Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Personal view
Nutrition research in the military Neil E Hill,1 J L Fallowfield,2 S K Delves,2 D R Wilson1 ABSTRACT Military research performed in an operational environment involves mission-specific considerations. The Institute of Naval Medicine was tasked in 2008 by the Surgeon General to investigate the nutritional status of deployed British military personnel, and how this might affect body composition, physical fitness and operational capability. This paper briefly describes the logistic and technical issues specific to military research that were encountered by the study team, how these issues were overcome and how this research has influenced military practice.
INTRODUCTION Undertaking research presents unique challenges, none more so than field-based research. Military-specific research is not necessarily more difficult than that undertaken in a civilian context, but military research performed in an operational environment involves additional considerations. In 2008, the Institute of Naval Medicine (INM) was tasked by the Surgeon General to investigate whether the nutritional status of deployed British military personnel affected their physical status and operational capability. Thus, following a successful pilot study in 2009, a large prospective observational study—the Surgeon General’s Armed Forces Feeding Project (SGAFFP)—investigated the effects of a 6-month deployment to Afghanistan on food availability and intake, nutritional status, body composition and body mass, strength and physical fitness, energy expenditure, vitamin D, gut and gonadotrophic hormone levels in British military personnel during summer 2010. This paper briefly describes the logistic and technical issues specific to military research encountered by the study team, how they were overcome and how this research has influenced practice.1
2010; in Afghanistan immediately before and after rest and recuperation and at the end of the deployment in Cyprus (for time-critical measures) during decompression on the journey home or in the UK (Figure 1).
VOLUNTEERS AND RECRUITMENT The number of potential research participants was determined partly by the size of the unit (approximately 600 personnel) and the proportion of personnel who were likely to be in camp during each of the 2 week pre-deployment measurement periods in January and March. It was anticipated that actual population numbers would be very fluid due to the requirements placed on units—with respect to specific pre-deployment training—during the final months prior to departure from the UK. The intention was to recruit a minimum of 250 volunteers to the study to allow for possible unforeseen non-attendances at the measurement time points, where the study team was cognisant of the pressures on troop movements in an operational theatre. Understandably, not all volunteers would be able to attend every measurement time point for a variety of reasons: predeployment training taking place at the same time as measurements in the UK, the specific mid-deployment leave of a volunteer not coinciding with the window the study team were permitted to deploy to theatre, lack of time on the part of a volunteer when arriving in Camp Bastion
before moving to other locations within the theatre of operations and possible injury and/or illness directly arising from the frontline roles of study volunteers.
LOGISTICS OF STUDY MEASUREMENTS The study team was comprised of civilian scientists, a civilian registered research dietitian, Army medical officers and Royal Navy officers. This combination of civilian and military—scientific and medical— subject-matter experts represented a strong study team for undertaking such an expansive and ambitious research activity. The pre-deployment measurements were undertaken over two 5 day periods (Monday–Friday) at the deploying unit’s main camp in the UK. All scientific equipment—including laboratory equipment for taking, processing, separating, freezing and storing more than 1500 blood samples, for undertaking anthropometric measurements, measuring fitness, as well as study stationary and computer hardware to record data—was transported in a specially designed Mobile Scientific Laboratory. Measurements were undertaken in situ in the unit’s Medical Centre. To facilitate deployment of the study team to Afghanistan, Command level discussions took place among the INM, Surgeon General’s Department, Permanent Joint Headquarters and Army Headquarters. The study team were subsequently granted permission to deploy to Afghanistan for 10 weeks between June and August 2010. All the scientific equipment required for the mid-deployment measurements was flown to Camp Bastion in advance of the study team’s arrival. The study team were administered by the UK Medical Group who were staffing the
STUDY DESIGN Measurements were taken at five time points: in the UK in January and March 1
Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK; 2 Institute of Naval Medicine, Alverstoke, UK Correspondence to Maj Neil Edward Hill, Academic Department of Military Medicine, Royal Centre for Defence Medicine, ICT Building, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, UK; [email protected]
Figure 1 Schematic diagram showing the design of the Surgeon General’s Armed Forces Feeding Project 2010.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
99
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Personal view field hospital located in Camp Bastion, and allocated space in the pathology department of the ‘resilience hospital’ (a fully functioning, but unmanned tented hospital located adjacent to the main hard-standing hospital, for use in the event of the main hospital becoming nonfunctioning). This air-conditioned area had electricity and access to freezers, and with ample space for volunteer measurements to be undertaken. The study team liaised daily with the rear echelon elements of the unit located in Camp Bastion to establish which volunteers were passing through on their way to and from rest and recuperation. In addition, a military member of the study team was able to deploy to the Forward Operating Base where the majority of study volunteers were located. This was essential to facilitate the accurate collection of energy expenditure measurements in situ of operational duties and the recording of local dietary intake data. Measurement of volunteers ‘outside the wire’ was limited by security and practical constraints. The study team has worked with military and Ministry of Defence (MOD) civilian colleagues to develop and manufacture portable, reliable and practical measurement devices that would be compatible with the operational environment. These unproven technologies required an additional layer of validation by the study team prior to application in the present study. Nevertheless, unique and specific data were gathered to inform understanding of the physical and physiological challenges of frontline roles. The potential for relatively poor compliance of volunteers with respect to the diary-based methods of food-intake assessment and energy expenditure of volunteers located in the Forward Operating Bases was a potential risk to the quality of data collection. This was partially mitigated by the thorough briefing of volunteers in the UK, as well as in situ when the study team was present in Afghanistan and by the forward deploying of a military member of the study team. Data quality was also assured and verified through triangulating the data from different modes of data acquisition, as well as maximising the number of volunteers that could be analysed at each time point. To enable preservation of the cold chain on returning to the UK, the volunteers’ serum samples were frozen to −40°C and packed into the same ‘golden hour’ boxes used to transport blood products into theatre. Rather than flying via the airport at Kandahar and changing aircraft (with the potential for delay that could 100
compromise the integrity of the frozen serum samples), the study team were given special permission to fly directly from Camp Bastion to the UK, stopping only briefly in Doha. On arrival at RAF Brize Norton, UK, the study team were met by scientists from the INM with portable freezers for the onward transfer of the serum samples to the INM. During the transit from Bastion to Brize Norton and onward to the INM, the inner golden hour box temperature was continuously monitored using a hard-wired thermistor probe. Temperature readings from the probe confirmed that all serum samples remained frozen during transit. The time-critical post-deployment measurements took place in October 2010 in Cyprus during the mandatory ‘decompression’ period. It was not possible for the study team to return to Afghanistan to complete the post-deployment measurements due to the number of study team members required to complete the required measures within a relatively narrow window of time. Nevertheless, undertaking the measurements in Cyprus also required high-level consultation within UK military Command before special permission—due to the prioritisation of this specific study—was granted. Deployment of the study team to Cyprus took place between October and November 2010, where an uplift in personnel incorporated into the study team enabled the larger flow of study volunteers to be measured as aircraft from Afghanistan arrived at RAF Akrotiri. While this research activity had high-level tasking and support, it was essential that the study team measurements did not delay volunteers during their return transit, nor that measurements interfered with the principal objectives of the protected decompression package. Measurements deemed by the study-team to be stable over a short period of time were undertaken when the whole unit reassembled in barracks within 3 weeks after returning to the UK.
HOW THIS RESEARCH HAS CHANGED PRACTICE This research was initially tasked to provide an evidence-base to inform the actual physical and nutritional requirements of military operational deployments. Concerns of adequate nutritional intake of frontline personnel had been voiced by senior military Command, through questions raised in the UK Houses of Parliament, as well as in the UK media.2 3 This study was designed to provide important data to address this
concern and to ensure that Command was better able to understand and manage the physical requirements of frontline personnel. However, the objectives of this expansive work programme also provided evidence to inform the better preparation of personnel prior to deployment, both in terms of physical training as well as operationally-specific education. This work has driven a renewed effort to consolidate personal field craft training—for example, with respect to how to best use the ingredients of the 10-man ration pack and 24 h operational ration packs. The SGAFFP has also informed the further development of operational ration packs to ensure that the required energy and appropriate nutrition are provided as food items that can be readily consumed as personnel undertake their frontline roles. As part of the MOD’s ongoing support to Serving personnel and those charged with their care, evidence from SGAFFP is guiding operationally-specific advice delivered by the Defence Nutrition Advisory Service. Finally, data obtained from this research are providing links between the ‘sharp end’ of military roles being practiced on the frontline, back to initial military training, and indeed to update selection criteria and selection standards for initial military training. Thus, evidence from this work could help to ensure that the right people are recruited into the right jobs to maintain the UK’s Defence capability.
SUMMARY When undertaking a study based on a repeated measures cohort design, good control of possible confounders and ensuring the high reliability of measures are essential in the laboratory. Similar requirements are equally essential in fieldbased research, but may be harder to consistently achieve. Nevertheless, field-based studies have the capacity to be more representative and ecologically valid with respect to the ‘real life’ context of a research question. Undertaking field research in a study of the magnitude of SGAFFP involved large numbers of engaged volunteers and study team personnel, agreement from the military unit involved and widespread support from across the military, the MOD and academia. Significant logistic challenges were overcome. This paper summarises key areas that were essential to achieving the scientific objectives of the study and how the information obtained from this research has been used to influence nutritional practices within the military.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Personal view Acknowledgements The authors wish to acknowledge the support of the Command and volunteers from the Royal Marines, as well as significant assistance from 34 Field Hospital, LAND Forces HQ, the UK Permanent Joint Head Quarters (PJHQ), and colleagues from the University of Surrey and Imperial College London for ongoing scientific advice and guidance. Contributors NEH wrote the first draft. JLF, SKD and DRW contributed to amending the subsequent drafts. Funding This study was funded by the UK Ministry of Defence.
Provenance and peer review Not commissioned; internally peer reviewed. To cite Hill NE, Fallowfield JL, Delves SK, et al. J R Army Med Corps 2014;160:99–101.
2
Received 15 December 2013 Accepted 16 December 2013 Published Online First 16 January 2014 J R Army Med Corps 2014;160:99–101. doi:10.1136/jramc-2013-000234
REFERENCES 1
Competing interests None.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
3
and Energy Intake, Body Composition and Physical Fitness of Uninjured Personnel on Op Herrick 12. Preliminary data. Institute of Naval Medicine; Report No 2011.016. Daily Hansard—Written Answers. Armed Forces: Nutrition (Online) 6 January 2010. http://www. parliament.the-stationeryoffice.co.uk/pa/cm200910/ cmhansrd/cm100106/text/100106w0025.htm (accessed 10 May 2010). Kiley S. Soldiers went hungry on the battlefield. The Times (Online) 9 June 2010. http://www.timesonline. co.uk/tol/news/world/afghanistan/article7146334.ece (accessed 11 Apr 2011).
Fallowfield JL, Delves S, Hill NE, et al. Surgeon General’s Casualty Nutrition Study. Report—1: Food
101
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Nutrition research in the military Neil E Hill, J L Fallowfield, S K Delves and D R Wilson J R Army Med Corps 2014 160: 99-101 originally published online January 16, 2014
doi: 10.1136/jramc-2013-000234 Updated information and services can be found at: http://jramc.bmj.com/content/160/2/99
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Personal view
Nutrition research in the military Neil E Hill,1 J L Fallowfield,2 S K Delves,2 D R Wilson1 ABSTRACT Military research performed in an operational environment involves mission-specific considerations. The Institute of Naval Medicine was tasked in 2008 by the Surgeon General to investigate the nutritional status of deployed British military personnel, and how this might affect body composition, physical fitness and operational capability. This paper briefly describes the logistic and technical issues specific to military research that were encountered by the study team, how these issues were overcome and how this research has influenced military practice.
INTRODUCTION Undertaking research presents unique challenges, none more so than field-based research. Military-specific research is not necessarily more difficult than that undertaken in a civilian context, but military research performed in an operational environment involves additional considerations. In 2008, the Institute of Naval Medicine (INM) was tasked by the Surgeon General to investigate whether the nutritional status of deployed British military personnel affected their physical status and operational capability. Thus, following a successful pilot study in 2009, a large prospective observational study—the Surgeon General’s Armed Forces Feeding Project (SGAFFP)—investigated the effects of a 6-month deployment to Afghanistan on food availability and intake, nutritional status, body composition and body mass, strength and physical fitness, energy expenditure, vitamin D, gut and gonadotrophic hormone levels in British military personnel during summer 2010. This paper briefly describes the logistic and technical issues specific to military research encountered by the study team, how they were overcome and how this research has influenced practice.1
2010; in Afghanistan immediately before and after rest and recuperation and at the end of the deployment in Cyprus (for time-critical measures) during decompression on the journey home or in the UK (Figure 1).
VOLUNTEERS AND RECRUITMENT The number of potential research participants was determined partly by the size of the unit (approximately 600 personnel) and the proportion of personnel who were likely to be in camp during each of the 2 week pre-deployment measurement periods in January and March. It was anticipated that actual population numbers would be very fluid due to the requirements placed on units—with respect to specific pre-deployment training—during the final months prior to departure from the UK. The intention was to recruit a minimum of 250 volunteers to the study to allow for possible unforeseen non-attendances at the measurement time points, where the study team was cognisant of the pressures on troop movements in an operational theatre. Understandably, not all volunteers would be able to attend every measurement time point for a variety of reasons: predeployment training taking place at the same time as measurements in the UK, the specific mid-deployment leave of a volunteer not coinciding with the window the study team were permitted to deploy to theatre, lack of time on the part of a volunteer when arriving in Camp Bastion
before moving to other locations within the theatre of operations and possible injury and/or illness directly arising from the frontline roles of study volunteers.
LOGISTICS OF STUDY MEASUREMENTS The study team was comprised of civilian scientists, a civilian registered research dietitian, Army medical officers and Royal Navy officers. This combination of civilian and military—scientific and medical— subject-matter experts represented a strong study team for undertaking such an expansive and ambitious research activity. The pre-deployment measurements were undertaken over two 5 day periods (Monday–Friday) at the deploying unit’s main camp in the UK. All scientific equipment—including laboratory equipment for taking, processing, separating, freezing and storing more than 1500 blood samples, for undertaking anthropometric measurements, measuring fitness, as well as study stationary and computer hardware to record data—was transported in a specially designed Mobile Scientific Laboratory. Measurements were undertaken in situ in the unit’s Medical Centre. To facilitate deployment of the study team to Afghanistan, Command level discussions took place among the INM, Surgeon General’s Department, Permanent Joint Headquarters and Army Headquarters. The study team were subsequently granted permission to deploy to Afghanistan for 10 weeks between June and August 2010. All the scientific equipment required for the mid-deployment measurements was flown to Camp Bastion in advance of the study team’s arrival. The study team were administered by the UK Medical Group who were staffing the
STUDY DESIGN Measurements were taken at five time points: in the UK in January and March 1
Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK; 2 Institute of Naval Medicine, Alverstoke, UK Correspondence to Maj Neil Edward Hill, Academic Department of Military Medicine, Royal Centre for Defence Medicine, ICT Building, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, UK; [email protected]
Figure 1 Schematic diagram showing the design of the Surgeon General’s Armed Forces Feeding Project 2010.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
99
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Personal view field hospital located in Camp Bastion, and allocated space in the pathology department of the ‘resilience hospital’ (a fully functioning, but unmanned tented hospital located adjacent to the main hard-standing hospital, for use in the event of the main hospital becoming nonfunctioning). This air-conditioned area had electricity and access to freezers, and with ample space for volunteer measurements to be undertaken. The study team liaised daily with the rear echelon elements of the unit located in Camp Bastion to establish which volunteers were passing through on their way to and from rest and recuperation. In addition, a military member of the study team was able to deploy to the Forward Operating Base where the majority of study volunteers were located. This was essential to facilitate the accurate collection of energy expenditure measurements in situ of operational duties and the recording of local dietary intake data. Measurement of volunteers ‘outside the wire’ was limited by security and practical constraints. The study team has worked with military and Ministry of Defence (MOD) civilian colleagues to develop and manufacture portable, reliable and practical measurement devices that would be compatible with the operational environment. These unproven technologies required an additional layer of validation by the study team prior to application in the present study. Nevertheless, unique and specific data were gathered to inform understanding of the physical and physiological challenges of frontline roles. The potential for relatively poor compliance of volunteers with respect to the diary-based methods of food-intake assessment and energy expenditure of volunteers located in the Forward Operating Bases was a potential risk to the quality of data collection. This was partially mitigated by the thorough briefing of volunteers in the UK, as well as in situ when the study team was present in Afghanistan and by the forward deploying of a military member of the study team. Data quality was also assured and verified through triangulating the data from different modes of data acquisition, as well as maximising the number of volunteers that could be analysed at each time point. To enable preservation of the cold chain on returning to the UK, the volunteers’ serum samples were frozen to −40°C and packed into the same ‘golden hour’ boxes used to transport blood products into theatre. Rather than flying via the airport at Kandahar and changing aircraft (with the potential for delay that could 100
compromise the integrity of the frozen serum samples), the study team were given special permission to fly directly from Camp Bastion to the UK, stopping only briefly in Doha. On arrival at RAF Brize Norton, UK, the study team were met by scientists from the INM with portable freezers for the onward transfer of the serum samples to the INM. During the transit from Bastion to Brize Norton and onward to the INM, the inner golden hour box temperature was continuously monitored using a hard-wired thermistor probe. Temperature readings from the probe confirmed that all serum samples remained frozen during transit. The time-critical post-deployment measurements took place in October 2010 in Cyprus during the mandatory ‘decompression’ period. It was not possible for the study team to return to Afghanistan to complete the post-deployment measurements due to the number of study team members required to complete the required measures within a relatively narrow window of time. Nevertheless, undertaking the measurements in Cyprus also required high-level consultation within UK military Command before special permission—due to the prioritisation of this specific study—was granted. Deployment of the study team to Cyprus took place between October and November 2010, where an uplift in personnel incorporated into the study team enabled the larger flow of study volunteers to be measured as aircraft from Afghanistan arrived at RAF Akrotiri. While this research activity had high-level tasking and support, it was essential that the study team measurements did not delay volunteers during their return transit, nor that measurements interfered with the principal objectives of the protected decompression package. Measurements deemed by the study-team to be stable over a short period of time were undertaken when the whole unit reassembled in barracks within 3 weeks after returning to the UK.
HOW THIS RESEARCH HAS CHANGED PRACTICE This research was initially tasked to provide an evidence-base to inform the actual physical and nutritional requirements of military operational deployments. Concerns of adequate nutritional intake of frontline personnel had been voiced by senior military Command, through questions raised in the UK Houses of Parliament, as well as in the UK media.2 3 This study was designed to provide important data to address this
concern and to ensure that Command was better able to understand and manage the physical requirements of frontline personnel. However, the objectives of this expansive work programme also provided evidence to inform the better preparation of personnel prior to deployment, both in terms of physical training as well as operationally-specific education. This work has driven a renewed effort to consolidate personal field craft training—for example, with respect to how to best use the ingredients of the 10-man ration pack and 24 h operational ration packs. The SGAFFP has also informed the further development of operational ration packs to ensure that the required energy and appropriate nutrition are provided as food items that can be readily consumed as personnel undertake their frontline roles. As part of the MOD’s ongoing support to Serving personnel and those charged with their care, evidence from SGAFFP is guiding operationally-specific advice delivered by the Defence Nutrition Advisory Service. Finally, data obtained from this research are providing links between the ‘sharp end’ of military roles being practiced on the frontline, back to initial military training, and indeed to update selection criteria and selection standards for initial military training. Thus, evidence from this work could help to ensure that the right people are recruited into the right jobs to maintain the UK’s Defence capability.
SUMMARY When undertaking a study based on a repeated measures cohort design, good control of possible confounders and ensuring the high reliability of measures are essential in the laboratory. Similar requirements are equally essential in fieldbased research, but may be harder to consistently achieve. Nevertheless, field-based studies have the capacity to be more representative and ecologically valid with respect to the ‘real life’ context of a research question. Undertaking field research in a study of the magnitude of SGAFFP involved large numbers of engaged volunteers and study team personnel, agreement from the military unit involved and widespread support from across the military, the MOD and academia. Significant logistic challenges were overcome. This paper summarises key areas that were essential to achieving the scientific objectives of the study and how the information obtained from this research has been used to influence nutritional practices within the military.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Personal view Acknowledgements The authors wish to acknowledge the support of the Command and volunteers from the Royal Marines, as well as significant assistance from 34 Field Hospital, LAND Forces HQ, the UK Permanent Joint Head Quarters (PJHQ), and colleagues from the University of Surrey and Imperial College London for ongoing scientific advice and guidance. Contributors NEH wrote the first draft. JLF, SKD and DRW contributed to amending the subsequent drafts. Funding This study was funded by the UK Ministry of Defence.
Provenance and peer review Not commissioned; internally peer reviewed. To cite Hill NE, Fallowfield JL, Delves SK, et al. J R Army Med Corps 2014;160:99–101.
2
Received 15 December 2013 Accepted 16 December 2013 Published Online First 16 January 2014 J R Army Med Corps 2014;160:99–101. doi:10.1136/jramc-2013-000234
REFERENCES 1
Competing interests None.
Hill NE, et al. J R Army Med Corps June 2014 Vol 160 No 2
3
and Energy Intake, Body Composition and Physical Fitness of Uninjured Personnel on Op Herrick 12. Preliminary data. Institute of Naval Medicine; Report No 2011.016. Daily Hansard—Written Answers. Armed Forces: Nutrition (Online) 6 January 2010. http://www. parliament.the-stationeryoffice.co.uk/pa/cm200910/ cmhansrd/cm100106/text/100106w0025.htm (accessed 10 May 2010). Kiley S. Soldiers went hungry on the battlefield. The Times (Online) 9 June 2010. http://www.timesonline. co.uk/tol/news/world/afghanistan/article7146334.ece (accessed 11 Apr 2011).
Fallowfield JL, Delves S, Hill NE, et al. Surgeon General’s Casualty Nutrition Study. Report—1: Food
101
Downloaded from http://jramc.bmj.com/ on September 1, 2015 - Published by group.bmj.com
Nutrition research in the military Neil E Hill, J L Fallowfield, S K Delves and D R Wilson J R Army Med Corps 2014 160: 99-101 originally published online January 16, 2014
doi: 10.1136/jramc-2013-000234 Updated information and services can be found at: http://jramc.bmj.com/content/160/2/99
These include:
Email alerting service
Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
