At a planning meeting on October 30, 1995, the Committee on Military Nutrition Research (CMNR) was asked by the Military Nutrition Division (MND, currently the Military Nutrition and Biochemistry Division), U.S. Army Research Institute of Environmental Medicine (USARIEM) and the U.S. Army Medical Research and Materiel Command (USAMRMC) to provide additional scientific guidance to the MND staff in reviewing their recent research related to iron deficiency in military women during U.S. Army Basic Combat Training (BCT). The committee's task was to review the previously published Army technical reports and new material presented at the subsequent meeting on November 13, 1995. The committee was asked to evaluate, comment upon, and make specific recommendations regarding these studies and proposed research plans, as well as to write a formal report that included responses to the following nine questions:

1. Do the data from recent research studies indicate that there is a problem related to iron deficiency in Army women in BCT?
2. Do the data indicate that the incidence of iron deficiency or low iron stores among military women is different from what exists in women with the same demographic characteristics in the civilian population?
3. In terms of military readiness, would military women benefit from a nutritional intervention?
4. Are there additional medical considerations related to iron status in military women that need to be addressed?
5. Should there be periodic screening of military women for anemia or iron deficiency?

6. In military personnel with low iron stores as well as anemia, is there an impairment of military readiness that is gender specific?
7. Are there additional analyses that should be conducted with the data in Friedl et al. (1990), Klicka et al. (1993), Westphal et al. (1995), or Westphal et al. (draft manuscript, 1995) on iron status issues in women in BCT? For future studies, are there additional specific analyses that should be considered?
8. What are the CMNR recommendations regarding the proposed intervention study?
9. Emphasis of the meeting on November 13, 1995 was on data collected during BCT, should there be additional research with military women dealing with iron status in military women in general?

To assist the CMNR in developing responses to these questions, John L. Beard, Department of Nutrition, The Pennsylvania State University, University Park, and Sean Lynch, Hematology and Oncology, Veterans Administration Medical Center, Hampton, Virginia, served as special consultants, who participated in the meeting and the initial discussion with the committee regarding this report. The report was drafted by the CMNR in executive session on the day following the meeting and was delivered to the sponsor in December 1995. It is a thoughtfully developed presentation incorporating the scientific opinion of the CMNR and the comments of the anonymous peer review panel of the National Research Council.

It is the view of the CMNR that iron status is an important issue for military women. From the preliminary data presented at this meeting, the potential for some compromise in physical performance has been demonstrated with low iron stores. Of equal military concern are the possible effects on cognitive performance that may result from impaired iron nutrition. Therefore, additional research should be conducted on the most susceptible groups of military women. It is important to determine whether the compromised iron status observed in women in BCT affects performance; therefore, initial studies should emphasize this issue, using an iron supplement that has the greatest potential for preventing or correcting decrements in iron status with appropriate nutrition counseling stressing the importance of taking such supplements, to help assure compliance with the study design. Following this determination, it then will be important to determine whether appropriate nutrition education methods can achieve similar results.

Since the stresses of military training are an approximation of the anticipated stresses of actual combat, it is important to collect and evaluate broadly all pertinent information from women involved in rigorous, physically stressful military training.

Any analysis of iron status must take into consideration the possible presence of any concurrent infectious or inflammatory processes, which are known to affect rapidly the results of clinical laboratory parameters used to measure iron status.

• Intervention studies be conducted with women in BCT to identify cognitive and physical performance decrements that may be related to iron status.
• An evaluation of the most appropriate approaches to correcting deficits in iron status be made (i.e., nutrition education versus iron supplements).
• An analysis of existing data be conducted using models of iron deficiency previously recommended for the NHANES II and III studies.
• A screening program for military women be established to identify the extent of deficits in iron status and periods of greatest vulnerability, in order that remedial steps can be instituted where appropriate.
• Enlistment of any individual with iron deficiency anemia be delayed until this medically-reversible condition has been corrected.

• Evaluate the effectiveness of dietary intervention using nutrition education in maintaining iron status.
• Evaluate the impact of dieting measures to meet weight standards on iron status and the potential for nutrition educational approaches to assist women in maintaining iron status when restricting calorie consumption.
• If a relationship between iron status and physical and cognitive performance is found, determine the measure of iron deficiency that best correlates with performance and the extent of iron deficiency that results in a compromised performance.
• In conjunction with monitoring iron status of military women, survey the impact of iron (and other macro- and micronutrient) status on immune function and the impact of iron status on the cardiovascular and pulmonary systems.
• If studies confirm instances of compromised iron status (in individuals who are free of active infections or inflammatory processes), evaluate various delivery systems to minimize or eliminate deficits in iron status such as:
• a diet naturally high in iron (along with nutrition education), and
• periodic nutritional supplements of iron (e.g., daily, weekly) (following a review of the dosage and effectiveness [as well as risk of complications such as gastrointestinal side-effects] as reported in the scientific literature).

• If such delivery systems prove to be ineffective, consider the evaluation of other interventions, such as:
• iron delivered orally in a hydrodynamically balanced solution (Cook et al., 1990), and
• the safety and effectiveness of oral heme iron.

<><><><><><><><><><><><>

The full text of this letter report plus the responses to the questions are included in Appendix E.