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Hand-to-hand combat training, known as combatives, instructs Soldiers in close-quarters combat techniques and how to cope with stress, understand controlled physical aggression, and develop self-confidence when engaged in such activities. Limited research in combat sports suggests men and women may respond to combatives stress differently. Given the increasing integration of women into close combat roles in the military, investigation of sex differences in the physiological and psychological response to combatives among military-trained personnel is warranted., Purpose: This study was designed to identify sex differences in stress and gonadal hormones, mucosal immunity, and mood states in a military combatives training course., Methods: U.S. Military Academy Cadets (men = 144, women = 37) enrolled in a 2-month Combat Applications Course at West Point completed the Profile of Mood States and Competitive State Anxiety Inventory-2 and provided salivary samples at baseline prior to the course, and immediately prior to their midterm and final combat matches. Combat matches were gender- and weight-matched. Additional salivary samples were collected immediately following the first midterm and final matches. Salivary cortisol, testosterone, secretory immunoglobulin A (SIgA) and estradiol (women only) were measured via immunoassay. Men and women were compared over time with linear mixed effects models., Results: In both men and women, confusion, tension, anger, cognitive anxiety, somatic anxiety, and self-confidence increased throughout the course whereas friendliness and SIgA secretion rate decreased (all p < 0.05). Compared to women, men had a greater acute increase in cortisol from pre- to post-match (p = 0.043). Prior to the final match, women displayed higher ratings of tension (20.5 ± 9.3 vs. 16.0 ± 8.6) and cortisol (0.6 ± 0.3 vs. 0.4 ± 0.3 µg/dL) than men (all p < 0.05). After controlling for previous combative experience, ratings of tension did not differ by sex but remained elevated prior to midterm and final compared to baseline., Conclusion: Combatives training elicited significant psychological and physiological stress and decreased mucosal immunity in both men and women. Women exhibited higher tension at the final match, likely due to lack of previous combative experience. Self-confidence increased from baseline suggesting that the skills learned may help Cadets prepare for combatives and other activities that require controlled aggression., Competing Interests: Declaration of Competing Interest None., (Published by Elsevier Ltd.)

Consuming a diet that meets energy demands and provides essential nutrients promotes a healthy immune system, while both under- and over-nutrition have been associated with immune dysfunction. Military personnel comprise a unique population who frequently endure multi-stressor environments, predisposing them to immune decrements. Additionally, 49% and 22% of active duty U.S. military personnel are classified as overweight and obese, respectively. A literature search on PubMed was conducted to identify studies, reports, review papers, and references within those sources relevant to the topic area. Military personnel experiencing either under- or over-nutrition can suffer from degraded health, readiness, and performance. Insufficient intake of nutrients during military operations increases infection risk and negatively impacts infection recovery. Energy, protein, iron, zinc, and vitamins C and D are nutritional areas of concern that may impact immune competence in a multi-stressor environment. Over-nutrition can promote accretion of excess body fat and obesity, which contributes to a chronic inflammatory state that coincides with immune impairments. Prioritizing efforts to optimize nutrient intake is one approach for reducing disease burden and improving readiness. This review discusses nutritional concerns concomitant to multi-stressor environments that impact immune function, and the relevance of obesity to infectious disease risk in the military population.

Introduction: Personnel engaged in high-stakes occupations, such as military personnel, law enforcement, and emergency first responders, must sustain performance through a range of environmental stressors. To maximize the effectiveness of military personnel, an a priori understanding of traits can help predict their physical and cognitive performance under stress and adversity. This work developed and assessed a suite of measures that have the potential to predict performance during operational scenarios. These measures were designed to characterize four specific trait-based domains: cognitive, health, physical, and social-emotional., Materials and Methods: One hundred and ninety-one active duty U.S. Army soldiers completed interleaved questionnaire-based, seated task-based, and physical task-based measures over a period of 3-5 days. Redundancy analysis, dimensionality reduction, and network analyses revealed several patterns of interest., Results: First, unique variable analysis revealed a minimally redundant battery of instruments. Second, principal component analysis showed that metrics tended to cluster together in three to five components within each domain. Finally, analyses of cross-domain associations using network analysis illustrated that cognitive, health, physical, and social-emotional domains showed strong construct solidarity., Conclusions: The present battery of metrics presents a fieldable toolkit that may be used to predict operational performance that can be clustered into separate components or used independently. It will aid predictive algorithm development aimed to identify critical predictors of individual military personnel and small-unit performance outcomes., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Purpose: Initial military training (IMT) is a transitionary period wherein immune function may be suppressed and infection risk heightened due to physical and psychological stress, communal living, and sleep deprivation. This study characterized changes in biomarkers of innate and adaptive immune function, and potential modulators of those changes, in military recruits during IMT., Methods: Peripheral leukocyte distribution and mitogen-stimulated cytokine profiles were measured in fasted blood samples, Epstein-Barr (EBV), varicella zoster (VZV), and herpes simplex 1 (HSV1) DNA was measured in saliva by quantitative polymerase chain reaction as an indicator of latent herpesvirus reactivation, and diet quality was determined using the healthy eating index measured by food frequency questionnaire in 61 US Army recruits (97% male) at the beginning (PRE) and end (POST) of 22-wk IMT., Results: Lymphocytes and terminally differentiated cluster of differentiation (CD)4+ and CD8+ T cells increased PRE to POST, whereas granulocytes, monocytes, effector memory CD4+ and CD8+ T cells, and central memory CD8+ T cells decreased ( P ≤ 0.02). Cytokine responses to anti-CD3/CD28 stimulation were higher POST compared with PRE, whereas cytokine responses to lipopolysaccharide stimulation were generally blunted ( P < 0.05). Prevalence of EBV reactivation was higher at POST ( P = 0.04), but neither VZV nor HSV1 reactivation was observed. Diet quality improvements were correlated with CD8+ cell maturation and blunted proinflammatory cytokine responses to anti-CD3/CD28 stimulation., Conclusions: Lymphocytosis, maturation of T-cell subsets, and increased T-cell reactivity were evident POST compared with PRE IMT. Although EBV reactivation was more prevalent at POST, no evidence of VZV or HSV1 reactivation, which are more common during severe stress, was observed. Findings suggest increases in the incidence of EBV reactivation were likely appropriately controlled by recruits and immune-competence was not compromised at the end of IMT., (Copyright © 2023 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a "œwork of the United States Government"œ for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

Sleep restriction alters gut microbiota composition and intestinal barrier function in rodents, but whether similar effects occur in humans is unclear. This study aimed to determine the effects of severe, short-term sleep restriction on gut microbiota composition and intestinal permeability in healthy adults. Fecal microbiota composition, measured by 16S rRNA sequencing, and intestinal permeability were measured in 19 healthy men (mean ± SD; BMI 24.4 ± 2.3 kg/m 2 , 20 ± 2 years) undergoing three consecutive nights of adequate sleep (AS; 7-9 h sleep/night) and restricted sleep (SR; 2 h sleep/night) in random order with controlled diet and physical activity. α-diversity measured by amplicon sequencing variant (ASV) richness was 21% lower during SR compared to AS (P = 0.03), but α-diversity measured by Shannon and Simpson indexes did not differ between conditions. Relative abundance of a single ASV within the family Ruminococcaceae was the only differentially abundant taxon (q = 0.20). No between-condition differences in intestinal permeability or β-diversity were observed. Findings indicated that severe, short-term sleep restriction reduced richness of the gut microbiota but otherwise minimally impacted community composition and did not affect intestinal permeability in healthy young men., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Background: Physiologic and psychologic stress slow healing from experimental wounds by impairing immune function., Objectives: We aimed to determine whether supplemental protein and multinutrient supplementation improved wound healing markers after acute stress induced by acute sleep restriction., Methods: In this single-blind, crossover study in generally healthy young adults (18 males/2 females; mean ± SD age: 19.7 ± 2.30 y), experimental wounds were created by removing the top layer of forearm blisters induced via suction after 48 h of 72-h sleep restriction (2-h nightly sleep), a protocol previously shown to delay wound healing. Skin barrier restoration (measured by transepidermal water loss) assessed wound healing ≤10 d postblistering, and local immune responses were evaluated by serial measurement of cytokine concentrations in fluid collected at wound sites for 48 h postblistering. Participants consumed controlled, isocaloric diets with either 0.900 g · kg-1 · d-1 protein plus placebo (PLA) or 1.50 g · kg-1 · d-1 protein plus multinutrient beverage [l-arginine: 20.0 g/d; l-glutamine: 30.0 g/d; omega-3 (n-3) fatty acids: 1.00 g/d; zinc sulfate: 24.0 mg/d; cholecalciferol: 800 IU/d; and vitamin C: 400 mg/d] (NUT) during sleep restriction and for 4 d afterwards., Results: Skin barrier restoration (primary outcome) was shorter for NUT (median: 3.98 d; IQR: 1.17 d) than for PLA (median: 5.25 d; IQR: 1.05 d) (P = 0.001). Cytokines from wound fluid (secondary outcome) increased over time (main effect of time P ≤ 0.001), except IL-13 (P = 0.07); however, no effects of treatment were observed., Conclusions: Supplemental nutrition may promote wound healing after sleep restriction in healthy adults including military personnel, the latter of which also have a high incidence of wounds and infection.This trial was registered at clinicaltrials.gov as NCT03525184., (Published by Oxford University Press on behalf of the American Society for Nutrition 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Enhancing dietary omega-3 highly unsaturated fatty acids (n-3 HUFA) intake may confer neuroprotection, brain resiliency, improve wound healing and promote cardiovascular health. This study determined the efficacy of substituting a few common foods (chicken meat, chicken sausage, eggs, salad dressings, pasta sauces, cooking oil, mayonnaise, and peanut butter) lower in omega-6 polyunsaturated fatty acids (n-6 PUFA) and higher in n-3 HUFA in a dining facility on blood fatty acid profile. An eight-week prospective, between-subjects ( n = 77), repeated measures, parallel-arm trial was conducted. Participants self-selected foods consumed from conventionally produced foods (control), or those lower n-6 PUFA and higher n-3 HUFA versions (intervention). Changes in blood omega-3 index, eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), n-6 PUFA, lipid profile, and food satisfaction were main outcomes. Between-group differences over time were assessed using a linear mixed model to measure the effect of diet on blood serum fatty acids and inflammatory markers. The intervention group achieved a higher omega-3 index score (3.66 ± 0.71 vs. 2.95 ± 0.77; p < 0.05), lower total n-6 (10.1 ± 4.6 vs. 15.3 ± 6.7 µg/mL; p < 0.05), and higher serum concentration of EPA (5.0 ± 1.31 vs. 4.05 ± 1.56 µg/mL; p < 0.05) vs. controls. Satisfaction in intervention foods improved or remained consistent. Substitution of commonly eaten dining facility foods with like-items higher in DHA and EPA and lower in n-6 PUFA can favorably impact fatty acid status and the omega-3 index.

Objective: Several nights of moderate (4-5 hr/night) sleep restriction increases appetite and energy intake, and may alter circulating concentrations of appetite regulating hormones. Whether more severe sleep restriction has similar effects is unclear. This study aimed to determine the effects of severe, short-term sleep restriction on appetite, ad libitum energy intake during a single meal, appetite regulating hormones, and food preferences., Methods: Randomized, crossover study in which 18 healthy men (mean ± SD: BMI 24.4 ± 2.3 kg/m 2 , 20 ± 2 yr) were assigned to three consecutive nights of sleep restriction (SR; 2 hr sleep opportunity/night) or adequate sleep (AS; 7-9 hr sleep opportunity/night) with controlled feeding and activity designed to maintain energy balance throughout the 3-day period. On day 4, participants consumed a standardized breakfast. Appetite, assessed by visual analogue scales, and circulating ghrelin, peptide-YY (PYY), glucagon-like peptide (GLP-1), insulin, and glucose concentrations were measured before and every 20-60 min for 4hr after the meal. Ad libitum energy and macronutrient intakes were then measured at a provided buffet lunch. Food preferences were measured by Leeds Food Preference Questionnaire (LFPQ) administered before and after the lunch., Results: Area under the curve (AUC) of postprandial hunger (-23%), desire to eat (-23%), and prospective consumption (-18%) ratings were all lower, and postprandial fullness AUC (25%) was higher after SR relative to after AS (p ≤ 0.02). Ad libitum energy intake at the lunch meal was 332 kcal [95% CI: -479, -185] (p<0.001) lower after SR relative to after AS, but relative macronutrient intakes and LFPQ scores did not differ. Postprandial glucose, insulin, PYY, GLP-1, and ghrelin AUCs did not differ between phases. However, mean concentrations of PYY (-11%) and GLP-1 (-4%) over the 4-hr testing period were lower, and glucose concentrations were 6% higher, after SR relative to after AS (p ≤ 0.01)., Conclusion: In contrast with reported effects of moderate sleep restriction, severe sleep restriction reduced appetite and energy intake, had no impact food preferences, and had little impact on appetite regulating hormones. Findings suggest that severe sleep restriction may suppress appetite and food intake, at least at a single meal, by a mechanism independent of changes in food preference or appetite regulating hormones., (Published by Elsevier Inc.)

Background Military personnel are at greater risk of psychological disorders and related symptoms than civilians. Limited participation in health-promoting behaviors may increase presence of these disorders. Alternatively, these symptoms may limit engagement in health-promoting behaviors. Methods Self-reported data from the 2015 Department of Defense Health Related Behaviors Survey were used to assess bi-directional relationships between health-related behaviors (obesity, physical activity [PA], alcohol, smoking, sleep) and self-reported psychological disorders (generalized anxiety disorder [GAD], depression, post-traumatic disorder [PTSD]) in U.S. military personnel. Outcomes Among 12 708 respondents (14.7% female; 28.2% 17-24 y; 13.7% obese), self-reported depression was reported by 9.2%, GAD by 13.9%, and PTSD by 8.2%. Obesity and short sleep were associated with self-reported depression, GAD, and PTSD; current smoking was associated with higher odds of GAD; higher levels of vigorous PA were associated with lower odds of GAD; higher levels of moderate PA associated with lower odds of PTSD; and higher alcohol intake associated with higher odds of depression and PTSD. Self-reported depression, GAD, and PTSD were associated with higher odds of short sleep, obesity, and low levels of PA. Interpretation Obesity, short sleep, and limited engagement in health-promoting behaviors are associated with higher likelihood of self-reported psychological disorders, and vice-versa. Encouraging and improving health-promoting behaviors may contribute to positive mental health in military personnel., (Copyright © 2021. Published by Elsevier B.V.)

Consuming a diet meeting energy demands and providing essential nutrients promotes a healthy immune system. Suboptimal nutritional status, resulting from either under- or overnutrition, disrupts immune health and compromises resistance to, and recovery from, infections. Multiple micronutrients contribute to immune health, for example vitamin D, iron, selenium and zinc. Inadequate intake and suboptimal micronutrient status have been observed in military personnel, which potentially increases the risk of acquiring, and recovering from, infectious diseases and may compromise readiness and lethality. This manuscript briefly reviews the relationship between nutrition, immune function, and infectious disease, and provides resources and future research directions.

Trends and relationships between health behaviors and conditions in US active duty military and Coast Guard personnel are understudied. Self-reported data from the 2011 and 2015 Department of Defense Health Related Behaviors Surveys were analyzed to estimate associations between seven behaviors (reasons for not exercising; moderate, vigorous, and strength training exercise; alcohol intake; sleep; and smoking) and five health conditions (high blood pressure [BP], blood sugar [BG], cholesterol [CH]; overweight/obesity [OW]; or obesity [OB]). In 33,531 respondents, 14.8%, 1.7%, 13.6%, 65.5%, and 12.1% had high BP, BG, CH, OW, or OB, respectively. Respondents in 2015, versus 2011, had higher odds of BP, BG, OW, and OB. Compared to exercising as much as desired, citing a disability or injury, or work commitments as reasons for not exercising associated with higher odds of each condition. Longer sleep associated with lower odds of each condition except BG. Current and former smoking associated with higher odds of BP; former smoking also associated with higher odds of high CH and OW. Three behaviors contributing to the best predictive models of each condition resulted in associations of reasons for not exercising with all conditions; strength training for OW and OB; alcohol intake for BP and BG; sleep for BP and CH; and moderate exercise for BG. Disability and injury and time constraints limiting exercise were consistent markers of self-reported health conditions. Military-specific initiatives to promote strategies for overcoming barriers to exercising, continued emphasis on adequate sleep, and reduction of alcohol intake and smoking are warranted., (Published by Elsevier Inc.)

Purpose: The objective of the study was to evaluate how controlled, short-term sleep restriction (SR; 72 h) alters markers of bone formation and resorption and urinary calcium (Ca) output., Methods: Ten healthy, sleep-adequate, male soldiers were housed in the research facility one day prior to and for the duration of SR. Diet was controlled to provide adequate energy balance and macronutrient distribution, meeting the recommended dietary allowance (RDA) for Ca. Subjects engaged in light activities to maintain wakefulness and were allowed 2 h of sleep per night (0430-0630 hours). Blood samples were collected each morning at 0 h (baseline) and 24, 48, and 72 h of SR. Serum was assayed for parathyroid hormone (PTH), bone alkaline phosphatase (BAP), tartrate-resistant acid phosphatase (TRAP), and C-terminal telopeptide of type I collagen (CTX). Urine was collected in 24 h increments during SR for measurement of Ca and creatinine (Cr)., Results: BAP was reduced at 24 h (P= 0.015) and resorption markers TRAP and CTX were increased after 48 and 72 h of SR compared to baseline (P < 0.05). The ratio of BAP:TRAP was significantly lower (P= 0.017) at 48 and 72 h of SR. In contrast, total 24 h urinary Ca and Ca/Cr excretion were unchanged., Conclusions: Markers of bone formation and resorption are uncoupled in response to as little as 48 h of SR even when Ca intake is at the RDA. Sleep deprivation may be a risk factor for reduced bone health due to perturbations in bone turnover.

Military personnel and emergency responders perform cognitively-demanding tasks during periods of sustained physical exertion and limited caloric intake. Cognitive function is preserved during short-term caloric restriction, but it is unclear if preservation extends to combined caloric restriction and physical exertion. According to the "reticular-activating hypofrontality" model, vigorous exertion impairs prefrontal cortex activity and associated functions. This double-blind, placebo-controlled, crossover study examined cognitive function during sustained exertion while volunteers were calorically-deprived. Twenty-three volunteers were calorie-depleted for two days on one occasion and fully-fed on another. They completed intermittent bouts of exercise at 40-65% VO 2peak while prefrontal cortex-dependent tasks of cognitive control, mood, and perceived exertion were assessed. Calorie deprivation impaired accuracy on the task-switching task of set-shifting (p < .01) and decreased sensitivity on the go/no-go task of response inhibition (p < .05). Calorie deprivation did not affect risk taking on the Rogers risk task. During exercise, calorie deprivation, particularly on day 2, increased perceived exertion (p < .05) and impaired mood states of tension, depression, anger, vigor, fatigue, and confusion (all p < .01). Physical exertion during severe calorie deprivation impairs cognitive control, mood, and self-rated exertion. Reallocation of cerebral metabolic resources from the prefrontal cortex to structures supporting movement may explain these deficits., (Published by Elsevier Inc.)

Consumption of certain berries appears to slow postprandial glucose absorption, attributable to polyphenols, which may benefit exercise and cognition, reduce appetite and/or oxidative stress. This randomised, crossover, placebo-controlled study determined whether polyphenol-rich fruits added to carbohydrate-based foods produce a dose-dependent moderation of postprandial glycaemic, glucoregulatory hormone, appetite and ex vivo oxidative stress responses. Twenty participants (eighteen males/two females; 24 (sd 5) years; BMI: 27 (sd 3) kg/m2) consumed one of five cereal bars (approximately 88 % carbohydrate) containing no fruit ingredients (reference), freeze-dried black raspberries (10 or 20 % total weight; LOW-Rasp and HIGH-Rasp, respectively) and cranberry extract (0·5 or 1 % total weight; LOW-Cran and HIGH-Cran), on trials separated by ≥5 d. Postprandial peak/nadir from baseline (Δmax) and incremental postprandial AUC over 60 and 180 min for glucose and other biochemistries were measured to examine the dose-dependent effects. Glucose AUC0-180 min trended towards being higher (43 %) after HIGH-Rasp v. LOW-Rasp (P=0·06), with no glucose differences between the raspberry and reference bars. Relative to reference, HIGH-Rasp resulted in a 17 % lower Δmax insulin, 3 % lower C-peptide (AUC0-60 min and 3 % lower glucose-dependent insulinotropic polypeptide (AUC0-180 min) P&lt;0·05. No treatment effects were observed for the cranberry bars regarding glucose and glucoregulatory hormones, nor were there any treatment effects for either berry type regarding ex vivo oxidation, appetite-mediating hormones or appetite. Fortification with freeze-dried black raspberries (approximately 25 g, containing 1·2 g of polyphenols) seems to slightly improve the glucoregulatory hormone and glycaemic responses to a high-carbohydrate food item in young adults but did not affect appetite or oxidative stress responses at doses or with methods studied herein.

Background: Health behaviors and cardiometabolic disease risk factors may differ between military and civilian populations; therefore, in U.S. active duty military personnel, we assessed relationships between demographic characteristics, self-reported health behaviors, and doctor-informed medical conditions., Methods: Data were self-reported by 27,034 active duty military and Coast Guard personnel who responded to the 2011 Department of Defense Health Related Behaviors Survey. Multivariate linear and logistic regressions were used to estimate cross-sectional associations between (1) demographic characteristics (age, sex, service branch, marital status, children, race/ethnicity, pay grade) and self-reported behaviors (exercise, diet, smoking, alcohol, sleep); (2) demographic characteristics and doctor-informed medical conditions (hypertension, hypercholesterolemia, low high density lipoprotein (HDL) cholesterol, hyperglycemia) and overweight/obesity; and (3) behaviors and doctor-informed medical conditions., Results: Among respondents (age 29.9 ± 0.1 years, 14.7% female), females reported higher intake than men of fruit, vegetables, and dairy; those with higher education reported higher intakes of whole grains; those currently married and/or residing with children reported higher intake of starches. Older age and female sex were associated with higher odds (ORs 1.25 to 12.54 versus the youngest age group) of overweight/obesity. Older age and female sex were also associated with lower odds (ORs 0.29 to 0.65 versus male sex) of doctor-informed medical conditions, except for blood glucose, for which females had higher odds. Those currently married had higher odds of high cholesterol and overweight/obesity, and separated/divorced/widowed respondents had higher odds of high blood pressure and high cholesterol. Short sleep duration (< 5 versus 7-8 h/night) was associated with higher odds (ORs 1.36to 2.22) of any given doctor-informed medical condition. Strength training was associated with lower probability of high cholesterol, high triglycerides, and low HDL, and higher probability of overweight/obesity. Dietary factors were variably associated with doctor-informed medical conditions and overweight/obesity., Conclusions: This study observed pronounced associations between health behaviors-especially sleep-and medical conditions, thus adding to evidence that sleep is a critical, potentially modifiable behavior within this population. When possible, adequate sleep should continue to be promoted as an important part of overall health and wellness throughout the military community.

Systemic immune function is impaired by sleep restriction. However, the impact of sleep restriction on local immune responses and to what extent any impairment can be mitigated by nutritional supplementation is unknown. We assessed the effect of 72-h sleep restriction (2-h nightly sleep) on local immune function and skin barrier restoration of an experimental wound, and determined the influence of habitual protein intake (1.5 g·kg -1 ·day -1 ) supplemented with arginine, glutamine, zinc sulfate, vitamin C, vitamin D3, and omega-3 fatty acids compared with lower protein intake (0.8 g·kg -1 ·day -1 ) without supplemental nutrients on these outcomes. Wounds were created in healthy adults by removing the top layer of less than or equal to eight forearm blisters induced via suction, after adequate sleep (AS) or 48 h of a 72-h sleep restriction period (SR; 2-h nightly sleep). A subset of participants undergoing sleep restriction received supplemental nutrients during and after sleep restriction (SR+). Wound fluid was serially sampled 48 h postblistering to assess local cytokine responses. The IL-8 response of wound fluid was higher for AS compared with SR [area-under-the-curve (log 10 ), 5.1 ± 0.2 and 4.9 ± 0.2 pg/ml, respectively; P = 0.03]; and both IL-6 and IL-8 concentrations were higher for SR+ compared with SR ( P < 0.0001), suggestive of a potentially enhanced early wound healing response. Skin barrier recovery was shorter for AS (4.2 ± 0.9 days) compared with SR (5.0 ± 0.9 days) ( P = 0.02) but did not differ between SR and SR+ ( P = 0.18). Relatively modest sleep disruption delays wound healing. Supplemental nutrition may mitigate some decrements in local immune responses, without detectable effects on wound healing rate. NEW & NOTEWORTHY The data herein characterizes immune function in response to sleep restriction in healthy volunteers with and without nutrition supplementation. We used a unique skin wound model to show that sleep restriction delays skin barrier recovery, and nutrition supplementation attenuates decrements in local immune responses produced by sleep restriction. These findings support the beneficial effects of adequate sleep on immune function. Additional studies are necessary to characterize practical implications for populations where sleep restriction is unavoidable.

Individuals entering US Army service are generally young and healthy, but many are overweight, which may impact cardiometabolic risk despite physical activity and fitness requirements. This analysis examines the association between Soldiers' BMI at accession and incident cardiometabolic risk factors (CRF) using longitudinal data from 731,014 Soldiers (17.0% female; age: 21.6 [3.9] years; BMI: 24.7 [3.8] kg/m2) who were assessed at Army accession, 2001-2011. CRF were defined as incident diagnoses through 2011, by ICD-9 code, of metabolic syndrome, glucose/insulin disorder, hypertension, dyslipidemia, or overweight/obesity (in those not initially overweight/obese). Multivariable-adjusted proportional hazards models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI) between BMI categories at accession and CRF. Initially underweight (BMI<18.5 kg/m2) were 2.4% of Soldiers, 53.5% were normal weight (18.5-<25), 34.2% were overweight (25-<30), and 10.0% were obese (≥30). Mean age range at CRF diagnosis was 24-29 years old, with generally low CRF incidence: 228 with metabolic syndrome, 3,880 with a glucose/insulin disorder, 26,373 with hypertension, and 13,404 with dyslipidemia. Of the Soldiers who were not overweight or obese at accession, 5,361 were eventually diagnosed as overweight or obese. Relative to Soldiers who were normal weight at accession, those who were overweight or obese, respectively, had significantly higher risk of developing each CRF after multivariable adjustment (HR [95% CI]: metabolic syndrome: 4.13 [2.87-5.94], 13.36 [9.00-19.83]; glucose/insulin disorder: 1.39 [1.30-1.50], 2.76 [2.52-3.04]; hypertension: 1.85 [1.80-1.90], 3.31 [3.20-3.42]; dyslipidemia: 1.81 [1.75-1.89], 3.19 [3.04-3.35]). Risk of hypertension, dyslipidemia, and overweight/obesity in initially underweight Soldiers was 40%, 31%, and 79% lower, respectively, versus normal-weight Soldiers. BMI in early adulthood has important implications for cardiometabolic health, even within young, physically active populations., Competing Interests: The authors have declared that no competing interests exist.

Background: In studies assessing the effects of acute undernutrition on cognitive function, volunteers are sedentary and findings are equivocal, even though glucose concentrations fall substantially. However, military personnel and endurance athletes often are underfed when physical demands, and consequently energy expenditure, are substantial., Objective: The objective of this study was to determine whether 2 d of near-total calorie deprivation combined with aerobic exercise degraded cognitive performance and mood., Methods: A double-blind, placebo-controlled, crossover design was used. Twenty-three volunteers [17 men (mean ± SD age: 20.5 ± 0.7 y) and 6 women (mean ± SD age: 23.3 ± 1.4 y); mean ± SD body mass index (in kg/m 2 ): 25 ± 3] participated for 68 h, including a 51-h inpatient phase in a calorie-deprived or fully fed state during which behavioral testing was conducted and interstitial glucose was monitored continuously. Mood and cognitive performance, including psychomotor and visual vigilance, visual match-to-sample, repeated acquisition (motor learning), N-back (working memory), and grammatical reasoning, were repeatedly assessed. During each condition, individual daily energy intake and expenditure were controlled. During calorie deprivation, volunteers consumed 266 ± 61 kcal/d; during full feeding, they consumed 3935 ± 769 kcal/d. Participants engaged in identical exercise sessions for 4 h/d at 40-65% of peak volume of oxygen uptake attained., Results: Calorie deprivation did not affect any aspect of cognitive performance, but produced robust effects on mood measured by the Profile of Mood States, including increased tension (P < 0.001), fatigue (P < 0.001), and total mood disturbance (from -0.80 ± 5.1 to 20.1 ± 6.1; P < 0.001), and decreased vigor (P = 0.002), as indicated by treatment × trial (time) effects on ANOVA. Interstitial glucose concentrations were lower during calorie deprivation than in the fully fed condition (P = 0.002, treatment × trial interaction) and declined to 61 mg/dL by the end of the treatment condition., Conclusion: In healthy young men and women, 2 d of severe calorie deprivation in combination with substantial aerobic exercise adversely affects multiple aspects of mood, but not cognition, in spite of substantial reductions in interstitial glucose concentrations. This trial was registered at clinicaltrials.gov as NCT01603550., (© 2017 American Society for Nutrition.)

Military personnel and some athlete populations endure short-term energy deficits from reduced energy intake and/or increased energy expenditure (EE) that may degrade physical and cognitive performance due to severe hypoglycemia (<3.1 mmol/l). The extent to which energy deficits alter normoglycemia (3.9-7.8 mmol/l) in healthy individuals is not known, since prior studies measured glucose infrequently, not continuously. The purpose of this study was to characterize the glycemic response to acute, severe energy deficit compared with fully fed control condition, using continuous glucose monitoring (CGM). For 2 days during a double-blind, placebo-controlled, crossover study, 23 volunteers (17 men/6 women; age: 21.3 ± 3.0 yr; body mass index: 25 ± 3 kg/m) increased habitual daily EE [2,300 ± 450 kcal/day [means ± SD)] by 1,647 ± 345 kcal/day through prescribed exercise (~3 h/day; 40-65% peak O 2 consumption), and consumed diets designed to maintain energy balance (FED) or induce 93% energy deficit (DEF). Interstitial glucose concentrations were measured continuously by CGM (Medtronic Minimed). Interstitial glucose concentrations were 1.0 ± 0.9 mmol/l lower during DEF vs. FED (P < 0.0001). The percentage of time spent in mild (3.1-3.8 mmol/l) hypoglycemia was higher during DEF compared with FED [mean difference = 20.5%; 95% confidence interval (CI): 13.1%, 27.9%; P = 0.04], while time spent in severe (<3.1 mmol/l) hypoglycemia was not different between interventions (mean difference = 4.6%; 95% CI: -0.6%, 9.8%; P = 0.10). Three of 23 participants spontaneously reported symptoms (e.g., nausea) potentially related to hypoglycemia during DEF, and an additional participant reported symptoms during both interventions. These findings suggest that severe hypoglycemia rarely occurs in healthy individuals enduring severe, short-term energy deficit secondary to heavy exercise and inadequate energy intake., (Copyright © 2016 the American Physiological Society.)

Introduction: Little data exist regarding the long-term impact of excess weight on lower extremity musculoskeletal injury/disorder (MID) in U.S. Army Soldiers. This prospective analysis examines the association between BMI of Soldiers at accession and risk of MID., Methods: A total of 736,608 Soldiers were followed from accession into the Army, 2001-2011. Data were analyzed January through March 2015. MID was categorized as any first incident lower extremity musculoskeletal injury/disorder, and secondarily, as first incident injury/disorder at a specific site (i.e., hips, upper legs/thighs, knees, lower legs/ankles, feet/toes). Multivariable-adjusted proportional hazards models estimated associations between BMI category at accession and MID risk., Results: During 15,678,743 person-months of follow-up, 411,413 cases of any first MID were documented (70,578 hip, 77,050 upper leg, 162,041 knee, 338,080 lower leg, and 100,935 foot injuries in secondary analyses). The overall MID rate was 2.62 per 100 person-months. Relative to Soldiers with normal BMI (18.5 to <25 kg/m(2)) at accession, those who were underweight (<18.5); overweight (25 to <30); or obese (≥30) had 7%, 11%, and 33% higher risk of MID, respectively, after adjustment. Risks were highest in Soldiers who were obese at accession, and lowest in those with a BMI of 21-23 kg/m(2)., Conclusions: Soldier BMI at accession has important implications for MID. A BMI of 21-23 kg/m(2) in newly accessing Soldiers was associated with the lowest risk of incident MID, suggesting that accession be limited to people within this range to reduce overall incidence of MID among service personnel., (Published by Elsevier Inc.)

Background: Military personnel frequently endure intermittent periods of severe energy deficit which can compromise health and performance. Physiologic factors contributing to underconsumption, and the subsequent drive to overeat, are not fully characterized. This study aimed to identify associations between appetite, metabolic homeostasis and endocrine responses during and following severe, short-term energy deprivation., Methods: Twenty-three young adults (17M/6F, 21±3years, BMI 25±3kg/m(2)) participated in a randomized, controlled, crossover trial. During separate 48-h periods, participants increased habitual energy expenditure by 1647±345kcal/d (mean±SD) through prescribed exercise at 40-65% VO2peak, and consumed provided isovolumetric diets designed to maintain energy balance at the elevated energy expenditure (EB; 36±93kcal/d energy deficit) or to produce a severe energy deficit (ED; 3681±716kcal/d energy deficit). Appetite, markers of metabolic homeostasis and endocrine mediators of appetite and substrate availability were periodically measured. Ad libitum energy intake was measured over 36h following both experimental periods., Results: Appetite increased during ED and was greater than during EB despite maintenance of diet volume (P=0.004). Ad libitum energy intake was 907kcal/36h [95% CI: 321, 1493kcal/36h, P=0.004] higher following ED compared to following EB. Serum beta-hydroxybutyrate, free fatty acids, branched-chain amino acids, dehydroepiandrosterone-sulfate (DHEA-S) and cortisol concentrations were higher (P<0.001 for all), whereas whole-body protein balance was more negative (P<0.001), and serum glucose, insulin, and leptin concentrations were lower (P<0.001 for all) during ED relative to during EB. Cortisol concentrations, but not any other hormone or metabolic substrate, were inversely associated with satiety during EB (R(2)=0.23, P=0.04). In contrast, serum glucose and DHEA-S concentrations were inversely associated with satiety during ED (R(2)=0.68, P<0.001). No associations between physiologic variables measured during EB and ad libitum energy intake following EB were observed. However, serum leptin and net protein balance measured during ED were inversely associated with ad libitum energy intake following ED (R(2)=0.48, P=0.01)., Conclusion: These findings suggest that changes in metabolic homeostasis during energy deprivation modulate appetite independent of reductions in diet volume. Following energy deprivation, physiologic signals of adipose and lean tissue loss may drive restoration of energy balance., Clinical Trials Registration: www.clinicaltrials.gov #NCT01603550., (Published by Elsevier Inc.)

Background: Adaptive responses of appetite-mediating hormones to negative energy balance are thought to contribute to a counterregulatory response that drives weight regain, but they have not been studied while controlling for reduced diet volume., Objective: In this secondary analysis, we aimed to determine the effects of short-term, severe energy deprivation (ED) on appetite and appetite-mediating hormone concentrations., Methods: Twenty-one adults with a mean ± SD age of 21 ± 3 y and body mass index of 25 ± 3 kg/m(2) consumed isovolumetric diets provided over separate 48-h periods while increasing habitual energy expenditure by 1683 ± 329 kcal/d through light- and moderate-intensity exercise. Energy intake was matched to energy expenditure to maintain energy balance (EB) (-44 ± 92 kcal/d) or was <10% of energy expenditure to generate a -3696 ± 742-kcal/d energy deficit. Postprandial appetite, glucose, insulin, acyl ghrelin, peptide YY, pancreatic polypeptide (PP), and glucagon-like peptide-1 (GLP-1) responses and ad libitum energy intake were measured as secondary outcomes after both experimental periods., Results: Fasting insulin (-56% ± 42%) and acyl ghrelin (-60% ± 17%) concentrations decreased during ED but not during EB (condition-by-time interaction; P-interaction ≤ 0.01), whereas fasting leptin concentrations decreased more during ED compared with during EB (-47% ± 27% compared with -20% ± 27%; P-interaction = 0.05). Postprandial insulin (57% ± 63%; P < 0.001), GLP-1 (14% ± 28%; P = 0.04), and PP (54% ± 52%; P < 0.001) areas under the curve (AUCs) were higher, whereas the acyl ghrelin AUC was lower (-56% ± 13%; P < 0.001) after ED compared with after EB. After ED, self-rated appetite was greater, and ad libitum energy intake was 811 kcal/36 h (95% CI: 184, 1439 kcal/36 h) higher relative to after EB (P = 0.01)., Conclusions: Short-term, severe ED suppressed acyl ghrelin concentrations and increased postprandial anorexigenic hormone concentrations. These effects preceded compensatory overeating, suggesting that in adults without obesity, altered sensitivity to appetite-mediating hormones may contribute to an adaptive counterregulatory response during the initial stages of negative EB. This trial was registered at clinicaltrials.gov as NCT01603550., (© 2016 American Society for Nutrition.)

Development of n-3 fortified, shelf-stable foods is facilitated by encapsulated docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), since natural n-3 food sources cannot withstand high temperature and prolonged shelf life. Organoleptic stability of n-3 fortified, shelf-stable foods has been demonstrated, but chemical changes in the food matrix throughout storage could conceivably impact digestibility of the protein-based encapsulant thereby compromising n-3 bioavailability. We assessed the effect of prolonged high-temperature storage and variations in food matrix (proteinaceous or carbohydrate) on the time course and magnitude of blood fatty acids changes associated with ingestion of n-3 fortified foods. Low-protein (i.e., cake) and high-protein (i.e., meat sticks) items were supplemented with 600 mg encapsulated DHA+EPA, and frozen either immediately after production (FRESH) or after 6 months storage at 100°F (STORED). Fourteen volunteers consumed one item per week (randomized) for 4 weeks. Blood samples obtained at baseline, 2, 4, and 6 h post-consumption were analyzed for circulating long-chain omega 3 fatty acids (LCn3). There was no difference in LCn3 area under the curve between items. LCn3 in response to cakes peaked at 2-h (FRESH: 54.0 ± 16.8 μg/mL, +18%; STORED: 53.0 ± 13.2 μg/mL, +20%), while meats peaked at 4-h (FRESH: 51.9 ± 12.5 μg/mL, +22%; STORED: 53.2 ± 16.9 μg/mL, +18%). There were no appreciable differences in time course or magnitude of n-3 appearance in response to storage conditions for either food types. Thus, bioavailability of encapsulated DHA/EPA, within low- and high-protein food items, was not affected by high-temperature shelf-storage. A shelf-stable, low- or high-protein food item with encapsulated DHA/EPA is suitable for use in shelf-stable foods.

Objective: The US Army recruits new soldiers from an increasingly obese civilian population. The change in weight status at entry into the Army between 1989 and 2012 and the demographic characteristics associated with overweight/obesity at entry were examined., Methods: 1,741,070 unique individuals with complete sex, age, and anthropometric information contributed data to linear and logistic regressions examining time trends and associations between demographic characteristics and overweight/obesity., Results: The prevalence of overweight (body mass index 25-<30 kg/m(2)) generally increased, from 25.8% (1989) to 37.2% (2012), peaking at 37.9% (2011). The prevalence of obesity (body mass index ≥30 kg/m(2)) also increased from 5.6% (1989) to 8.0% (2012), peaking at 12.3% (2009); 2005-2009 annual prevalence exceeded 10%. The most consistent demographic characteristics predicting overweight/obesity were male sex, older age, Hispanic or Asian/Pacific Island race/ethnicity, and being married. There were no distinct geographic trends., Conclusions: The US Army is not immune to the US obesity epidemic. Demographic characteristics associated with being overweight or obese should be considered when developing military-sponsored weight management programs for new soldiers., (© 2015 The Obesity Society.)

Skin wound healing models can be used to detect changes in immune function in response to interventions. This study used a test-retest format to assess the reliability of a skin suction blister procedure for quantitatively evaluating human immune function in repeated measures type studies. Up to eight suction blisters (~30 mm(2)) were induced via suction on each participant's left and right forearm (randomized order; blister session 1 and 2), separated by approximately one week. Fluid was sampled from each blister, and the top layer of each blister was removed to reveal up to eight skin wounds. Fluid from each wound was collected 4, 7 and 24h after blisters were induced, and proinflammatory cytokines were measured. Transepidermal water loss (TEWL), to assess skin barrier recovery, was measured daily at each wound site until values were within 90% of baseline values (i.e., unbroken skin). Sleep, stress and inflammation (i.e., factors that affect wound healing and immune function), preceding the blister induction, were assessed via activity monitors (Actical, Philips Respironics, Murrysville, Pennsylvania), the Perceived Stress Scale (PSS) and C-reactive protein (CRP), respectively. Area-under-the-curve and TEWL, between blister session 1 and 2, were compared using Pearson correlations and partial correlations (controlling for average nightly sleep, PSS scores and CRP). The suction blister method was considered reliable for assessing immune response and skin barrier recovery if correlation coefficients reached 0.7. Volunteers (n=16; 12 M; 4F) were 23 ± 5 years [mean ± SD]. Time to skin barrier restoration was 4.9 ± 0.8 and 4.8 ± 0.9 days for sessions 1 and 2, respectively. Correlation coefficients for skin barrier restoration, IL-6, IL-8 and MIP-1α were 0.9 (P<0.0001), 0.7 (P=0.008) and 0.9 (P<0.0001), respectively. When average nightly sleep, PSS scores and CRP (i.e., percent difference between sessions 1 and 2) were taken into consideration, correlations in immune response between sessions 1 and 2 were improved for IL-8 (0.8, P=0.002) and TNF-α (0.7, P=0.02). The skin suction blister method is sufficiently reliable for assessing skin barrier restoration and immune responsiveness. This data can be used to determine sample sizes for cross-sectional or repeated-measures types of studies testing the impact of various stressors on immune response, and/or the efficacy of interventions to mitigate decrements in immune response to stress., (Published by Elsevier B.V.)

Objective: To determine if overweight or obesity is associated with mental health disorder (MHD) symptoms among military personnel Methods: Secondary analysis using the 2005 Department of Defense Health Related Behaviors Survey (N = 15,195). Standard Body Mass Index (BMI) categories were used to classify participants' body composition., Results: For women, obesity was associated with symptoms of serious psychological distress (SPD), post-traumatic stress disorder, and depression. For men, obesity and overweight was associated with symptoms of generalized anxiety disorder and SPD, respectively. Self-reported high personal stress was the strongest predictor of MHD symptoms and suicide attempts., Conclusion: Self-reported stress was a stronger predictor of MHD symptoms than BMI. There is potential value in screening personnel for personal stress as a MHD risk factor.

Objective: To assess whether active duty military personnel meet Healthy People 2010 objectives for physical activity and fruit, vegetable, and whole-grain intake; the relationship of select demographic characteristics, lifestyle factors (eg, smoking), and eating patterns (eg, frequency and location of meals) on achieving diet and exercise-related Healthy People 2010 objectives; and the relationship of eating patterns to self-reported weight gain., Methods: Secondary data from 15,747 participants in the 2005 Department of Defense Health Related Behaviors Survey was analyzed., Results: More than 57% of respondents met the Healthy People 2010 guidelines for moderate or vigorous leisure exercise but only 3% reported eating fruit (once), vegetables (3 times), and whole grains (3 times) daily. Individuals who reported gaining weight during the previous year were more likely to skip breakfast and eat at, or from, a restaurant ≥2 times per week compared with those who did not gain weight (P<0.001). Regression analysis indicated that women were more likely to eat fruits (odds ratio [OR] 1.25) and vegetables (OR 1.20) and less likely than men to eat whole grains (OR 0.76) or engage in moderate or vigorous exercise (OR 0.71). Military personnel who skipped breakfast ≥2 times per week (OR 0.45) or ate at a restaurant/takeout food (OR 0.54) ≥2 times per week were significantly less likely to meet Healthy People 2010 guidelines for food intake (defined as achieving a daily intake of one or more fruits, three or more vegetables, and three or more servings of whole grains) and exercise (OR 0.88 and 0.82, respectively)., Conclusions: Although the majority of military personnel met guidelines for physical activity, their intake of fruits, vegetables, and whole grains was suboptimal. Skipping breakfast and eating at, or from, restaurants were risk factors for poor nutrient intake and associated with weight gain. These data suggest that skipping breakfast and eating out deter achieving Healthy People 2010 objectives and provide targets for military programs to promote achieving these objectives., (Copyright © 2013 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

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., (Published by Elsevier Inc.)

College students are susceptible to upper respiratory infections (URI) due to inadequate sleep, stress and close living quarters. Certain probiotic strains modulate immune function and may improve health-related quality of life (HRQL) during URI. The present study recruited apparently healthy college students and assessed the effect of probiotics on HRQL outcomes (i.e. self-reported duration, symptom severity and functional impairment of URI) in those who developed URI. Missed school and work days due to URI were also considered. Subjects (n 231) were apparently healthy college students living on campus in residence halls at the Framingham State University (Framingham, MA, USA), and were randomised to receive placebo (n 117) or probiotic-containing powder (daily dose of minimum 1 billion colony-forming units of each Lactobacillus rhamnosus LGG® (LGG®) and Bifidobacterium animalis ssp. lactis BB-12® (BB-12®); n 114) for 12 weeks. Subjects completed The Wisconsin Upper Respiratory Symptom Survey-21 to assess HRQL during URI. The final analyses included 198 subjects (placebo, n 97 and probiotics, n 101). The median duration of URI was significantly shorter by 2 d and median severity score was significantly lower by 34% with probiotics v. placebo (P,0·001), indicating a higher HRQL during URI. Number of missed work days was not different between groups (P=0·429); however, the probiotics group missed significantly fewer school days (mean difference = 0·2 d) compared to the placebo group (P=0·002). LGG® and BB-12® may be beneficial among college students with URI for mitigating decrements in HRQL. More research is warranted regarding mechanisms of action associated with these findings and the cost-benefit of prophylactic supplementation.

In the United States, nationally representative civilian studies have shown that BMI is associated with select sociodemographic characteristics. Active-duty military personnel are not included in these surveys and the persistence of these associations in military personnel is unknown. Data from the worldwide, representative 2002 and 2005 Department of Defense (DoD) Surveys of Health-Related Behaviors Among Active Duty Military Personnel were used to assess the prevalence of overweight and obesity and, the association of BMI with sociodemographic characteristics. The final response bases included 12,756 (2002) and 16,146 (2005) personnel. Results indicated that the combined prevalence of overweight and obesity in military personnel increased to an all-time high in 2005 (60.5%) with higher prevalence of obesity in 2005 compared to 2002 (12.9% vs. 8.7, respectively, P ≤ 0.01). Holding other variables constant, regression analysis indicated that women were significantly less likely than men to be overweight or obese in both survey years (P ≤ 0.0001), which is contrary to civilian data. Similar to civilian data, the prevalence of obesity was significantly associated with increased age, black or Hispanic/Latino race/ethnicity, and being married (P ≤ 0.01). US military personnel are not immune to the US obesity epidemic. Demographic characteristics associated with being overweight should be considered when developing military-sponsored weight management programs.

A higher body mass index is associated with exercise-related injuries and increased risk for musculoskeletal and connective tissue disorders, which are relevant to military personnel. Studies show the efficacy of orlistat 60 mg for promoting weight and body fat loss in civilians; however, its efficacy among predominantly young, male soldiers is unknown. This study's objective was to examine the effect of a 6-month, standard education-based weight-management program with and without orlistat 60 mg on changes in weight and body fat in overweight soldiers. Data were collected for this randomized, controlled trial from March 2008 to November 2010 at Fort Bragg, NC. Participants were enrolled in an education-based weight management program (n=435; 75% men) and were randomized to placebo or orlistat 60 mg, three capsules daily with meals. All participants were recommended to maintain a reduced-energy, low-fat diet. Among study completers (14% retention rate; placebo n=22, orlistat n=35) members of both groups lost significant weight from baseline (placebo -3.0±5.2 kg; orlistat -3.2±4.7 kg; P<0.01), but only the orlistat group lost fat mass (-2.5±3.9 kg; P<0.001), whereas the placebo group lost lean mass (-1.4±2.7 kg; P <0.01). An intent-to-treat analysis (?1 follow-up body weight measure) demonstrated that the orlistat group lost more fat mass vs the placebo group (-1.3±2.9 kg vs ?0.6±1.8 kg, respectively; P<0.05), but less lean mass (-0.2±2.0 kg vs -0.8±1.8 kg, respectively; P<0.01). Orlistat 60 mg may be an effective adjunct to an education-based weight management program in a mostly young, male soldier population., (Published by Elsevier Inc.)

Background and Objectives: The Patient-centered Medical Home (PCMH) concept, essential functions of primary care, and an appropriate primary care workforce have been shown to improve health outcomes and reduce health care costs. This paper describes a curriculum that uses the PCMH and related health policy concepts as the foundation for didactic, clinical, and self-directed elements. The PCMH-focused curriculum improved overall student clerkship ratings and maintained student performance on the National Board of Medical Education subject exam.

Background: Probiotics may enhance gastrointestinal health and immune function. The efficacy of different probiotic dosing strategies on colonization and persistence of probiotics is undefined., Objective: The authors assessed colonization and persistence of Lactobacillus reuteri (L. reuteri) DSM17938 (BioGaia AB, Stockholm, Sweden) after daily or alternate-day dosing., Methods: Volunteers ate pudding with L. reuteri (10(9) CFU) daily (n = 9) or on alternate days (n = 9) over 7 days. Fecal samples were collected on dosing days (D1-7) and after dosing ended (D13-15 and D20-22) and were analyzed for the presence of L. reuteri. Results are reported in 3-day increments (D2-4, D5-7, D13-15, and D20-22)., Results: L. reuteri count rose in response to daily supplementation ([mean ± SD] D2-4: 4 × 10⁴ ± 2 × 10⁴ CFU, p < 0.01; D5-7: 10 × 10⁴ ± 9 × 10⁴ CFU, p < 0.01) and alternate-day supplementation (D2-4: 21 × 10⁴ ± 20 × 10⁴ CFU, p < 0.01; D5-7: 11 × 10⁴ ± 15 × 10⁴ CFU, p = 0.06) and fell in both groups 1 week after dosing ended (p < 0.01). Total volunteers with detectable L. reuteri 1 and 2 weeks after dosing ended was similar in response to daily feeding (4/9 and 2/9, respectively) and alternate-day feeding (3/9 and 2/9, respectively). L. reuteri count was higher D2-4 in response to alternate-day vs daily feeding (p < 0.05) but similar thereafter., Conclusions: Alternate-day probiotic intake achieves equivalent colonization to daily intake, but colonization declines rapidly once dosing stops. It is possible that, initially, responsiveness to probiotics may differ between individuals, but those differences do not persist with longer consumption.

Background: Inadequate energy intake induces changes in endogenous glucose production (GP) to preserve muscle mass. Whether addition provision of dietary protein modulates GP response to energy deficit is unclear. The objective was to determine whether exercise-induced energy deficit effects on glucose metabolism are mitigated by increased dietary protein., Methods: Nineteen men ([mean ± SD] 23 ± 2 y, VO2peak 59 ± 5 ml·kg-1·min-1) were divided into three groups, two consuming moderate (MP; 0.9 g protein kg-1 d-1), and one high (HP; 1.8 g protein kg-1 d-1) protein diets (55% energy from carbohydrate) for 11 days. Following 4 days of energy balance (D1-4), energy expenditure was increased for 7 days (D5-12) in all groups. Energy intake was unchanged in two, creating a 1000 kcal d-1 deficit (DEF-MP, DEF-HP; n = 6, both groups), whereas energy balance was maintained in the third (BAL-MP, n = 7). Biochemical markers of substrate metabolism were measured during fasting rest on D4 and D12, as were GP and contribution of gluconeogenesis to endogenous glucose production (fgng) using 4-h primed, continuous infusions of [6,6-2H2]glucose (dilution-method) and [2-13C]glycerol (MIDA technique). Glycogen breakdown (GB) was derived from GP and fgng., Results: Plasma β-hydroxybutyrate levels increased, and plasma glucose and insulin declined from D4 to D12, regardless of group. DEF-MP experienced decreased plasma GP from D4 to D12 ([mean change ± SD] 0.24 ± 0.24 mg·kg-1·min-1), due to reduced GB from D4 (1.40 ± 0.28 mg·kg-1·min-1) to D12 (1.16 ± 0.17 mg·kg-1·min-1), P < 0.05. Conversely, BAL-MP and DEF-HP sustained GP from D4 to D12 ([mean change ± SD] 0.1 ± 0.5 and 0.0 ± 0.2 mg·kg-1·min-1, respectively) by maintaining GB., Conclusion: Exercise-induced energy deficit decreased GP and additional dietary protein mitigated that effect.

Probiotics are defined as "live organisms which, when administered in adequate amounts confer a benefit on the host." The purpose of this review was to determine whether there is evidence-based justification to recommend purchase and promotion of probiotic-containing food in military dining facilities (DFACs). Peer-reviewed literature was searched to identify well-conducted systematic reviews and original research related to the efficacy of probiotics in preventing and/or treating acute infectious diarrhea, irritable bowel syndrome, respiratory tract infections, allergic rhinitis, dental health issues, and female urogenital conditions. Probiotics may be useful for preventing and/or treating military-relevant health conditions. However, the available scientific evidence is not sufficient to warrant widespread procurement and promotion of probiotic-containing food items in military DFACs. Health care practitioners considering recommending probiotics should understand that health effects and clinical outcomes discussed herein are specific to the probiotic strain, dose, and method of delivery studied in the articles cited.

Excess weight is associated with negative health outcomes. Meal replacements are effective in promoting favorable body composition changes in civilian populations; however, their efficacy with military service members who have unique lifestyles is unknown. The objective of this randomized controlled trial was to determine the efficacy of the Army's education-based weight-management program, "Weigh to Stay," with and without meal replacements for improving blood lipids, and to promote weight and body fat loss in overweight US Army soldiers. Soldiers (n=113; 76 males/37 females) attending Weigh to Stay at Fort Bragg, NC, in 2006/2007 were randomized to Weigh to Stay only or a commercially available meal-replacement program (two meal replacements per day) in conjunction with Weigh to Stay, and followed until Army body fat standards were met or for 6 months if standards were not met. Study completers (n=46) in both treatment groups lost weight (Weigh to Stay: -2.7+/-4.3 kg; meal replacers: -3.8+/-3.5 kg) and fat mass (Weigh to Stay, -2.7+/-3.2 kg; meal replacers: -2.9+/-2.5 kg), and improved high-density lipoprotein cholesterol concentrations (Weigh to Stay: 13+/-9 mg/dL [0.34+/-0.23 mmol/L]; meal replacers: 8+/-7 mg/dL [0.21+/-0.18 mmol/L]; P<0.05); however, no between-group differences were observed. Attrition was lower (P=0.009) and success in meeting body fat standards tended to be higher (P=0.06) for the meal replacers vs Weigh to Stay participants. Intent-to-treat analysis demonstrated that meal replacers lost more weight (1.2+/-0.5 kg), percent body fat (1.0%+/-0.4%), and fat mass (0.8+/-0.4 kg) compared to Weigh to Stay volunteers (P<0.05). Our findings suggest that meal replacement use can be recommended as a potential adjunct strategy to Weigh to Stay., (Published by Elsevier Inc.)

New approaches to assess energy intake (EI) may have advantages over traditional written methods, but validity of these emerging methodologies must be demonstrated. This exploratory study compared EI obtained using a hand-held personal digital assistant (PDA) and traditional written records with total energy expenditure measured by doubly labeled water (TEE(DLW)). Twenty-six volunteers (aged 23+/-4 years, body mass index [calculated as kg/m(2)] 24+/-2) participated in a randomized (either PDA or written record group) and matched (for sex, age, and body mass index) study for 7 consecutive days between June 2005 and April 2006 to record EI. Group comparisons were made with t and Mann-Whitney U tests. Bland-Altman plots were used to compare limits of agreement between methods. Volunteers remained weight stable during the study period (0.2+/-0.8 kg; P>0.05). Reported EI by written record and PDA were similar to TEE(DLW); 105% vs 92% of TEE(DLW), respectively (P>0.05). There was a significant relationship between reported EI by PDA and TEE(DLW) (r=0.60, P<0.05), but not for written record (r=0.45, P>0.05). Limits of agreement indicated both written record and PDA had large variability (range 1,394 to -1,472 kcal/day). Findings suggest the bias in using a PDA is similar to that observed when using a written record for estimation of EI in weight-stable volunteers.

Background: A sudden increase in exercise and energy expenditure is associated with an increase in protein turnover and nitrogen excretion. This study examined how a sudden increase in exercise-induced energy expenditure affected whole body protein metabolism and nitrogen balance in people of differing levels of aerobic fitness. We hypothesized that alterations in whole-body protein turnover would be attenuated, and nitrogen balance would be preserved, in individual with higher levels of aerobic fitness., Methods: Eleven men, categorized as either having a lower (LOW-FIT; n = 5) or higher (FIT; n = 6) aerobic fitness level, completed a 4-d baseline period (BL) of an energy balance diet while maintaining usual physical activity level, followed by a 7-d intervention consisting of 1,000 kcal·d⁻¹ increased energy expenditure via exercise (50-65% VO₂peak). All volunteers consumed 0.9 g protein.kg⁻¹·d⁻¹ and total energy intake was adjusted to maintain energy balance throughout the 11-d study. Mean nitrogen balance (NBAL) was determined for BL, days 5-8 (EX1), and days 9-11 (EX2). Whole-body protein turnover was derived from phenylalanine and tyrosine kinetics assessed while fasting at rest on days 4, 7, and 12 using a priming dose of L-[ring-¹⁵N]tyrosine and a 4-h primed, continuous infusion of L-[¹⁵N]phenylalanine and L-[ring-²H₄]tyrosine., Results: A significant main effect of time indicated that NBAL increased over the course of the intervention; however, a group-by-time interaction was not observed. Although FIT demonstrated a lower net protein oxidation and higher net protein balance compared to LOW-FIT, neither the effect of time nor a group-by-time interaction was significant for Phe flux, net protein oxidation, or derived whole-body protein synthesis and net protein balance., Conclusion: The absence of significant group-by-time interactions in protein metabolism (i.e., NBAL and whole-body protein turnover) between LOW-FIT and FIT males suggest that aerobic fitness level does not modulate protein "sparing" in response to an unaccustomed increase in energy expenditure.

Purpose: To examine how different proteins in a carbohydrate-protein beverage affect postprandial amino acid (AA), glucose, and insulin responses., Methods: Two randomized, repeated-measures experiments were performed. In one, 10 volunteers drank 3 carbohydrate-protein beverages (380 kcal, 76 g carbohydrate, 19 g protein, 2 g fat) in separate (>7 days) trials, each differing in protein type. All drinks consisted of cocoa (4 g) and nonfat dry milk (1 g) supplemented with casein (CAS), whey (WP), or a casein and whey blend (CAS-WP). Ten additional volunteers consumed the same drinks after 60 min of varying-intensity exercise (60% and 85% VO2peak). Blood glucose, insulin, glucose-dependent insulinotrophic polypeptide (GIP), and AAs were measured every 15-30 min for 4 hr after beverage consumption., Results: Branched-chain AA concentrations peaked at 30 min and did not differ between beverages at rest (0.69 +/- 0.12 mmol/L) or postexercise (0.70 +/- 0.07 mmol/L). There were no significant differences between beverages with respect to initial (time 0-60) or total area under the curve (time 0-240) for any outcome measures at rest or postexercise., Conclusion: High-carbohydrate beverages containing various proportions of milk proteins procured from a supplier to the commercial industry had no impact on AA concentration. Retrospective chemical analysis of commercial proteins showed that casein was partially hydrolyzed; therefore, consumers should carefully consider the manufacturer (to ensure that the product contains intact protein) or other factors (i.e., cost or taste) when procuring these beverages for their purported physiological effects.

Purpose: This study examined how a high-protein diet affected nitrogen balance and protein turnover during an exercise-induced energy deficit., Methods: Twenty-two men completed a 4-d (D1-4) baseline period (BL) of an energy balance diet while maintaining usual physical activity level, followed by 7 d (D5-11) of 1000 kcal.d increased energy expenditure via exercise (50-65% V O2peak). One group consumed 0.9 g of protein per kilogram per day and maintained energy balance throughout the 11-d intervention (BAL, N = 8). The other two groups consumed their BL energy intake throughout the 11 days, resulting in a 7-d, 1000-kcal.d energy deficit. These groups consumed either 0.9 g of protein per kilogram per day (DEF, N = 7) or 1.8 g of protein per kilogram per day (DEF-HP, N = 7). Mean nitrogen balance (NB), calculated per kilogram of fat-free mass (FFM), was determined for BL, days 5-8 (EX1), and days 9-11 (EX2). Whole-body protein turnover was derived from phenylalanine and tyrosine kinetics assessed while fasting at rest on days 4, 7, and 12, using a priming dose of L-[ring-N]tyrosine and a 4-h, primed, continuous infusion of L-[N]phenylalanine and L-[ring-H4]tyrosine., Results: DEF experienced a decrease in NB from BL to EX 1 that was maintained in EX 2. No changes in NB occurred for BAL or DEF-HP over time. No within- or between-group differences were found over time for Phe flux (Qp), conversion rate of Phe to Tyr (Qpt), or the derived protein synthesis value (Sp)., Conclusion: Increased dietary protein maintained NB during exercise-induced energy deficit, but this did not impact resting whole-body protein turnover.

The purpose of this study was to determine the impact of dietary factors and exercise-associated factors on the response of IGF-I and its binding proteins (IGFBPs) during a period of increased physical activity. Twenty-nine men completed a 4-day (days 1-4) baseline period of a controlled energy balanced diet while maintaining their normal physical activity level followed by 7 days (days 5-11) of a 1,000 kcal/day increase in physical activity above their normal activity levels. Two subject groups, one sedentary (Sed, mean Vo(2peak): 39 mlxkg(-1)xmin(-1), n = 7) and one fit (FIT1, mean Vo(2peak): 56 ml.kg(-1)xmin(-1), n = 8) increased energy intake to maintain energy balance throughout the 7-day intervention. In two other fit subject groups (FIT2, n = 7 and FIT3, n = 7), energy intake remained at baseline resulting in a 1,000 kcal/day exercise-induced energy deficit. Of these, FIT2 received an adequate protein diet (0.9 g/kg), and FIT3 received a high-protein diet (1.8 g/kg). For all four groups, IGF-I, IGFBP-3, and the acid labile subunit (ALS) were significantly decreased by day 11 (27 +/- 4%, 10 +/- 2%, and 19 +/- 4%, respectively) and IGFBP-2 significantly increased by 49 +/- 21% following day 3. IGFBP-1 significantly increased only in the two negative energy balance groups, FIT2 (38 +/- 6%) and FIT3 (46 +/- 8%). Differences in initial fitness level and dietary protein intake did not alter the IGF-I system response to an acute increase in physical activity. Decreases in IGF-I were observed during a moderate increase in physical activity despite maintaining energy balance, suggesting that currently unexplained exercise-associated mechanisms, such as increased energy flux, regulate IGF-I independent of energy deficit.