Iron b vit def v7

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BCT Female Nutritional Deficiencies

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BCT Female Iron and B-vitamin DeficienciesUSARIEM BCT Study

• 1993 study of 174 women in an all-female 8-week BCT company at Fort Jackson, SC (158 graduated).

• Serum ferritin (body iron stores) were low pre-BCT (56% females at less than 20 ng/ml iron) and decreased further by graduation (84%)(pg.109).

• Anemia was correlated with poor PT performance (pg. 111) • Serum folate levels were low normal pre-BCT and “decreased

significantly over BCT.” (pg. 2)• Maternal low folate intake and blood levels have been

"associated with (fetal) neural tube defects“ (pg. 39) (note: neural tube defects can be fatal for the fetus).

• Menu was adequate in energy, but inadequate in B6, folic acid, calcium, magnesium, iron, and zinc.

• Source: “Health, Performance, and Nutritional Status of U.S. Army Women during Basic Combat Training,” (1995)(ADA302042)

• NOTE: Study BCT menu governed by the 1985 AR 40-25



BCT Female Iron and B-vitamin Deficiencies

Institute of Medicine (IOM) Review• Separate review of multiple studies.• 17% of women were iron deficient (<12 ng/ml) and 8% were anemic at BCT entry.

• 35% were deficient and 26% were anemic at AIT entry.• Source: National Academy of Science’s Institute of Medicine (IOM) Committee on Military Nutrition Research (CMNR) 1995 “Review of Issues Related to Iron Status in Women During U.S. Army Basic Combat Training”




General Population• General Population: 9-11% of adolescent and child-bearing age women are iron deficient and 2-5% are anemic.

• Source: The National Health and Nutrition Examination Survey (NHANES)(1988-1994)(TAB D) conducted by the Center for Disease Control (CDC)

• NOTE: The NHANES uses a more conservative iron deficiency definition than the USARIEM study.



BCT Female Iron and B-vitamin Deficiencies1985 AR 40-25

• AR 40-25, “Nutrition Allowances, Standards, and Education” (BUMEDINST 10110.6; AFI 44-141)

• Establishes the dietary allowances for all Soldiers 17-50 y/o with moderate activity levels.

• 1985 AR 40-25:• “The dietary allowance for females and 17- to 18-year old males is 18 milligrams (mg)/day …” (page 3, Chapter 2-5, e)

• "Moderately active female personnel consuming an average of 2,400 calories per day may require supplemental iron to meet the recommended 18 mg/day“ (page 3, Chapter 2-5, e)

• “The computed iron density represents an interpolation between the male and female MRDA for iron. … This iron density (6 mg/1,000 calories) may be inadequate for women." (page 3, Chapter 3-1).

• MRDA for men was 10-18 mg/day and 18 mg/day for females.• AR 40-25 was updated in 2001.



BCT Female Iron and B-vitamin Deficiencies2001 AR 40-25

• Established iron MRDI at 10 mg/day for men and 15 mg/day for women.

• Added notes that the MRDIs for iron, calcium, phosphorous, and magnesium are low for 17-18 year-olds and menus should be adjusted if the dining facility has a large <19 y/o population. (page 6, Table 2-1, Notes 9-12)

NOTE 1: Current IOM standards for menstruating women on a regular diet are 18 mg/day of iron (27 mg/day for vegetarians) while men only need 12 mg/day. Excess iron is not desirable.

NOTE 2: Federal dietary policy shifted between 1985 and 2001. The 1985 policy was the ‘minimum needed to avoid disease’ while today’s policy is to ‘optimize health.’




Deficiency Common CausesDiet

• Too little dietary iron• Iron absorption factors:

• plant-based iron is less bio-available than meat-based iron

• vitamin C-rich foods increase iron absorption• tea/coffee binds iron in food

Blood loss • Menses• Gastro Intestinal bleeding• Ulcers

NOTE: Anemia should be evaluated by a physician.



Deficiency Common ImpactsIron Deficiency/Anemia• Decreased PT/work performance• Fatigue/weakness• Psychological (e.g. Irritability, etc.)• Shortness of breath• Mild decreased cognitive ability

Folate Deficiency Anemia• Birth defects• Fatigue• Anorexia nervosa • Pale skin • Paranoia • Rapid heart beat • Sore, inflamed tongue • Weakness • Weight loss.


•Bruises or tires easily •Feels ill for more than five days •Feels weak or out of breath •Looks pale or jaundiced.




Courses of Action (Nov ’01)1. Vitamin/mineral supplement.

• MEDDACs issue a gender-specific multi-vitamin/mineral supplement with iron.

• This would increase MEDDAC costs.• May prevent low or marginally deficient women from further decline of iron stores.

• It would not correct anemic women. It may take 2 months to 1 year to restore depleted iron stores in an anemic woman.



Courses of Action (Nov ’01)(Cont.)2. MEPCOM conduct pre-entry iron deficiency

screening. • MEPCOM does not currently screen for iron deficiency. • MEPCOM would require additional resources (45,522 female tests/year at $2.05/hematocrit finger stick screening testa = $93,320.).

• Anemic women who re-applied after treatment by their family doctor would require additional testing ($182-$284K, assuming 16-25% test deficient at $25/testb)(Screen/Test Total: $93 + $284 = approx. $377k worst case).

• Anemic women would be screened out IAW AR 40-501, possibly reducing qualified applicants by 7-11k (women would have to get treatment at their own expense; MEPS cannot treat).

NOTE a. The hematocrit test is an inexpensive screen, but is not highly accurate.

NOTE b. The $25 test offers better accuracy.





Courses of Action (Nov ’01)(cont.)3. Reception BN-based testing.

• OTSG/MEDCOM develop a Reception Battalion-based iron screening, education, and treatment program.

• MEDCOM would screen all female recruits for iron deficiency (FY01 25k). The screening cost ($2.05/test) would be $51,250 (25k tests).

• Anemic women would require additional testing and treatment over 2 months to 1 year. Minimum costs would range from $100-$190K, assuming 16-25% of 25k test deficient at $25/evaluation test plus treatment costs (TBD).



Courses of Action (Nov ’01)(cont.)4. OTSG/MEDCOM/MRDC conduct further research on BCT

females. • Determine

• Current entry nutritional status• Nutritional status impact on 9-week BCT performance/injuries/attrition

• 9-week BCT nutritional requirements• Best Technical Approach (BTA), costs, and cost-benefits for nutritional screening and supplementation. Test new BTA in BCT.

• Cost-benefit of any recommended nutritional education/marketing interventions

• Align AR 40-25, Nutritional Standards and Education, and AR 30-1, The Army Food Service Program, so that menu standards, planning, and execution are consistent.





MEDCOM Response (Aug ’01)

• Non-concur with all proposed August COA.• Soldiers may abuse vitamins or other supplements• MEPCOM screen is cost-prohibitive• MEDCOM screen is cost prohibitive• AR 40-25 was recently updated. Diet can easily be enhanced with iron-rich foods and vitamin C-rich foods.

Source: COL Forman, Nutrition Care Program Manager




Consideration of MEDCOM Non-Concurrence• Soldiers may abuse vitamins or other supplements

BCT has well-established control procedures. Other supplements are not available or are forbidden. Vitamin poisonings typically occurs in children, not

adults.• MEPCOM screen is cost-prohibitive

MEPCOM would give 45k female Army tests Cost would be approximately $2.05/test

• MEDCOM screen is cost prohibitive MEDCOM would give 25k female Army tests Cost would be approximately $2.05/test

• AR 40-25 was recently updated. Diet can easily be enhanced with iron-rich foods and vitamin C-rich foods.

AR 40-25 diet is untested in an operational BCT setting Recruits do not have the option to enhance their diet



BCT Female Iron and B-vitamin DeficienciesRecommendation

• Request OTSG/MEDCOM conduct further research on BCT females.• MEDCOM determine entry nutritional status and 9-week BCT nutritional training requirements.

• The 2001 AR 40-25 military diet is untested in the 9-week BCT operational environment, therefore there is no evidence it will fix the deficiencies.

• AR 40-25, Nutritional Standards and Education, and AR 30-1, The Army Food Service Program, should be aligned.

• This research could also include CHPPM and ARL to look at any nutrition-injury and nutrition-performance linkages. Entry bone status and bone remodeling during IET, for example, may be problem areas.

• MEDCOM design and evaluate cost-effective testing, education, and treatment solutions based on their research.

• Fixing these issues will positively affect Readiness and Land Warrior mission performance. Conserve the Fighting Strength

Iron b vit def v7

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