Publications by authors named "Susan M McGraw"

23 Publications

  • Page 1 of 1

Development and Validation of the Military Eating Behavior Survey.

J Nutr Educ Behav 2021 Jun 29. Epub 2021 Jun 29.

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA.

Objective: To describe the Military Eating Behavior Survey (MEBS), developed, and validated for use in military populations.

Design: Questionnaire development using a 6-phase approach that included item generation, subject matter expert review, cognitive interviewing, factor analysis, test-retest reliability testing, and parallel forms testing.

Setting: US Army soldiers were surveyed at 8 military bases from 2016 to 2019 (n = 1,561).

Main Outcome Measure: Content, face, and construct validity and reliability of the MEBS.

Analysis: Item variability, internal consistency, and exploratory factor analysis using principal coordinates analysis, orthogonal varimax rotation, and scree test (correlation coefficient and Cronbach alpha), as well as consistency and agreement (intraclass correlation coefficient) of test-retest reliability and parallel forms reliability.

Results: Over 6 phases of testing, a comprehensive tool to examine military eating habits and mediators of eating behavior was developed. Questionnaire length was reduced from 277 items to 133 items (43 eating habits; 90 mediating behaviors). Factor analysis identified 14 eating habit scales (hunger, satiety, food craving, meal pattern, restraint, diet rigidity, emotional eating, fast/slow eating rate, environmental triggers, situational eating, supplement use, and food choice) and 8 mediating factor scales (body composition strategy, perceived stress, food access, sleep habits, military fitness, physical activity, military body image, and nutrition knowledge).

Conclusions And Implications: The MEBS provides a new approach for assessing eating behavior in military personnel and may be used to inform and evaluate health promotion interventions related to weight management, performance optimization, and military readiness and resiliency.
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June 2021

Exceeding body composition standards is associated with a more negative body image and increased weight cycling in active duty U.S. soldiers.

Eat Behav 2021 May 24;42:101532. Epub 2021 May 24.

Medical Center of Excellence, U.S. Military-Baylor University Graduate Program in Nutrition, 3599 Winfield-Scott Rd, Building 2841, Fort Sam Houston, TX 78234, USA. Electronic address:

Negative body image is more often identified in individuals with overweight or obesity. More than 65% of U.S. soldiers have a body mass index (BMI) that classifies them with overweight or obesity. Additionally, all soldiers must meet body composition and physical fitness standards which may increase the risk of negative body image. This cross-sectional study aimed to identify associations between compliance with body composition standards, body image, and weight cycling through surveying 969 active-duty soldiers (86% male, 24.0 ± 5.5 years of age, BMI 26.0 ± 3.6 kg/m). Compliance with body composition standards was measured by whether a soldier had ever taken and failed the circumference-based body fat assessment. Weight cycling was self-reported as ≥3 weight fluctuations of ≥5% of body weight during their military career. Multivariate linear and logistic regression models were used to examine the relationship between compliance with body composition standards, body image, weight cycling, and sociodemographic characteristics while controlling for BMI. Failing the circumference-based body fat assessment was associated with increased concern with conforming to military image. Negative body image was associated with higher odds of weight cycling. Further examination is warranted to understand the effects of body composition standards on soldiers' body image and weight cycling.
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May 2021

Eating Behaviors Are Associated With Physical Fitness and Body Composition Among US Army Soldiers.

J Nutr Educ Behav 2021 Jun 3;53(6):480-488. Epub 2021 Mar 3.

US Military-Baylor University Graduate Program in Nutrition, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX.

Objective: Examine associations between soldiers' eating behaviors, compliance with body composition and fitness standards, and physical performance.

Design: Cross-sectional study.

Setting: Eight Army installations.

Participants: US Army Soldiers (n = 1,591; 84% male).

Main Outcome Measures: Characteristics, eating behaviors, compliance with body composition and physical fitness standards, and fitness level were assessed via questionnaire.

Analysis: Bivariate and multivariable logistic regression.

Results: Eating mostly at a dining facility was associated with lower odds of body composition failure (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.26-0.73); whereas, eating at a fast rate (OR, 1.51; 95% CI, 1.05-2.17) or often/always ignoring satiety cues (OR, 2.12; 95% CI, 1.06-4.27) was associated with higher odds of body composition failure. Eating mostly fast-food/convenience meals (OR, 1.75; 95% CI, 1.19-2.59) and eating at a fast rate (OR, 1.42; 95% CI, 1.04-1.93) was associated with higher odds of physical fitness failure. Skipping breakfast was associated with lower odds of high physical performance (OR, 0.41; 95% CI, 0.23-0.74); whereas, nutrition education was associated with higher odds of high physical performance (OR, 1.02; 95% CI, 1.01-1.04).

Conclusions And Implications: As eating behaviors are modifiable, findings suggest opportunities for improving the specificity of Army health promotion and education programs.
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June 2021

Dietary Supplement Use in US Army Personnel: A Mixed-Methods, Survey and Focus-Group Study Examining Decision Making and Factors Associated With Use.

J Acad Nutr Diet 2021 Jun 27;121(6):1049-1063. Epub 2021 Feb 27.

Background: Dietary supplement (DS) use by Army personnel is high and is a safety and readiness issue.

Objective: Our aim was to examine factors motivating use of DSs among US Army personnel and preferred safety education strategies.

Design: This mixed-method study used a validated DS questionnaire and subsequent focus groups that were formed based on questionnaire-identified demographic characteristics. An embedded qualitative dominant design was used.

Participants/setting: Data were collected from April to July 2015 from active duty soldiers at 3 military installations in the United States.

Main Outcome Measures: A self-report questionnaire (n = 289) provided data on demographic characteristics, health, exercise, detailed use, and attitudes regarding DS safety and efficacy. Fourteen focus-group sessions (n = 129) examined factors motivating DS use, education strategies, and identified themes and DS-related behaviors.

Statistical Analysis Performed: Descriptive statistics and χ analyses were conducted.

Results: Of the soldiers who completed questionnaires, 83% were male, 60% were enlisted, and 40% were officers; mean age ± standard deviation was 27.6 ± 0.36 years and 75% used at least 1 type of DS per week: 52% used protein/amino acids, 47% used multivitamins/minerals, and 35% used a combination of products. Focus groups indicated reasons for use included physical appearance, fitness, peer endorsement, ease of access, limited availability of healthy food, occupational demands, and health. Participants requested education from an expert on safe use that was not focused on dangerous products.

Conclusions: Soldiers are high DS users, especially products marked for purported performance enhancement. Motivating factors for DS use are fitness/appearance and occupational demands, but soldiers lack knowledge of DS regulatory requirements and safety/efficacy. Soldiers wished to receive education on DSs from trusted health care professionals, such as registered dietitian nutritionists, that was not focused on dangerous products. Study findings suggest guidance and education should occur before periods of high DS use, such as deployment.
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June 2021

Caffeine, Energy Beverage Consumption, Fitness, and Sleep in U.S. Army Aviation Personnel.

Aerosp Med Hum Perform 2020 Aug;91(8):641-650

Caffeine-containing products and dietary supplements are widely used by military populations, but little is known about their use by aviation personnel. This study assessed self-reported sleep, fitness, work-schedules, and caffeine/energy drink use. A standardized survey was conducted in person by study personnel using tablet computers. A total of 188 aircrew members from the Combat Aviation Brigade at Fort Campbell, KY, participated in the survey. Focus groups were conducted with a subset of 47 subjects. The majority of subjects reported their physical fitness, health, and diets were good. They reported sleeping about 6 h per day and stated they needed additional sleep to feel fully rested. Their caffeine consumption averaged 346 ± 23 mg · d with most derived from coffee (139 ± 12 mg · d) and energy drinks (110 ± 13 mg · d). About half (55%) of participants used energy drinks at least once per week and they consumed greater amounts of caffeine than nonusers. Focus group data indicated crewmembers primarily consumed energy drinks to enhance performance degraded by variations in work schedules and lack of sufficient sleep. Participants expressed a desire for additional education on diets and energy drinks as well as on aeromedical policies governing energy drink and supplement use. Caffeinated products, including coffee and energy drinks, are routinely used by Army aircrews to increase alertness. Aircrew personnel consider them generally safe, but would like to receive education about these beverages, other dietary issues, and Army policies governing their use in aircrew.
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August 2020

Body weight status, perceived stress, and emotional eating among US Army Soldiers: A mediator model.

Eat Behav 2020 01 16;36:101367. Epub 2020 Jan 16.

US Military-Baylor University Graduate Program in Nutrition, Joint Base San Antonio, Fort Sam Houston, TX 78234, United States of America.

Background: In civilians, overweight and obesity are associated with emotional eating behaviors such as eating in response to stress, but this association has not been examined in Soldiers, a population with unique stressors. This cross-sectional study examined the relationship between perceived stress (PS), emotional eating (EE), and outcomes of body mass index (BMI), and failing Army body composition (BC) standards among Soldiers.

Methods: Soldiers (N = 1460, 83% male, 23.5 ± 5.2 years old) completed validated surveys on PS, EE, and adherence with military BC standards. Conditional process models and mediation models tested gender as a moderator and EE as a mediator of associations between PS and BMI and PS and BC failure, respectively.

Results: Higher PS was associated with more frequent self-reported EE behaviors (p < 0.001), higher BMI (p < 0.001), and BC failure (p < 0.001). BMI significantly increased with frequency of reported EE behaviors (p < 0.001). Gender was not a statistically significant moderator in the relationship between PS, EE, and, BMI (p = 0.83) or BC failure (p = 0.57). PS appears to affect BMI indirectly through EE behaviors (c' = 0.03, 95% CI: 0.02, 0.04). PS may affect BC failure directly (c' = 1.04, 95% CI: 1.01, 1.08) and indirectly (ab = 1.02, 95% CI: 1.01, 1.03) through EE as a mediator.

Conclusions: EE behaviors may mediate the positive association between PS, BMI, and BC failure. Prospective investigation is warranted to better understand the role of EE in health-related outcomes among Soldiers and populations in high stress professions.
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January 2020

A Survey Instrument to Assess Intake of Dietary Supplements, Related Products, and Caffeine in High-Use Populations.

J Nutr 2018 08;148(suppl_2):1445S-1451S

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA.

Substantial data on the use of dietary supplements by the general adult population are available, but many population subgroups have not been extensively studied. Because military service members and young people consume large amounts of dietary supplements, including for enhancement of physical performance, weight control, and bodybuilding, which can be dangerous, we developed a comprehensive questionnaire to characterize patterns of supplement use in these and other populations. The questionnaire has been used to study >7000 military service members and 1000 college students. This supplement article presents a detailed description of the questionnaire, which contains comprehensive questions on demographic characteristics, exercise habits, attitudes with regard to dietary supplements, and amount of money spent on supplements. Intakes of specific dietary supplements and caffeine, frequency of use, and reasons for use are assessed. The questionnaire was designed for studying dietary supplement and caffeine intake patterns with the use of paper-and-pencil administration to military populations and was modified for use with college students and for computer and Web administration. It is available online at and in the Supplemental File for this publication. It can be used to study other populations if minor modifications are made. The online version of the questionnairewill be updated periodically as newversions become available. In conclusion, a validated, detailed, noncopyrighted questionnaire designed to assess the use of dietary supplements, energy drinks (and related products), and caffeine is available for use in diverse populations. The format of the questionnaire is adaptable to computer administration and scoring, and it can be customized for specific subpopulations, locations, and product categories including updates that reflect changes in the availability of supplements or availability of new products.
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August 2018

Performance Nutrition Dining Facility Intervention Improves Special Operations Soldiers' Diet Quality and Meal Satisfaction.

J Nutr Educ Behav 2018 Nov - Dec;50(10):993-1004. Epub 2018 Aug 29.

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA.

Objective: To assess the impact of the Special Operations Forces Human Performance Program dining facility (DFAC) intervention on patron diet quality and meal satisfaction.

Design: Nonrandomized, controlled time series study using digital food photography and surveys pre-post intervention (0, 4, 8, and 12 months).

Setting: Two Fort Bragg, NC military installation DFACs.

Participants: Volunteers (n = 688 total; n = 573 complete dataset) were US Army active duty soldiers.

Intervention: The DFAC intervention included food choice architecture, new performance-optimizing food recipes to increase nutrient density, revised menus to offer more performance foods daily, and nutrition labeling to influence food choice.

Main Outcome Measures: Daily DFAC nutrient intake and Healthy Eating Index (HEI) 2010 scores.

Analysis: Descriptive and ANOVA statistical analyses were performed between control and intervention groups and from baseline to 4, 8, and 12 months postintervention (α = .05; 80% power).

Results: The intervention resulted in a higher posttest HEI score (60.1 ± 8.8 points; +3.4%; P = .005) and DFAC satisfaction compared with control (49.0 ± 10.4 points; P > .05). Improved intervention HEI scores were attributed to changes in citrus and melon fruit (+46%), red and orange vegetables (+35%), whole grains (+181%), legumes (65%), yogurt (+45%), oils (-26%), and solid fat (-18%) consumption (all P < .05).

Conclusions And Implications: These data illustrate that the Special Operations Forces Human Performance Program military DFAC nutrition intervention was feasible to implement and was associated with diet quality improvements. Access to high-quality ingredients and recipes may improve soldier meal quality and acceptance in other settings and warrants further investigation.
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November 2019

Personality Traits and Occupational Demands Are Linked to Dietary Supplement Use in Soldiers: A Cross-sectional Study of Sensation Seeking Behaviors.

Mil Med 2019 03;184(3-4):e253-e262

Walter Reed National Military Medical Center, 8901 Wisconsin Ave., Bethesda, MD.

Introduction: Military personnel use dietary supplements (DS) more frequently and in a higher quantity than the general population. Patterns of DS used and the motivation for use among the military population are different than those of the civilian population. Soldiers are much more likely to use potentially dangerous DS purported to enhance physical performance and/or promote weight loss in spite of limited evidence regarding the safety and efficacy of these products. Sensation seeking (SS) behaviors can be associated with risky lifestyle behaviors and may be associated with use of DS by Soldiers. This study assessed Soldiers' SS behaviors in relation to DS use and various demographic factors.

Materials And Methods: Demographic and behavioral questionnaires were administered to 289 Soldiers (mean ± SD, 28 ± 6 years, 27 ± 3 kg/m2 BMI, 83% male) at three U.S. military installations. The Brief SS Scale (four 10-point subscales) and Arnett Inventory of SS (two 40-point subscales) were used to assess SS behaviors. Independent sample t-tests determined the significant differences between SS subscale scores of DS users and non-users for each type of DS (i.e., protein, multivitamin, etc.). One-way analysis of variances and Tukey's post hoc comparisons assessed differences in SS scores across demographic categories. Tukey's post hoc analyses assessed SS scores between users and non-users within the DS categories.

Results: Overall, 75% of Soldiers used DS ≥1 time/week. The most frequently used DS were protein/amino acids (52%), multivitamins/multiminerals (47%), "other" supplements (43%), and combination products (35%). Overall, DS users scored higher in experience seeking (8.0 ± 1.7 vs 7.5 ± 2.0; p < 0.05) and novelty (28.4 ± 3.7 vs 26.8 ± 4.7; p < 0.05) than non-users. Protein/amino acid users scored higher than non-users for all six SS traits: experience seeking (p < 0.001), boredom susceptibility (p < 0.001), thrill seeking (p < 0.001), disinhibition (p < 0.01), novelty (p < 0.001), and intensity (p < 0.001). Users of bodybuilding DS scored higher than non-users in four of the six SS traits: boredom susceptibility (p < 0.05), thrill seeking (p < 0.001), disinhibition (p < 0.01), and intensity (p < 0.001).

Conclusions: Soldiers who use DS that are frequently associated with health risks scored higher for sensation-seeking characteristics which are predictors of risky behaviors. Protein/AA and combination product DS users scored higher in sensation-seeking traits and this may be due to underestimation of risk, anticipation of positive outcomes, and/or high levels of confidence in these types of DS by high sensation seekers. Additional investigation into the association of sensation-seeking behaviors as predictors of harmful DS use is warranted.
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March 2019

Digital food photography technology improves efficiency and feasibility of dietary intake assessments in large populations eating ad libitum in collective dining facilities.

Appetite 2017 09 17;116:389-394. Epub 2017 May 17.

U.S. Military-Baylor University Graduate Program in Nutrition, Joint Base San Antonio, TX 78234, United States.

Background: Accurate assessment of dietary intake continues to challenge researchers, especially in field, or non-laboratory settings.

Objective: In this study, digital food photography (DFP) methodology was used to assess nutritional intake (NI) of Soldiers participating in the US Army's Ranger Selection and Assessment Program (RASP).

Methods: During this high-intensity six-week course, Soldiers complete simulated operational missions, perform various military tasks, and importantly, eating time is severely limited. Therefore, this study provided an opportunity to evaluate the utility of DFP methods for accurate assessment of energy balance in conditions where consumption of large numbers of subjects must be completed in a very short periods of time (≤20 min). NI of 131 male, enlisted Soldiers (21 ± 4 years, 178±7 cm, and 78±8 kg) enrolled in the RASP course was assessed in their garrison dining facility using DFP utilizing visual estimation of pre- and post-meal photos of participant meals concurrently with photos of weighed, standardized portions. Total daily energy expenditure (TDEE) was assessed using doubly-labeled water (HO) in a sub-group of 19 volunteers.

Results: During the study, data loss (i.e., missing meal photos) was less than 5% per meal, and during the visual estimation process discrepancies in food identification averaged less than 10% per meal, while approximately a third of serving size estimations required a third party adjudication prior to finalization and calculation NI.

Conclusions: We conclude that the use of DFP allows an adequately reliable approach for quantifying NI in real-world scenarios involving large numbers of participants who must be assessed very rapidly, and researchers must have a small footprint.
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September 2017

Caffeine consumption among active duty United States Air Force personnel.

Food Chem Toxicol 2017 Jul 3;105:377-386. Epub 2017 May 3.

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, United States.

Data from the National Health and Nutrition Examination Survey (NHANES) indicated that 89% of Americans regularly consumed caffeinated products, but these data did not include military personnel. This cross-sectional study examined caffeine consumption prevalence, amount of daily consumption, and factors associated with caffeine intake in active duty United States (US) Air Force personnel. Service members (N = 1787) stationed in the US and overseas completed a detailed questionnaire describing their intake of caffeine-containing products in addition to their demographic, lifestyle, and military characteristics. Overall, 84% reported consuming caffeinated products ≥1 time/week with caffeine consumers ingesting a mean ± standard error of 212 ± 9 mg/day (224 ± 11 mg/day for men, 180 ± 12 mg/day for women). The most commonly consumed caffeinated products (% users) were sodas (56%), coffee (45%), teas (36%), and energy drinks (27%). Multivariate logistic regression modeling indicated that characteristics independently associated with caffeine consumption (≥1 time/week) included older age, ethnicity other than black, tobacco use, less aerobic training, and less sleep; energy drink use was associated with male gender, younger age, tobacco use, and less sleep. Compared to NHANES data, the prevalence of caffeine consumption in Air Force personnel was similar but daily consumption (mg/day) was higher.
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July 2017

Adherence to the Dietary Guidelines for Americans Is Associated with Psychological Resilience in Young Adults: A Cross-Sectional Study.

J Acad Nutr Diet 2017 Mar 5;117(3):396-403. Epub 2016 Nov 5.

Background: The 2010 Healthy Eating Index (HEI-2010), a measure of diet quality, is used to quantify adherence to the Dietary Guidelines for Americans. Better HEI scores have been associated with positive health outcomes; however, the relationship between diet quality and psychological resilience, a mental health attribute for coping with adversity, has not been assessed.

Objective: The objective of the present study was to assess the relationship between diet quality and psychological resilience, and the relationship between resilience and demographics, anthropometrics, socioeconomic status, and health behavior.

Design: In this cross-sectional study, HEI-2010 scores and resilience were assessed using the Block food frequency questionnaire and the Connor-Davidson Resilience Scale. Other factors that can affect the relationship between HEI-2010 scores and resilience were assessed using surveys, and height and weight were measured to calculate body mass index.

Participants/setting: Male and female Army and Air Force recruits (n=834) enrolled in a randomized controlled trial and 656 (mean±standard deviation [SD] age=21±3.3 years) were included in this analysis. Data were collected before the initiation of military training at Fort Sill, OK (2012-2013) and Lackland Air Force Base, TX (2013-2014).

Statistical Analysis Performed: Participants were split into low- and high-resilience groups based on Connor-Davidson Resilience Scale scores. Student's t test and χ tests were used to determine differences between groups for continuous and categorical variables, respectively. Logistic regression was utilized to identify predictors of resilience.

Results: Better diet quality was associated with resilience; higher HEI predicted an increased likelihood (odds ratio=1.02; 95% CI 1.01 to 1.04) of a participant being in the high-resilience group after including race, ethnicity, education, smoking, age, body mass index, sex, and military branch in the full model. The data indicate that with every 10-point increase in HEI score, there was a 22% increased likelihood of being in the high-resilience group.

Conclusions: Registered dietitian nutritionists should continue to encourage attainable changes to improve diet; study data suggest that small improvements in diet quality can be associated with better psychological resilience.
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March 2017

Longitudinal trends in use of dietary supplements by U.S. Army personnel differ from those of civilians.

Appl Physiol Nutr Metab 2016 Dec 14;41(12):1217-1224. Epub 2016 Jul 14.

a Military Nutrition Division, U.S. Army Research Institute of Environmental Medicine, 10 General Greene Avenue, Natick, MA 01760, USA.

Prevalence and patterns of dietary supplement (DS) use by U.S. Army soldiers differ from the civilian population. Longitudinal trends in use of DSs by civilians have been examined, but are unavailable in subpopulations such as military service members. The present study examined longitudinal changes in DS use by soldiers. A standardized questionnaire on DS use was administered in 2006-2007 (N = 989) and 2010-2011 (N = 1196) to convenience samples of active duty soldiers. Data were weighted for total population demographics of age, sex, and rank. Regular use of DSs by soldiers increased significantly (56% ± 1.6% vs. 64% ± 1.7%; p ≤ 0.001) over the 4 years primarily because of an increase of DS use among the youngest 18- to 24-year-old soldiers (43.0% ± 2.5% vs 62.3% ± 2.4%; p ≤ 0.01). Protein (22% ± 1.4% vs. 26% ± 1.5%; p ≤ 0.001) and combination (10.0% ± 1.0% vs. 24% ± 1.4%; p ≤ 0.001) product consumption also increased over the 4 years. Individual vitamin and mineral use - including iron, magnesium, selenium, and vitamins A, B, B, and D - significantly increased as well (p ≤ 0.05). In addition, expenditures on DSs by soldiers increased over time (p < 0.01). Reasons reported by soldiers for DS use suggest use increased to meet the occupational demands of military service. Educational interventions to minimize inappropriate use of DSs by soldiers are necessary to reduce adverse events resulting from unnecessary use of DSs and the financial burden associated with their use.
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December 2016

Demographic, Lifestyle Factors, and Reasons for Use of Dietary Supplements by Air Force Personnel.

Aerosp Med Hum Perform 2016 Jul;87(7):628-37

U.S. Army Research Institute of Environmental Medicine, Natick, MA, USA.

Background: Dietary supplement (DS) use is common among U.S. Army personnel to purportedly improve health, provide energy, and increase strength. However, a comprehensive analysis of DS use among U.S. Air Force (USAF) personnel has not been conducted using the same survey instrument, which would permit direct comparisons to DS use by Army personnel.

Methods: A standardized questionnaire was used to assess DS use, demographic factors, and reasons for use of DS by USAF personnel (N = 1750). Logistic regression models adjusted for age, sex, and rank were used to determine relationships among categories of DS (multivitamin and multimineral, individual vitamins and minerals, protein/amino acid supplements, combination products, herbal supplements, purported steroid analogs, and other) and demographic factors. Findings were compared to reports from other military services and civilian populations.

Results: DS were used by 68% of USAF personnel: 35% used 1-2 DS ≥ 1 time/wk, 13% 3-4 DS ≥ 1 time/wk, and 20% ≥ 5 DS ≥ 1 time/wk. There were 45% of personnel who used a multivitamin and mineral, 33% protein supplements, 22% individual vitamins/minerals, 22% combination products, and 7% herbals. Logistic regression demonstrated aerobic exercise duration and strength training were associated with increased DS use. Individuals who previously deployed were more likely to use DS.

Conclusions: Like Army personnel, college students and athletes, USAF personnel use more DS than the general population and are more likely to use purported performance enhancing DS, such as protein supplements, and concurrently consume multiple DS. Austin KG, Price LL, McGraw SM, Leahy G, Lieberman HR. Demographic, lifestyle factors, and reasons for use of dietary supplements by Air Force personnel. Aerosp Med Hum Perform. 2016; 87(7):628-637.
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July 2016

Soldier use of dietary supplements, including protein and body building supplements, in a combat zone is different than use in garrison.

Appl Physiol Nutr Metab 2016 Jan 9;41(1):88-95. Epub 2015 Oct 9.

b Military Nutrition Division, US Army Research Institute of Environmental Medicine (USARIEM), Natick, MA 01760-5007, USA.

United States Army personnel in garrison who are not deployed to combat theater report using dietary supplements (DSs) to promote health, increase physical and mental strength, and improve energy levels. Given the substantial physical and cognitive demands of combat, DS use may increase during deployment. This study compared DS use by garrison soldiers with DS use by personnel deployed to a combat theater in Afghanistan. Prevalence and patterns of DS use, demographic factors, and health behaviors were assessed by survey (deployed n = 221; garrison n = 1001). Eighty-two percent of deployed and 74% of garrison soldiers used DSs ≥ 1 time·week(-1). Logistic regression analyses, adjusted for significant demographic and health predictors of DS use, showed deployed personnel were more likely than garrison soldiers to use protein, amino acids, and combination products. Deployed females were more likely to use protein supplements and deployed males were more likely to use multivitamins, combination products, protein, and body building supplements than garrison respondents. Significantly more deployed (17%) than garrison (10%) personnel spent more than $50∙month(-1) on DSs. Higher protein supplement use among deployed personnel was associated with higher frequency of strength training and lower amounts of aerobic exercise for males but similar amounts of strength training and aerobic exercise for females. Protein supplements and combination products are used more frequently by deployed than garrison soldiers with the intent of enhancing strength and energy.
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January 2016

Predictors of Dietary Supplement Use by U.S. Coast Guard Personnel.

PLoS One 2015 31;10(7):e0133006. Epub 2015 Jul 31.

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, Massachusetts, 01760, United States of America.

Background: Personnel in Armed Forces entities such as the US Coast Guard (USCG) engage in strenuous tasks requiring high levels of physiological and psychological fitness. Previous reports have found increased prevalence of dietary supplement (DS) use by military personnel to meet the demands of their occupation.

Objective: This study assessed DS prevalence and patterns of use in USCG personnel and compared these findings to reports from other Armed Forces personnel.

Design: Use of DS by USCG personnel (n = 1059) was assessed by survey at USCG installations. Data were weighted by age, sex, and rank to be representative of total USCG demographics.

Results: Seventy percent of USCG personnel reported using a DS at least 1 time/wk. Thirty-three percent used 1-2 DS ≤ 1 time/wk, 18% 3-4 DS ≥ 1 time/wk, and almost 19% ≥ 5 DS ≥ 1 time/wk. Average expenditure on DSs by UCSG personnel was $40/mo. More than 47% of USCG personnel used a multivitamin and mineral, 33% consumed protein supplements, 22% used individual vitamins and minerals, 23% reported taking combination products, and 9% consumed herbal supplements. Increased use of DS use was associated with high intensity operational occupations, participating in high volumes of aerobic exercise and strength training. Use of DS was not associated with age, education or body mass index.

Conclusion: Occupation is an important determinate of DS use. Prevalence of DS use by USCG personnel is greater than reported for other Armed Forces personnel and reflects high levels of participation in aerobic and strength training activities.
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May 2016

Effects of winter military training on energy balance, whole-body protein balance, muscle damage, soreness, and physical performance.

Appl Physiol Nutr Metab 2014 Dec;39(12):1395-401

a Military Nutrition Division, US Army Research Institute of Environmental Medicine, 15 Kansas Street, Bldg. 42, Natick, MA 01760, USA.

Physiological consequences of winter military operations are not well described. This study examined Norwegian soldiers (n = 21 males) participating in a physically demanding winter training program to evaluate whether short-term military training alters energy and whole-body protein balance, muscle damage, soreness, and performance. Energy expenditure (D2(18)O) and intake were measured daily, and postabsorptive whole-body protein turnover ([(15)N]-glycine), muscle damage, soreness, and performance (vertical jump) were assessed at baseline, following a 4-day, military task training phase (MTT) and after a 3-day, 54-km ski march (SKI). Energy intake (kcal·day(-1)) increased (P < 0.01) from (mean ± SD (95% confidence interval)) 3098 ± 236 (2985, 3212) during MTT to 3461 ± 586 (3178, 3743) during SKI, while protein (g·kg(-1)·day(-1)) intake remained constant (MTT, 1.59 ± 0.33 (1.51, 1.66); and SKI, 1.71 ± 0.55 (1.58, 1.85)). Energy expenditure increased (P < 0.05) during SKI (6851 ± 562 (6580, 7122)) compared with MTT (5480 ± 389 (5293, 5668)) and exceeded energy intake. Protein flux, synthesis, and breakdown were all increased (P < 0.05) 24%, 18%, and 27%, respectively, during SKI compared with baseline and MTT. Whole-body protein balance was lower (P < 0.05) during SKI (-1.41 ± 1.11 (-1.98, -0.84) g·kg(-1)·10 h) than MTT and baseline. Muscle damage and soreness increased and performance decreased progressively (P < 0.05). The physiological consequences observed during short-term winter military training provide the basis for future studies to evaluate nutritional strategies that attenuate protein loss and sustain performance during severe energy deficits.
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December 2014

Multivitamin and protein supplement use is associated with positive mood states and health behaviors in US Military and Coast Guard personnel.

J Clin Psychopharmacol 2014 Oct;34(5):595-601

From the *US Army Research Institute of Environmental Medicine, Natick, MA; and †Oak Ridge Institute for Science and Education, Belcamp, MD.

Approximately 60% of Armed Forces personnel regularly consume dietary supplements (DSs). We investigated the association of mood and health behaviors with multiple classes of DSs in military and Coast Guard personnel (N = 5536). Participants completed a survey of DS use and the Quick Mood Scale to assess mood domains of wakeful-drowsiness, relaxed-anxious, cheerful-depressed, friendly-aggression, clearheaded-confused, and well coordinated-clumsy. Supplements were categorized as multivitamin/minerals (MVM), individual vitamin/minerals, protein/amino acid supplements (PS), combination products (C), herbals (H), purported steroid analogs, (S) and other (O). One-way analyses of covariance assessed associations of DSs and perceived health behavior with mood controlling for age. Logistic regression determined associations between DS use and health behavior. Users of MVM and PS reported feeling significantly (P < 0.05) more awake, relaxed, cheerful, clearheaded, and coordinated. Participants using PS and S reported feeling less friendly (more aggressive, P < 0.02). Users of MVM and PS were more likely to report their general health, eating habits, and fitness level as excellent/good (P < 0.05). Participants reporting health behaviors as excellent/good were more (P < 0.01) awake, relaxed, cheerful, friendly, clearheaded, and coordinated. As no known biological mechanisms can explain such diverse effects of MVM and PS use on multiple mood states, health, eating habits, and fitness, we hypothesize these associations are not causal, and DS intake does not alter these parameters per se. Preexisting differences in mood and other health-related behaviors and outcomes between users versus nonusers of DSs could be a confounding factor in studies of DSs.
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October 2014

Energy requirements of US Army Special Operation Forces during military training.

Nutrients 2014 May 12;6(5):1945-55. Epub 2014 May 12.

Military Nutrition Division, United States Army Research Institute of Environmental Medicine, 15 Kansas Street, Building 42, Natick, MA 01760, USA.

Special Operations Forces (SOF) regularly engage in physically demanding combat operations and field training exercises, resulting in high daily energy expenditure, and thus increased energy requirements. However, the majority of studies assessing energy requirements of SOF have been conducted on soldiers going through intense SOF initiation training. The objective of the current investigation was to determine the energy expenditure of SOF conducting military training operations. Thirty-one soldiers taking part in Pre-Mission Training (PMT n = 15) and Combat Diver Qualification Courses (CDQC n = 16) volunteered to participate in this observational study. Energy expenditure was determined using doubly labeled water. Body weight (83 ± 7 kg) remained stable during both training periods. Overall energy expenditure adjusted for body composition was 17,606 ± 2326 kJ·day(-1). Energy expenditure was 19,110 ± 1468 kJ·day(-1) during CDQC and 16,334 ± 2180 kJ·day(-1) during PMT, with physical activity levels of 2.6 ± 0.2 and 2.2 ± 0.3 during CDQC and PMT, respectively. Compared to the Military Dietary Reference Intakes for energy (13,598 kJ·day(-1)), these data are in agreement with previous reports that energy requirement for SOF Soldiers exceed that of the average soldier.
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May 2014

A retrospective cohort study on the influence of UV index and race/ethnicity on risk of stress and lower limb fractures.

BMC Musculoskelet Disord 2013 Apr 12;14:135. Epub 2013 Apr 12.

U.S. Army Research Institute of Environmental Medicine, Bldg. 42, Kansas St., Natick, MA 01760, USA.

Background: Low vitamin D status increases the risk of stress fractures. As ultraviolet (UV) light is required for vitamin D synthesis, low UV light availability is thought to increase the risk of vitamin D insufficiency and poor bone health. The purpose of this investigation was to determine if individuals with low UV intensity at their home of record (HOR) or those with darker complexions are at increased risk of developing stress fractures and lower limb fractures during U.S. Army Basic Combat Training (BCT).

Methods: This was a retrospective cohort study using the Armed Forces Health Surveillance Center data repository. All Basic trainees were identified from January 1997 to January 2007. Cases were recruits diagnosed with stress fractures and lower limb fractures during BCT. The recruit's home of record (HOR) was identified from the Defense Manpower Data Center database. The average annual UV intensity at the recruits' HOR was determined using a U.S National Weather Service database and recruits were stratified into low (≤3.9); moderate (4.0-5.4), and high (≥5.5) UV index regions. Race was determined from self-reports.

Results: The dataset had 421,461 men and 90,141 women. Compared to men, women had greater risk of developing stress fractures (odds ratio (OR) = 4.5, 95% confidence interval (95%CI) = 4.4-4.7, p < 0.01). Contrary to the hypothesized effect, male and female recruits from low UV index areas had a slightly lower risk of stress fractures (male OR (low UV/high UV) = 0.92, 95%CI = 0.87-0.97; females OR = 0.89, 95%CI = 0.84-0.95, p < 0.01) and were at similar risk for lower limb fractures (male OR = 0.98, 95%CI = 0.89-1.07; female OR = 0.93, 95%CI = 0.80-1.09) than recruits from high UV index areas. Blacks had lower risk of stress and lower limb fractures than non-blacks, and there was no indication that Blacks from low UV areas were at increased risk for bone injuries.

Conclusions: The UV index at home of record is not associated with stress or lower limb fractures in BCT. These data suggest that UV intensity is not a risk factor for poor bone health in younger American adults.
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April 2013

Effects of modified foodservice practices in military dining facilities on ad libitum nutritional intake of US army soldiers.

J Acad Nutr Diet 2013 Jul 16;113(7):920-7. Epub 2013 Feb 16.

Military Nutrition Division, US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA.

Background: Modifying foodservice practices in military dining facilities could influence ad libitum nutritional intake patterns of soldiers.

Objective: We aimed to determine how changes in foodservice operations consistent with 2005 Dietary Guidelines for Americans affected soldiers' ad libitum nutritional intake in military dining facilities (DFACs).

Design: Ten DFACs participated, and the intervention was implemented in five DFACs in an independently sampled, partial crossover design. Nutrient intake of diners was assessed during a test meal using digital photography, and customer satisfaction with foodservice was assessed via surveys at baseline (n=602), and again at 6 months (n=519) and 12 months (n=458) after the intervention was implemented.

Participants: Volunteers were US Army active duty soldiers recruited from among diners at 10 DFACs on Fort Bragg, NC.

Main Outcome Measures: Primary outcomes were intakes of energy and total fat, and percent energy from fat and saturated fat. Differences between diners' intakes in control and intervention DFACs were assessed using independent samples t tests.

Results: At 6 months after implementing the intervention, diners at intervention DFACs had significantly lower lunchtime intakes of energy (945±338 kcal vs 1,061±380 kcal), total fat (38±19 g vs 47±25 g), percent energy from fat (35%±10% vs 39%±11%) and saturated fat (4.7%±1.7% vs 5.6%±2.3%), discretionary fat (30±18 g vs 39±24 g), and refined grains (2.3±1.7 oz equivalents vs 2.8±2.4 oz equivalents) compared with diners at control DFACs. Further, diners at intervention DFACs rated customer satisfaction higher than diners at control DFACs.

Conclusions: These findings suggest that modest changes in military DFAC serving practices to promote healthy eating and food selection can facilitate positive changes in soldiers' nutritional intake.
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July 2013

Use of dietary supplements among active-duty US Army soldiers.

Am J Clin Nutr 2010 Oct 28;92(4):985-95. Epub 2010 Jul 28.

US Army Research Institute of Environmental Medicine, Natick, MA 01760, USA.

Background: US Army soldiers engage in strenuous activities and must maintain fitness and body weight to retain their jobs. Anecdotal reports suggest that the use of dietary supplements (DSs) by soldiers may reflect their unique occupational requirements and the complexity of their job and family responsibilities.

Objective: We assessed the use of DSs by soldiers.

Design: We conducted a survey of 990 randomly selected soldiers at 11 army bases globally. Data were weighted by age, sex, rank, and Special Forces status to represent the active-duty army.

Results: Overall, 53% of soldiers reported the use of DSs ≥1 time/wk; 23% of soldiers used sports beverages, 6% of soldiers used sports bars or gels, and 3% of soldiers reported the use of meal-replacement beverages. Most commonly used DSs were multivitamins or multiminerals (37.5%), protein and amino acids (18.7%), individual vitamins and minerals (17.9%), combination products (9.1%), and herbal supplements (8.3%). Many soldiers reported the use of performance-enhancement and weight-reduction products, and 22% of soldiers consumed ≥3 different DSs/wk. Logistic regression modeling indicated that older age, educational attainment, higher body mass index, and strength training were associated with DS use (P < 0.05). Reported reasons for DS use were to improve health (64%), provide more energy (31%), increase muscle strength (25%), and enhance performance (17%). Among DS users, mean monthly expenditures on DSs were $38, whereas 23% of soldiers spent >$50/mo.

Conclusions: Soldiers, like civilians, use large amounts of DSs, often in combination. Soldiers use more DSs purported to enhance performance than civilians use when matched for key demographic factors. These differences may reflect the unique occupational demands and stressors of military service.
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October 2010

The effect of proposed improvements to the Army Weight Control Program on female soldiers.

Mil Med 2006 Aug;171(8):800-5

U.S. Army Research Institute of Environmental Medicine, Natick, MA 01754-5007, USA.

Objective: To comply with Army Regulation 600-9, The Army Weight Control Program (AWCP), soldiers must meet age-adjusted body fat standards, regardless of whether they meet or exceed weight-for-height allowances. Recent revisions to Department of Defense (DoD) policies require changes to the AWCP. Specifically, we assessed the effects of increasing weight-for-height allowances and adoption of the DoD body fat equation on compliance with the AWCP in women.

Methods: Weight, height, circumferences (neck, forearm, wrist, waist, and hip) to measure body fat, and Army Physical Fitness Test results were obtained from 909 female soldiers (mean (SD) age, 26.2 (6.5) years; body mass index, 24.6 (3.3) kg/m2; body fat, 29.7% (5.0)).

Results: Increasing the screening weight-for-height allowances resulted in a 20% reduction in those requiring a body fat measurement (from 55% [n = 498) to 35% [n = 319]). Adopting the DoD body fat equation did not change the proportion of overfat women, i.e., noncompliant with the AWCP, (from 26% [n = 232] to 27% [n = 246]). More women with a waist circumference > 35 inches (i.e., at increased disease risk) were identified as noncompliant with the AWCP by the proposed body fat equation (from 76% [n = 61] to 96% [n = 77]).

Conclusions: Proposed changes reduce the proportion of women unnecessarily measured for body fat and do not change the proportion of women on the AWCP, yet select more women at increased disease risk and most in need of an effective intervention.
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August 2006