Calcium bone health v2b

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Loyalty Duty Respect Selfless Service Honor Integrity Personal Courage
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BCT
Bone Health
and
Stress Fractures
BCT
Bone Health
and
Stress Fractures
V MAY 07
DRAFT

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1. Stress fractures are a significant issue in IET.
1. Rates may be significantly under reported (OPN Aegis).
2. Female rates are significantly higher. Pubic Ramus & Femoral Neck fractures generally unique to females.
3. Stress fractures can be slow and difficult to diagnose.
2. Bone health:
a. Measured by ‘Bone Geometry’ (gold standard) and Bone Mineral Density (BMD) (DEXA test).
b. Exercise & variety of nutrients and vitamins are needed to grow strong bones.
c. Bone strength increases are slower than muscle increases.
3. Multiple hypotheses for high stress fracture rates:
a. Overtraining (too much; too soon) (CHPPM). Higher mileage rates increases injury rates with little fitness increase.
b. Osteopenia (Dr. Rivero Navy BT study). 50% of female & 80% of male stress fractures had osteopenia.
c. Calcium losses in sweat (Klesges, et al. 1996 basketball player study). Athletes lose 1 gm calcium/day in sweat.
-- Lappe et al Navy BT study reduced stress fractures by 20% with calcium-D supplement
d. Inadequate diet. CDC documents shifts from milk to colas. Amenorrhea in BCT may reflect inadequate calories.
e. Smoking (toxins interfere with bone remodeling).
f. Marching TTP (small-to-tall) (AF, Navy, Army, Aus Army).
g. Boot/shoe fitting & design. See also CHPPM Airborne Boot Brace & Israeli boot research.
4. Conclusions/recommendations:
a. Upgrade Clinical Practice Guidelines to include evaluating stress fractures for osteopenia.
b. Navy calcium-D study suggests supplements reduce BCT stress fracture rates.
c. Stress Fracture Conference at FJATC FEB 08.
d. More research needed on entry incidence of osteopenia & predictive value.

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How big is the problem?

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Admiral Nelson 11 March 1804 to Dr. Mosely:
“The greatest thing in all military service is health; and you will agree with me that it is easier for an
officer to keep men healthy than it is for a physician to cure them”.
• BCT (CHPPM)
– Males: 19-37% are injured in a 9-wk cycle
– Females: 42-67% are injured in a 9-wk cycle
• Most injuries are overuse, compared to traumatic
– Males: 75%
– Females: 78%
• Most injuries involve the lower extremity (low back, pelvis, hip and leg)*
– Males: 83%
– Females: 87%
• Activities associated with injuries in BCT
– Weight bearing activity; predominantly running, marching, walking
Overall Injury Rates

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Lower Extremity Stress FX as a Percent
of Soldiers in Training (SIT)
0.0
1.0
2.0
3.0
4.0
FY
Percent
Lower Extremity
Stress FX
Lower
Extremity
Stress FX
2.1 3.0 3.4
FY 2004 FY 2005 FY 2006
110,057 SIT99,649 SIT
32,163 SIT
(Feb06)
Data Source – MDR/COL Schneider, OTSG
How big is the problem?

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• BCT grads arrived at AIT with high injury rates (approx. 28% men; 48% women).
• PT running was the primary cause of musculoskeletal injuries.
• Changing the running program
– Reduced Clinic Visits - 36.5%
– Reduced Profiles - 48.6%
– No difference in APFT Scores
– Reduced APFT retakes - 50%
– Saved 612 limited duty days/week/BN
AMEDDC&S Operation Aegis Injury Control
If implemented at all IET/AIT sites:
$9M/yr & 1.5M limited duty days/yr Potential
Savings

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5.00
6.00
7.00
8.00
9.00
10.00
11.00
12.00
6/16 6/23 6/30 7/7 7/14
Miles per Day
1. CHPPM collected pedometer data on 10 FJATC BCT companies.
2. Average daily distance for the 63 days was 11.7+_4.4 km/day (M+_SD).
3. During the 3-day FTX, daily distances were 16.2+_9.7 km/day.
4. Overuse injuries are a dose-response relationship: more miles equals more
injuries.
Mileage, Mileage, Mileage
USMA FTU Study
Two
studi
es

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Stress Fractures by Gender
0
10
20
30
40
50
60
70
Patients
Single
Multiple
Single 29 37
Multiple 10 28
Male Female
26%
74%
57%
43%
104 Total Stress Fractures
Jun 2001 - Jan 2002
39
65
Osteopenia in Males
80%
20%
Osteopenia
Non Osteopenia
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Osteopenia (soft bones)
Source: Dr. Rivero study at Great Lakes Naval Training Center (2001-2002).
• Women had higher rates of stress fractures.
• 50% of female stress fractures had osteopenia.
• 80% of male stress fractures had osteopenia.
Osteopenia in Females
50%50%
Osteopenia
Non Osteopenia
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What are risk factors?

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Risk Factors for Stress Fracture
Genetic
– Female gender
– Race (White, Hispanic or Asian)
– Short height
– Low bone density or poor bone structure
Lifestyle/Diet
– Amenorrhea (associated with inadequate diet)(see USARIEM 1995
BCT study; nutrient status poorer at BCT grad than entry)
– Smoking, alcohol consumption
– Low calcium intake (see also USARIEM iron and vitamin D studies;
both were poorer at BCT grad than entry).
Fitness
– Previous injury
– Low fitness or activity before enlistment
– Poor muscle strength

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OSTEOPORSIS RISK FACTORS
• Age. Older ages have greater risk of osteoporosis. Bones become weaker and less dense as you age.
• Gender. Chances of developing osteoporosis are greater if female. Women have less bone tissue
and lose bone more rapidly than men because of the changes involved in menopause.
• Family History and Personal History of Fractures as an Adult. Susceptibility to fracture may
be, in part, hereditary. Young women whose mothers have a history of vertebral fractures also seem to
have reduced bone mass. A personal history of a fracture as an adult also increases your fracture risk.
• Race. Caucasian and Asian women are more likely to develop osteoporosis. However, African
American and Hispanic women are still at significant risk for developing the disease.
• Bone Structure and Body Weight. Small-boned and thin women (under 127 pounds) are at
greater risk.
• Menopause/Menstrual History. Normal or early menopause increases the risk of developing
osteoporosis. In addition, women who stop menstruating (amenorrhea) before menopause because of
conditions such as anorexia or bulimia, or because of excessive physical exercise, may also lose bone
tissue and develop osteoporosis. NOTE: Amenorrhea in BCT is documented in USARIEM study.
• Lifestyle. Current cigarette smoking, drinking too much alcohol, consuming an inadequate amount of
calcium or getting little or no weight-bearing exercise, increases your chances of developing
osteoporosis. NOTE: Consider poor sunlight exposure/vit D levels & not drinking fortified milk.
• Medications/Chronic Diseases. Use of certain medications to treat disorders such as rheumatoid
arthritis, endocrine disorders (i.e. an under-active thyroid), seizure disorders and gastrointestinal
diseases may have side effects that can damage bone and lead to osteoporosis.

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Rickets
• At the turn of the 20th century, rickets was rampant among children living in US
northern cities.
• Lack of sunlight and diet were major factors.
• Vitamin D milk fortification eradicated rickets in the United States.
• Vitamin D deficiencies still occur, especially above 40 degrees latitude.
Those at higher risk for developing rickets
today include:
• Dark-skinned children
• Breast-fed infants whose mothers are not exposed to
sunlight or don’t take vit D supplements
• Breast-fed infants who are not exposed to sunlight or don’t
take vit D supplements
• Individuals not consuming fortified milk, such as those on
vegetarian or vegan diets, or lactose intolerant individuals

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What solutions have been tried?

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MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR
Pre CPG (56)
CPG (98)
1. New Clinical Practice Guideline for Hip Pain.
2. Early effective management works:
a.Finding early avoids the fracture.
b.75% Increase in FNFF detection
Source: CPT Short, MAH
Femoral Neck Fracture
1. Even though small numbers, high costs.
2. 100% Medical Board.
3. Lifetime of treatment.

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Reducing Stress Fracture in Physically Active Military Women, Subcommittee on Body
Composition, Nutrition, and Health of Military Women, Committee on Military Nutrition
Research, Food and Nutrition Board, INSTITUTE OF MEDICINE, NATIONAL ACADEMY
PRESS, Washington, D.C. 1998
National Academy of Sciences Recommendations for Military
Women:
• Ensure ”adequate energy and nutrient intakes to reflect the needs of the body at
a moderate activity level (2,000-2,800 kcal/d) .
• Put “nutritional labeling of all dining hall menu items and provision of food
selection guidelines to women in garrison.”
• “develop aggressive education programs for military women aimed at helping
them identify and select appropriate foods and fortified food products to increase
the number of women meeting their requirements for these nutrients.”
• “If nutrition education and counseling sessions fail to promote increased intakes,
the use of calcium-fortified products becomes essential.”
• “Calcium supplements should be recommended under appropriate guidance by
the military to meet women's special needs.”

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Navy Calcium-D Study (decreased stress fractures by
20%):
1. Calcium balance is compromised: Calcium (Ca) deficient diet upon BT entry:
a. Minimum recommended (NAS IOM) 14-18 y/o 1,300 mg/day
19-30 y/o 1,000 mg/day
b. Average Ca intake 19 – 30 yrs 600-700 mg/day
c. Median Ca intake of women during BT 700-900 mg/day
2. High Ca losses occur in sweat during strenuous activity. Athletes lose 1 gm/day
in sweat. (Study with collegiate basketball players Klesges, et al. 1996)
3. Recruits below age 30 have not achieved peak bone mass and require a positive
Ca balance for bone gain. (maximize peak bone mass).
4. Intense training stimulates bone formation, increasing Ca demands. (maximize
bone adaptation).
5. Microfracture repair is dependent upon Ca availability (maximize repair process)

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Navy Calcium-D Study (cont)
1. 5,200 female U.S. Navy recruits, ages 17 to 35, doing eight weeks of
basic training.
2. 2,000 mg Ca and 800 I.U. of Vit D/day (Oscal plus D)
3. Control group suffered 20 percent more stress fractures than the
supplement group.

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1. Equally fit men and women will have roughly equal injury rates.
2. However, significantly more women enter less fit than men. Recent GIT 1-1-1
failure rates were:
a. Overall male 17.86%
b. Overall female 34.57%
3. “No FTU” study shows eliminating the FTU increases injuries and attrition.
4. Experimental FTU study shows a well-designed FTU decreases injuries and
attrition.
3. AIT injury study showed approx. 28% men and 48% women arriving at AIT injured.
Male-Female Fitness

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BU

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0.43
0.116 0.094
0
0.1
0.2
0.3
0.4
0.5
Results:All Sports; All Knee Injuries per 1,000 Athlete
Exposures
1. Females are at risk for knee injuries
2. PT to balance leg muscles is
effective: Reduces knee injuries by
80%.
Pre-training Post-training

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0
5
10
15
20
25
%
111
Pass
BCT
111
Fail
PCU
111
Fail
PCU-
X
111
Fail
No
PCU
BCT Discharge Rates
0
5
10
15
20
25
%
111
Pass
BCT
111
Fail
PCU
111
Fail
PCU-
X
111
Fail
No
PCU
BCT Injury Rates
CHPPM No-PCU and USMA Experimental PCU-X
1. BLUF: The FTU PCU lowers overall discharge attrition by 500-800+ Soldiers (0.4-0.8+%), as well as
lowers course attrition and injury rates.
2. 4%-7% of men and 10%-24% of women fail the RECBN 1-1-1 assessment historically. 50-75% of the
PCU at GIT sites will be female.
3. PCU Results:
a. Lower course attrition: In the “1-1-1 Fail No PCU” group, men are 2.5 times and women are 1.5 times more likely to
attrit from BCT.
b. Lower discharge attrition: In the “1-1-1 Fail No PCU” group, men are 3.0 times and women are 1.9 times more likely
to be discharged from BCT.
c. Lower injury rates.
d. The USMA experimental PCU-X vice the traditional PCU improved female outcomes, but male outcomes were worse
(but still better than no PCU). Recommendation is that USAPFS design a new PCU PT POI.
4. The optimum solution would be a 12 week BCT PCU company to maximize program flexibility,
maintain bonding, provide non-PT training, get resourced, etc.

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BCT Female Iron and B-vitamin DeficienciesBCT Female Iron and B-vitamin Deficiencies
USARIEM BCT Study
• 1993 study of 174 women in an all-female 8-week BCT company at
Fort Jackson, SC (158 graduated).
• Serum ferritin (body iron stores) were low pre-BCT (56% females
at less than 20 ng/ml iron) and decreased further by graduation
(84%)(pg.109).
• Anemia was correlated with poor PT performance (pg. 111)
• Serum folate levels were low normal pre-BCT and “decreased
significantly over BCT.” (pg. 2)
• Maternal low folate intake and blood levels have been "associated
with (fetal) neural tube defects“ (pg. 39) (note: neural tube defects
can be fatal for the fetus).
• Menu was adequate in energy, but inadequate in B6, folic acid,
calcium, magnesium, iron, and zinc.
• Source: “Health, Performance, and Nutritional Status of U.S.
Army Women during Basic Combat Training,” (1995)(ADA302042)
• NOTE: Study BCT menu governed by the 1985 AR 40-25
USARIEM BCT Study
• 1993 study of 174 women in an all-female 8-week BCT company at
Fort Jackson, SC (158 graduated).
• Serum ferritin (body iron stores) were low pre-BCT (56% females
at less than 20 ng/ml iron) and decreased further by graduation
(84%)(pg.109).
• Anemia was correlated with poor PT performance (pg. 111)
• Serum folate levels were low normal pre-BCT and “decreased
significantly over BCT.” (pg. 2)
• Maternal low folate intake and blood levels have been "associated
with (fetal) neural tube defects“ (pg. 39) (note: neural tube defects
can be fatal for the fetus).
• Menu was adequate in energy, but inadequate in B6, folic acid,
calcium, magnesium, iron, and zinc.
• Source: “Health, Performance, and Nutritional Status of U.S.
Army Women during Basic Combat Training,” (1995)(ADA302042)
• NOTE: Study BCT menu governed by the 1985 AR 40-25

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Institute of Medicine (IOM) Review
• Separate review of multiple studies.
• 17% of women were iron deficient (<12 ng/ml) and 8% were
anemic at BCT entry.
• 35% were deficient and 26% were anemic at AIT entry.
• Source: National Academy of Science’s Institute of Medicine
(IOM) Committee on Military Nutrition Research (CMNR) 1995
“Review of Issues Related to Iron Status in Women During
U.S. Army Basic Combat Training”
Institute of Medicine (IOM) Review
• Separate review of multiple studies.
• 17% of women were iron deficient (<12 ng/ml) and 8% were
anemic at BCT entry.
• 35% were deficient and 26% were anemic at AIT entry.
• Source: National Academy of Science’s Institute of Medicine
(IOM) Committee on Military Nutrition Research (CMNR) 1995
“Review of Issues Related to Iron Status in Women During
U.S. Army Basic Combat Training”

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General Population
• General Population: 9-11% of adolescent and child-bearing
age women are iron deficient and 2-5% are anemic.
• Source: The National Health and Nutrition Examination Survey
(NANHES)(1988-1994)(TAB D) conducted by the Center for
Disease Control (CDC)
• NOTE: The NANHES uses a more conservative iron deficiency
definition than the USARIEM study.
General Population
• General Population: 9-11% of adolescent and child-bearing
age women are iron deficient and 2-5% are anemic.
• Source: The National Health and Nutrition Examination Survey
(NANHES)(1988-1994)(TAB D) conducted by the Center for
Disease Control (CDC)
• NOTE: The NANHES uses a more conservative iron deficiency
definition than the USARIEM study.

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1985 AR 40-25
• AR 40-25, “Nutrition Allowances, Standards, and Education”
(BUMEDINST 10110.6; AFI 44-141)
• Establishes the dietary allowances for all soldiers 17-50 y/o with
moderate activity levels.
• 1985 AR 40-25:
• “The dietary allowance for females and 17- to 18-year old
males is 18 milligrams (mg)/day …” (page 3, Chapter 2-5, e)
• "Moderately active female personnel consuming an average of
2,400 calories per day may require supplemental iron to meet
the recommended 18 mg/day“ (page 3, Chapter 2-5, e)
• “The computed iron density represents an interpolation
between the male and female MRDA for iron. … This iron
density (6 mg/1,000 calories) may be inadequate for women."
(page 3, Chapter 3-1).
• MRDA for men was 10-18 mg/day and 18 mg/day for females.
• AR 40-25 was updated in 2001.
1985 AR 40-25
• AR 40-25, “Nutrition Allowances, Standards, and Education”
(BUMEDINST 10110.6; AFI 44-141)
• Establishes the dietary allowances for all soldiers 17-50 y/o with
moderate activity levels.
• 1985 AR 40-25:
• “The dietary allowance for females and 17- to 18-year old
males is 18 milligrams (mg)/day …” (page 3, Chapter 2-5, e)
• "Moderately active female personnel consuming an average of
2,400 calories per day may require supplemental iron to meet
the recommended 18 mg/day“ (page 3, Chapter 2-5, e)
• “The computed iron density represents an interpolation
between the male and female MRDA for iron. … This iron
density (6 mg/1,000 calories) may be inadequate for women."
(page 3, Chapter 3-1).
• MRDA for men was 10-18 mg/day and 18 mg/day for females.
• AR 40-25 was updated in 2001.

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2001 AR 40-25
• Established iron MRDI at 10 mg/day for men and 15 mg/day for
women.
• Added notes that the MRDIs for iron, calcium, phosphorous, and
magnesium are low for 17-18 year-olds and menus should be
adjusted if the dining facility has a large <19 y/o population.
(page 6, Table 2-1, Notes 9-12)
NOTE 1: Current IOM standards for menstruating women on a regular diet
are 18 mg/day of iron (27 mg/day for vegetarians) while men only need 12
mg/day. Excess iron is not desirable.
NOTE 2: Federal dietary policy shifted between 1985 and 2001. The 1985
policy was the ‘minimum needed to avoid disease’ while today’s policy is to
2001 AR 40-25
• Established iron MRDI at 10 mg/day for men and 15 mg/day for
women.
• Added notes that the MRDIs for iron, calcium, phosphorous, and
magnesium are low for 17-18 year-olds and menus should be
adjusted if the dining facility has a large <19 y/o population.
(page 6, Table 2-1, Notes 9-12)
NOTE 1: Current IOM standards for menstruating women on a regular diet
are 18 mg/day of iron (27 mg/day for vegetarians) while men only need 12
mg/day. Excess iron is not desirable.
NOTE 2: Federal dietary policy shifted between 1985 and 2001. The 1985
policy was the ‘minimum needed to avoid disease’ while today’s policy is to

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Deficiency Common Impacts
Iron Deficiency/Anemia
• Decreased PT/work performance
• Fatigue/weakness
• Psychological (e.g. Irritability, etc.)
• Shortness of breath
• Mild decreased cognitive ability
Folate Deficiency Anemia
• Birth defects
• Fatigue
• Anorexia nervosa
• Pale skin
• Paranoia
• Rapid heart beat
• Sore, inflamed tongue
• Weakness
• Weight loss.
Deficiency Common Impacts
Iron Deficiency/Anemia
• Decreased PT/work performance
• Fatigue/weakness
• Psychological (e.g. Irritability, etc.)
• Shortness of breath
• Mild decreased cognitive ability
Folate Deficiency Anemia
• Birth defects
• Fatigue
• Anorexia nervosa
• Pale skin
• Paranoia
• Rapid heart beat
• Sore, inflamed tongue
• Weakness
• Weight loss.
•Bruises or tires easily
•Feels ill for more than five days
•Feels weak or out of breath
•Looks pale or jaundiced.

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Calcium bone health v2b

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