Vitamin Deficiencies in the Military

by Benjamin Bunting BA(Hons) PGCert

Ben Bunting BA(Hons) PGCert Sports and Exercise Nutrition Level 2 Strength and Conditioning CoachWritten by Ben Bunting: BA(Hons), PGCert. Sport & Exercise Nutrition. L2 Strength & Conditioning Coach.

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The United States Department of Defense (DoD) has launched a campaign to educate and promote the importance of vitamin D in bone health among service members. The campaign, "Strong Bones", is a two-part effort aimed at raising awareness about vitamin D and bone health. The first part includes food fortification and dietary modifications. The second part focuses on screening for vitamin D deficiency. It also highlights the importance of dietary supplements.

Nutritional deficiencies in military personnel

It has been identified that there's a prevalence of deficiency in (Glucose-6-phosphate dehydrogenase) G6PD was similar among all service members, there were differences in the rate of G6PD deficiency among service members. A deficiency means that the person has a genetic disorder that reduces the G6PD enzyme that they have which in turn means their red blood cells breakdown prematurely. 

The rates were significantly higher for non-Hispanic black males than for non-Hispanic white males. The highest proportion of service members with G6PD deficiency was found in the Navy and Air Force. The least likely to be deficient were service members in the Coast Guard and Marine Corps.

This study featuring on the Military Health Sytem website aimed to determine the incidence of vitamin deficiency among U.S. military personnel. It also aimed to understand demographic and temporal trends of vitamin deficiencies. This study used the Defense Medical Epidemiological Database to identify vitamin deficiencies in service members. The researchers also looked at vitamin A and vitamin D deficiency in women and black people. They also found that these deficiencies were more common in older service members.

Dietary intake

The military is a very demanding profession, and soldiers are no exception. The stress of the job demands a varied and nutritious diet, but many soldiers don't get the proper balance of nutrients. A US Army survey found that many personnel blame the on base facilities for offering a lack of healthy options.

In Britain, malnutrition among soldiers during the industrial age resulted in a 6 inch height loss. Today, some soldiers are consuming far too few fruits and vegetables and don't get adequate amounts of vitamins and minerals. In this article, we'll outline the specific nutritional requirements of 'soldier athletes', who go through rigorous training and maintain a state of readiness.

Military personnel should reduce the intake of empty calories and increase their consumption of fruits and vegetables. Dietary iron and zinc should be adequate sources. They should also be given access to perishable foods to improve their diet.

Food fortification

Fortified foods are enriched with additional nutrients, such as vitamins and minerals. Foods that have been fortified are regulated by the Food and Drug Administration to meet a variety of standards. These guidelines also outline which foods can be fortified. Foods can be fortified with additional vitamins, minerals, or both. Foods can also be fortified with protein or other nutrients. The food manufacturers need to meet a variety of safety standards before they add fortifications to their products.

Fortified foods help lower multiple deficiencies caused by poor diets. Fortified foods can help children grow up, and women of reproductive age maintain a healthy pregnancy and lactation. A good example are breakfast cereals and milk. Fortified foods also contribute micronutrients from a balanced diet that are close to natural levels. 

Military rations

A new study has examined vitamin deficiency and disorder incidence rates in the US military population. While overall rates of vitamin deficiencies and disorder were low, the rate of diagnosis was significantly higher among black men and women. The findings support the need for dietary modifications and screening for specific deficiencies among military populations, and are useful in public health messages targeting certain demographic groups. In the meantime, the study shows that the costs of dietary modifications are relatively low.

The military first adapted rations to improve their vitamin content by increasing the amount of fruits and vegetables. Vitamin C, for example, was contained in C-rations. However, troops called lemon juice powder "bug juice" and used it for other purposes like bleaching floors. Consequently, the military added vitamin C to rations components. The changes were gradual, but significant.

Deficiencies increase Cardiovascular Risk

In the Intermountain Heart Collaborative study, nearly 200,000 women in the military reported having suboptimal vitamin D levels. Women who were ill from vitamin D deficiencies were more likely to develop heart failure or stroke. In addition, suboptimal vitamin D status is associated with increased arterial stiffness and vascular endothelial dysfunction, two risk factors for cardiovascular disease. As a result, it is important to understand the cause and treatment options for vitamin deficiencies.

The prevalence of vitamin D deficiency in older adults is between 40 percent and 60 percent. Supplementation can improve executive functions and may improve overall cognition. In one study, vitamin D supplementation improved cognitive maintenance versus the placebo and wasn't associated with any cognitive decline instances over a 2-3 year period. That said, more research needs to be done to assess the effect of vitamin D supplementation on a person's overall cognitive function.

Although military personnel in many places are exposed to a limited amount of sunlight, dietary modifications may help increase vitamin D intake. However, dietary modifications are unlikely to solve the problem for most people. This is due to the small quantities of vitamin D found in food. 

Statistical analysis of vitamin D deficiency in the military

A recent study of a large cohort of active duty personnel revealed that 35% of those studied had serum 25(OH)D concentrations below the normal range. Another study found that 67% of female recruits entering basic training had serum 25(OH)D concentrations below the normal range at the beginning of the study. In addition, 57% of female recruits were in the deficient range after eight weeks of outdoor training. This is probably a result of tactical clothing and thus the lack of skin exposure prevented adequate vitamin D production.

In a 2014 study, soldiers with poor vitamin D status had a higher risk of stress fractures and completed fractures. These findings have implications for force health protection, warfighter readiness, attrition, and the cost of medical care. Although vitamin D deficiency is undertreated in the military, early detection and treatment can modify the effects of low levels. This study supports the importance of early detection and treatment of vitamin D deficiency as a risk factor for bone health and warfighter readiness.

Screening for vitamin D deficiency

Many active duty service members suffer from low levels of vitamin D. However, this can be a preventable problem. A new screening protocol can help military personnel identify those at risk for low vitamin D levels. This screening protocol can save money and time. A 25(OH)D assay can be added to a recruit's blood sample for about $4.10. For another $3.96, ergocalciferol 50,000 IU weekly can be given to service members for 12 weeks. If all enlisted trainees are screened at basic training, it could save more than $20,000 over the life of each service member.

According to USPSTF guidelines, screening for vitamin D deficiency in the civilian population for those with no symptoms is no longer covered by Tricare. The decision was made in response to recommendations from medical associations. Some medical organizations question the accuracy of the screening process and point to a lack of consensus within the medical community as to what constitutes deficiency. 

Dietary sources of vitamin D

The dietary sources of vitamin D in the military have not been widely studied. The most common dietary sources of vitamin D include dairy products and fish oil. Mushrooms are also a good source of vitamin D, but these are often not a staple in a chow hall or MRE. There is a need to increase vitamin D intake in soldiers, as the body cannot produce it itself. The military also wears protective clothing that prevents sunlight from reaching the skin. There is a high prevalence of vitamin D deficiency among service personnel, and researchers have linked low serum 25(OH)D levels to stress fractures, this can especially affect recruits who are not physically conditioned. This study demonstrated that stress fractures and vitamin D deficiencies are associated among Royal Marine recuits in the UK during their 32 week basic training. 

Studies have shown that deficiency of vitamin D is associated with numerous illnesses, including heart disease, hypertension, and obesity. It has also been linked to an increased risk of cancer and other diseases. In the military, dietary sources of vitamin D are not widely available and exposure to sunlight is one of the best sources, but excessive exposure can lead to health problems in itself. A diet rich in vitamin D is essential for healthy living and would be idealfor soldier to stay healthy, although a supplement is probably the most effective and convenient option moving forward.

Symptoms of vitamin D deficiency

The prevalence of vitamin D deficiency among US service members is high. There are many potential consequences of vitamin D deficiency, including increased risk of stress fractures (as we have covered) and musculoskeletal problems. Additionally, a deficiency of vitamin D can have adverse effects on the central nervous system and the cardiovascular system. This is why monitoring vitamin D levels in military personnel may help health organizations develop preventive programs.

Obvious symptoms tolook out for include:

  • Fatigue and/or weakness
  • Muscular aches and pains
  • Bone pain (a university lecturer at Leeds Beckett's Carnegie School of Sport once said she found it difficult to walk up stairs)

However, there are many symptoms that aren't obvious until a deficiency has been prolongued and become severe.

These symptoms or conditions maybe chronic and can include:

  • Depression/schizophrenia¬†
  • Osteoarthritis
  • High blood pressure
  • Type 2 diabetes
  • Cancer
  • Heart disease
  • Cognitive dysfunction

Vitamin D and Testosterone

Low levels of vitamin D have been associated with low testosterone. A 2011 study based over a 1 year period found that daily supplementation of vitamin D increased testosterone levels whereas the placebo group saw no increase. 

Treatment options

In the U.S. military, treating vitamin d deficiency with calcium-vitamin D supplements may be a viable option. Supplementation can improve bone health, reduce stress fractures, and enhance physical and cognitive performance. Several recent studies have shown positive effects of vitamin D and calcium supplements on bone health.

A 2009 study of 5201 female naval recruits saw that those allocated a vitamin D and calcium supplements were 20% less likely to suffer from a stress fracture compared to those recruits using a placebo.

Treatment options for vitamin D deficiency in the military include supplementation with supplements or food fortified with this vitamin. However, ensuring that all personnel are taking supplements or eating fortified foods could be challenging.

Iron Deficiencies and Military Personnel

Research published by the United States Army Medical Department looked at the effects of basic combat training on iron status among soldiers. 

The study acknowledges that iron is required for both physical and mental performance. The results of the study indicate that even with an 25% increase of iron consumption per day, both genders saw a decline in iron status over the course of their battle combat training by 21% (males) and 47% (females). 

Though the exact incidence of iron-deficiency in US military personnel has not been examined in detail. Women in the military are more likely than men to develop an iron-deficiency, so it is important to monitor their intake of iron-containing foods and minerals. Iron deficiency is common in female athletes or those who are involved in exercise regimes and it can lead to health issues including osteoporosis. It is commonly referred to as the female athlete triad.

Soldiers with anemia and physical performance

A study amongst Taiwanese soldiers saw that those with mild anemia were less likely to perform 2-minute sit-ups, although the reduction was not statistically significant but overall, those with mild anemia were more likely to be in the 10% of worst performers.

The researchers examined associations between moderate and severe anemia, and exercise intolerance. The researchers also analyzed the relationship between the presence of iron deficiency and the prevalence of a specific physical condition. Those with severe anemia were more likely to suffer from osteoporosis, and experienced more fatigue. The results indicate that mild anemia can affect skeletal muscle function, as well. 

The study conducted at Hualien Armed Forces General Hospital in Eastern Taiwan found that serum 25-OH vitamin D levels were inversely related to HEI-2010 scores, while vitamin D levels were positively associated with iron stores. These findings suggest that personnel who deploy frequently should try to avoid empty calories and eat vegetables, while consuming adequate amounts of vitamin D and iron. Additionally, improving access to perishable foods may improve the quality of the diet. Nevertheless, the findings in this study should serve as a wake-up call for the medical community.

Effects of low-dose daily iron supplementation on iron status

A recent study has found that female soldiers have decreased levels of serum ferritin during military training, which can affect their physical and cognitive performance. The researchers studied the effects of low-dose iron supplementation on women soldiers during intense physical training. They measured iron status indicator assays, two-mile-run times, and mood scores at three and six-month intervals. The results of the study suggest that low-dose daily iron supplements improve iron status in female soldiers.

Iron deficiency in women during basic combat training was positively associated with decreased aerobic fitness, gastrointestinal bleeding, and fatigue.This 2009 study found that daily 100-mg ferrous sulfate supplementation improved aerobic capacity in female soldiers.  

Effects of basic combat training on iron status

In this study published by the Cambridge University Press male and female soldiers enrolled in US Army basic combat training (BCT) were randomized to receive either a placebo or a calcium and vitamin D (ca/vitamin D) snack bar. Males who received the ca/vitamin D snack bar showed lower levels of iron just like those eating the placebo. This means that a combination of low-dose daily iron intake and BCT could reduce iron status in military personnel regardless of ca/vitamin D supplementation.

The Nursing Clinics of North America journal published a report identifying the prevelance of iron deficiency among women compared to their male counterparts which affects oxygen capapcity of the blood. The report recognized that females may also have fewer iron rich food choices when deployed and when combined with higher levels of physical activity can decrease energy deficiency.

A study from 2006 found that 77% of female recruits were suffering from iron depletion and shared concerns that the iron deficiency status wasn't just a result of military training but had developed during their adolescent years which means many females are iron deficient from an early age. Secondly, without being rectified, iron deficiency overall perfromance would could be compromised. Therefore it was recommended that an iron suplement is provided as it is proven to increase performance. 

Iron and testosterone

Anemia is associated with low testosterone in older adults. Iron and testosterone appear to regulate each other, therefore, low iron levels could reduce your testosterone.

Zinc Deficiencies in Military Personnel

A lack of zinc in the diet is a common condition among military personnel. Zinc deficiency in military personnel can lead to a number of physical and psychological problems. Deficiency of zinc can worsen the effects of TBI, which increases the losses of zinc from the body. Zinc deficiency in military personnel may affect the cellular mechanisms of TBI ie. excessive intracellular calcium levels induced by excitotoxicity. Various studies have used animal models to examine these mechanisms in controlled conditions.

Phytates

A study in Iran during the 1960s showed that male army recruits were often short and lacked sexual maturity. While these symptoms have been linked to other conditions, zinc deficiency was evident in these soldiers who had a diet that mainly comprised of cereals, these cereals contain zinc but also phytates which inhibit the absorption of zinc.

The main cause of zinc deficiency is diet, and this is largely due to a lack of fat and protein in their diets. Phytates in many carbohydrates reduce nutrient absorption. They also bind to zinc, making it difficult for the body to use it. This is why some soldiers are more susceptible to developing zinc deficiency. This deficiency is especially dangerous for military personnel because they need to perform multiple tasks.

COVID-19 virus

Recent research has indicated that zinc can rebalance immune response and protect soldiers from COVID-19, a virus that causes severe illness among soldiers. Although the connection between zinc deficiency and COVID-19 is still controversial, it has been found to be related to viral infection and respiratory tract infections. Moreover, zinc may also prevent or reduce viral infections by supporting the immune and redox systems. 

In fact, recent research has indicated that Zinc supplements may reduce COVID-19-related symptoms, including aching limbs, impaired taste and smell, fever, rash, sore throat, and general weakness. Additionally, zinc supplements can inhibit the effects of COVID-19 on the immune system, preventing the vascular complications that accompany the disease. Zinc is a cost-effective and highly effective therapeutic option for COVID-19 infection.

Slower recovery from training

Military personnel are at increased risk of developing zinc deficiency because of a lower than ideal intake coupled with increased requirements due to their activity levels. Zinc is involved in many bodily functions, including digestion. People with digestive issues and those who engage in an active lifestyle are also at risk of zinc deficiency. And while zinc isn't directly linked to any physical or mental illnesses, it does play a role in immune system function and inflammation.

In addition to maintaining cell membranes and gene signaling, zinc improves the ability of cells to heal. It also prevents oxidative stress and inflammation. Deficiency in zinc can lead to slower recovery from training. This mineral also improves immune cell activity, increases activity of the enzyme superoxide dismutase, and protects tissues from infection and pathogens.

Effects of zinc supplementation

Supplementation of zinc can protect against myocardial infarction by inhibiting adipokine production, and reduce lung injury. In addition, zinc supplements have anti-cancer activity, promoting tumor cell inhibition through pro-apoptotic family members.

Despite recent improvements in the research on zinc, one problem remains: a reliable biomarker for zinc deficiency. While serum levels are frequently taken as a reliable indicator of zinn deficiency, they do not reflect intracellular concentrations in humans. When these levels are normal, clear clinical signs may exist. However, no single study has been able to pinpoint the causes of zinc deficiencies in military personnel. 

Zinc and testosterone

Low leves of zinc can reduce your testosteroe levels. A study published by the Journal of Exercise Physiology found that 30mg of supplemented zinc increased testosterone levels and strength.

Deficiencies during deployment

Yet, few studies have evaluated dietary intake in a deployed environment. This study aims to assess the changes in iron, glucose, and lipids among military personnel in a deployment environment.

To conduct this study, researchers recruited healthy active-duty Soldiers from an elite U.S. Army Special Operations unit. They met certain eligibility criteria, including being assigned to a position with increased physical demands. Additionally, all potential participants had received full medical clearance.

To avoid excluding Soldiers who would not benefit from the study, all qualified Soldiers were invited to an informational briefing. The time frame was carefully scheduled to ensure that available Soldiers were not in training at the time.

The study looked at the impact being deployed would have on:

  • Vitamin D
  • Iron
  • Glucose
  • Lipids (fats)
  • Parathyroid hormone (PTH) - controls calcium levels in the blood

The participants' dietary intake was measured, compared and assessed using the Healthy Eating Index-2010.

Upon deployment the soldiers Health Eating Index-2010 scores decreased due to their reduced intake of fruit (also including fruit juices) and dairy which had an impact on their vitamin D and calcium intake.

This caused PTH levels to increase which in turn increases the calsium levels to rise in your blood. In extreme cases, high PTH can lead to kidney stones and deteriotion of the bones. 

The result showed no difference in serum vitamin D concentrations but iron levels did reduce.  

Glucose and lipids remained the same. This would be expected due to the available high calorie foods (yet nutritionally low) available on deployment.

Conclusion 

Soldiers lead physical lives that require more nutrients to maintain health and fitness. Unfortunately there are instances whereby some are deficicent in vitamins and minerals which can reduce their effectiveness. The impact of these deficiencies can lead to stress fractures, fatigue, weakness, a decline in aerobic capacity and in extreme circumstances, chronic diseases. 

Even those eleite soldiers who are likely to be conscious of their nutritional needs can see a reduction of healthy eating habits when deployed, and soldiers have complained about the dietary options available on barracks. 

It has been itendifiec that more perishable foods (fresh fruits and vegetables for instance), diary products and supplements can alleviate these issues and promote better health.  

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