calcium bone health v2b

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VICTORY STARTS HERELoyalty Duty Respect Selfless Service Honor Integrity Personal Courage

BCT

Bone Health

and

Stress Fractures

V MAY 07DRAFT

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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

Perc

ent Lower Extremity

Stress FX

LowerExtremityStress FX

2.1 3.0 3.4

FY 2004 FY 2005 FY 2006

110,057 SIT99,649 SIT32,163 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

Accumulated Profiles

05

101520253035

1 2 3 4 5 6 7 8 9Week of Training

MSI

Pro

files

(%)

Pre-RT RT

77

7


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, MileageUSMA FTU Study

Twostudi

es

88

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Stress Fractures by Gender

0

10

20

30

40

50

60

70

Patie

nts

Single

Multiple

Single 29 37

Multiple 10 28

Male Female

26%

74%

57%

43%

104 Total Stress Fractures Jun 2001 - Jan 2002

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65

Osteopenia in Males

80%

20%

OsteopeniaNon Osteopenia

82

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%

OsteopeniaNon 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/dayc. 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

2020

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0.43

0.116 0.094

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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 injuries2. 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

%

111PassBCT

111FailPCU

111Fail

PCU-X

111FailNo

PCU

BCT Discharge Rates

0

5

10

15

20

25

%

111PassBCT

111FailPCU

111Fail

PCU-X

111FailNo

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 DeficienciesUSARIEM 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”

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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.

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BCT Female Iron and B-vitamin Deficiencies1985 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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BCT Female Iron and B-vitamin Deficiencies2001 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 ‘optimize health.’

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Deficiency Common ImpactsIron 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.

BCT Female Iron and B-vitamin Deficiencies

•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

Health & Medicine