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Carrasco A, Navren M, Larsson I, Taube F, Björkman F. Systematic Review and Meta-Analysis: Iron Deficiency and Iron Deficiency Anemia Among Military Recruits Undergoing Basic Combat Training. Mil Med 2024:usae437. [PMID: 39301668 DOI: 10.1093/milmed/usae437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 08/12/2024] [Accepted: 09/02/2024] [Indexed: 09/22/2024] Open
Abstract
INTRODUCTION The first period of military service consists of a physically and mentally challenging basic combat training (BCT) program. Factors like demanding physical exercise, limited recovery time, and restricted diet choice and food intake may challenge iron intake and homeostasis in recruits undergoing BCT. Iron-deficient individuals may experience reduced work capacity, fatigue, weakness, frequent infections, and increased injury risk. Limited knowledge is available on the extent of this potential health risk among military recruits. The aim of the present study was to systematically review published studies on the prevalence and change in prevalence of anemia, iron deficiency (ID), and ID anemia (IDA) among recruits undergoing BCT. MATERIALS AND METHODS Electronic searches were conducted in the databases Medline (Ovid), Embase (Embase.com), and Web of Science (Clarivate Analytics) from database inception up until April 16, 2024. Inclusion criteria were observational studies with both cross-sectional and observational longitudinal designs that examined the effects of BCT (intervention) on iron status (outcome) in military recruits (population). Extracted data were the number of participants (n), age, sex, country/population, BCT duration, and relevant measures of prevalence and changes in prevalence of anemia, ID, and IDA (primary outcome) and physical performance, mood state, stress fractures, attrition rate, and nutritional supplements (secondary outcomes). The study quality and risk of bias were assessed using the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data and The National Institutes of Health Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group. Meta-analyses were performed using restricted maximum-likelihood models, and the effect size was calculated as Cohen's h with 95% CI. RESULTS Twenty-two articles were systematically reviewed (n = 111,764 men and 12,650 women), and six of these papers (n = 388 men and 773 women) were included in the meta-analysis. There was a varying prevalence of anemia, ID, and IDA among military recruits at the start of BCT. Results from meta-analyses showed negligible and nonsignificant effects of BCT on the prevalence of anemia, ID, and IDA. The quality of the included cross-sectional studies ranging from fair to good, whereas a large proportion of the included longitudinal studies were classified as poor. No sign of publication bias was found. CONCLUSIONS The prevalence of anemia, ID, and IDA in military recruits seems not to be affected by the completion of BCT shorter than 16 weeks, whereas the effects of longer BCT durations remain unclear. Even though body iron homeostasis seems unaffected, adequate energy and nutritional intake should remain a priority. Future research could focus on dietary interventions to determine the optimal diet among female recruits in specifically exposed populations.
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Affiliation(s)
- Anna Carrasco
- Department of Medicine, Center for Infectious Medicine, Karolinska Institute, Stockholm 171 77, Sweden
| | - Mats Navren
- Defence Health, Command and Control Regiment, Enkoping 749 40, Sweden
| | - Ingrid Larsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg 413 41, Sweden
- Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg 405 30, Sweden
| | - Fabian Taube
- Research Centre for Disaster Medicine, Institute for Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg 405 30, Sweden
- Joint Centre for Defence Medicine, Swedish Armed Forces, Gothenburg 426 05, Sweden
| | - Frida Björkman
- Department of Physical Activity and Health, The Swedish School of Sport and Health Sciences, Stockholm 114 33, Sweden
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Angelidi AM, Stefanakis K, Chou SH, Valenzuela-Vallejo L, Dipla K, Boutari C, Ntoskas K, Tokmakidis P, Kokkinos A, Goulis DG, Papadaki HA, Mantzoros CS. Relative Energy Deficiency in Sport (REDs): Endocrine Manifestations, Pathophysiology and Treatments. Endocr Rev 2024; 45:676-708. [PMID: 38488566 DOI: 10.1210/endrev/bnae011] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 09/18/2024]
Abstract
Research on lean, energy-deficient athletic and military cohorts has broadened the concept of the Female Athlete Triad into the Relative Energy Deficiency in Sport (REDs) syndrome. REDs represents a spectrum of abnormalities induced by low energy availability (LEA), which serves as the underlying cause of all symptoms described within the REDs concept, affecting exercising populations of either biological sex. Both short- and long-term LEA, in conjunction with other moderating factors, may produce a multitude of maladaptive changes that impair various physiological systems and adversely affect health, well-being, and sport performance. Consequently, the comprehensive definition of REDs encompasses a broad spectrum of physiological sequelae and adverse clinical outcomes related to LEA, such as neuroendocrine, bone, immune, and hematological effects, ultimately resulting in compromised health and performance. In this review, we discuss the pathophysiology of REDs and associated disorders. We briefly examine current treatment recommendations for REDs, primarily focusing on nonpharmacological, behavioral, and lifestyle modifications that target its underlying cause-energy deficit. We also discuss treatment approaches aimed at managing symptoms, such as menstrual dysfunction and bone stress injuries, and explore potential novel treatments that target the underlying physiology, emphasizing the roles of leptin and the activin-follistatin-inhibin axis, the roles of which remain to be fully elucidated, in the pathophysiology and management of REDs. In the near future, novel therapies leveraging our emerging understanding of molecules and physiological axes underlying energy availability or lack thereof may restore LEA-related abnormalities, thus preventing and/or treating REDs-related health complications, such as stress fractures, and improving performance.
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Affiliation(s)
- Angeliki M Angelidi
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Konstantinos Stefanakis
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Sharon H Chou
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston, MA 02115, USA
| | - Laura Valenzuela-Vallejo
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Konstantina Dipla
- Exercise Physiology and Biochemistry Laboratory, Department of Sports Science at Serres, Aristotle University of Thessaloniki, Serres 62100, Greece
| | - Chrysoula Boutari
- Second Propaedeutic Department of Internal Medicine, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Konstantinos Ntoskas
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Panagiotis Tokmakidis
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
- Department of Internal Medicine, 251 Air Force General Hospital, Athens 11525, Greece
| | - Alexander Kokkinos
- First Propaedeutic Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, Athens 11527, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Helen A Papadaki
- Department of Hematology, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion 71500, Greece
| | - Christos S Mantzoros
- Department of Medicine, Boston VA Healthcare System, Boston, MA 02115, USA
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital (BWH), Harvard Medical School, Boston, MA 02115, USA
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O'Leary TJ, Jackson S, Izard RM, Walsh NP, Carswell AT, Oliver SJ, Tang JCY, Fraser WD, Greeves JP. Iron status is associated with tibial structure and vitamin D metabolites in healthy young men. Bone 2024; 186:117145. [PMID: 38838798 DOI: 10.1016/j.bone.2024.117145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 04/16/2024] [Accepted: 06/01/2024] [Indexed: 06/07/2024]
Abstract
The influence of iron on collagen synthesis and vitamin D metabolism has implications for bone health. This cross-sectional observational study investigated associations between markers of iron status and tibial structure, vitamin D metabolites, and circulating biochemical markers of bone metabolism in young healthy men. A total of 343 male British Army recruits participated (age 22 ± 3 y, height 1.77 ± 0.06 m, body mass 75.5 ± 10.1 kg). Circulating biochemical markers of iron status, vitamin D metabolites, and bone metabolism, and tibial structure and density by high-resolution peripheral quantitative computed tomography scans (HRpQCT) were measured in participants during week 1 of basic military training. Associations between markers of iron status and HRpQCT outcomes, bone metabolism, and vitamin D metabolites were tested, controlling for age, height, lean body mass, and childhood exercise volume. Higher ferritin was associated with higher total, trabecular, and cortical volumetric bone mineral density, trabecular volume, cortical area and thickness, stiffness, and failure load (all p ≤ 0.037). Higher soluble transferrin receptor (sTfR) was associated with lower trabecular number, and higher trabecular thickness and separation, cortical thickness, and cortical pore diameter (all p ≤ 0.033). Higher haemoglobin was associated with higher cortical thickness (p = 0.043). Higher ferritin was associated with lower βCTX, PINP, total 25(OH)D, and total 24,25(OH)2D, and higher 1,25(OH)2D:24,25(OH)2D ratio (all p ≤ 0.029). Higher sTfR was associated with higher PINP, total 25(OH)D, and total 24,25(OH)2D (all p ≤ 0.025). The greater density, size, and strength of the tibia, and lower circulating concentrations of markers of bone resorption and formation with better iron stores (higher ferritin) are likely as a result of the direct role of iron in collagen synthesis.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom; Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Sarah Jackson
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom
| | - Rachel M Izard
- Defence Science and Technology, Ministry of Defence, Porton Down, United Kingdom
| | - Neil P Walsh
- Faculty of Science, Liverpool John Moores University, Liverpool, United Kingdom
| | - Alexander T Carswell
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom; School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Samuel J Oliver
- College of Human Sciences, Bangor University, Bangor, United Kingdom
| | - Jonathan C Y Tang
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom; Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - William D Fraser
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom; Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom; Division of Surgery and Interventional Science, UCL, London, United Kingdom; Norwich Medical School, University of East Anglia, Norwich, United Kingdom.
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Kasper KB, Cockerell M, Escamilla C, Gonzalez R. Multivitamin Compliance Reduces Injuries of Female Recruits at Air Force Basic Training: A Randomized Controlled Cohort Study. Mil Med 2024; 189:93-98. [PMID: 39160796 DOI: 10.1093/milmed/usae044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/06/2023] [Accepted: 02/06/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Department of the Air Force basic military training (BMT) is the 7.5-week initial entry training for all enlisting U.S. Air Force and Space Force recruits. Overuse musculoskeletal injuries (MSKI) during training threaten success in BMT, and trainees with nutritional deficiencies are at higher risk. Several efforts are made at BMT to mitigate these issues to help trainees graduate on time, such as the distribution of multivitamins (MVI) to female recruits. However, trainee compliance with the prescribed MVI has been reported to be low, calling into question the effectiveness of this intervention. This study evaluated the effect of briefing modality offered to these trainees at the time of distribution on educational effectiveness, MVI compliance, and injury rates. MATERIALS AND METHODS This was a randomized controlled cohort study of BMT female trainees. Subjects included all female trainees of a single iteration of BMT concurrently completing training within the same squadron. At the outset of training, cohorts were randomly educated in one of two ways regarding the provided MVI. The control cohort (n = 80) was presented with the standard educational video created by BMT-registered dietitians, while the test cohort (n = 79) was presented the video and then also briefed in-person by a group of subject matter experts. At the end of BMT, the trainees completed a questionnaire regarding their knowledge, confidence, and compliance with the MVI. Additionally, a routinely collected training database was queried and analyzed for differences in injuries and training outcomes using the chi-squared test with significance set to α ≤ 0.05. RESULTS Although both cohorts found their educational presentation useful, the "in-person" cohort reported significantly higher compliance rates and were found to be diagnosed with MSKI and bone stress injuries at significantly lower rates (43% and 66% relative risk reductions, respectively). CONCLUSIONS Education to female BMT trainees regarding the MVI, which included a face-to-face discussion with subject matter experts, resulted in greater compliance and reduced incidence of MSKI and bone stress injury, compared to a video prepared by registered dietitians alone. Such educational approaches should continue to be strived for in this and other military population health measures. This study's implication of MVI efficacy for injury risk reduction in female trainees should be further studied, verified, and improved upon in this and other populations.
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Affiliation(s)
- Korey B Kasper
- 559th Trainee Health Squadron, JBSA-Lackland, TX 78236, USA
| | | | - Clarissa Escamilla
- 37th Training Wing, Human Performance Directorate, JBSA-Lackland, TX 78236, USA
| | - Richard Gonzalez
- 37th Training Wing, Human Performance Directorate, JBSA-Lackland, TX 78236, USA
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Fallowfield JL, McClung JP, Gaffney-Stomberg E, Probert B, Peterson R, Charlebois A, Boilard H, Carins J, Kilding H. Nutrition as a military capability to deliver human advantage: more people, more ready, more of the time. BMJ Mil Health 2024:e002738. [PMID: 38942432 DOI: 10.1136/military-2024-002738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 05/22/2024] [Indexed: 06/30/2024]
Abstract
Soldiers must achieve high-level mission-preparedness to endure extended periods of physical and cognitive activity, with unpredictable recovery, in all environments. Nutrition provides the foundation for health and performance. Militaries have not maximised the strategic and financial value that considering nutrition as a military capability could deliver. A whole system approach to military nutrition, based on the prepare-perform-recover human capability cycle phases, is presented. Trainee nutrition requirements, through to very-high-readiness forces undertaking arduous roles at reach, must be specifically addressed. Promoting military performance diets in the prepare phase, through practitioner-supported nutrition education and food provision, will ensure mission readiness and mitigate ill health. Delivering nutrition in field settings in the perform phase-through smaller/lighter, nutritionally optimised rations and smart packaging technologies-will improve utility and minimise waste. Strategic dietary supplement use can provide a mission performance-enhancing adjunct to a food-first philosophy. Impact value chain analysis of military nutrition capability investments could support cost-benefit measurement.
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Affiliation(s)
| | - J P McClung
- US Army Research Institute of Environmental Medicine, Natick, Massachusetts, USA
| | | | - B Probert
- Defence Science and Technology Group, Launceston, Tasmania, Australia
| | - R Peterson
- Defence Science and Technology Group, Launceston, Tasmania, Australia
| | - A Charlebois
- Department of National Defence, CANSOFCOM, Ottawa, Ontario, Canada
| | - H Boilard
- Strategic Joint Staff, Department of National Defence, Ottawa, Ontario, Canada
| | - J Carins
- Griffith University, Brisbane, Queensland, Australia
| | - H Kilding
- Sports Performance Research Institute New Zealand, Auckland University of Technology, Auckland, New Zealand
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O’Leary TJ, Jackson S, Izard RM, Walsh NP, Coombs CV, Carswell AT, Oliver SJ, Tang JCY, Fraser WD, Greeves JP. Sex differences in iron status during military training: a prospective cohort study of longitudinal changes and associations with endurance performance and musculoskeletal outcomes. Br J Nutr 2024; 131:581-592. [PMID: 37732392 PMCID: PMC10803825 DOI: 10.1017/s0007114523001812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/20/2023] [Accepted: 08/09/2023] [Indexed: 09/22/2023]
Abstract
This study investigated sex differences in Fe status, and associations between Fe status and endurance and musculoskeletal outcomes, in military training. In total, 2277 British Army trainees (581 women) participated. Fe markers and endurance performance (2·4 km run) were measured at the start (week 1) and end (week 13) of training. Whole-body areal body mineral density (aBMD) and markers of bone metabolism were measured at week 1. Injuries during training were recorded. Training decreased Hb in men and women (mean change (-0·1 (95 % CI -0·2, -0·0) and -0·7 (95 % CI -0·9, -0·6) g/dl, both P < 0·001) but more so in women (P < 0·001). Ferritin decreased in men and women (-27 (95 % CI -28, -23) and -5 (95 % CI -8, -1) µg/l, both P ≤ 0·001) but more so in men (P < 0·001). Soluble transferrin receptor increased in men and women (2·9 (95 % CI 2·3, 3·6) and 3·8 (95 % CI 2·7, 4·9) nmol/l, both P < 0·001), with no difference between sexes (P = 0·872). Erythrocyte distribution width increased in men (0·3 (95 % CI 0·2, 0·4)%, P < 0·001) but not in women (0·1 (95 % CI -0·1, 0·2)%, P = 0·956). Mean corpuscular volume decreased in men (-1·5 (95 % CI -1·8, -1·1) fL, P < 0·001) but not in women (0·4 (95 % CI -0·4, 1·3) fL, P = 0·087). Lower ferritin was associated with slower 2·4 km run time (P = 0·018), sustaining a lower limb overuse injury (P = 0·048), lower aBMD (P = 0·021) and higher beta C-telopeptide cross-links of type 1 collagen and procollagen type 1 N-terminal propeptide (both P < 0·001) controlling for sex. Improving Fe stores before training may protect Hb in women and improve endurance and protect against injury.
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Affiliation(s)
- Thomas J. O’Leary
- Army Health and Performance Research, Army Headquarters, Andover, MA, UK
- Division of Surgery and Interventional Science, UCL, London, UK
| | - Sarah Jackson
- Army Health and Performance Research, Army Headquarters, Andover, MA, UK
| | - Rachel M. Izard
- Defence Science and Technology, Ministry of Defence, Porton Down, Porton, UK
| | - Neil P. Walsh
- Faculty of Science, Liverpool John Moores University, Liverpool, UK
| | | | - Alexander T. Carswell
- Norwich Medical School, University of East Anglia, Norwich, UK
- School of Health Sciences, University of East Anglia, Norwich, UK
| | | | - Jonathan C. Y. Tang
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
| | - William D. Fraser
- Norwich Medical School, University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Julie P. Greeves
- Army Health and Performance Research, Army Headquarters, Andover, MA, UK
- Division of Surgery and Interventional Science, UCL, London, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Martin NM, von Hurst PR, Conlon CA, Smeele RJM, Mugridge OAR, Beck KL. Body Fat Percentage and Blood Donation are the Strongest Determinants of Iron Stores in Premenopausal Women Joining the New Zealand Army. Mil Med 2023; 188:e2550-e2556. [PMID: 36794880 PMCID: PMC10363006 DOI: 10.1093/milmed/usad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/22/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
INTRODUCTION Suboptimal iron status is an issue for women joining the military because of its association with impaired aerobic performance, yet no studies have investigated dietary and non-dietary determinants of iron status simultaneously in this population. The purpose of this study was to explore associations between iron stores, dietary patterns (DPs), and potential non-dietary determinants of iron status in premenopausal women at the commencement of basic military training (BMT) in the New Zealand Army. METHODS During week 1 of BMT, demographic, body composition, lifestyle, medical history, and dietary data were measured as potential determinants of serum ferritin (SF) in 101 participants. Following univariate analysis, age, body fat percentage, previous blood donation, at least 6 h of exercise per week that raised the heart rate, and a vegetarian DP were analyzed using a multiple linear regression model. RESULTS An increase in body fat percentage was associated with increased SF (P < .009), although blood donation in the past year decreased SF (P < .011) compared to those participants who did not donate blood. There was no association between SF and a vegetarian DP or hours of exercise per week. The model explained 17.5% of the variance in SF at the commencement of BMT. CONCLUSION Body fat percentage and blood donation in the past year were the strongest determinants of iron stores in healthy premenopausal women commencing BMT. It is recommended that women joining the New Zealand Army are provided information to maintain or improve their iron status based on these findings. This includes clinical screening of iron status, advice for women considering blood donation, and dietary advice regarding total energy requirements and iron bioavailability.
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Affiliation(s)
- Nicola M Martin
- New Zealand Defence Force, Defence House, Wellington 6011, New Zealand
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Sir Neil Waters Lecture Theatres, Auckland 0632, New Zealand
| | - Pamela R von Hurst
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Sir Neil Waters Lecture Theatres, Auckland 0632, New Zealand
| | - Cathryn A Conlon
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Sir Neil Waters Lecture Theatres, Auckland 0632, New Zealand
| | | | - Owen A R Mugridge
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Sir Neil Waters Lecture Theatres, Auckland 0632, New Zealand
| | - Kathryn L Beck
- School of Sport, Exercise and Nutrition, College of Health, Massey University, Sir Neil Waters Lecture Theatres, Auckland 0632, New Zealand
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Abbott A, Wang C, Stamm M, Mulcahey MK. Part II: Risk Factors for Stress Fractures in Female Military Recruits. Mil Med 2023; 188:93-99. [PMID: 35253041 DOI: 10.1093/milmed/usac033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/24/2022] [Accepted: 01/31/2022] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Stress fractures (SFx) represent a significant proportion of injuries in military recruits internationally. Stress fractures disproportionately affect female recruits, a disparity that has similarly been consistently demonstrated in female athletes. Stress fractures result in medical morbidity, financial burden, and medical discharge from military service. This review presents current literature regarding SFx risk factors to identify and/or mitigate in this high-risk population. METHODS A literature review was conducted using PubMed to find relevant articles. We utilized keywords stress fracture, military, recruits, female, risk factors, modifiable, non-modifiable, overuse, nutrition, and/or prevention. Articles older than 10 years (published before 2010) were not considered. Review articles were considered, but if a research article was cited by a review, the research was included directly. Articles with primary military data, members of the military as subjects, especially when female recruits were included, were strongly considered for inclusion in this review. RESULTS Modifiable risk factors for SFx include nutritional deficiency, especially of iron, vitamin D, and possibly calcium, poor physical fitness, suboptimal training programming for injury development and recovery, load carriage, and military footwear. Non-modifiable risk factors include female sex, greater height, lower weight and body mass index in females but lower or higher weight and body mass index in males, lower body fat percentage, and lower bone mineral density. In addition, menstrual dysfunction, low energy availability, later age at menarche, and iron deficiency pose unique risks to female recruits. Preventive measures include leadership education, programs with recovery considerations, and risk factor screening. CONCLUSION This review, Part II of a two-part series, guides multidisciplinary management of military recruits, especially females, who are at risk for developing SFx. Unique nuances of the military recruit require specific knowledge to reduce high incidence rates of injury internationally.
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Affiliation(s)
- Alexandra Abbott
- Department of Pediatrics, University of California, Los Angeles, CA 90095, USA
| | - Cindy Wang
- Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Michaela Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA 70118, USA
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Scott JM, Swallow EA, Metzger CE, Kohler R, Wallace JM, Allen MR, Gasier HG. Iron deficiency and high-intensity running interval training do not impact femoral or tibial bone in young female rats. Br J Nutr 2022; 128:1518-1525. [PMID: 34758890 PMCID: PMC9150815 DOI: 10.1017/s0007114521004426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the USA, as many as 20 % of recruits sustain stress fractures during basic training. In addition, approximately one-third of female recruits develop Fe deficiency upon completion of training. Fe is a cofactor in bone collagen formation and vitamin D activation, thus we hypothesised Fe deficiency may be contributing to altered bone microarchitecture and mechanics during 12-weeks of increased mechanical loading. Three-week old female Sprague Dawley rats were assigned to one of four groups: Fe-adequate sedentary, Fe-deficient sedentary, Fe-adequate exercise and Fe-deficient exercise. Exercise consisted of high-intensity treadmill running (54 min 3×/week). After 12-weeks, serum bone turnover markers, femoral geometry and microarchitecture, mechanical properties and fracture toughness and tibiae mineral composition and morphometry were measured. Fe deficiency increased the bone resorption markers C-terminal telopeptide type I collagen and tartate-resistant acid phosphatase 5b (TRAcP 5b). In exercised rats, Fe deficiency further increased bone TRAcP 5b, while in Fe-adequate rats, exercise increased the bone formation marker procollagen type I N-terminal propeptide. In the femur, exercise increased cortical thickness and maximum load. In the tibia, Fe deficiency increased the rate of bone formation, mineral apposition and Zn content. These data show that the femur and tibia structure and mechanical properties are not negatively impacted by Fe deficiency despite a decrease in tibiae Fe content and increase in serum bone resorption markers during 12-weeks of high-intensity running in young growing female rats.
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Affiliation(s)
- Jonathan M. Scott
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Elizabeth A. Swallow
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Corinne E. Metzger
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rachel Kohler
- Department of Biomedical Engineering, Indiana University Purdue University of Indianapolis, Indianapolis, Indiana, USA
| | - Joseph M. Wallace
- Department of Biomedical Engineering, Indiana University Purdue University of Indianapolis, Indianapolis, Indiana, USA
| | - Matthew R. Allen
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Biomedical Engineering, Indiana University Purdue University of Indianapolis, Indianapolis, Indiana, USA
- Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, USA
| | - Heath G. Gasier
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
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Barney DE, Ippolito JR, Berryman CE, Hennigar SR. A Prolonged Bout of Running Increases Hepcidin and Decreases Dietary Iron Absorption in Trained Female and Male Runners. J Nutr 2022; 152:2039-2047. [PMID: 35661896 DOI: 10.1093/jn/nxac129] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 04/22/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Declines in iron status are frequently reported in those who regularly engage in strenuous physical activity. A possible reason is increases in the iron regulatory hormone hepcidin, which functions to inhibit dietary iron absorption and can be induced by the inflammatory cytokine interleukin-6 (IL-6). OBJECTIVES The current study aimed to determine the impact of a prolonged bout of running on hepcidin and dietary iron absorption in trained female and male runners. METHODS Trained female and male collegiate cross country runners (n = 28, age: 19.7 ± 1.2 y, maximal oxygen uptake: 66.1 ± 6.1 mL $\cdot$ kg -1$\cdot$ min-2, serum ferritin: 21.9 ± 13.3 ng/mL) performed a prolonged run (98.8 ± 14.7 min, 21.2 ± 3.8 km, 4.7 ± 0.3 min/km) during a team practice. Participants consumed a stable iron isotope with a standardized meal 2 h postrun and blood was collected 1 h later. The protocol was repeated 2 wk later except participants abstained from exercise (rest). RBCs were collected 15 d after exercise and rest to determine isotope enrichment. Differences between exercise and rest were assessed by paired t tests and Wilcoxon matched-pairs signed rank tests. Data are means ± SDs. RESULTS Plasma hepcidin increased 51% after exercise (45.8 ± 34.4 ng/mL) compared with rest (30.3 ± 27.2 ng/mL, P = 0.0010). Fractional iron absorption was reduced by 36% after exercise (11.8 ± 14.6 %) compared with rest (18.5 ± 14.4 %, P = 0.025). Plasma IL-6 was greater after exercise (0.660 ± 0.354 pg/mL) than after rest (0.457 ± 0.212 pg/mL, P < 0.0001). Exploratory analyses revealed that the increase in hepcidin with exercise may be driven by a response in males but not females. CONCLUSIONS A prolonged bout of running increases hepcidin and decreases dietary iron absorption compared with rest in trained runners with low iron stores. The current study supports that IL-6 contributes to the increase in hepcidin with prolonged physical activity, although future studies should explore potential sex differences in the hepcidin response.This trial was registered at Clinicaltrials.gov as NCT04079322.
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Affiliation(s)
- David E Barney
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - James R Ippolito
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - Claire E Berryman
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
| | - Stephen R Hennigar
- Department of Nutrition & Integrative Physiology, Florida State University, Tallahassee, FL, USA
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Gaffney-Stomberg E, Hughes JM, Guerriere KI, Staab JS, Cable SJ, Bouxsein ML, McClung JP. Once daily calcium (1000 mg) and vitamin D (1000 IU) supplementation during military training prevents increases in biochemical markers of bone resorption but does not affect tibial microarchitecture in Army recruits. Bone 2022; 155:116269. [PMID: 34861430 DOI: 10.1016/j.bone.2021.116269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/22/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022]
Abstract
Basic combat training (BCT) is a period of novel physical training including load carriage resulting in higher risk of stress fracture compared to any other time during military service. Prior trials reported a 20% reduction in stress fracture incidence with Ca and vitamin D (Ca + D) supplementation (2000 mg Ca, 800 IU vitamin D), and greater increases in tibia vBMD during BCT compared to placebo. The primary objective of this randomized, double-blind, placebo-controlled trial was to determine the efficacy of a lower dose of Ca (1000 mg/d Ca, 1000 IU vit D) on PTH, bone biomarkers and tibial microarchitecture during BCT. One hundred volunteers (50 males, 50 females; mean age 21.8 ± 3.5 y) were block randomized by race and sex to receive a daily Ca + D fortified food bar or placebo. Anthropometrics, dietary intake, fasted blood draws and high resolution pQCT scans of the distal and mid-shaft tibia were obtained at the start of BCT and 8 wks later at the conclusion of training. As compliance was 98% in both treatment groups, an intent-to-treat analysis was used. At the distal tibia, total vBMD, Tb.vBMD, Tb.N, Th.Th and Tb.BV/TV increased (+1.07 to 2.12% for all, p < 0.05) and Tb.Sp decreased (0.96 to 1.09%, p < 0.05) in both treatment groups. At the mid-shaft, Ct.Pm increased (+0.18 to 0.21%, p = 0.01) and Ct.vBMD decreased (-0.48 to -0.77%, p < 0.001) in both groups. Ca + D prevented increases in CTX and TRAP, which were observed in the placebo group (group-by-time, p < 0.05). Mean circulating 25OHD, BAP, P1NP and iCa increased and PTH decreased in both treatment groups (p < 0.05). These results, in agreement with other studies, suggest that bone microarchitectural changes indicative of bone formation occur during BCT. While Ca + D supplementation at lower doses than those tested in previous studies prevented increases in biochemical markers of bone resorption in this study, there were no significant changes in bone tissue after 8 wks of Army BCT.
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Affiliation(s)
- Erin Gaffney-Stomberg
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, United States of America.
| | - Julie M Hughes
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, United States of America
| | - Katelyn I Guerriere
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, United States of America
| | - Jeffery S Staab
- Military Performance Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, United States of America
| | - Sonya J Cable
- Womack Army Medical Center, Ft Bragg, NC 28310, United States of America
| | - Mary L Bouxsein
- Endocrine Unit, Massachusetts General Hospital, Boston, MA 02114, United States of America; Center for Advanced Orthopedic Studies, Beth Israel Deaconess Medical Cente, United States of America; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02215, United States of America
| | - James P McClung
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, United States of America
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12
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Giersch GEW, Charkoudian N, McClung HL. The Rise of the Female Warfighter: Physiology, Performance, and Future Directions. Med Sci Sports Exerc 2021; 54:683-691. [PMID: 34939610 DOI: 10.1249/mss.0000000000002840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT Since 1948, the United States military has been open to both men and women as permanent party service members. However, in the majority of the time since, there have been a subset of military occupational specialties (MOS), or job descriptions, open only to men. In particular, jobs requiring more intense physical and/or environmental strain were considered to be beyond the physiological capabilities of women. In the present analysis, we review the literature regarding neuromuscular, physical performance, and environmental physiology in women, to highlight that women have no inherent limitation in their capacity to participate in relevant roles and jobs within the military, within accepted guidelines to promote risk mitigation across sexes. First, we discuss performance and injury risk: both neuromuscular function and physical capabilities. Second, physiological responses to environmental stress. Third, we discuss risk as it relates to reproductive health and nutritional considerations. We conclude with a summary of current physiological, performance and injury risk data in men and women that support our overarching purpose, as well as suggestions for future directions.
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Affiliation(s)
- Gabrielle E W Giersch
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA Biophysical and Biomedical Modeling Division, United States Army Research Institute of Environmental Medicine, Natick, MA Oak Ridge Institute for Science and Technology, Oak Ridge, TN
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13
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Knapik JJ, Farina EK, Fulgoni VL, Lieberman HR. Clinically diagnosed iron and iodine deficiencies and disorders in the entire population of US military service members from 1997 to 2015. Public Health Nutr 2021; 24:3187-3195. [PMID: 33541462 PMCID: PMC8314918 DOI: 10.1017/s1368980021000495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/24/2020] [Accepted: 02/01/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Iron and/or iodine deficiencies can have multiple serious adverse health outcomes, but examination of incidence rates of these deficiencies has rarely been conducted in any large population. This study examined incidence rates, temporal trends and demographic factors associated with medically diagnosed iron and iodine deficiencies/disorders in US military service members (SM). DESIGN The Defense Medical Epidemiological Database (DMED) was queried for medical visits of active duty SM to obtain specific International Classification of Diseases, Version 9, codes involving clinically diagnosed iron and iodine deficiencies/disorders. SETTING Analysis of existing database (DMED). PARTICIPANTS Entire population of US military SM from 1997 to 2015 (average n per year = 1 382 266, 15 % women). RESULTS Overall incidence rates for iron and iodine were 104 and 36 cases/100 000 person-years, respectively. Over the 19-year period, rates for iron disorders increased steadily (108 % for men, 177 % for women). Rates for iodine disorders also increased steadily for men (91 %), but, for women, there was an initial rise followed by a later decline. Overall, women's rates were 12 and 10 times higher than men's for iron and iodine, respectively. Compared with whites, blacks and those of other races had higher rates of deficiencies of both minerals. Incidence rates for iodine deficiency increased substantially with age. CONCLUSIONS The overall incidence of clinically diagnosed iron and iodine deficiency among SM was low, but increased over the 19 years examined, and certain demographic groups were at significantly greater risk. Given the unexpected increases in incidence of these mineral disorders, increased surveillance may be appropriate.Clinical Trial Registration No. ISRCTN58987177 (http//:www.isrctn.com/ISRCTN58987177).
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Affiliation(s)
- Joseph J Knapik
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA01760, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Emily K Farina
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA01760, USA
| | - Victor L Fulgoni
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA01760, USA
- Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Harris R Lieberman
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA01760, USA
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14
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Karl JP, Margolis LM, Fallowfield JL, Child RB, Martin NM, McClung JP. Military nutrition research: Contemporary issues, state of the science and future directions. Eur J Sport Sci 2021; 22:87-98. [PMID: 33980120 DOI: 10.1080/17461391.2021.1930192] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The importance of diet and nutrition to military readiness and performance has been recognized for centuries as dietary nutrients sustain health, protect against illness, and promote resilience, performance and recovery. Contemporary military nutrition research is increasingly inter-disciplinary with emphasis often placed on the broad topics of (1) determining operational nutrition requirements in all environments, (2) characterizing nutritional practices of military personnel relative to the required (role/environment) standards, and (3) developing strategies for improving nutrient delivery and individual choices. This review discusses contemporary issues shared internationally by military nutrition research programmes, and highlights emerging topics likely to influence future military nutrition research and policy. Contemporary issues include improving the diet quality of military personnel, optimizing operational rations, and increasing understanding of biological factors influencing nutrient requirements. Emerging areas include the burgeoning field of precision nutrition and its technological enablers.
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Affiliation(s)
- J Philip Karl
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Lee M Margolis
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Joanne L Fallowfield
- Environmental Medicine and Science Division, Institute of Naval Medicine, Alverstoke, Hampshire, UK
| | - Robert B Child
- School of Chemical Engineering, University of Birmingham, Birmingham, UK
| | - Nicola M Martin
- New Zealand Army, New Zealand Defence Force, Upper Hutt, New Zealand
| | - James P McClung
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine, Natick, MA, USA
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15
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Henjum S, Groufh-Jacobsen S, Stea TH, Tonheim LE, Almendingen K. Iron Status of Vegans, Vegetarians and Pescatarians in Norway. Biomolecules 2021; 11:454. [PMID: 33803700 PMCID: PMC8003004 DOI: 10.3390/biom11030454] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/17/2022] Open
Abstract
Although plant-based diets provide well-established physical and environmental health benefits, omitting meat or meat products has also been associated with a risk of being deficient in specific nutrients, such as iron. As data on the iron status among Norwegian vegans, vegetarians and pescatarians are lacking, the present study aimed to assess iron status in these groups of healthy adults. Blood markers for iron status were measured in 191 participants (18-60 years old) comprising 106 vegans, 54 vegetarians and 31 pescatarians: serum-ferritin (S-Fe), serum-iron (S-Iron) and serum-total iron binding capacity (S-TIBC). Serum-transferrin-saturation (S-TSAT) was estimated (S-Iron/S-TIBC × 100). The median concentration of blood markers for iron status were within the normal range with no difference between the different dietary practices. In total, 9% reported iron supplement use the last 24 h. S-Fe concentrations below reference (<15 μg/L) were found in 8% of the participating women, of which one participant reported iron supplement use. In multiple regression analysis, duration of adherence to dietary practices and the female gender were found to be the strongest predictors for decreased S-Fe concentration. In conclusion, although the participants were eating a plant-based diet, the majority had sufficient iron status. Female vegans and vegetarians of reproductive age are at risk of low iron status and should have their iron status monitored.
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Affiliation(s)
- Sigrun Henjum
- Department of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Kunnskapsveien 55, 2007 Kjeller, Norway; (L.E.T.); (K.A.)
| | - Synne Groufh-Jacobsen
- Department of Nutrition and Public Health, Faculty of Health and Sport Sciences, University of Agder, Universitetsveien 25, 4630 Kristiansand, Norway;
| | - Tonje Holte Stea
- Department of Health and Nursing Sciences, Faculty of Health and Sport Sciences, University of Agder, Universitetsveien 25, 4630 Kristiansand, Norway;
| | - Live Edvardsen Tonheim
- Department of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Kunnskapsveien 55, 2007 Kjeller, Norway; (L.E.T.); (K.A.)
| | - Kari Almendingen
- Department of Nursing and Health Promotion, Faculty of Health Science, Oslo Metropolitan University, Kunnskapsveien 55, 2007 Kjeller, Norway; (L.E.T.); (K.A.)
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16
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Sandroni A, House E, Howard L, DellaValle DM. Synbiotic Supplementation Improves Response to Iron Supplementation in Female Athletes during Training. J Diet Suppl 2021; 19:366-380. [PMID: 33615951 DOI: 10.1080/19390211.2021.1887423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Iron deficiency (ID) affects ∼30% of female athletes, and its consequences are highly relevant to athletic performance. Poor iron (Fe) uptake remains a major factor in the development of ID. While studies suggest that consumption of either prebiotics or probiotics may improve Fe uptake, consumption of synbiotics has not been well-studied. The main objective of this study was to determine the effects of synbiotic supplementation on the Fe status of female athletes during Fe repletion. METHODS The Fe status of 32 female athletes was screened early in the season. Twenty eligible athletes (hemoglobin:12.3 ± 0.9g/dL; serum ferritin, sFer:18.1 ± 9.2 µg/L) were randomized to receive either a daily synbiotic supplement (5 g prebiotic fiber + 8 billion colony forming units, CFU probiotic B. lactis) or placebo, along with Fe supplementation (140 mg ferrous sulfate, FeSO4/d) for 8 weeks using a double-blind design. Fe status was assessed again at mid-point and after the trial. RESULTS Nineteen athletes (n = 9 supplement, 10 placebo) completed the trial and there were no differences in compliance or GI symptoms reported between groups. After controlling for baseline Fe status, regression analyses revealed improvements in log sFer in the supplement group after both 4 and 8 weeks (p = 0.01 and p = 0.05, respectively), compared to placebo. CONCLUSIONS Synbiotic supplementation along with FeSO4 improved athletes' Fe status over 8 weeks. This data is essential to advancing our understanding of how dietary and supplemental Fe uptake in active women can be enhanced by synbiotic supplementation, as well as by foods containing pre- and probiotics.
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Affiliation(s)
- Amanda Sandroni
- Department of Nutrition and Dietetics, Marywood University, Scranton, PA, USA
| | - Elaine House
- Department of Nutrition and Dietetics, Marywood University, Scranton, PA, USA
| | - Lindsay Howard
- Department of Athletic Training and Exercise Science, Marywood University, Scranton, PA, USA
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17
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O'Leary TJ, Wardle SL, Greeves JP. Energy Deficiency in Soldiers: The Risk of the Athlete Triad and Relative Energy Deficiency in Sport Syndromes in the Military. Front Nutr 2020; 7:142. [PMID: 32984399 PMCID: PMC7477333 DOI: 10.3389/fnut.2020.00142] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/21/2020] [Indexed: 12/15/2022] Open
Abstract
Military personnel experience energy deficit (total energy expenditure higher than energy intake), particularly during combat training and field exercises where exercising energy expenditures are high and energy intake is reduced. Low energy availability (energy intake minus exercising energy expenditure expressed relative to fat free mass) impairs endocrine function and bone health, as recognized in female athletes as the Female Athlete Triad syndrome. More recently, the Relative Energy Deficiency in Sport (RED-S) syndrome encompasses broader health outcomes, physical and cognitive performance, non-athletes, and men. This review summarizes the evidence for the effect of low energy availability and energy deficiency in military training and operations on health and performance outcomes. Energy availability is difficult to measure in free-living individuals but doubly labeled water studies demonstrate high total energy expenditures during military training; studies that have concurrently measured energy intake, or measured body composition changes with DXA, suggest severe and/or prolonged energy deficits. Military training in energy deficit disturbs endocrine and metabolic function, menstrual function, bone health, immune function, gastrointestinal health, iron status, mood, and physical and cognitive performance. There are more data for men than women, and little evidence on the chronic effects of repeated exposures to energy deficit. Military training impairs indices of health and performance, indicative of the Triad and RED-S, but the multi-stressor environment makes it difficult to isolate the independent effects of energy deficiency. Studies supplementing with energy to attenuate the energy deficit suggest an independent effect of energy deficiency in the disturbances to metabolic, endocrine and immune function, and physical performance, but randomized controlled trials are lacking.
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Affiliation(s)
- Thomas J O'Leary
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Sophie L Wardle
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom
| | - Julie P Greeves
- Army Health and Performance Research, Army Headquarters, Andover, United Kingdom.,Division of Surgery and Interventional Science, UCL, London, United Kingdom.,Norwich Medical School, University of East Anglia, Norwich, United Kingdom
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18
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Molloy JM, Pendergrass TL, Lee IE, Hauret KG, Chervak MC, Rhon DI. Musculoskeletal Injuries and United States Army Readiness. Part II: Management Challenges and Risk Mitigation Initiatives. Mil Med 2020; 185:e1472-e1480. [DOI: 10.1093/milmed/usaa028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/18/2019] [Accepted: 01/29/2020] [Indexed: 11/15/2022] Open
Abstract
AbstractIntroductionNoncombat injuries (“injuries”) threaten soldier health and United States (U.S.) Army medical readiness, accounting for more than twice as many outpatient medical encounters among active component (AC) soldiers as behavioral health conditions (the second leading cause of outpatient visits). Noncombat musculoskeletal injuries (MSKIs) account for more than 80% of soldiers’ injuries and 65% of medically nondeployable AC soldiers. This review focuses on MSKI risk reduction initiatives, management, and reporting challenges within the Army. The authors will summarize MSKI risk reduction efforts and challenges affecting MSKI management and reporting within the U.S. Army.Materials/MethodsThis review focuses on (1) initiatives to reduce the impact of MSKIs and risk for chronic injury/pain or long-term disability and (2) MSKI reporting challenges. This review excludes combat or battle injuries.ResultsPrimary risk reduction Adherence to standardized exercise programming has reduced injury risk among trainees. Preaccession physical fitness screening may identify individuals at risk for injury or attrition during initial entry training. Forward-based strength and conditioning coaching (provided in the unit footprint) and nutritional supplementation initiatives are promising, but results are currently inconclusive concerning injury risk reduction.Secondary risk reductionForward-based access to MSKI care provided by embedded athletic trainers and physical therapists within military units or primary care clinics holds promise for reducing MSKI-related limited duty days and nondeployability among AC soldiers. Early point-of-care screening for psychosocial risk factors affecting responsiveness to MSKI intervention may reduce risk for progression to chronic pain or long-term disability.Tertiary risk reductionOperational MSKI metrics enable commanders and clinicians to readily identify soldiers with nonresolving MSKIs. Monthly injury reports to Army leadership increase command focus on soldiers with nonresolving MSKIs.ConclusionsStandardized exercise programming has reduced trainee MSKI rates. Secondary risk reduction initiatives show promise for reducing MSKI-related duty limitations and nondeployability among AC soldiers; timely identification/evaluation and appropriate, early management of MSKIs are essential. Tertiary risk reduction initiatives show promise for identifying soldiers whose chronic musculoskeletal conditions may render them unfit for continued military service.Clinicians must document MSKI care with sufficient specificity (including diagnosis and external cause coding) to enable large-scale systematic MSKI surveillance and analysis informing focused MSKI risk reduction efforts. Historical changes in surveillance methods and injury definitions make it difficult to compare injury rates and trends over time. However, the U.S. Army’s standardized injury taxonomy will enable consistent classification of current and future injuries by mechanism of energy transfer and diagnosis. The Army’s electronic physical profiling system further enablesstandardized documentation of MSKI-related duty/work restrictions and mechanisms of injury. These evolving surveillance tools ideally ensure continual advancement of military injury surveillance and serve as models for other military and civilian health care organizations.
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Affiliation(s)
- Joseph M Molloy
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830
- Physical Performance Service Line, G 3/5/7, U.S. Army Office of the Surgeon General, Falls Church, VA 22042
| | - Timothy L Pendergrass
- Physical Performance Service Line, G 3/5/7, U.S. Army Office of the Surgeon General, Falls Church, VA 22042
| | - Ian E Lee
- Solution Delivery Division, U.S. Defense Health Agency, Falls Church, VA 22042
| | - Keith G Hauret
- U.S. Army Public Health Center, Injury Prevention Program, Aberdeen Proving Ground, Aberdeen, MD 21005
| | - Michelle C Chervak
- U.S. Army Public Health Center, Injury Prevention Program, Aberdeen Proving Ground, Aberdeen, MD 21005
| | - Daniel I Rhon
- Oak Ridge Institute for Science and Education, Oak Ridge, TN 37830
- Physical Performance Service Line, G 3/5/7, U.S. Army Office of the Surgeon General, Falls Church, VA 22042
- Center for the Intrepid, Brooke Army Medical Center, Joint Base San Antonio Fort Sam Houston, San Antonio, TX 78234
- Duke Clinical Research Institute, Duke University, Durham, NC 27701
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19
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Merkel D, Moran DS. Coping with Iron Deficiency and Iron Deficiency Anemia in Combat Recruits. Acta Haematol 2019; 139:166-167. [PMID: 29597195 DOI: 10.1159/000487387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 02/02/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Drorit Merkel
- Division of Hematology, Chaim Sheba Medical Center, Tel Hashomer affiliated with Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Iron status and associations with physical performance during basic combat training in female New Zealand Army recruits. Br J Nutr 2019; 121:887-893. [PMID: 30862317 DOI: 10.1017/s0007114519000199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Decreases in Fe status have been reported in military women during initial training periods of 8-10 weeks. The present study aimed to characterise Fe status and associations with physical performance in female New Zealand Army recruits during a 16-week basic combat training (BCT) course. Fe status indicators - Hb, serum ferritin (sFer), soluble transferrin receptor (sTfR), transferrin saturation (TS) and erythrocyte distribution width (RDW) - were assessed at the beginning (baseline) and end of BCT in seventy-six volunteers without Fe-deficiency non-anaemia (sFer 10 mg/l at baseline or end. A timed 2·4 km run followed by maximum press-ups were performed at baseline and midpoint (week 8) to assess physical performance. Changes in Fe status were investigated using paired t tests and associations between Fe status and physical performance evaluated using Pearson correlation coefficients. sFer (56·6 (sd 33·7) v. 38·4 (sd 23·8) µg/l) and TS (38·8 (sd 13·9) v. 34·4 (sd 11·5) %) decreased (P<0·001 and P=0·014, respectively), while sTfR (1·21 (sd 0·27) v. 1·39 (sd 0·35) mg/l) and RDW (12·8 (sd 0·6) v. 13·2 (sd 0·7) %) increased (P<0·001) from baseline to end. Hb (140·6 (sd 7·5) v. 142·9 (sd 7·9) g/l) increased (P=0·009) during BCT. At end, sTfR was positively (r 0·29, P=0·012) and TS inversely associated (r -0·32, P=0·005) with midpoint run time. There were no significant correlations between Fe status and press-ups. Storage and functional Fe parameters indicated a decline in Fe status in female recruits during BCT. Correlations between tissue-Fe indicators and run times suggest impaired aerobic fitness. Optimal Fe status appears paramount for enabling success in female recruits during military training.
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Abstract
Iron and zinc are nutritionally essential trace elements that function through incorporation into proteins and enzymes; many of these proteins and enzymes affect physical performance. Poor iron status (iron deficiency and iron deficiency anemia) is prevalent in both developed and developing nations. Zinc deficiency has been reported in clinical and population studies, although the incidence is difficult to quantify due to the lack of a reliable zinc status indicator. The objective of this manuscript is to review the relationship between iron and zinc status and physical performance. In sum, numerous reports indicate diminished physical performance in individuals with poor iron and/or zinc status, whereas, in individuals with adequate status, evidence supporting a beneficial role of iron or zinc at levels beyond the recommended dietary allowance for optimizing physical performance is lacking.
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Affiliation(s)
- James P McClung
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA, 01760, USA.
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Fulgoni VL, Agarwal S, Kellogg MD, Lieberman HR. Establishing Pediatric and Adult RBC Reference Intervals With NHANES Data Using Piecewise Regression. Am J Clin Pathol 2019; 151:128-142. [PMID: 30285066 PMCID: PMC6306047 DOI: 10.1093/ajcp/aqy116] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives To develop age- and sex-specific RBC reference intervals using the National Health and Nutrition Examination Survey (NHANES) 1999 to 2012, a large nationally representative, population-based, cross-sectional database (n = 44,328). Methods Comprehensive medical data were used to define a “healthy” population. Reference intervals for RBC count, hemoglobin, hematocrit, mean cell hemoglobin, mean cell hemoglobin concentration, mean cell volume, and red cell distribution width were computed using piecewise regression, an evidence-based statistical procedure that identifies breakpoints. Results The derived reference intervals were sex specific, unlike many current standards, and more precise for individuals of different ages, especially for children, adolescents, and elderly individuals, as additional breakpoints were detected for these groups. Suggested reference values for hematocrit and hemoglobin of older adult males were substantially lower than current values. Conclusions The reference intervals provided here, based on a large, nationally representative healthy population, contribute to the ongoing transition to precision medicine.
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Affiliation(s)
| | - Sanjiv Agarwal
- Oak Ridge Institute for Science and Education, Belcamp, MD
| | - Mark D Kellogg
- Department of Laboratory Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Harris R Lieberman
- Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA
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Rubeor A, Goojha C, Manning J, White J. Does Iron Supplementation Improve Performance in Iron-Deficient Nonanemic Athletes? Sports Health 2018; 10:400-405. [PMID: 29792778 PMCID: PMC6116100 DOI: 10.1177/1941738118777488] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
CONTEXT Supplementing iron-deficient nonanemic (IDNA) athletes with iron to improve performance is a trend in endurance sports. OBJECTIVES To investigate the benefits of iron on performance, identify a ferritin level cutoff in IDNA athletes, and determine which iron supplementation regimens are most effective. DATA SOURCES A search of the PubMed, CINAHL, Embase, ERIC, and Cochrane databases was performed in 2014 including all articles. Citations of pertinent review articles were also searched. In 2017, the search was repeated. STUDY SELECTION Inclusion criteria comprised studies of level 1 to 3 evidence, written in the English language, that researched iron supplementation in nonanemic athletes and reported performance outcomes. STUDY DESIGN Systematic review. LEVEL OF EVIDENCE Level 3. DATA EXTRACTION The search terms used included athletic performance, resistance training, athletes, physical endurance, iron, iron deficiency, supplement, non-anemic, low ferritin, ferritin, ferritin blood level, athletes, and sports. RESULTS A total of 1884 studies were identified through the initial database search, and 13 were identified through searching references of relevant review articles. A subsequent database search identified 46 studies. Following exclusions, 12 studies with a total of 283 participants were included. Supplementing IDNA athletes with iron improved performance in 6 studies (146 participants) and did not improve performance in the other 6 studies (137 participants). In the 6 studies that showed improved performance with iron supplementation, all used a ferritin level cutoff of ≤20 μg/L for treatment. Additionally, all studies that showed improved performance used oral iron as a supplement. CONCLUSION The evidence is equivocal as to whether iron supplementation in IDNA athletes improves athletic performance. Supplementing athletes with ferritin levels <20 μg/L may be more beneficial than supplementing athletes with higher baseline ferritin levels.
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Affiliation(s)
- Amity Rubeor
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Jeffrey Manning
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jordan White
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Knapik JJ, Sharp MA, Steelman RA. Secular Trends in the Physical Fitness of United States Army Recruits on Entry to Service, 1975-2013. J Strength Cond Res 2017; 31:2030-2052. [PMID: 28403029 DOI: 10.1519/jsc.0000000000001928] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Knapik, JJ, Sharp, MA, and Steelman, RA. Secular trends in the physical fitness of United States Army recruits on entry to service, 1975-2013. J Strength Cond Res 31(7): 2030-2052, 2017-A systematic literature search was conducted to identify and analyze articles that reported on physical fitness of new US Army recruits. The National Library of Medicine's PubMed and the Defense Technical Information Center were searched using the keywords (military personnel OR trainee OR recruit OR soldier) AND (physical fitness OR strength OR endurance OR flexibility OR balance OR coordination OR muscle contraction OR running OR exercise OR physical conditioning). Reference lists of obtained articles and contact with authors enhanced the search. Studies were selected if they involved recruits in Basic Combat Training or One-Station Unit Training, provided a quantitative assessment of at least one fitness measure, and the fitness measure(s) were obtained early in training. Average values for each fitness measure were obtained, plotted by the year of data collection, and fitted to linear regression models (fitness measure × year). Fifty-three articles met the review criteria. Regression analysis indicated little temporal change in height, but body weight, body mass index, body fat, and fat-free mass increased over time. Limited V[Combining Dot Above]O2max data suggested no temporal change in male recruits, but those in female recruits V[Combining Dot Above]O2max seem to have slightly improved. Apparently contradicting the V[Combining Dot Above]O2max findings, performance on endurance runs (1- and 2-mile) declined, possibly because of the increase in body weight. Muscular endurance (push-ups, sit-ups) demonstrated little systematic change over time. Limited but multiple measures of muscular strength suggest a temporal increase in strength. Specific components of US Army recruit fitness seem to have changed over time.
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Affiliation(s)
- Joseph J Knapik
- 1US Army Research Institute of Environmental Medicine, Natick, Massachusetts; 2US Army Public Health Center, Aberdeen Proving Ground, Maryland; 3Oak Ridge Institute for Science and Education, Belcamp, Maryland; and 4Defense Health Agency, Falls Church, Virginia
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Hadjira C, Kamel AM, Zahia B, El Amin AMY, Arezki B. Iron deficiency anemia and nutritional status among women of childbearing age. MEDITERRANEAN JOURNAL OF NUTRITION AND METABOLISM 2017. [DOI: 10.3233/mnm-17144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Chiheb Hadjira
- Laboratory of Human Nutrition and Food Technology, Higher National School of Agronomy (ENSA), El Harrach, Algiers, Algeria
| | - Assami Mustapha Kamel
- Laboratory of Human Nutrition and Food Technology, Higher National School of Agronomy (ENSA), El Harrach, Algiers, Algeria
| | - Bouchene Zahia
- University Hospital Center Beni-Messous, Pediatric ward, Laboratory Mother Child, Beni-Messous, Algeria
| | - Aissiou Mohammed Yehya El Amin
- Laboratory of Human Nutrition and Food Technology, Higher National School of Agronomy (ENSA), El Harrach, Algiers, Algeria
| | - Bitam Arezki
- Laboratory of Human Nutrition and Food Technology, Higher National School of Agronomy (ENSA), El Harrach, Algiers, Algeria
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Farina EK, Taylor JC, Means GE, Murphy NE, Pasiakos SM, Lieberman HR, McClung JP. Effects of deployment on diet quality and nutritional status markers of elite U.S. Army special operations forces soldiers. Nutr J 2017; 16:41. [PMID: 28673301 PMCID: PMC5496422 DOI: 10.1186/s12937-017-0262-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/21/2017] [Indexed: 12/03/2022] Open
Abstract
Background Special Operations Forces (SOF) Soldiers deploy frequently and require high levels of physical and cognitive performance. Nutritional status is linked to cognitive and physical performance. Studies evaluating dietary intake and nutritional status in deployed environments are lacking. Therefore, this study assessed the effects of combat deployment on diet quality and serum concentrations of nutritional status markers, including iron, vitamin D, parathyroid hormone (PTH), glucose, and lipids, among elite United States (U.S.) Army SOF Soldiers. Methods Changes from baseline to post-deployment were determined with a repeated measure within-subjects design for Healthy Eating Index-2010 (HEI-2010) scores, intake of foods, food groups, key nutrients, and serum nutritional status markers. Dietary intake was assessed with a Block Food Frequency Questionnaire. The association between post-deployment serum 25-hydroxy vitamin D (25-OH vitamin D) and PTH was determined. Analyses of serum markers were completed on 50 participants and analyses of dietary intake were completed on 33 participants. Results In response to deployment, HEI-2010 scores decreased for total HEI-2010 (70.3 ± 9.1 vs. 62.9 ± 11.1), total fruit (4.4 ± 1.1 vs. 3.7 ± 1.5), whole fruit (4.6 ± 1.0 vs. 4.2 ± 1.4), dairy (6.2 ± 2.7 vs. 4.8 ± 2.4), and empty calories (14.3 ± 3.2 vs. 11.1 ± 4.5) (P ≤ 0.05). Average daily intakes of foods and food groups that decreased included total dairy (P < 0.01), milk (P < 0.01), and non-juice fruit (P = 0.03). Dietary intake of calcium (P = 0.05) and vitamin D (P = 0.03) decreased. PTH increased from baseline (3.4 ± 1.6 vs. 3.8 ± 1.4 pmol/L, P = 0.04), while there was no change in 25-OH vitamin D. Ferritin decreased (385 ± 173 vs. 354 ± 161 pmol/L, P = 0.03) and soluble transferrin receptor increased (16.3 ± 3.7 vs. 17.1 ± 3.5 nmol/L, P = 0.01). There were no changes in glucose or lipids. Post-deployment, serum 25-OH vitamin D was inversely associated with PTH (r = −0.43, P < 0.01). Conclusions HEI-2010 scores and dietary intake of milk, calcium, and vitamin D decreased following deployment. Serum PTH increased and iron stores were degraded. No Soldiers were iron deficient. Personnel that deploy frequently should maintain a high diet quality in the U.S. and while deployed by avoiding empty calories and consuming fruits, vegetables, and adequate sources of calcium, vitamin D, and iron. Improving availability and quality of perishable food during deployment may improve diet quality.
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Affiliation(s)
- Emily K Farina
- Henry Jackson Foundation for the Advancement of Military Medicine, 6720-A Rockledge Drive, Suite 100, Bethesda, MD, 20817, USA. .,Oak Ridge Institute for Science and Education, 492 Millennium Drive, Suite 101, Belcamp, MD, 21017, USA. .,U.S. Army Research Institute of Environmental Medicine, Military Nutrition Division, 10 General Greene Avenue, Building 42, Natick, MA, 01760, USA.
| | - Jonathan C Taylor
- Department of Health and Human Sciences, Office of the National Coordinator for Health Information Technology, 330 C Street, NW, Washington, DC, 20201, USA
| | - Gary E Means
- U.S. Army Special Operations Command, 2929 Desert Storm Drive, Fort Bragg, NC, 28303, USA
| | - Nancy E Murphy
- U.S. Army Research Institute of Environmental Medicine, Military Nutrition Division, 10 General Greene Avenue, Building 42, Natick, MA, 01760, USA
| | - Stefan M Pasiakos
- U.S. Army Research Institute of Environmental Medicine, Military Nutrition Division, 10 General Greene Avenue, Building 42, Natick, MA, 01760, USA
| | - Harris R Lieberman
- U.S. Army Research Institute of Environmental Medicine, Military Nutrition Division, 10 General Greene Avenue, Building 42, Natick, MA, 01760, USA
| | - James P McClung
- U.S. Army Research Institute of Environmental Medicine, Military Nutrition Division, 10 General Greene Avenue, Building 42, Natick, MA, 01760, USA
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Hodonsky CJ, Jain D, Schick UM, Morrison JV, Brown L, McHugh CP, Schurmann C, Chen DD, Liu YM, Auer PL, Laurie CA, Taylor KD, Browning BL, Li Y, Papanicolaou G, Rotter JI, Kurita R, Nakamura Y, Browning SR, Loos RJF, North KE, Laurie CC, Thornton TA, Pankratz N, Bauer DE, Sofer T, Reiner AP. Genome-wide association study of red blood cell traits in Hispanics/Latinos: The Hispanic Community Health Study/Study of Latinos. PLoS Genet 2017; 13:e1006760. [PMID: 28453575 PMCID: PMC5428979 DOI: 10.1371/journal.pgen.1006760] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 05/12/2017] [Accepted: 04/12/2017] [Indexed: 01/13/2023] Open
Abstract
Prior GWAS have identified loci associated with red blood cell (RBC) traits in populations of European, African, and Asian ancestry. These studies have not included individuals with an Amerindian ancestral background, such as Hispanics/Latinos, nor evaluated the full spectrum of genomic variation beyond single nucleotide variants. Using a custom genotyping array enriched for Amerindian ancestral content and 1000 Genomes imputation, we performed GWAS in 12,502 participants of Hispanic Community Health Study and Study of Latinos (HCHS/SOL) for hematocrit, hemoglobin, RBC count, RBC distribution width (RDW), and RBC indices. Approximately 60% of previously reported RBC trait loci generalized to HCHS/SOL Hispanics/Latinos, including African ancestral alpha- and beta-globin gene variants. In addition to the known 3.8kb alpha-globin copy number variant, we identified an Amerindian ancestral association in an alpha-globin regulatory region on chromosome 16p13.3 for mean corpuscular volume and mean corpuscular hemoglobin. We also discovered and replicated three genome-wide significant variants in previously unreported loci for RDW (SLC12A2 rs17764730, PSMB5 rs941718), and hematocrit (PROX1 rs3754140). Among the proxy variants at the SLC12A2 locus we identified rs3812049, located in a bi-directional promoter between SLC12A2 (which encodes a red cell membrane ion-transport protein) and an upstream anti-sense long-noncoding RNA, LINC01184, as the likely causal variant. We further demonstrate that disruption of the regulatory element harboring rs3812049 affects transcription of SLC12A2 and LINC01184 in human erythroid progenitor cells. Together, these results reinforce the importance of genetic study of diverse ancestral populations, in particular Hispanics/Latinos.
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Affiliation(s)
- Chani J. Hodonsky
- Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, United States of America
| | - Deepti Jain
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Ursula M. Schick
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- The Genetics of Obesity and Related Metabolic Traits Program, The Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
| | - Jean V. Morrison
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Lisa Brown
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Caitlin P. McHugh
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
- New York Genome Center, New York, NY, United States of America
| | - Claudia Schurmann
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- The Genetics of Obesity and Related Metabolic Traits Program, The Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Diane D. Chen
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, United States of America
| | - Yong Mei Liu
- School of Medicine, Wake Forest University, Winston-Salem, NC, United States of America
| | - Paul L. Auer
- Joseph J. Zilber School of Public Health, University of Wisconsin Milwaukee, Milwaukee, WI, United States of America
| | - Cecilia A. Laurie
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Kent D. Taylor
- Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA United States of America
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA United States of America
| | - Brian L. Browning
- Department of Medicine, University of Washington, Seattle, WA United States of America
| | - Yun Li
- Department of Genetics, University of North Carolina, Chapel Hill, NC, United States of America
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, United States of America
- Department of Computer Science, University of North Carolina, Chapel Hill, NC, United States of America
| | - George Papanicolaou
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, United States of America
| | - Jerome I. Rotter
- Institute for Translational Genomics and Population Sciences, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA United States of America
- Department of Pediatrics, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA United States of America
| | - Ryo Kurita
- Research and Development Department, Central Blood Institute, Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Yukio Nakamura
- Cell Engineering Division, RIKEN BioResource Center, Tsukuba, Ibaraki, Japan
- Comprehensive Human Sciences, Tsukuba University, Tsukuba, Ibaraki, Japan
| | - Sharon R. Browning
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Ruth J. F. Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- The Genetics of Obesity and Related Metabolic Traits Program, The Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Kari E. North
- Department of Epidemiology, University of North Carolina Gillings School of Public Health, Chapel Hill, NC, United States of America
- Department of Genetics, University of North Carolina, Chapel Hill, NC, United States of America
| | - Cathy C. Laurie
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Timothy A. Thornton
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Nathan Pankratz
- Division of Laboratory Medicine & Pathology, University of Minnesota, Minneapolis, MN, United States of America
| | - Daniel E. Bauer
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA, United States of America
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, United States of America
- Department of Pediatrics, Harvard Medical School and Harvard Stem Cell Institute, Harvard University, Boston, MA, United States of America
| | - Tamar Sofer
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Alex P. Reiner
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America
- * E-mail:
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High-Resolution Metabolomics for Nutrition and Health Assessment of Armed Forces Personnel. J Occup Environ Med 2016; 58:S80-8. [DOI: 10.1097/jom.0000000000000770] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Myhre KE, Webber BJ, Cropper TL, Tchandja JN, Ahrendt DM, Dillon CA, Haas RW, Guy SL, Pawlak MT, Federinko SP. Prevalence and Impact of Anemia on Basic Trainees in the US Air Force. SPORTS MEDICINE-OPEN 2016; 2:23. [PMID: 27239430 PMCID: PMC4863912 DOI: 10.1186/s40798-016-0047-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 04/27/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anemia has been implicated in adverse health outcomes of athletes and military trainees, ranging from overuse injuries to degraded physical and cognitive performance. The purpose of this study was to investigate prevalence of anemia among US Air Force (USAF) basic trainees, to compare physical performance and discharge rates between anemic and non-anemic trainees, and to determine the risks and relative risks of being discharged for anemic versus non-anemic women and men. METHODS All USAF basic trainees were screened for anemia between July 2013 and January 2014, during an 8-week basic training course at Joint Base San Antonio-Lackland, TX. Age, sex, screening hemoglobin, anthropometric measurements, initial/final physical fitness assessment scores, and discharge data were collected from trainees. Those identified as anemic (hemoglobin <13.5 g/dL for males and <12.0 g/dL for females) received additional labwork, nutritional counseling, and oral iron-replacement, if indicated. Mean percent improvement was calculated for all performance parameters from beginning to end of training. Anemic trainees were compared to non-anemic trainees by t test with Welch modification. Results were stratified by sex and anemia severity with post-hoc Bonferroni correction. RESULTS Prevalence of anemia was 12.6 % (N = 18,827). 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. Mean 1.5-mile run-time, push-up and sit-up counts improved from beginning to end of training for both anemic and non-anemic trainees (p < 0.001 both). Non-anemic trainees had slightly greater run-time improvements than borderline and moderate anemics (female: 17.7 vs. 15.2, and 15.1 % improvement, p < 0.05 both; male: 14.9 vs. 13.2, and 13.5 % improvement, p < 0.05 both). One-way ANOVA demonstrated statistically significant differences between initial and final fitness data for all measures and both genders (p < 0.001) with the exception of final sit-up counts for male trainees (p = 0.082). Discharge rate for anemic trainees was 9.0 % (20 % for severely anemic trainees) as compared to 5.7 % for non-anemics. CONCLUSIONS Anemia was prevalent among USAF basic trainees. Identification and treatment of anemia may optimize physical performance and decrease the rate of medical discharge.
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Affiliation(s)
- Kathryn E Myhre
- Joint Base San Antonio, Adolescent and Young Adult Medicine Service, Fort Sam Houston, San Antonio, TX USA ; University of Texas School of Public Health, San Antonio, USA
| | | | | | | | - Dale M Ahrendt
- Joint Base San Antonio, Adolescent and Young Adult Medicine Service, Fort Sam Houston, San Antonio, TX USA
| | - Christopher A Dillon
- Joint Base San Antonio, Adolescent and Young Adult Medicine Service, Fort Sam Houston, San Antonio, TX USA
| | - Roy W Haas
- Joint Base San Antonio, Lackland, San Antonio, TX USA
| | | | - Mary T Pawlak
- Joint Base San Antonio, Lackland, San Antonio, TX USA
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Louzada ML, Hsia CC, Al-Ani F, Ralley F, Xenocostas A, Martin J, Connelly SE, Chin-Yee IH, Minuk L, Lazo-Langner A. Randomized double-blind safety comparison of intravenous iron dextran versus iron sucrose in an adult non-hemodialysis outpatient population: A feasibility study. BMC HEMATOLOGY 2016; 16:7. [PMID: 26973791 PMCID: PMC4788943 DOI: 10.1186/s12878-016-0046-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 03/08/2016] [Indexed: 11/15/2022]
Abstract
Background Intravenous iron therapy is a treatment option for iron deficient patients who are intolerant to oral iron or where oral iron is ineffective, but with possible adverse effects. Currently, prospective studies comparing different intravenous iron formulations are needed to determine safety and efficacy of these agents. Methods We conducted a prospective, double-blind, randomized controlled trial (RCT) to assess the feasibility of a trial comparing the safety of high molecular weight intravenous iron dextran, Infufer®, with intravenous iron sucrose, Venofer®, in non-hemodialysis adult outpatients. Primary outcome was the occurrence of immediate severe drug reactions. Results We enrolled 143 patients in a one-year period. Overall, 45/143 (31.5 %) patients (20 iron dextran, 25 iron sucrose) developed 48 infusion reactions (14 immediate, 28 delayed, and 3 both). The risk of an immediate reaction was similar in both groups, 9/73 (12.3 %) iron dextran versus 8/70 (11.4 %) iron sucrose, RR = 0.93 (95 % CI; 0.38 to 2.27). The risk of a delayed reaction was significantly higher in the iron sucrose group 22/70 (31.4 %) versus the iron dextran group 9/73 (12.3 %), RR = 2.55 (95 % CI; 1.26 to 5.15; p = 0.0078). Conclusion In this limited feasibility study, no major differences in immediate reactions were seen, but a significantly higher number of delayed reactions were seen in the iron sucrose group. Further, under our assumptions and design a full RCT to evaluate the safety of different intravenous iron preparations is not feasible. Future studies should consider modifying the clinical outcomes, utilize multiple centers, and consider other emerging parenteral iron formulations. (ClinicalTrials.gov NCT005936197 January 3, 2008).
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Affiliation(s)
- Martha L Louzada
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada
| | - Cyrus C Hsia
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada ; London Health Sciences Centre, Department of Medicine, Division of Hematology. Rm E6-219A, Victoria Hospital, 800 Commissioners Road E., London, ON N6A 5W9 Canada
| | | | - Fiona Ralley
- University of Western Ontario, London, ON Canada ; Department of Anesthesia and Perioperative Medicine, London, ON Canada
| | - Anargyros Xenocostas
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada
| | - Janet Martin
- University of Western Ontario, London, ON Canada ; Department of Pharmacy, London Health Sciences Centre, London, ON Canada
| | - Sarah E Connelly
- University of Western Ontario, London, ON Canada ; Department of Pharmacy, London Health Sciences Centre, London, ON Canada
| | - Ian H Chin-Yee
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada
| | - Leonard Minuk
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, London, ON Canada ; University of Western Ontario, London, ON Canada ; Department of Epidemiology & Biostatistics, London, ON Canada
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Consumption of a calcium and vitamin D-fortified food product does not affect iron status during initial military training: a randomised, double-blind, placebo-controlled trial. Br J Nutr 2015; 115:637-43. [DOI: 10.1017/s0007114515004766] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractCa/vitamin D supplementation maintains bone health and decreases stress fracture risk during initial military training (IMT); however, there is evidence that Ca may negatively affect the absorption of other critical micronutrients, particularly Fe. The objective of this randomised, double-blind, placebo-controlled trial was to determine whether providing 2000 mg/d Ca and 25µg/d vitamin D in a fortified food product during 9 weeks of military training affects Fe status in young adults. Male (n98) and female (n54) volunteers enrolled in US Army basic combat training (BCT) were randomised to receive a snack bar with Ca/vitamin D (n75) or placebo (snack bar without Ca/vitamin D;n77) and were instructed to consume 2 snack bars/d between meals throughout the training course. Circulating ionised Ca was higher (P<0·05) following BCT among those consuming the Ca/vitamin D bars compared with placebo. Fe status declined in both groups over the course of BCT. Transferrin saturation, serum ferritin and Hb were reduced (P<0·05) and soluble transferrin receptor increased (P<0·05) following BCT. There were no differences (P>0·05) in markers of Fe status between placebo and Ca/vitamin D groups. Collectively, these data indicate that Ca/vitamin D supplementation through the use of a fortified food product consumed between meals does not affect Fe status during IMT.
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DELLAVALLE DIANEM, HAAS JERED. Iron Supplementation Improves Energetic Efficiency in Iron-Depleted Female Rowers. Med Sci Sports Exerc 2014; 46:1204-15. [DOI: 10.1249/mss.0000000000000208] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Pei SN, Ma MC, You HL, Fu HC, Kuo CY, Rau KM, Wang MC, Lee CT. TMPRSS6 rs855791 polymorphism influences the susceptibility to iron deficiency anemia in women at reproductive age. Int J Med Sci 2014; 11:614-9. [PMID: 24782651 PMCID: PMC4003547 DOI: 10.7150/ijms.8582] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/14/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Genome-wide-association studies have identified the TMPRSS6 polymorphism rs855791 has the strongest association with red blood cell indices or iron parameters in general population. Whether this genetic variant influences the susceptibility of iron deficiency anemia (IDA) in women with menstruation has not been well studied. METHODS In this case-control study, we enrolled 67 women with IDA and 107 healthy volunteers, and analyzed their complete blood counts, rs855791 genotypes, and menstrual amounts. Menstrual blood loss was evaluated with a pictorial blood-loss assessment chart. RESULTS There were significantly fewer rs855791 C homozygotes in the IDA group than in the healthy group (11.9% vs. 25.2%, p = 0.03). The odds ratio (OR) of C homozygotes having IDA versus non-CC subjects having IDA was 0.4 (95% CI, 0.17 - 0.95, p = 0.04). When the analysis was confined to study subjects with menorrhagia, this difference became more prominent (9.6% vs. 28.6%, p = 0.01; OR, 0.27, 95% CI, 0.09 - 0.77, p = 0.01). For women with non-CC genotypes, there was an inverse correlation between hemoglobin levels and menstrual loss (p < 0.001); however, this association was not found for those with genotypes CC (p = 0.15). CONCLUSIONS Our study suggests homozygosity for TMPRSS6 rs855791 C genotype has a protective role against IDA in women at reproductive age, especially in those with menorrhagia.
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Affiliation(s)
- Sung-Nan Pei
- 1. Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan ; 2. Chang Gung University College of Medicine, Taoyuan, Taiwan ; 3. Graduate Institute of Clinical Medical Sciences, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chun Ma
- 1. Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Huey-Ling You
- 2. Chang Gung University College of Medicine, Taoyuan, Taiwan ; 4. Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital
| | - Hung-Chun Fu
- 2. Chang Gung University College of Medicine, Taoyuan, Taiwan ; 5. Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital
| | - Ching-Yuan Kuo
- 1. Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kun-Ming Rau
- 1. Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan ; 2. Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ming-Chung Wang
- 1. Division of Hema-Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan ; 2. Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chien-Te Lee
- 2. Chang Gung University College of Medicine, Taoyuan, Taiwan ; 6. Division of Nephrology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Abstract
Moderate/severe obesity is on the rise in the United States. Weight management includes bariatric surgery, which is effective and can alleviate morbidity and mortality from obesity-associated diseases. However, many individuals are dealing with nutritional complications. Risk factors include: 1) preoperative malnutrition (e.g., vitamin D, iron); 2) decreased food intake (due to reduced hunger and increased satiety, food intolerances, frequent vomiting); 3) inadequate nutrient supplementation (due to poor compliance with multivitamin/multimineral regimen, insufficient amounts of vitamins and/or minerals in supplements); 4) nutrient malabsorption; and 5) inadequate nutritional support (due to lack of follow-up, insufficient monitoring, difficulty in recognizing symptoms of deficiency). For some nutrients (e.g., protein, vitamin B-12, vitamin D), malnutrition issues are reasonably addressed through patient education, routine monitoring, and effective treatment strategies. However, there is little attention paid to other nutrients (e.g., zinc, copper), which if left untreated may have devastating consequences (e.g., hair loss, poor immunity, anemia, defects in neuro-muscular function). This review focuses on malnutrition in essential minerals, including calcium (and vitamin D), iron, zinc, and copper, which commonly occur following popular bariatric procedures. There will be emphasis on the complexities, including confounding factors, related to screening, recognition of symptoms, and, when available, current recommendations for treatment. There is an exceptionally high risk of malnutrition in adolescents and pregnant women and their fetuses, who may be vulnerable to problems in growth and development. More research is required to inform evidence-based recommendations for improving nutritional status following bariatric surgery and optimizing weight loss, metabolic, and nutritional outcomes.
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Affiliation(s)
| | - Breanne N. Wright
- Department of Nutrition Science, Purdue University, West Lafayette, IN
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Abstract
BACKGROUND Maternal anemia and several complications of pregnancy can affect fetal iron acquisition. AIM Because it is unknown whether the effects of demographic and maternal risk factors (RF) are summative, we examined cord iron status in newborns with multiple RF for acquiring iron deficiency. METHODS Cord blood indices from healthy control newborns with and without RF for newborn or infant iron deficiency were studied. RESULTS Newborns with greater RF had poorer erythrocyte and storage iron status. Poorest status was seen if mothers with comorbid obesity and diabetes delivered large-for-gestation newborns. Findings highlight the importance of identifying RF.
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McClung JP, Murray-Kolb LE. Iron Nutrition and Premenopausal Women: Effects of Poor Iron Status on Physical and Neuropsychological Performance. Annu Rev Nutr 2013; 33:271-88. [DOI: 10.1146/annurev-nutr-071812-161205] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- James P. McClung
- Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine (USARIEM), Natick, Massachusetts 01760;
| | - Laura E. Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, University Park, Pennsylvania 16802
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Sharma S, Sheehy T, Kolonel LN. Contribution of meat to vitamin B₁₂, iron and zinc intakes in five ethnic groups in the USA: implications for developing food-based dietary guidelines. J Hum Nutr Diet 2013; 26:156-68. [PMID: 23398393 DOI: 10.1111/jhn.12035] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND To describe the sources of meat and their contributions to vitamin B₁₂, iron and zinc in five ethnic groups in the USA. METHODS Dietary data for the Multiethnic Cohort, established in Hawaii and Los Angeles, were collected using a quantitative food frequency questionnaire from more than 215,000 subjects, aged 45-75 years at baseline (1993-1996). Participants included African American, Latino, Japanese American, Native Hawaiian and Caucasian men and women. Servings of meat items were calculated based on the US Department of Agriculture recommendations and their contributions to intakes of total meat, red meat, vitamin B₁₂, iron and zinc were determined. RESULTS Of all types of meat, poultry contributed the most to meat consumption, followed by red meat and fish among all ethnicities, except for Latino (born in Mexico and Central/South America) men who consumed more beef. Lean beef was the most commonly consumed red meat for all ethnic-sex groups (9.3-14.3%), except for Native Hawaiian and Japanese American men, and Japanese American women whose top contributor was stew/curry with beef/lamb and stir-fried beef/pork with vegetables, respectively. The contribution of meat was most substantial for zinc (11.1-29.3%) and vitamin B₁₂ (19.7-40%) and, to a lesser extent, for iron (4.3-14.2%). CONCLUSIONS This is the first large multiethnic cohort study to describe meat sources and their contributions to selected nutrients among ethnic minorities in the USA. These findings may be used to develop ethnic-specific recommendations for meat consumption aiming to improve dietary quality among these groups.
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Affiliation(s)
- S Sharma
- Epidemiology Program, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI, USA.
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Physiological employment standards IV: integration of women in combat units physiological and medical considerations. Eur J Appl Physiol 2012; 113:2673-90. [DOI: 10.1007/s00421-012-2558-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 11/22/2012] [Indexed: 12/20/2022]
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Latunde-Dada GO. Iron metabolism in athletes - achieving a gold standard. Eur J Haematol 2012; 90:10-5. [DOI: 10.1111/ejh.12026] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 01/01/2023]
Affiliation(s)
- Gladys O. Latunde-Dada
- Diabetes and Nutritional Sciences Division; School of Medicine; King's College London; London; UK
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Abstract
Iron deficiency (ID) is the most prevalent micronutrient deficiency disorder in the world. In the developed world, the greatest prevalence of ID and iron deficiency anemia (IDA) occurs in premenopausal women. Premenopausal women experience ID and IDA due to inadequate consumption of dietary iron coupled with iron losses through physiologic processes such as menstruation. Further, female athletes may experience an elevated risk of ID and IDA, as hepcidin, a peptide hormone that inhibits iron absorption and sequesters iron in the macrophage, may rise in response to physical activity. Declines in physical and cognitive performance have been demonstrated in female athletes with ID and IDA. Performance decrements are attenuated as iron status improves. This review will focus on iron status in female athletes, and will include a review of nutritional countermeasures to prevent ID and IDA.
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Affiliation(s)
- James P McClung
- Military Nutrition Division, United States Army Research Institute of Environmental Medicine (USARIEM), Natick, MA 01760, USA.
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Yanovich R, Merkel D, Israeli E, Evans RK, Erlich T, Moran DS. Anemia, iron deficiency, and stress fractures in female combatants during 16 months. J Strength Cond Res 2012; 25:3412-21. [PMID: 22080308 DOI: 10.1519/jsc.0b013e318215f779] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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.
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Affiliation(s)
- Ran Yanovich
- Heller Institute of Medical Research, Sheba Medical Center, Tel Hashomer, Israel
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Lai JF, Dobbs J, Dunn MA. Evaluation of clams as a food source of iron: Total iron, heme iron, aluminum, and in vitro iron bioavailability in live and processed clams. J Food Compost Anal 2012. [DOI: 10.1016/j.jfca.2011.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Che LL, Xiao DS, Xu HX, Lu L. Changes of iron stores and duodenal transepithelial iron transfer during regular exercise in rats. Biol Trace Elem Res 2011; 143:1044-53. [PMID: 21174168 DOI: 10.1007/s12011-010-8919-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 12/05/2010] [Indexed: 11/28/2022]
Abstract
It is unclear whether regular exercise depletes body iron stores and how exercise regulates iron absorption. In this study, growing female Sprague-Dawley rats were fed a high-iron diet (300 mg iron/kg) and subjected to swimming for 1, 3, or 12 months. Their body weight, liver nonheme iron content (NHI), spleen NHI, blood hemoglobin (Hb) concentration, hematocrit (Hct), and kinetics of 59Fe transfer across isolated duodenal segments were then compared with sedentary controls. The main results were as follows: exercise for 1 month enhanced the transepithelial 59Fe transfer and increased liver NHI content and Hb concentration; exercise for 3 months inhibited transepithelial 59Fe transfer without affecting the liver and spleen NHI content, Hb concentration, and Hct; exercise for 12 months did not affect these parameters as compared with the corresponding sedentary controls; and the changes in transepithelial iron transfer were not associated with basolateral iron transfer. Our findings demonstrated that chronic, regular exercise in growing rats with a high dietary iron content does not deplete iron stores in the liver and spleen and may possibly enhance or inhibit duodenal iron absorption and even maintain duodenal iron absorption at the sedentary level, at least, in part depending on growth.
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Affiliation(s)
- Li-Long Che
- Department of Physiology, School of Medical Science and Laboratory Medicine, Jiangsu University, Zhenjiang, 212013, China
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Bass LJ, McClung JP. Iron Nutrition and the Female Athlete: Countermeasures for the Prevention of Poor Iron Status. J Evid Based Complementary Altern Med 2011. [DOI: 10.1177/2156587211401747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Iron is a trace element found in the diet and is essential for cognition and energy metabolism. Poor iron status is a concern for female athletes, who might not consume adequate levels of dietary iron and could experience elevated iron loss from physiologic processes associated with physical activity. Physical performance and cognitive decrements have been demonstrated in female athletes with iron deficiency anemia; both improve with increased iron intake. Two approaches for increasing iron intake in female athletes are the consumption of iron supplements and increasing dietary intake of foods high in iron to include iron-fortified foods. Both of these approaches have advantages and disadvantages that should be considered when treating female athletes with poor iron status.
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Affiliation(s)
- Laura J. Bass
- United States Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA
| | - James P. McClung
- United States Army Research Institute of Environmental Medicine (USARIEM), Natick, MA, USA
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Abstract
PURPOSE OF REVIEW In the United States, blood donation rates of African-Americans are 25-50% of that of white individuals. As African-Americans make up an ever increasing and now substantial minority, and African-American recipients of blood transfusion, both specialized, such as sickle cell disease patients, and general hospitalized patients, have a better chance of receiving phenotype-matched or appropriate red blood cell units when there is a significant percentage of products in the inventory from African-American donors, it is important to understand the reason for the observed difference. RECENT FINDINGS Possible reasons for this discrepancy in donation rates include increased rates of donor deferral and ineligibility; increased barriers to donation, such as fear and distrust; and different marketing and education strategies. Thus, to increase the blood availability to African-American recipients, the reasons for these donation rate differences must be better understood and subsequently addressed through improved blood donor recruitment programs. The majority of African-American donor recruitment programs have focused on donating for sickle cell disease patients, particularly children, which have been of limited success. SUMMARY Significant improvements in African-American donor recruitment are needed to adequately meet the demand of African-American patients as well as the entire population.
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Affiliation(s)
- Beth H Shaz
- New York Blood Center, New York, New York 10065, USA.
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Abstract
Incidence rates for oesophageal adenocarcinoma have increased by over 500% during the past few decades without clear reasons. Gastro-oesophageal reflux disease, obesity and smoking have been identified as risk factors, although the demographic distribution of these risk factors is not consistent with the demographic distribution of oesophageal adenocarcinoma, which is substantially more common among whites and males than any other demographic groups. Numerous epidemiological studies have suggested associations between dietary factors and the risks of oesophageal adenocarcinoma and its precursor, Barrett's oesophagus, though a comprehensive review is lacking. The main aim of the present review is to consider the evidence linking dietary factors with the risks of oesophageal adenocarcinoma, Barrett's oesophagus, and the progression from Barrett's oesophagus to oesophageal adenocarcinoma. The existing epidemiological evidence is strongest for an inverse relationship between intake of vitamin C, β-carotene, fruits and vegetables, particularly raw fruits and vegetables and dark green, leafy and cruciferous vegetables, carbohydrates, fibre and Fe and the risk of oesophageal adenocarcinoma and Barrett's oesophagus. Patients at higher risk for Barrett's oesophagus and oesophageal adenocarcinoma may benefit from increasing their consumption of fruits and vegetables and reducing their intake of red meat and other processed food items. Further research is needed to evaluate the relationship between diet and the progression of Barrett's oesophagus to oesophageal adenocarcinoma. Evidence from cohort studies will help determine whether randomised chemoprevention trials are warranted for the primary prevention of Barrett's oesophagus or its progression to cancer.
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Karl JP, Lieberman HR, Cable SJ, Williams KW, Young AJ, McClung JP. Randomized, double-blind, placebo-controlled trial of an iron-fortified food product in female soldiers during military training: relations between iron status, serum hepcidin, and inflammation. Am J Clin Nutr 2010; 92:93-100. [PMID: 20444958 DOI: 10.3945/ajcn.2010.29185] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Iron status degrades in female soldiers during military training. Inflammation-mediated up-regulation of hepcidin, a key mediator of iron homeostasis, may be a contributing factor. OBJECTIVE We measured the efficacy of an iron-fortified food product for maintaining iron status in female soldiers during basic combat training (BCT) and examined relations between iron status, serum hepcidin concentrations, and inflammation. DESIGN A randomized, double-blind, placebo-controlled trial was conducted. Volunteers received an iron-fortified food product (total dose = 56 mg Fe/d) or a placebo twice daily during the 9-wk BCT course. Iron-status indicators, serum hepcidin concentrations, and markers of inflammation were measured pre- and post-BCT. RESULTS BCT affected iron status; serum ferritin concentrations decreased (P < or = 0.05), and concentrations of soluble transferrin receptor (sTfR) and hemoglobin and the red cell distribution width increased (P < or = 0.05). Consumption of the iron-fortified food product attenuated declines in iron status in iron-deficient anemic soldiers; a group-by-time interaction was observed for hemoglobin and sTfR concentrations (P < or = 0.05). Serum hepcidin concentrations were not affected by BCT; however, hepcidin concentrations were lower in iron-deficient anemic soldiers than in those with normal iron status (P < or = 0.05) and were positively associated with serum ferritin (P < or = 0.05) and C-reactive protein (P < or = 0.05) concentrations pre- and post-BCT. CONCLUSIONS Twice-daily consumption of an iron-fortified food product improved iron status in iron-deficient anemic soldiers but not in iron-normal or iron-deficient nonanemic soldiers. Serum hepcidin concentrations were not affected by training but were associated with iron status and inflammation pre- and post-BCT. This trial was registered at clinicaltrials.gov as NCT01100905.
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Affiliation(s)
- J Philip Karl
- US Army Research Institute of Environmental Medicine, Natick, MA, USA
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Wilson C, Brothers M. Iron deficiency in women and its potential impact on military effectiveness. Nurs Clin North Am 2010; 45:95-108. [PMID: 20510697 DOI: 10.1016/j.cnur.2010.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Iron 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.
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Affiliation(s)
- Candy Wilson
- Nursing Research, Wilford Hall Medical Center, 2200 Bergquest Drive, Lackland Air Force Base, TX 78236-9908, USA.
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McClung JP, Karl JP. Vitamin D and stress fracture: the contribution of vitamin D receptor gene polymorphisms. Nutr Rev 2010; 68:365-9. [DOI: 10.1111/j.1753-4887.2010.00295.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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