draft - university of toronto t-space · draft 2 24 abstract 25 u.s. army personnel in garrison who...

Draft

Soldier use of dietary supplements, including protein and

body building supplements, in a combat zone is different than use in garrison

Journal: Applied Physiology, Nutrition, and Metabolism

Manuscript ID apnm-2015-0387.R1

Manuscript Type: Article

Date Submitted by the Author: 15-Sep-2015

Complete List of Authors: Austin, Krista; US Army Research Institute of Environmental Medicine ,

Military Nutrition Division; Oak Ridge Institute for Science and Education, McLellan, Tom; TM McLellan Research Inc., ; Oak Ridge Institute for Science and Education, Farina, Emily; US Army Research Institute of Environmental Medicine , Military Nutrition Division; Oak Ridge Institute for Science and Education, McGraw, Susan; US Army Research Institute of Environmental Medicine, Military Nutrition Division Lieberman, Harris; US Army Research Institute of Environmental Medicine, Military Nutrition Division

Keyword: vitamins, minerals, sex differences, strength training < exercise, aerobic training

https://mc06.manuscriptcentral.com/apnm-pubs

Applied Physiology, Nutrition, and Metabolism

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1 Soldier use of dietary supplements, including protein and body building supplements, in a 2

combat zone is different than use in garrison 3 4

Krista G. Austin1,2, Tom M. McLellan1,3, Emily K. Farina1,2, Susan M. McGraw2 5

and Harris R. Lieberman2 6

7

1Oak Ridge Institute for Science and Education, Belcamp, MD 21017 8

2Military Nutrition Division, US Army Research Institute of Environmental Medicine 9

(USARIEM), Natick, MA 01760-5007, U.S.A. 10

3TM McLellan Research Inc., Stouffville, ON L4A8A7, CANADA 11

12

Address correspondence and request for reprints to: 13

Dr. Harris R. Lieberman 14

Military Nutrition Division 15

US Army Research Institute of Environmental Medicine 16

Natick, MA 01760 17

Phone: (508) 233-4856 18

Fax: (508) 233-5854 19

E-mail: [email protected] 20

21

Running Title: Deployment and Dietary Supplement Use 22

23

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Abstract 24

U.S. Army personnel in garrison who are not deployed to combat theater report using dietary 25

supplements (DSs) to promote health, increase physical and mental strength and improve energy 26

levels. Given the substantial physical and cognitive demands of combat, DS use may increase 27

during deployment. This study compared DS use by garrison soldiers to use by personnel 28

deployed to a combat theater in Afghanistan. Prevalence and patterns of DS use, demographic 29

factors, and health behaviors were assessed by survey (deployed n=260; garrison n=1218). 30

Seventy-three percent of deployed and 63% of garrison soldiers used DSs ≥ 1 time/week. 31

Logistic regression analyses, adjusted for significant demographic and health predictors of DS 32

use, showed deployed personnel were more likely than garrison soldiers to use protein, amino 33

acids and combination products. Deployed females were more likely to use protein supplements 34

and deployed males were more likely to use multivitamins, combination products, protein and 35

body building supplements than garrison respondents. Significantly more deployed (17%) than 36

garrison (10%) personnel spent more than $50/month on DS. Higher protein supplement use 37

among deployed personnel was associated with higher frequency of strength training and lower 38

amounts of aerobic exercise for males but similar amounts of strength training and aerobic 39

exercise for females. Protein supplements and combination products are used more frequently by 40

deployed than garrison soldiers with the intent of enhancing strength and energy. 41

Key Words: Vitamins, minerals, military, warfare, exercise, sex differences, strength training, 42

aerobic training 43

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Introduction 44

Dietary supplement (DS) use is common among adults (Radimer et al. 2004) and global 45

consumer demand for DS was estimated to exceed $30 billion in 2011 (Anonymous 2012). 46

Healthy civilian adults who consume DSs are typically more active, better educated and non-47

smokers (Lyle et al. 1998; Radimer et al. 2004). Surveys of active duty Army personnel in 48

garrison who are not deployed to combat theater reveal a greater prevalence of DS use and 49

increased use of performance enhancing DSs, such as protein and amino acid supplements, 50

compared to the U.S. civilian population (Radimer et al. 2004; Lieberman et al. 2010; Knapik et 51

al. 2014). The most frequent reasons cited for DS use by active duty soldiers include promoting 52

general health, increasing energy levels, enhancing performance and promoting gains in strength 53

(Lieberman et al. 2010; Knapik et al. 2014). 54

Active duty military personnel, due in part to the unique occupational demands of their 55

profession, use greater amounts of certain DSs compared to the general population (Lieberman et 56

al. 2010). Soldiers deployed to combat theater are often exposed to physical and cognitive 57

stressors such as ascent to altitude, heavy load carriage, long periods of reduced sleep and 58

exposure to high ambient temperatures (Lieberman et al. 2005; Nindl et al. 2013). During 59

deployment, soldiers also sometimes reduce their aerobic training but increase frequency of 60

strength training to maintain lean body mass (Sharp et al. 2008; Lester et al. 2010). In addition, 61

the nature and availability of food differs in combat theaters compared to more permanent 62

facilities. Together, these factors may increase the extent of soldiers using DSs when deployed. 63

Recent findings from a survey of British soldiers deployed in Iraq revealed that 32% of 64

responders (325 of 1017 soldiers) were current users of specific DSs, such as creatine, protein 65

and amino acids, and of these DS users, almost two-thirds initiated their use during deployment 66

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(Boos et al. 2010). However, this survey may have underestimated DS use since use of 67

multivitamins, which are frequently used by UK soldiers during training, was not assessed in the 68

survey (Casey et al. 2014). A subsequent report assessing DS use of British soldiers deployed in 69

Afghanistan found that over 40% used DSs (Boos et al. 2011). More than two-thirds of the 70

British soldiers surveyed in Iraq and Afghanistan who used DSs reported using protein and 71

amino acid supplements to increase strength and aid in training and recovery. These findings are 72

consistent with a 49% DS use rate by a small number of U.S. soldiers deployed in Iraq in 2006-73

2007 (Lieberman et al. 2010). Although the prevalence of DS use among these deployed soldiers 74

was not significantly different from a larger cohort of soldiers stationed in the U.S., it appeared 75

that fewer deployed soldiers used multivitamins and there was a tendency for increased use of 76

protein and amino acid supplements. Separately, a larger cohort of deployed U.S. military 77

personnel had higher prevalence of bodybuilding, energy and weight-loss supplement use 78

compared to soldiers who had never deployed (Jacobson et al. 2012). A more recent survey of 79

deployed U.S. Marines in Afghanistan reported that 70% of respondents used DSs and that 80

almost 30% of supplement users began consuming supplements during deployment (Cassler et 81

al. 2013). Protein supplements were the most common supplement used. Collectively, these 82

studies suggest the prevalence and/or pattern of DS use is altered by deployment to a combat 83

theater. However, it should be noted that none of these previous investigations directly compared 84

garrison and deployed personnel with the same survey instrument to determine the influence of 85

deployment on patterns of DS use. 86

Supplement use among garrison soldiers is associated with demographic and lifestyle 87

factors such as age, rank, education, body mass index, aerobic exercise and participation in 88

strength training (Lieberman et al. 2010). However, it is not known whether similar and/or 89

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additional factors affect patterns and types of DS consumed during deployment. Therefore, the 90

present study examined, using the same survey instrument, factors that influenced DS use by 91

garrison and deployed personnel. 92

Methods 93

Participants 94

This was approved by the Human Use Review Committee at the U.S. Army Research Institute of 95

Environmental Medicine. Data were collected from 2010-2011. The sample consisted of 1,218 96

active duty U.S. Army personnel in garrison from 11 U.S. bases, including 9 U.S. and 2 overseas 97

sites in non-combat regions, and 260 deployed military personnel in Afghanistan. Both users and 98

non-users of DS were included in the sample. Survey sites for garrison personnel were chosen 99

based on the availability of the soldier population and healthcare providers to administer the 100

survey. Personnel who were on temporary or transitional status, including individuals who were 101

absent without leave, incarcerated, or moving between duty stations were excluded. Since DS 102

use is not permitted in Basic Combat Training or Advanced Individual Training, soldiers 103

enrolled in these courses were excluded from the survey. Sites for enrolling deployed personnel 104

were chosen based on the availability and distribution of soldiers and included individuals 105

stationed in forward operating bases, including those located in austere environments. No 106

incentives were offered to participants, and they completed the survey after an explanation that 107

all information obtained would remain confidential, participation was voluntary and they were 108

free to withdraw from the study. 109

Survey Administration 110

Prior to administering the anonymous survey, participants were briefed regarding its contents 111

and provided instructions for completing all questions. Garrison participants completed the 112

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Dietary Supplement Survey of US Army Active Duty Personnel (Lieberman et al. 2010; 113

Lieberman et al. 2012) and deployed participants completed a version of the survey customized 114

for use in a combat theater, the Dietary Supplement Survey for Deployed Military Personnel. 115

The latter survey included minor modifications such as specific questions about their current 116

deployment and whether participants were in a Special Forces unit. Other than these 117

modifications, the surveys were identical. To recruit volunteers, a time and place was arranged to 118

distribute the survey through a unit commander or class leader. The local healthcare provider 119

administering the survey delivered a standardized study briefing to potential volunteers 120

describing the purpose and contents of the survey and its confidential and voluntary nature, as 121

well as describing procedures for completing multipart questions. 122

Both surveys consisted of 43 identical questions assessing type, frequency and reasons 123

for DS use, money spent on DSs, as well as demographic and lifestyle information. The survey 124

included questions for each supplement regarding frequency and reasons for use, including 125

performance enhancement, general health, promoting energy, weight loss, increasing endurance, 126

improving muscle strength, and “other.” Individual supplements listed on the survey included 55 127

generic supplements such as multivitamins, combination antioxidants and individual vitamins 128

and minerals, as well as 37 brand-name supplements. Participants were also instructed to write in 129

supplements they used that were not listed on the survey. Specific brand-name DSs were chosen 130

for inclusion in the survey based on patterns of DS purchases from the Army Air Force 131

Exchange System and General Nutrition Center stores located on or in close proximity to Army 132

bases. 133

Demographic and lifestyle information collected with the survey included sex, age, 134

military assignment (combat arms, combat support or combat service support) and rank, 135

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education, marital status, tobacco use, weight management practice and aerobic and strength 136

training exercise performed by soldiers with their unit and individually. In addition, self-reported 137

height and weight were collected and used to calculate body mass index. Self-reported 138

assessments of health, eating habits, fitness and confidence in DS efficacy and safety were also 139

included in the survey. Survey questions assessing participants’ health behavior beliefs were as 140

follows: “How do you consider your general health?”, “How do you consider your overall 141

eating habits?” and “How do you consider your overall fitness level?”. For each question, 142

participants selected between four response options: “Excellent”, “Good”, “Fair” or “Poor”. 143

After preliminary data analyses were conducted, response options were collapsed into the 144

categories of “Excellent/Good” and “Fair/Poor” due to low cell counts in some response 145

options. Participants’ beliefs regarding the efficacy and safety of DS were assessed as follows: 146

“How confident are you that your dietary supplements will do as they claim?” and “How 147

confident are you that your dietary supplements are safe for consumption?”. Participants 148

selected between four response options: “Extremely confident”, “Very confident”, “Somewhat 149

confident” or “Not at all confident”. 150

Data Analyses 151

Surveys were scanned using ScanTools Plus with ScanFlex (version 6.301; Scantron 152

Corporation, Eagan, MN, U.S.A.) and imported to SPSS for all analyses (version 15.0; SPSS 153

Inc., Chicago, IL, U.S.A.). Prior to data analyses, supplements were grouped into the following 154

categories: multivitamins and multiminerals, protein and amino acids, individual vitamins and 155

minerals, combination products, or purported steroid analogues. Those DSs that could not be 156

placed in one of these categories were termed ‘other’. Supplements were categorized based on 157

the definitions provided in Table 1. A standardized taxonomy, similar to what is used in national 158

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surveys such as the National Health and Nutrition and Examination Survey, was used to 159

categorize DSs (Lieberman et al. 2010). Responders were classified as DS users if they reported 160

consuming a DS at least once/week during the 6 months before the survey; all others were 161

classified as non-users. Sport drinks, bars, gels or meal replacement beverages were not included 162

as DSs as they are not classified as DSs by U.S. law. 163

Insert Table 1 about here. 164

Logistic regression models were used to examine the likelihood of DS use by deployed and 165

garrison personnel as a function of sex, age, rank, education, assignment, BMI, tobacco use, 166

marital status, weight control, eating habits, ratings of fitness, participation in aerobic exercise 167

and frequency of strength training. Given the significant relationship between the predictor 168

variables (education, assignment, and self-perceived ratings of fitness and health) and 169

supplement use (Table 2), we adjusted our models for these covariates in all other analyses that 170

examined differences in patterns and types of DS use between the populations. Results of logistic 171

regression models are expressed as odds ratios and 95% confidence intervals and tests of 172

interactions between demographic factors and deployed status (deployed vs. garrison) were 173

included. Logistic regression examined the interaction of demographic factors as a function of 174

deployed versus garrison status and use of specific DS class. Results were stratified by deployed 175

status for significant interaction terms in which model integrity could be confirmed. 176

Wald chi-square analyses were used to assess differences in reasons for DS use between 177

deployed and garrison responders. Analysis of variance was used to compare the total amount of 178

weekly aerobic exercise or strength training sessions respondents conducted within their unit or 179

individually. When a significant F-ratio for the interaction term was observed, a Newman-Keuls 180

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post-hoc analysis was performed to isolate differences among treatment means. Statistical 181

significance was defined as p < 0.05. 182

Results 183

DS Use Associations by Garrison Personnel 184

The extent of overall use of any DSs by garrison respondents was not significantly associated 185

with sex, age, education, health rating, marital status, tobacco use or eating habits (Table 2). 186

However, use of any DS was more likely in garrison respondents who were assigned to combat 187

arms when compared to combat service support personnel, had a BMI of 25-29.9 kg/m2 when 188

compared to those with a BMI less than 25, were officers rather than those in the junior enlisted 189

ranks or were desiring to gain weight versus those wanting to maintain body weight. In addition, 190

garrison personnel with excellent or high personal ratings of their fitness and who were 191

extremely or very confident in the efficacy and safety of DSs were more likely to use 192

supplements compared to those who perceived their fitness as fair or poor. Participating in more 193

aerobic exercise and strength training were also significantly associated with DS use by garrison 194

personnel. 195

DS Use Associations by Deployed Personnel 196

Like garrison personnel, the overall use of DS by deployed respondents was not significantly 197

associated with sex, age, marital status, or eating habits (Table 2). Also like garrison personnel, 198

deployed soldiers who were officers rather than in the junior enlisted ranks, provided excellent or 199

good ratings of their fitness, were extremely or very confident in the efficacy and safety of DS 200

use, and engaged in more weekly aerobic exercise and strength training, were more likely to use 201

DSs. However there were several differences in predictors of DS use between deployed and 202

garrison personnel. For example, the use of DSs by deployed personnel was not associated with 203

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assignment, body mass index or weight control but was significantly associated with education, 204

self-perceived health and tobacco use. 205


Prevalence and Cost of DS Use 207

A majority of garrison and deployed soldiers used DS, and prevalence of overall use was not 208

significantly different between garrison (63%) and deployed (73%) groups (Table 3). There were 209

also no differences between garrison and deployed personnel in the likelihood of use of 210

multivitamins or multiminerals, single vitamins or minerals, herbals, steroid analogues or ‘other’ 211

supplements. After controlling for significant predictors of DS use education, assignment, and 212

self-perceived ratings of fitness and health, logistic regression analysis showed deployed 213

personnel were significantly more likely than garrison personnel to use protein supplements and 214

combination products. 215

Amount of money spent during the last 3 months on DSs by deployed personnel ($62.45 216

± $7.30 as mean ± SD) was not different than garrison personnel ($63.55 ± $3.10). However, 217

17% of deployed responders spent more than $50/month, a significantly higher proportion than 218

the 10% of garrison personnel who spent more than $50. 219


Reasons for DS Use 221

A significantly greater proportion of deployed (50%) than garrison (41%) personnel reported use 222

of DSs to promote general health, as well as to increase muscle strength (deployed: 30% vs. 223

garrison: 20%), and provide more energy (deployed: 25% vs. garrison: 20%). Use of a 224

multivitamin and mineral to improve health was more prevalent among deployed (38%) than 225

garrison (29%) and similarly the use of single vitamins and minerals to improve strength was 226

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more prevalent in deployed personnel than non-deployed respondents (2% vs. 0.5%). A 227

significantly greater proportion of deployed soldiers also reported the use of protein and amino 228

acid supplements (24% vs. 16%) and combination products (15% vs. 7%) to improve muscle 229

strength. Use of combination products to increase energy was also more prevalent (12% vs. 6%) 230

among deployed personnel when compared to garrison respondents. The prevalence of DS use 231

for promoting weight loss was significantly less among deployed (12%) compared to garrison 232

(16%) personnel. However, use of weight loss DS to improve weight loss was more prevalent 233

among garrison (3%) than deployed (0.5%) soldiers. A significantly greater proportion (3% vs. 234

0.5%) of those deployed also reported the use of herbals for weight loss when compared to those 235

in garrison. 236

Association between Demographics, Deployment Status, and DS Class 237

All models were adjusted for the demographic characteristics of education, assignment, and self-238

perceived ratings of fitness and health. Deployment status, gender, eating habits and use of 239

protein supplements were found to be significant interactions. Deployed male personnel were 240

more likely (OR: 1.79; 95% CI: 1.29, 2.48) to use protein supplements, as were female deployed 241

(OR: 6.35; 95% CI 2.57, 15.71) when compared to non-deployed respondents. Deployed 242

personnel reporting excellent/good eating habits were also more likely than garrison soldiers to 243

use protein supplements (OR: 3.08; 95% CI: 1.71, 5.56) and supplements classified as ‘other’ 244

(OR: 2.09; 95% CI: 1.09,4.02). 245

Aerobic Exercise and Strength Training Frequency of Garrison and Deployed Personnel 246

The total number of weekly aerobic exercise and strength training sessions reported by deployed 247

and garrison personnel with their unit and on their own time is presented in Figure 1. Total 248

aerobic exercise time was significantly greater for garrison personnel, and both male and female 249

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garrison personnel performed a significantly greater amount of aerobic exercise with their unit 250

than deployed personnel. Deployed males had significantly less total aerobic exercise time but a 251

greater number of strength training sessions compared with male garrison respondents. In 252

contrast, female deployed personnel had similar weekly aerobic exercise time and number of 253

total strength training sessions compared with female garrison respondents but conducted more 254

exercise on their own. Both garrison and deployed males reported performing more strength 255

training than did female respondents, but females still engaged in substantial strength training. 256

Insert Figure 1 about here. 257

Discussion 258

This study documents various associations between use of specific DSs and current 259

deployment status among male and female U.S. military personnel. Demographic and lifestyle 260

factors, including education, rank, tobacco use, ratings of fitness and health and amount of 261

strength and aerobic training influenced choice of DS use during deployment. We observed 262

significantly greater use of protein and combination supplements in deployed compared to 263

garrison personnel. Compared to data collected four years earlier using the same survey 264

(Lieberman et al. 2010), a greater proportion of both garrison and deployed soldiers used DSs. 265

Supplement use increased from 53% to 63% for soldiers stationed in garrison at non-combat 266

bases and from 49% for soldiers deployed in Iraq in 2006-2007 to 73% for respondents deployed 267

to Afghanistan in 2010-2011. 268

Our observation of greater DS use in theater is in agreement with several previous studies 269

of DS use. Deployed male British soldiers reported high levels of protein supplements and body 270

building products in combat theater (Boos et al. 2010; Boos et al. 2011). Also, a large cohort 271

study reported greater use of body building and weight loss supplements in both males and 272

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females with a history of deployment to a combat theater (Jacobson et al. 2012). Another study 273

found greater DS use by U.S. Marines who were deployed to Afghanistan (Cassler et al. 2013). 274

The prevalence of overall DS use we observed among deployed personnel was much higher than 275

the 35-40% levels reported in the recent studies of British soldiers deployed in Afghanistan or 276

Iraq, but this may reflect differences in the questionnaires used in each study (Boos et al. 2010; 277

Boos et al. 2011) or general differences between British and American DS use. In the U.S. 278

compared to the U.K. a much wider variety of DSs are available. Interestingly, our findings of 279

DS use among deployed personnel are remarkably similar to DS use by U.S. Marines deployed 280

to the same region of conflict (Cassler et al. 2013). Previous reports of DS use for deployed 281

soldiers (Boos et al. 2010; 2011; Cassler et al. 2013; Jacobson et al. 2012) did not directly 282

compare deployed and garrison personnel using the same survey instrument as was done in the 283

current investigation. Therefore, this report is the first we are aware of that definitively 284

demonstrates that patterns of DS use change during deployment. 285

In comparison to data we collected 4 years earlier (2006-2007) using the same survey 286

procedures (Lieberman et al. 2010), we observed that in 2010-2011 greater use of DSs in 287

deployed personnel was due to increased consumption of multiple DS classes, including 288

multivitamin and multiminerals, individual vitamins and minerals, protein supplements, 289

combination products and herbals. In comparison, the increased prevalence of DS use by 290

garrison responders was attributable to use of only two types of DSs, protein supplements and 291

combination products. Consistent with widespread DS use we observed in both deployed and 292

garrison personnel, soldiers spent significant sums of money on DS. Although average monthly 293

spending of $20 may seem reasonable, 17% of deployed and 10% of garrison personnel spent 294

more than $50/month on DSs. Ensuring that military personnel receive accurate information 295

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about the purported efficacy and potential risk of DS consumption could potentially reduce 296

unnecessary spending. Education about proper dietary choices, such as the ingestion of chocolate 297

milk to promote gains in muscle strength resulting from resistance training rather purchasing and 298

using protein supplements and combination products (Hartman et al. 2007; Josse et al. 2010), 299

may be one strategy to emphasize in dining facilities. However, limitations in the availability and 300

quality of perishable food items (such as some dairy products and other protein sources) in a 301

combat theater may prevent such recommendations from being implemented. Therefore, 302

education regarding use of safe and effective dietary supplements may also be warranted. 303

Occupational assignment has not previously been found to be associated with soldiers’ 304

use of DSs (Lieberman et al. 2010); however, in this study we found increased use of DSs in 305

garrison personnel serving in the combat arms, the individuals most likely to engage in actual 306

combat. Occupational assignment was not associated with DS use by deployed personnel in the 307

current study but this could reflect the small numbers of combat arms personnel recruited. 308

However, our findings of greater use of DSs by deployed personnel to garrison personnel are 309

consistent with those of Jacobson et al. (Jacobson et al. 2012) who reported a higher prevalence 310

of DS use in U.S. military personnel who had a history of combat deployment. Thus, the 311

growing popularity of DSs among active duty soldiers may reflect the increased number of 312

deployments to a combat theater. For many deployed British soldiers, DS use was initiated while 313

in a combat theater (Boos et al. 2010). The data presented by Jacobson et al. (Jacobson et al. 314

2012) and the current findings, especially for combat arms personnel in garrison, suggest that 315

soldiers continue DS use initiated in a combat theater upon returning to their home bases. 316

The prevalence of protein supplement use by soldiers appears to have increased. 317

Lieberman et al. (Lieberman et al. 2010) previously reported that during 2006-2007 318

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approximately 15-20% of active duty U.S. soldiers stationed in non-combat bases and 25% of 319

soldiers deployed in Iraq had consumed protein supplements. A systematic review and meta-320

analysis of data collected prior to 2008 also reported that use of protein supplements to be about 321

20% in non-deployed elite military groups (Knapik et al. 2014). The present study using survey 322

data collected in 2010-2011 indicates that protein supplement use has increased to approximately 323

28% in garrison personnel and 42% in deployed personnel. Greater protein supplement use by 324

both deployed and garrison personnel appears to be consistent with the growing popularity of 325

protein supplements by recreationally active civilian adults (Young and Stephens 2009; Goston 326

and Correia 2010; Tsitsimpikou et al. 2011). In contrast, less than one percent of the general 327

civilian population reports the use of protein supplements (Radimer et al. 2004; Bailey et al. 328

2013). Recently, an expert panel convened by the DoD Center Alliance of Dietary Supplements 329

Research and the U.S. Army Medical Research and Materiel Command examined the safety and 330

efficacy of protein supplements for Armed Forces personnel and concluded that during periods 331

of high metabolic demand, such as deployment, 1.5 – 2.0 g kg-1 of protein be consumed 332

(Pasiakos et al. 2013). High-quality protein foods were the recommended source of protein, but 333

supplements, notwithstanding the additional costs involved, were considered to be an acceptable 334

alternative (Pasiakos et al. 2013). 335

Consistent with previous reports from civilian and active duty soldier populations, DS 336

use was highest in those respondents who engaged in greater amounts of aerobic and strength 337

training exercise and rated their fitness and health as excellent or good, and significantly less in 338

respondents engaged in unhealthy behaviors such as tobacco use (Lyle et al. 1998; Radimer et al. 339

2004; Lieberman et al. 2010). Reasons cited for greater DS use among deployed personnel, such 340

as to promote general health, give more energy and for greater muscle strength, are also 341

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consistent with reasons for supplement use reported by other military surveys (Lieberman et al. 342

2010; Knapik et al. 2014). These findings suggest military personnel in general and deployed 343

personnel in particular consider the use of these DSs to be important for sustaining the high 344

volume of physical training necessary to maintain the strength and cardiovascular fitness their 345

jobs require. 346

Although protein supplement use was greater among both male and female deployed 347

personnel who engaged in greater aerobic and strength training exercise, different exercise 348

patterns among female and male deployed personnel, and between garrison and deployed 349

females were observed (see Figure 1). Changes in exercise patterns during deployment have 350

previously been documented for male soldiers (Sharp et al. 2008; Lester et al. 2010) but no data 351

are available for females. The present study confirmed that participation in aerobic training is 352

lower and participation in strength training activity is greater among male deployed soldiers 353

compared to garrison respondents. In males, these differences in exercise patterns during 354

deployment are associated with decreased maximal oxygen consumption while muscle strength 355

is either maintained or increased (Sharp et al. 2008; Lester et al. 2010). Thus, the greater use of 356

protein supplements and greater strength training sessions among male deployed personnel are 357

consistent with the scientific evidence that use of these supplements can result in gains in muscle 358

strength and muscle protein accretion during strength training (Pasiakos et al. 2015). In this 359

study, deployed females engaged in similar volumes of aerobic training as garrison females; 360

however, deployed females engaged in more aerobic training on their own time and they trained 361

less with their unit. Consistent with deployed males, the deployed females also reported more 362

frequent strength training on their own compared with their garrison counterparts, but total 363

weekly strength training sessions remained comparable with female garrison respondents. 364

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Whether the change in exercise patterns for deployed females together with their greater use of 365

protein supplements impacted their maximal oxygen consumption and muscle strength during 366

and following deployment is not known. However, given that total aerobic exercise time and 367

strength training sessions were unchanged for deployed females, changes would not be expected 368

in maximal aerobic power and muscle strength post-deployment. 369

Limitations and Strengths 370

While the present analyses provide insight into differences in DS use by deployed and garrison 371

populations, the limitations of this study design should be acknowledged. As with all self-372

reported survey data, report and recall bias cannot be ruled out; however they would be similar 373

for both deployed and garrison respondents. Since it was not possible to weight the sample 374

populations to be representative of U.S. Army deployed and garrison personnel, some sampling 375

bias may have been present as the deployed population consisted of somewhat fewer combat 376

arms soldiers, had attained higher education levels, had higher health and fitness ratings, and 377

used less tobacco. However, all of these predictors were adjusted for in our logistic regression 378

models, which minimize the influence of population sampling differences. Despite these 379

limitations the strengths of the present study, including the use of multivariate analyses to control 380

for demographic differences, assessment of both groups during the same time period and use of 381

the same survey, indicate that the findings from this study should generalize to the larger active 382

duty soldier population. 383

Conclusion 384

This study found that prevalence of DS use among deployed personnel was greater 385

compared to their non-deployed counterparts. Higher use of protein supplements during 386

deployment was observed for individuals engaging in more strength and aerobic training and 387

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who reported greater perceived physical fitness. In addition, use of DSs among military 388

personnel appears to have increased over the 4-year period of 2006-2007 to 2010-2011, 389

especially the use of protein supplements and combination products. Further research should be 390

conducted to understand the association between the increased prevalence of protein supplement 391

use and strength training, as well as whether these patterns of DS use and physical activity are of 392

benefit for maintaining or improving the musculoskeletal integrity of deployed soldiers, 393

especially females. 394

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Acknowledgments 395

The authors are indebted to all of the soldiers who volunteered their time to complete the 396

survey. The investigators have adhered to the policies for protection of human subjects as 397

prescribed in DOD Instruction 3216.02 and the research was conducted in adherence with the 398

provisions of 32 CFR Part 219. The opinions or assertions contained herein are the private views 399

of the author(s) and are not to be construed as official or as reflecting the views of the Army or 400

the Department of Defense. Citations of commercial organizations and trade names in this report 401

do not constitute an official Department of the Army endorsement or approval of the products or 402

services of these organizations. 403

Financial Support 404

This work was supported by the US Army Medical Research and Materiel Command 405

(USAMRMC) and the Department of Defense Center Alliance for Dietary Supplements 406

Research. 407

Conflict of Interest 408

None of the authors had a personal or financial conflict of interest. 409

Authorship 410

KGA was involved with formulating the research question, designing the study, analysing 411

the data and writing the article. 412

TMM was involved with analysing the data and writing the article. 413

EKF was involved with designing the study, analysing the data and writing the article. 414

SMM was involved with designing and carrying out the study, analysing the data and 415

writing the article. 416

HRL was involved with all aspects of the research. 417

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482

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Table 1 Dietary supplement categories as defined for study analyses. 483

484

485

Category Definition

Dietary Supplement (DS)

Any DS as defined by the Dietary Supplement Health and Education Act of 1994

Multivitamin and mineral

DS containing two or more vitamins and/or minerals

Protein and Amino Acid

Amino acid mixtures, protein powders, and similar products where the intention is to provide a single or complex protein source

Individual Vitamins or Minerals

DS that were single nutrient ingredient supplements, such as calcium or vitamin D

Combination Products DS with mixtures of ingredients; included two or more categories and multiple ingredients.

Herbal Supplements DS that primarily included one or more herbal ingredients; may include other nutrients or supplement ingredients; also includes plant-derived

ingredients

Purported Steroid Analogs

Steroidal hormones or herbal substitutes for hormones that were marketed as DS and included the Supplement Facts panel on the label

486

487

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Table 2 Association of dietary supplement (DS) use > 1 time/week over the past 6 months for military personnel deployed to combat theater or garrison personnel in non-combat bases in United States or overseas with selected demographic and lifestyle characteristics.

All Participants Garrison Deployed

Variable Grouping N (%) OR (CI) N (%) OR (CI) N (%) OR (CI) Subgroup Deployed

Garrison 221 (18.1) 1001 (82.0)

1.59 (1.10, 2.30) ** 1.0

Sex Male Female

1032 (84.5) 190 (15.6)

1.0 1.21 (0.83, 1.76)

855 (85.4)

146 (14.6) 1.0

1.13 (0.75, 1.70) 177 (80.1)

44 (19.9) 1.0

1.51 (0.59, 3.86)

Assignment Combat Arms Combat Support Combat Service

Support

485 (40.1) 199 (16.5) 525 (43.4)

1.36 (1.02, 1.82) * 1.01 (0.70, 1.41)

1.0

438 (44.0)

156 (15.7)

402 (40.4)

1.50 (1.10, 2.05) * 1.09 ( 0.72, 1.63)

1.0

47 (22.1)

43 (20.2)

123 (57.8)

1.31 (0.52, 3.32) 0.87 (0.37, 2.07)

1.0

Body Mass Index

18.5 – 24.9 kg·m-2

25 – 29.9 kg·m-2 ≥ 30 kg·m-2

326 (27.1) 545 (44.5) 351 (28.4)

1.0 1.53 (1.11, 2.10)** 1.11 (0.79, 1.55)

249 (24.9)

430 (43.0)

322 (32.2)

1.0 1.52 (1.06, 2.16)** 1.11 (0.77, 1.63)

77 (34.8)

115 (52.0)

29 (13.1)

1.0 1.64 (0.79, 3.42) 1.91 (0.58, 6.25)

Age Group < 25 25 – 29 30 – 39

≥ 40

463 (37.9) 365 (29.9) 307 (25.1)

87 (7.1)

0.64 (0.36, 1.13) 0.79 (0.44, 1.42) 0.80 (0.44, 1.44)

1.0

390 (39.0) 314 (31.4) 246 (24.6)

51 (5.1)

0.83 (0.42, 1.65) 0.91 (0.45, 1.82) 0.91 (0.45, 1.86)

1.0

73 (33.0) 51 (23.1) 61 (27.6) 36 (16.3)

0.40 (0.14, 1.18) 1.48 (0.39, 5.62) 0.93 (0.28, 3.06)

1.0

Education High School College

Bachelor or Graduate

626 (51.2) 528 (43.2)

68 (6.9)

1.0a 1.35 (1.03, 1.77)**

4.01 (1.73, 9.59)***

579 (57.8)

419 (41.9) 3 (0.3)

1.0 1.19 (0.89, 1.59)

47 (21.3)

109 (49.3)

65 (29.4)

1.0a 3.07 (1.39, 6.78)***b

5.57 (1.98, 15.69)***b

Rank Junior Enlisted Senior Enlisted

Officer

646 (52.9) 463 (37.9) 113 (9.2)

0.37 (0.21, 0.65)*** 0.58 (0.32, 1.05)

1.0

553 (55.1)

383 (38.5)

65 (6.5)

0.49 (0.25, 0.96)* 0.71 (0.35, 1.41)

1.0

93 (42.1)

80 (36.2)

48 (3.9)

0.23 (0.08, 0.72)* 0.64 (0.19, 2.17)

1.0

Health Rating

Excellent/Good Fair/Poor

1019 (83.4) 203 (16.6)

1.47 (1.06, 2.05)* 1.0

1019 (83.4) 203 (16.6)

1.30 (0.92, 1.83) 1.0

216 (97.7)

5 (2.3) 7.26 (1.16, 45.28)*

1.0

Fitness Rating

Excellent/Good Fair/Poor

872 (71.4) 350 (28.6)

1.50 (1.13, 2.10)** 1.0

687 (56.2)

314 (25.7) 1.34 (1.00, 1.81)*

1.0

185 (83.7)

36 (16.3) 2.80 (1.25, 6.27)**

1.0

Eating Excellent/Good 713 (58.3) 0.91(0.70, 1.19) 543 (54.2) 1.03 (0.77, 1.36) 170 (75.8) 1.14 (0.51, 2.53)

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Habits Fair/Poor 509 (41.7) 1.0 458 (45.6) 1.0

51 (24.2) 1.0

Weight Control

Lose Weight Gain Weight

Maintain

686 (56.1) 168 (13.7) 368 (30.1)

1.07 (0.80, 1.43) 1.44 (0.92, 2.26)

1.0

582 (47.6)

134 (11.0)

285 (23.3)

1.18 (0.86, 1.62) 1.71 (1.04, 2.81)**

1.0

104 (47.1)

34 (15.4)

83 (37.8)

0.78 (0.36, 1.69) 0.72 (0.26, 2.00)

1.0

Marital Status

Not married Married

521 (42.6) 701 (57.4)

1.0 1.30 (1.00, 1.70)

429 (42.9) 572 (57.1)

1.0 1.22 (0.91, 1.61)

92 (41.6) 129 (58.4)

1.0 1.94 (0.97, 3.88)

Tobacco Use Current Former Never

554 (45.3) 230 (18.8) 438 (35.8)

0.91 (0.68, 1.22) 1.12 (0.76, 1.63)

1.0a

469 (46.9)

196 (19.6)

336 (33.4)

1.04 (0.76, 1.43) 1.21 (0.80, 1.82)

1.0

85 (38.5)

34 (15.4)

102 (46.2)

0.56 (0.27, 1.18)* 1.00 (0.33, 3.01)

1.0

Confidence in DS

Efficacy

Extremely/Very Somewhat/Not at all

467 (38.2) 755 (61.8)

3.58 (2.60, 4.93)*** 1.0a

363 (36.3) 638 (63.7)

3.36 (2.37, 4.75)*** 1.0

104 (47.1) 117 (52.9)

4.52 (1.97, 10.37)*** 1.0

Confidence in DS Safety

Extremely/Very Somewhat/Not at all

536 (43.9) 686 (56.1)

3.84 (2.83, 5.21)*** 1.0a

421 (42.1) 580 (57.9)

3.52 (2.53, 4.89)*** 1.0

115 (52.0) 106 (48.0)

5.78 (2.52, 13.30)*** 1.0

Amount of Weekly Aerobic Exercise

< 60 min 61 – 314

315 – 464 >465 min

60 (4.9) 525 (43.0) 308 (25.2) 329 (26.9)

1.0a 1.83 (1.05, 3.20)* 1.83 (1.03, 3.28)*

2.53 (1.41, 4.56)**

37 (3.7) 411 (41.1)

266 (26.6)

287 (28.7)

1.0 1.98 (1.00, 3.93) 2.13 (1.05, 4.32)*

2.96 (1.45, 6.03)**

23 (10.4)

114 (51.6)

42 (19.0)

42 (19.0)

1.0 2.19 (0.79, 6.09) 1.86 (0.57, 6.08) 2.63 (0.75, 9.15)*

Strength Training

No Yes

224 (18.3) 998 (81.7)

1.0a 2.24 (1.65, 3.05)***

199 (19.9)

802 (80.1) 1.0

1.92 (1.38, 2.67)*** 25 (11.3)

196 (88.7) 1.0

5.54 (2.29, 13.41)***

Prevalence is reported as number with percentage in parentheses. Results of logistic regression are presented as odds ratios (OR) with 95% confidence intervals (CIs) in parentheses. Values are presented on the basis of logistic regression modeling with the reference category represented as no supplements being

consumed on a weekly basis. 1

Not included in the analyses due to small participant numbers in that category. Values not sharing a common superscript letter are

significantly different. * P < 0.05, ** P < 0.01, *** P < 0.001.

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Table 3 Number and percentage of personnel deployed to combat theater or garrison personnel in non-combat bases in United States or overseas using various dietary supplement (DS) categories minus products categorized as sport drinks, gels, bars or meal replacement beverages. Odds ratios (OR) and confidence intervals (CI) compare deployed to garrison personnel with covariates education, assignment, and self-perceived ratings of fitness and health.

Supplement Category N (%) OR (CI)

P-Value

Any DS Deployed Garrison

181 (81.9) 742 (74.1)

1.16 (0.96, 1.77) 1.0

0.11

Multivitamins or minerals Deployed Garrison

116 (52.5) 419 (41.9)

1.28 (0.90, 1.82) 1.0

0.08

Single vitamins or minerals

Deployed Garrison

63 (28.5) 218 (21.8)

1.42 (0.96, 2.11) 1.0

0.15

Protein powders or amino acids

Deployed Garrison

105 (47.5)

328 (32.8) 2.22 (1.53, 3.23)***

1.0

p < 0.001

Combination Products Deployed Garrison

92 (41.6) 298 (29.8)

2.01 (1.46, 2.90)*** 1.0

p < 0.001

Herbal supplements Deployed Garrison

30 (13.6) 98 (9.8)

1.56 (0.91, 2.68) 1.0

0.11

Steroid supplements Deployed Garrison

5 (2.3) 19 (1.9)

1.83 (0.62, 5.45) 1.0

0.28

Other supplements Deployed Garrison

48 (21.7) 188 (18.8)

1.09 (0.70, 1.70) 1.0

0.70

Prevalence is reported as number with percentage in parentheses. Results of logistic regression are presented as odds ratios with 95% CIs in parentheses. * P < 0.05, ** P < 0.01, *** P < 0.001.

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Figure Legend

Figure 1 Weekly aerobic exercise (A) and strength training sessions (B) for military personnel

deployed to combat theater in Afghanistan or garrison personnel stationed at non-combat bases

in United States or overseas. Total exercise patterns are broken down into training conducted

with the unit or on their own for all responders, as well as for males and females. Significant

difference between deployed and garrison (*) personnel and between males and females (†) are

provided.

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