As outlined in Chapter 1, military personnel are required to adhere to standards of body composition, fitness, and appearance for the purpose of achieving and maintaining readiness. The purpose of this report is to examine whether the present standards for body composition, fitness, and appearance support readiness by ensuring optimal health and performance of active-duty women. After reviewing the relevant literature and current military policies, the Subcommittee on Body Composition, Nutrition, and Health provides the following conclusions and recommendations in response to the three questions posed by the military. Recommendations for future research are provided following the responses to the questions.

1. What body composition standards best serve military women's health and fitness, with respect to minimum lean body mass, maximum body fat, and site specificity of fat deposition? Are the appearance goals of the military in conflict with military readiness?

• The BCNH subcommittee recommends the revision of the two-tiered body composition and fitness screen.

• As illustrated in Figure 1, the first tier should consist of semiannual assessment of BMI and fitness (including strength and endurance). The acceptable range of BMIs, based on considerations of health, is recommended to be 19 to 25, independent of age. Individuals whose BMI falls within the desirable range and who pass the fitness test need no further screening. Individuals with a BMI greater than 25 should be subjected to a second tier of screening, based on body fat assessment. The subcommittee believes that women with BMIs less than 19 can be fit to perform. However, as BMI decreases below 19, women may be at risk for malnutrition and should be considered for medical evaluation.
  
  

  Individuals whose body fat is assessed at 36 percent or less and who pass the fitness test will be considered within standard. Individuals whose body fat exceeds 30 percent and who fail the fitness test will be referred to weight management and fitness programs. Individuals whose body fat exceeds 36 percent will be referred to a weight management program, regardless of fitness score.

• The BCNH subcommittee also recommends development of a single service-wide equation derived from circumference measurements for assessment of women's body fat, to be validated against a four-compartment model using a population of active-duty women or a population that is identical in ethnic and

FIGURE 1

Revised flowchart for screening recommendation. BMI, bodymassindex; BF, bodyfat.

• age diversity to that of military women. Development and validation of this equation may result in reconsideration of the recommended BMI cut-offs, in part as a result of establishing the measurement error.
• The BCNH subcommittee recommends an increasing emphasis on general fitness for health and readiness by enforcing uniformly across all services and MOSs regular and monitored participation in a fitness program consisting of a minimum of 3 d/wk of endurance exercise at 60 to 80 percent of maximum capacity for 20 to 60 minutes and 2 d/wk of resistance exercise using all major muscle groups at 85 percent of one repetition maximum (ACSM, 1990). Such a program, in addition to promoting fitness, assists in maintenance of weight and FFM and may result in lower body fat. Periodic fitness and body composition testing adjusted appropriately for gender should be conducted to determine both endurance and strength and should be similar across all services. More frequent testing would promote continuous adherence to weight and physical fitness programs and decrease injurious behaviors that result from efforts to pass performance and body composition tests.
• The subcommittee further recommends development of task-specific, gender-neutral strength and endurance tests and standards for use in the determination of placement in MOSs that require moderate and heavy lifting. Additional fitness programs should be created and enforced to develop and maintain the strength, endurance, and flexibility required by these MOSs.
• The BCNH subcommittee recommends that, in view of the association between FFM (as an indirect indicator of skeletal muscle mass) and strength, the military consider developing an appropriate minimum recommended BMI for accession of women.
• The current appearance standard does not appear to be linked to performance, fitness, nutrition, or health. The BCNH subcommittee recommends that if the military deems appearance standards to be necessary, objective criteria (that do not discriminate on the basis of ethnicity) should be developed and utilized.

2. Should any part of the MRDAs be further adjusted for women? Should there be any intervention for active-duty women with respect to food provided, dietary supplementation, or education?

• In view of current ongoing efforts by the Food and Nutrition Board to revise the RDAs upon which the MRDAs (AR 40–25, 1985) are based, the BCNH subcommittee advises that revision of the MRDAs be deferred to a later time and has chosen to concentrate on several nutritional issues of importance to active-duty women.
• The BCNH subcommittee reinforces the requirement for adequate energy and nutrient intakes to reflect the needs of the body at a moderate activity level

• (2,000–2,800 kcal/d). To ensure adequate nutrient intakes, female personnel must be educated on how to meet both energy and nutrient needs whether they are deployed and subsisting on operational rations or whether they are in garrison. This education is required to enable women to choose foods of higher nutrient density and to maintain a fitness program that will allow greater energy intake. The subcommittee reinforces the recent efforts of the Army to begin providing complete nutritional labeling of all ration components and to include information to enable identification of nutrient-dense components that would help women meet the MRDAs at their usual energy intake. The subcommittee also supports efforts to create ration supplements that would satisfy requirements that may not be readily met through the usual intake of rations. The subcommittee recommends nutritional labeling of all dining hall menu items and provision of food selection guidelines to women in garrison.
• The BCNH subcommittee recommends that all military women maintain or achieve healthy weight through a continuous exercise and fitness program. If weight loss is a goal, nutrition education and ongoing counseling should be provided for guidance in achieving a healthy, but reduced energy, diet. Emphasis must be placed on preventing overweight and maintaining long-term weight management through lifestyle changes, rather than on crash dieting to lose weight for a scheduled weigh-in. Adequate energy intake should be encouraged to reduce risks of injury and amenorrhea.

3. What special guidance should be offered with respect to return-to-duty standards and nutrition for women who are pregnant or breastfeeding?

• The BCNH subcommittee recommends that all women be encouraged to eat an adequate diet during pregnancy and lactation as recommended by the IOM (1990, 1991). The subcommittee further recommends an intake of 400 μg/d dietary folate during childbearing years, 600 μg/d dietary folate during pregnancy and 500 μg/d during lactation as recommended by the IOM (1998). A daily supplement of 30 mg of ferrous iron (IOM, 1990) is recommended during the second and third trimesters of pregnancy. During pregnancy and lactation, women should abstain from smoking. Although alcohol should be avoided during pregnancy, a very moderate intake may be permitted during lactation (IOM, 1990).
• The BCNH subcommittee recommends that pregnant women without obstetrical or medical complications engage in moderate levels of physical activity to maintain cardiovascular and muscular fitness throughout the pregnancy and the postpartum period. The American College of Obstetricians and Gynecologists (ACOG, 1994) has published guidelines that should be used to advise pregnant active-duty women to modify their physical fitness program. Programs should be individualized and made available to healthy women who

• can and wish to exercise. These programs may also incorporate strength training, although the extent of the benefits of such training during pregnancy remains to be determined.
• The BCNH subcommittee recommends the endorsement of the IOM guidelines for gestational weight gain as outlined in the text. Women should be encouraged to gain within the IOM recommendations during pregnancy and to lose weight postpartum through appropriate nutritional counseling and exercise programs. The BCNH subcommittee recommends that the proposed time allowance for compliance to weight and body fat standards postpartum be consistent with IOM recommendations for gestational weight gain. When satisfactory progress is being made toward compliance, an allowance of up to 1 year postpartum should be given for attainment of body weight standards.
• Resumption of exercise postpartum will depend on the type of delivery and postpartum state of the woman and should be left to the discretion of the woman's obstetrician. Once clearance is given to resume exercise, a time allowance of 180 days should be sufficient for the woman to meet physical fitness standards.
• The Healthy People 2000 (DHHS, 1991) goal for breastfeeding specifies that at least 75 percent of women should breastfeed their babies in the early postnatal period and 50 percent of women should continue to breastfeed until their babies are 5 to 6 months old. As the military has provided no indication as to why they should not strive to comply with this goal, the subcommittee recommends that efforts be made to promote and support breastfeeding among all servicewomen, where appropriate. Promotion of breastfeeding can be incorporated into prenatal classes, family support classes, hospital policies, and training of health care providers.
• The BCNH subcommittee calls attention to the persistent anemia and musculoskeletal and cardiovascular changes that may continue in some women postpartum. These changes may present potential health problems for the mother and compromise her fitness status. Women with low iron stores before pregnancy or excessive blood losses at delivery may require an extended period (5–10 months) to replete and normalize stores.
• An increase in the length of exemption from deployment from 4 to 6 months postpartum is recommended to support maternal postpartum recovery, breastfeeding, and enhanced infant health and development.
• The BCNH subcommittee acknowledges that childbearing is compatible with a military career when planning and education on effective birth control and counseling on the importance of timing pregnancy in one's military career are provided to all servicemembers. The subcommittee therefore recommends training and education for all supervisory personnel regarding pregnancy policy, as well as a prenatal counseling program for pregnant active-duty women. These policies should be implemented to reduce attrition and enhance military readiness.

Currently, there are no systematically collected data describing what military women do to meet weight and fitness standards (both before and after childbirth), how effective their behaviors are at maintaining weight and fitness standards, and the long-term health consequences of these behaviors. A DoD-wide evaluation system is recommended.

Relevant Data from Previous Surveys of Military Personnel and in Existing DoD Databases

Several research projects have been conducted by the services on the health-related behaviors of servicemembers. In addition to the wide variety of demographic and personnel data maintained in the Defense Manpower Data Center database, health outcome data are maintained in several medical cost accounting databases.

Effective Use of Existing Data

A combination of the survey instruments that have been used in the past would be suitable for collecting most of the information needed (including longitudinal data). The personnel and medical databases are capable of producing much of the remaining information needed. However, the subcommittee finds that there are two problems with this method of data collection. First, some of the survey data were collected anonymously (with no identification numbers of any type), precluding any attempt to examine the data longitudinally or merge the databases with existing personnel and medical databases that contain the demographic and health outcome data needed for a comprehensive analysis of the data. Second, the personnel and medical databases were not designed to be linked to each other or to survey databases. Thus, although much potentially worthwhile information is collected, little meaningful analysis can be performed.

Recommendations for New Methods

The subcommittee recommends that the military survey a representative sample of active-duty personnel individually and review the individuals' personnel and medical records during the course of the interview. This method would enable the investigator to obtain all the data needed in a single effort, ensure quality control of the data, build a database that would preserve the anonymity of the individual, and obviate the need to merge automated information

systems with highly sensitive data. However, the need to create a system that will obtain information from several large and representative samples of the entire DoD over the course of several years may make this choice cost-prohibitive.

An alternative recommendation is to expand the triennial Survey of Health-Related Behaviors among Military Personnel to include the demographic, medical, nutrition, fitness, and pregnancy data needed. Changing the questionnaire to include social security number, as was done with the Navy's Perceptions of Wellness and Readiness Assessment survey and the Army's Health Risk Appraisal survey, would permit a longitudinal and potentially integrated database to be developed. The practice of using questions from federal surveys of health and fitness-related behaviors in the general U.S. population should be continued so that comparisons between military and civilian populations can be made.

Additional Data Needed

As recommended by an earlier IOM report (1992), longitudinal studies of people admitted to military weight management or remedial fitness programs should be conducted to determine the outcome of these programs as recommended changes in program procedures are implemented.

Career, active-duty, military women constitute a unique population of individuals who are required to maintain their weight and body fat and fitness at prescribed levels. Longitudinal studies of health risk factors (cardiovascular, musculoskeletal, metabolic) and outcomes are recommended for these women.

The DoD is encouraged to monitor pregnancy outcome (birth weight, preterm delivery, low birth weight and small-for-date infants, and congenital anomalies) as well as pregnancy wastage (miscarriage) according to service, rank, and MOS to identify potential problems associated with certain military jobs, physical training, or hazardous environments. Longitudinal studies are recommended on body weight and fitness of women who have given birth. It is recommended that health surveys be expanded to collect information on the pregnancy history of active-duty women. Suggested questions are those used by Evans and Rosen (1996).

• Additional research is needed to refine and standardize anthropometric equations for body fat prediction and to validate them against current four-compartment models. This research must include a population that is representative of active-duty military women in ethnic and age profile.

• In view of the relationship between skeletal muscle/FFM and strength, and recent developments in the ability to assess these parameters, research is recommended to develop an expedient method for the prediction of FFM using anthropometric measurements.
• The use of standard military equations in postpartum women for estimating body fat at return-to-duty testing has not been validated. Therefore, the BCNH subcommittee recommends that validation studies be conducted in these women, controlling for ethnicity, age, and parity.
• Task assessment and redesign are recommended, where appropriate, to ensure gender-neutral accession and retention standards in individual MOSs.
• Further research is recommended on the incidence and risk factors for stress fracture and other musculoskeletal injuries in active-duty women.
• Additional research is needed on the effects of environmental stressors on the nutritional status and needs of active-duty women. It is recommended that the military coordinate its research efforts in this area with those of the civilian sector.

ACOG (American College of Obstetricians and Gynecologists). 1994. Exercise during pregnancy and the postpartum period. ACOG Technical Bulletin 189. February. Washington, D.C.: ACOG.

ACSM (American College of Sports Medicine). 1990. ACSM position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness in healthy adults. Med. Sci. Sports Exerc. 22:265–274.

AR (Army Regulation) 40–25. 1985. See U.S. Departments of the Army, the Navy, and the Air Force, 1985.

DHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS (PHS) Publ. No. 91-50212. Public Health Service, U.S. Department of Health and Human Services. Washington, D.C.: U.S. Government Printing Office.

Evans, M.A., and L. Rosen. 1996. Women in the military: Pregnancy, command climate, organizational behavior, and outcomes. Technical Report No. HR 96-001, Part I, Defense Women's Health Research Program. Fort Sam Houston, Tx.: U.S. Army Medical Department Center and School.

IOM (Institute of Medicine). 1990. Nutrition during Pregnancy: Part I, Weight Gain; Part II, Nutrient Supplements. Subcommittee on Nutritional Status and Weight Gain during Pregnancy, Subcommittee on Dietary Intake and Nutrient Supplements during Pregnancy, Committee on Nutritional Status during Pregnancy and Lactation, Food and Nutrition Board. Washington, D.C.: National Academy Press.

IOM. 1991. Nutrition during Lactation. Subcommittee on Lactation, Committee on Nutritional Status during Pregnancy and Lactation, Food and Nutrition Board. Washington, D.C.: National Academy Press.

IOM 1992. Body Composition and Physical Performance, Applications for the Military Services, B.M. Marriott and J. Grumstrup-Scott, eds. Committee on Military Nutrition Research, Food and Nutrition Board. Washington, D.C.: National Academy Press.

IOM. 1998. Dietary Reference Intakes: Folate, Other B Vitamins, and Choline. Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, Food and Nutrition Board. Washington, D.C.: National Academy Press.