women: a consensus statement from the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO).Rizzoli R1, Stevenson JC2, Bauer JM3, van Loon LJ4, Walrand S5, Kanis JA6, Cooper C7, Brandi ML8, Diez-Perez A9, Reginster JY10; ESCEO Task Force.Author information
Erratum inMaturitas. 2015 Mar;80(3):337.
AbstractFrom 50 years of age, postmenopausal women are at an increased risk of developing sarcopenia and osteoporosis as a result of deterioration of musculoskeletal health. Both disorders increase the risk of falls and fractures. The risk of developing sarcopenia and osteoporosis may be attenuated through healthy lifestyle changes, which include adequate dietary protein, calcium and vitamin D intakes, and regular physical activity/exercise, besides hormone replacement therapy when appropriate. Protein intake and physical activity are the main anabolic stimuli for muscle protein synthesis. Exercise training leads to increased muscle mass and strength, and the combination of optimal protein intake and exercise produces a greater degree of muscle protein accretion than either intervention alone. Similarly, adequate dietary protein intake and resistance exercise are important contributors to the maintenance of bone strength. Vitamin D helps to maintain muscle mass and strength as well as bone health. These findings suggest that healthy lifestyle measures in women aged >50 years are essential to allow healthy ageing. The European Society for Clinical and Economic Aspects of
Sports Med. 2005;35(9):779-830.Physical activity in the prevention and amelioration of osteoporosis in women : interaction of mechanical, hormonal and dietary factors.Borer KT1.Author information
AbstractOsteoporosis is a serious health problem that diminishes quality of life and levies a financial burden on those who fear and experience bone fractures. Physical activity as a way to prevent osteoporosis is based on evidence that it can regulate bone maintenance and stimulate bone formation including the accumulation of mineral, in addition to strengthening muscles, improving balance, and thus reducing the overall risk of falls and fractures. Currently, our understanding of how to use exercise effectively in the prevention of osteoporosis is incomplete. It is uncertain whether exercise will help accumulate more overall peak bone mass during childhood, adolescence and young adulthood. Also, the consistent effectiveness of exercise to increase bone mass, or at least arrest the loss of bone mass after menopause, is also in question. Within this framework, section 1 introduces mechanical characteristics of bones to assist the reader in understanding their responses to physical activity. Section 2
reviews hormonal, nutritional and mechanical factors necessary for the growth of bones in length, width and mineral content that produce peak bone mass in the course of childhood and adolescence using a large sample of healthy Caucasian girls and female adolescents for reference. Effectiveness of exercise is evaluated throughout using absolute changes in bone with the underlying assumption that useful exercise should produce changes that approximate or exceed the absolute magnitude of bone parameters in a healthy reference population. Physical activity increases growth in width and mineral content of bones in girls and adolescent females, particularly when it is initiated before puberty, carried out in volumes and at intensities seen in athletes, and accompanied by adequate caloric and calcium intakes. Similar increases are seen in young women following the termination of statural growth in response to athletic training, but not to more limited levels of physical activity characteristic of longitudinal training studies. After 9-12 months of regular exercise, young adult women often show very small benefits to bone health, possibly because of large subject attrition rates, inadequate exercise intensity, duration or frequency, or because at this stage of life accumulation of bone mass may be at its natural peak. The important influence of hormones as well as dietary and specific nutrient abundance on bone growth and health are emphasised, and premature bone loss associated with dietary restriction and estradiol withdrawal in exercise-induced amenorrhoea is described. In section 3, the same assessment is applied to the effects of physical activity in postmenopausal women. Studies of postmenopausal women are presented from the perspective of limitations of the capacity of the skeleton to adapt to mechanical stress of exercise due to altered hormonal status and inadequate intake of specific nutrients. After menopause, effectiveness of exercise to increase bone mineral depends heavily on adequate availability of dietary calcium. Relatively infrequent evidence that physical activity prevents bone loss or increases bone mineral after menopause may be a consequence of inadequate calcium availability or low intensity of exercise in training studies. Several studies with postmenopausal women show modest increases in bone mineral toward the norm seen in a healthy population in response to high-intensity training. Physical activities continue to stimulate increases in bone diameter throughout the lifespan. These exercise-stimulated increases in bone diameter diminish the risk of fractures by mechanically counteracting
the thinning of bones and increases in bone porosity. Seven principles of bone adaptation to mechanical stress are reviewed in section 4 to suggest how exercise by human subjects could be made more effective. They posit that exercise should: (i) be dynamic, not static; (ii) exceed a threshold intensity; (iii) exceed a threshold strain frequency; (iv) be relatively brief but intermittent; (v) impose an unusual loading pattern on the bones; (vi) be supported by unlimited nutrient energy; and (vii) include adequate calcium and cholecalciferol (vitamin D3) availability.PMID: 16138787
The Effect of Neuromuscular Training onthe Incidence of Knee Injury in Female AthletesA Prospective StudyTimothy E. Hewett,* PhD, Thomas N. Lindenfeld, MD, Jennifer V. Riccobene, and Frank R. Noyes, MD
Stress Fractures May Be PreventablePublished: Jul 12, 2013
By Charles Bankhead, Staff Writer, MedPage Today
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
Lower-extremity stress fractures often occurred in association with potentially modifiable muscular and biomechanical factors.Note that women were almost three times as likely as men to have lower-extremity stress fractures, and that landing with greater than 5 degrees of knee valgus or greater than 5 degrees of internal knee rotation significantly increased the likelihood of a stress fracture.
Lower-extremity stress fractures often occurred in association with potentially modifiable muscular and biomechanical factors, according to a study of 1,800 military cadets.
A detailed motion analysis of jump landing showed that landing with greater than 5 degrees of knee valgus or greater than 5 degrees of internal knee rotation significantly increased the likelihood of stress fracture.
Women were almost three times as likely as men to have lower-extremity stress fractures, Kenneth L. Cameron, PhD, of Keller Army Hospital in West Point, N.Y., reported at the American Orthopaedic Society for Sports Medicine meeting in Chicago."Several potentially modifiable muscular and biomechanical factors may be playing a part in the increased rates of stress fractures in athletes and military personnel," Cameron said in a statement. "It's possible that injury prevention programs targeted to address these movement patterns can help reduce stress fracture risk."
Reduced knee and hip flexion angles and increased vertical and medial ground reaction forces also were associated with an increased risk of stress fractures involving the lower extremities.
Athletes and military personnel account for a disproportionate share of lower-extremity stress fractures, and the frequency appears to be increasing. Whether stress fracture is associated with potentially modifiable factors had not been studied extensively.
Cameron reported findings from a retrospective analysis of 1,843 U.S. Military Academy cadets who completed baseline testing during 2005 to 2008, placing them in class years 2009 to 2013. Stress fracture during follow-up was documented by records of the Defense Medical Surveillance System and the Cadet Injury and Illness Tracking System.
Lower-extremity stress fractures identified in the records were reviewed and confirmed by orthopedic surgeons with sports medicine fellowship training.
At the beginning of cadet training, physical assessment included a detailed motion analysis study at various stages of landing after a jump. Investigators studied the association between stress fracture and sagittal, frontal, and transverse plane hip and knee kinematics at initial contact and at 15% (T15), 50% (T50), 85% (T85), and 100% (T100) of stance phase.Cameron reported that 94 cadets had lower-extremity stress fractures during the study period. Women had a significantly higher incidence than did men (IRR 2.86, 95% CI 1.88-4.34, P<0.001).
Analysis of data for the different stance phases showed that cadets with neutral or varus knee alignment had a significantly lower risk of stress fracture compared with cadets who had>5 degrees of knee valgus. The difference ranged from 43% lower at initial contact (P=0.10) and T85 (P=0.04) to 53% lower at T50 (P=0.05).
Internal knee rotation>5 degrees more than doubled the likelihood of lower-extremity stress fracture as compared with cadets who had neutral or external knee rotation alignment. Incident rate ratios ranged from 2.31 at T15 and T85 (P=0.05, P=0.10, respectively) to IRR 3.98 at T50 (P=0.05).
Lower-extremity movement patterns and strength have previously
been associated with stress fractures and overuse injuries," said Cameron. "However, our study is one of the first to identify dynamic knee rotation and frontal plane angles as important prospective risk factors for lower-extremity stress fractures.
"We hope that by better understanding the movement patterns associated with lower-extremity stress fracture injury we can help create programs for prevention."
Lower Extremity Stress Fractures in the Militaryhttp://www.sportsmed.theclinics.com/article/S0278-5919(14)00051-9/abstract
Seven Steps for Developing and Implementing a Preventive Training Program: Lessons Learned from JUMP ACL and Beyondhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4185282/
Landing Error Scoring System (LESS) Items are Associated with the Incidence Rate of Lower Extremity Stress FractureKenneth L. Cameron, Karen Y. Peck, Brett D. Owens, Steven J. Svoboda, Lindsay J. DiStefano, Stephen W. Marshall, Sarah de la Motte, Anthony I. Beutler, Darin A. Padua, et alOrthopaedic Journal of Sports Medicine July 2014 3:
Objectives: Lower-extremity stress fracture injuries are a major cause of morbidity in physically active populations. The ability to efficiently screen for modifiable risk factors associated with injury is critical in developing and implementing effective injury prevention programs. The purpose of this study was to determine if baseline Landing Error Scoring System (LESS) scores were associated with the incidence rate of lower-extremity stress fracture during four years of follow-up.
Methods: To accomplish this objective we conducted a prospective cohort study at a US Service Academy. A total of 1772 eligible subjects with complete baseline data and no history of lower-extremity stress fracture were included in this study. At baseline we conducted motion analysis during a jump landing task using the LESS. Incident lower-extremity stress fracture cases were identified
during the four year follow-up period using the injury surveillance systems at our institution. The primary outcome of interest was the incidence rate of lower-extremity stress fracture during follow-up. The electronic medical records of each potential incident case were reviewed and case status was determined by an adjudication committee consisting of two sports medicine fellowship-trained orthopaedic surgeons who were blinded to baseline LESS data. The association between baseline LESS scores and the incidence rate of lower-extremity stress fracture was examined for total LESS score and for each individual LESS item. Univariate and multivariable Poisson regression models were used to estimate the association between baseline LESS scores and the incidence rate of lower-extremity stress fracture during follow-up.
Results: During the follow-up period, 94 incident lower-extremity stress fractures were documented in the study cohort and the cumulative incidence of stress fracture was 5.3% (95%CI: 4.3%, 6.5%). In univariate analyses total LESS score at baseline was associated with the incidence rate of lower-extremity stress fracture during follow-up. For every additional movement error documented at baseline there was a 15% increase in the incidence rate of lower-extremity stress fracture during follow-up (IRR=1.15; 95%CI: 1.02, 1.31, p=0.025). Based on univariate analyses, several individual LESS items at baseline were also associated with the incidence rate of stress fracture during follow-up. Ankle flexion at initial contact (p=0.055), stance width at initial contact (p=0.026), asymmetrical landing at initial contact (p=0.003), trunk flexion at initial contact (p=0.036), and overall impression (p=0.021) were significantly associated with the incidence rate of stress fracture. In multivariable analyses controlling for sex and year of entry into the cohort, subjects who consistently landed flat-footed or heel-to-toe were 2.33 times (IRR=2.33; 95%CI: 1.36, 3.97, p=0.002) more likely to sustain a lower-extremity stress fracture during follow-up. Similarly, subjects who consistently demonstrated asymmetric landing at initial contact were 2.53 times (IRR=2.53; 95%CI: 1.34, 4.74, p=0.004) more likely to sustain a stress fracture during follow-up.
Conclusion: These data suggest that specific LESS items may be predictive of lower-extremity stress fracture risk and may be helpful in
injury screening and prevention.
Functional tests to predict lower extremity injury riskhttp://lermagazine.com/article/functional-tests-to-predict-lower-extremity-injury-risk
Association Between Single Gene Polymorphisms andBone Biomarkers and Response to Calcium and VitaminD Supplementation in Young Adults Undergoing MilitaryTraining
Erin Gaffney-Stomberg,1 Laura J Lutz,1 Anna Shcherbina,2 Darrell O Ricke,2 Martha Petrovick,2Thomas L Cropper,3 Sonya J Cable,4 and James P McClung11United States (US) Army Research Institute of Environmental Medicine, Natick, MA, USA2Massachusetts Institute for Technology Lincoln Laboratory, Lexington, MA, USA3Lackland Air Force Base, San Antonio, TX, USA4Initial Military Training Center of Excellence, Fort Eustis, VA, USA ABSTRACTInitial military training (IMT) is associated with increased stress fracture risk. In prior studies, supplemental calcium (Ca) and vitamin D provided daily throughout IMT reduced stress fracture incidence, suppressed parathyroid hormone (PTH), and improved measuresof bone health compared with placebo.
Data were analyzed from a randomized, double-blind, placebo-
controlled trial to determine whether single-nucleotide polymorphisms (SNPs) in Ca and vitamin D–related genes were associated with circulating biomarkers of bone metabolism in young adults entering IMT, and whether responses to Ca and vitamin D supplementationwere modulated by genotype. Associations between SNPs, including vitamin D receptor (VDR), vitamin D binding protein (DBP), and1-alpha-hydroxylase (CYP27B1), and circulating biomarkers were measured in fasting blood samples from volunteers (n.748)starting IMT.
Volunteers were block randomized by race and sex to receive Ca (2000 mg) and vitamin D (1000 IU) or placebo dailythroughout Army or Air Force IMT (7 to 9 weeks). Total Ca and vitamin D intakes were calculated as the sum of supplemental intakebased on intervention compliance and dietary intake. Relationships between SNPs, Ca, and vitamin D intake tertile and change inbiomarkers were evaluated in trial completers (n.391). At baseline, the minor allele of a DBP SNP (rs7041) was positively associatedwith both 25OHD (B.4.46, p.1.97E-10) and 1,25(OH)2D3 (B.9.63, p<0.001). Combined genetic risk score (GRS) for this SNP and asecond SNP in the VDR gene (rs1544410) was inversely associated with baseline 25OHD (r.–0.28, p<0.001) and response to Ca andvitamin D intake differed by GRS (p<0.05). In addition, presence of the minor allele of a second VDR SNP (rs2228570) was associatedwith lower P1NP (B.–4.83, p.0.04) and osteocalcin (B.–0.59, p.0.03). These data suggest that VDR and DBP SNPs are associatedwith 25OHD status and bone turnover and those with the highest GRS require the greatest vitamin D intake to improve 25OHDduring IMT.
MILITARY MEDICINE, 181, 1:86, 2016Optimizing Performance, Health, and Well-being:Nutritional FactorsJames P. McClung, PhD*; Erin Gaffney-Stomberg, RD, PhD†
ABSTRACT Nutrition is essential for maintaining peak health and performance of Warfighters. This review will focus on a series of nutrients of concern for female Warfighters. Biological function, dietary sources, and requirements will be reviewed, and recommendations for women in combat roles will be provided. Iron, essential for physical and cognitive performance, is critical for female Warfighters because of elevated dietary requirements as compared to male Warfighters,as well as declines in iron status that may occur in response to physical activities, such as military training.
Calcium and vitamin D are essential for bone health, and should be considered in efforts to prevent stress fractures, which occur withgreater frequency in female Warfighters as compared to their male counterparts.
Folate, essential for the prevention of neural tube defects during pregnancy and gestation, is critical for female Warfighters because of elevated dietary requirements before pregnancy. Providing optimal levels of these nutrients will facilitate readiness as women prepare to serve in combat roles.
https://www.ncbi.nlm.nih.gov/pubmed/27825793
Adherence to the Dietary Guidelines for Americans Is Associated with Psychological Resilience in Young Adults: A Cross-Sectional Study
Laura J. Lutz, MS, RD, Erin Gaffney-Stomberg, PhD, RD, Kelly W. Williams, PhD, Susan M. McGraw, Philip J. Niro, J. Philip Karl, PhD, RD, COL Sonya J. Cable, MS, RD, Thomas L. Cropper, PhD, James P. McClung, PhD
Correspondence information about the author PhD James P. McClung
Abstract
Background
The 2010 Healthy Eating Index (HEI-2010), a measure of diet quality, is used to quantify adherence to the Dietary Guidelines for Americans. Better HEI scores have been associated with positive health outcomes; however, the relationship between diet quality and psychological resilience, a mental health attribute for coping with adversity, has not been assessed.
Objective
The objective of the present study was to assess the relationship between diet quality and psychological resilience, and the relationship between resilience and demographics, anthropometrics, socioeconomic status, and health behavior.
Design
In this cross-sectional study, HEI-2010 scores and resilience were assessed using the Block food frequency questionnaire and the Connor-Davidson Resilience Scale. Other factors that can affect the relationship between HEI-2010 scores and resilience were assessed using surveys, and height and weight were measured to calculate body mass index.
Participants/setting
Male and female Army and Air Force recruits (n=834) enrolled in a randomized controlled trial and 656 (mean±standard deviation [SD] age=21±3.3 years) were included in this analysis. Data were collected before the initiation of military training at Fort Sill, OK (2012-2013) and Lackland Air Force Base, TX (2013-2014).
Statistical analysis performed
Participants were split into low- and high-resilience groups based on Connor-Davidson Resilience Scale scores. Student’s t test and χ2 tests were used to determine differences between groups for continuous and categorical variables, respectively. Logistic regression was utilized to identify predictors of resilience.
Results
Better diet quality was associated with resilience; higher HEI predicted an increased likelihood (odds ratio=1.02; 95% CI 1.01 to 1.04) of a participant being in the high-resilience group after including race, ethnicity, education, smoking, age, body mass index, sex, and military branch in the full model. The data indicate that with every 10-point increase in HEI score, there was a 22% increased likelihood of being in the high-resilience group.
Conclusions
Registered dietitian nutritionists should continue to encourage attainable changes to improve diet; study data suggest that small improvements in diet quality can be associated with better psychological resilience.
