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International Review of the
Armed Forces Medical Services
Revue Internationale des Services
de Santé des Forces Armées
Vol. 95/4 | Quarterly: December 2022 | Trimestriel : Décembre 2022
www.cimm-icmm.org
ICMM 4_2022_Umbruch.indd 1 16.12.22 14:22
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Contents
Sommaire
Imprint 2 The specificities of thyroid surgery in a country
with limited resources and in an operational
Editorial and best Wishes 2023 4 context: our experience in Mali
Les spécificités de la chirurgie thyroïdienne dans un pays aux
ressources limitées et dans un contexte opérationnel : notre
Reprint expérience au Mali
Réimpression A. CRAMBERT, JB CARUHEL, A. GUYEN-BOMBA, S. MARTY,
G. SCHLIENGER, JB. MORVAN. FRANCE 30
Vitamin D deficiency: An often underestimated
risk
Carence en vitamine D : Un risque souvent sous-estimé
E. VITS, M. STAUDT, M. BERRESHEIM, U. ROHDE, T. EGER, Emerging issues in the field of water for human
C. BICKEL, D. LEYK. GERMANY 7 consumption: implications for the armed forces
Problématiques émergentes dans le domaine des eaux
destinées à la consommation humaine : conséquences
Original articles pour les forces armées
Articles originaux G. BORNERT and F. CALVET. FRANCE 36
Nutritional requirements during training
for special operation forces
Besoins nutritionnels pendant l’entraînement des forces Understanding the risks of Civil-Military
d’opérations spéciales Relationships in Healthcare; a validated
G. Rietjens,G. Plasqui, D. A.M.S.W. Frenken, J. Most. THE typology
NETHERLANDS 14 Comprendre les risques des relations civilo-militaires
dans les soins de santé ; une typologie validée
Medical and Biological aspects of human living in S.HORNE and S. BOLAND. UNITED KINGDOM 42
space
Aspects médicaux et biologiques de la vie humaine dans
l’espace
A.U. SHIMKO, K.V., BELYAKOV, N.N. KOMAROV. RUSSIA 20 World Health Organization Organisation
Mondiale de la Santé
Prise en charge thérapeutique des tumeurs
cutanées de la face lors des missions Advancing Civil-Military Health Collaboration
humanitaires : profil épidémiologique Key to Strengthen Health Emergency
et limites Preparedness
Therapeutic management of facial skin tumors in Dr Stella CHUNGONG, Director, World Health Organization’s
humanitarian missions: epidemiologic profile and limitations Health Security Preparedness Department (HSP) 50
A.ACHBOUK, Y.RIBAG, K. ABABOU, FZ. FOUADI, A.OUARDI,
MK. EL KHATIB. MAROC 25
Views and opinions expressed in this Review are those of the au- Les idées et opinions exprimées dans cette Revue sont celles des
thors and imply no relationship to author’s official authorities auteurs et ne reflètent pas nécessairement la politique officielle,
policy, present or future. présente ou future des autorités dont relèvent les auteurs.
International Review of the
the Armed
Armed Forces
Forces Medical
Medical Services Vol. 95/3
95/4 Revue Internationale des Services
Revuede Santé des Forces Armées International ReviewArmées
of the
International
Armed Forces Review
MedicalofServices Services Vol. 95/3
Vol. Revue Internationale
Internationale des Services
des Services de Santé
de Santé des
des Forces
Forces Armées 1
ICMM 4_2022_Umbruch.indd 1 16.12.22 14:22
International Review of the
ARMED FORCES MEDICAL SERVICES
Revue Internationale des Services de Santé des Forces Armées
Official publication of the
International Committee of Military Medicine
Publication officielle du
Comité International de Médecine Militaire
SCIENTIFIC COMMITTEE / COMITÉ SCIENTIFIQUE EDITION / REDACTION
Col. (Vet.) L. BUCHNER Director / Directeur
(Germany / Allemagne) Lt. Gen. P. NEIRINCKX (MD)
Col. Maj. M. BEJIL (MD) SecGen@cimm-icmm.org
(Tunisia / Tunisie)
Editor-in-Chief (a.i.) / Redacteur en chef par Interim
Gp. Capt. Prof. D. LAMB
Maj. Gen. Prof. (ret.) H. BOISSEAUX (MD)
(United Kingdom/Royaume-Uni)
ChairSC@cimm-icmm.org
Maj: Gen. (ret.) KHALID A. ABU-AZAMAH AL-SAEDI (MD)
(Saudi Arabia / Arabie Saoudite)
Assistant Chief-Editor (a.i.) /
Col. (ret.) Prof. I. KHOLIKOV (MC) Rédacteur en chef adjoint par Interim
(Russian Federation / Federation de Russie) Maj. Gen. Prof. J.J. LATAILLADE (MD)
AN 62 1.0 04-2019/A-E
Col. K. KORZENIEWSKI (MD) DepChairSC@cimm-icmm.org
(Poland / Pologne)
Col. (Dent.) A. KOSARAJU Secretary of the Editorial Board
(United States of America / Etats-Unis d’Amérique) Secrétaire du Comite de rédaction
Captain. Pharmacist L. PIERRE-VICTOR
Sen. Col. (Pharm.) A. KRAPPITZ
(Germany / Allemagne) OffMgr@cimm-icmm.org
Col. (ret.) Dr. Prof. A. SINGH KUSHWAHA
Secretary of. the Editorial Board
(India / Inde)
Secrétaire du Comité de rédaction
Sen. Col. Prof. M. YU Chief Warrant Officer C. VAN DEN BERGHE
(China / Chine) ExecSrt@cimm-icmm.org
Col. D. WINKLER (MD)
(Switzerland / Suisse) Editor’s office / Bureau de la redaction
International Committee of Military Medicine
Index of Advertising Comite International.de Medecine Militaire
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International Review of the
the Armed
Armed Forces
Forces Medical
Medical Services Vol. 95/3
95/4 Revue Internationale des Services
Revuede Santé des Forces Armées International ReviewArmées
of the
2 International
Armed Forces Review
MedicalofServices Services Vol. 95/3
Vol. Revue Internationale
Internationale des Services
des Services de Santé
de Santé des
des Forces
Forces Armées
ICMM 4_2022_Umbruch.indd 2 16.12.22 14:22
AN 62 1.0 04-2019/A-E
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Editorial and best wishes 2023
This issue of the International Review of the Armed Forces Medical Services closes the year
2022.
After two years in which the international health situation had profoundly disrupted the
activities of the International Committee of Military Medicine, the year that is now coming
to an end finally allowed us to meet again, in Brussels, for our 44th ICMM World Congress
on Military Medicine.
The start of the second centenary of our organization was an occasion to reaffirm its mis-
sions as well as the values that it intends to continue to promote.
Our world meeting was an opportunity to engage with our international partner organi-
sations, which underlined the importance they attribute to our organisation.
The scientific program of this long-awaited meeting was of a very high level, allowing us
to reaffirm not only the specificities of medical practice in a military environment but also
the scientific level of a specialty that has its place among the greatest medical fields.
Humbert BOISSEAUX, MD
This year was also the occasion to rethink our internal communication as well as the dis-
semination of scientific information. The ICMM website is being reorganized and a new presentation style for the International Review
of the Armed Forces Medical Services has been created. A new editorial policy is being put in place, too, which, without neglecting the
indispensable contribution of the articles resulting from the presentations made at our congresses and also spontaneously sent by
health service personnel, will henceforth make room for the inclusion of thematic reports specific to the practice of medicine within the
armed forces. This should open up many opportunities for the Technical Commissions but also for all those who have a particular exper-
tise in the field of medicine in the armed forces. Finally, we believe that offering greater international visibility to articles that are often
remarkable but only published in our national journals will also help to raise more awareness of military medicine. This is undoubtedly
one of the missions of the ICMM, along with reporting on the activities of international partner organisations.
We hope that 2023 will see the full deployment of this strategy and, at the same time, offer the opportunity for us to meet again on dif-
ferent continents, in order to resume our meetings and the activities of the regional working groups, which have not been able to meet
face to face for almost five years.
At the end of the year 2022, the entire editorial staff of the IRAFMS joins me in wishing everyone a happy holiday season, whether with
their families or on the battlefields that unfortunately inflame our Earth. I hope that respect of humanitarian laws will continue to be a
concern among all belligerents. Finally, I would like to wish everyone good health and happiness for the New Year.
Humbert BOISSEAUX, MD,
Major General Prof.
Editor-in-Chief of the IRAFMS
Chairman of the Scientific Council of the ICMM
4 International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées
ICMM 4_2022_Umbruch.indd 4 16.12.22 14:22
Editorial et vœux 2023
Ce numéro de la Revue Internationale des Services de Santé des Forces Armées vient clore
l’année 2022.
Après deux années au cours desquelles la situation sanitaire internationale avait profon-
dément bouleversé les activités du Comité International de Médecine Militaire, cette an-
née qui se termine nous a enfin permis de nous retrouver, à Bruxelles, pour notre 44°
Congrès mondial de Médecine Militaire.
Cette entrée dans le second centenaire de notre organisation a été l’occasion d’en réaffir-
mer les missions comme les valeurs qu’elle voulait continuer à promouvoir.
Notre rendez-vous mondial a été l’occasion d’échanger avec les organisations internatio-
nales partenaires qui ont ainsi souligné toute l’importance qu‘elles accordaient à notre
organisation.
Le programme scientifique de cette réunion si longtemps attendue s’est avéré de très haut
niveau, permettant de réaffirmer non seulement les spécificités de l’exercice médical en
Humbert BOISSEAUX, MD milieu militaire mais le niveau scientifique d’une spécialité qui a toute sa place au sein des
plus grandes spécialités médicales.
Cette année a été également l’occasion de repenser notre communication interne de même que la diffusion de l’information scientifique.
Ainsi le site internet du CIMM est en voie de réorganisation et une nouvelle présentation de la Revue Internationale des Services de Santé
des Forces Armées a vu le jour. Une nouvelle ligne éditoriale se met en place qui sans négliger l’indispensable apport des articles issus
des communications présentées lors de nos congrès mais aussi spontanément adressés par les personnels de nos services de santé, va
faire désormais une place à la présentation de dossiers thématiques propres à l’exercice de la médecine au sein des armées. La possibilité
pour les Commissions Techniques mais aussi pour tous ceux qui possèdent une expertise particulière dans le domaine de la médecine
aux armées doivent ainsi pouvoir être distingués. Offrir enfin une plus grande visibilité internationale à des articles souvent remarquables
mais publiés dans nos revues nationales nous semble également de nature à mieux faire connaître la médecine militaire. C’est sans doute
une des missions du CIMM tout comme d’informer de l’action des organisations internationales partenaires.
Nous souhaitons que 2023 puisse voir le plein déploiement de tout cela en même temps qu’offrir l’occasion de nous retrouver sur les
différents continents afin de reprendre le cours de nos rencontres et l’activité des groupes de travail régionaux qui n’avaient pas pu être
réunis en présentiel depuis bientôt 5 ans.
En cette fin d’année 2022 toute la rédaction de la RISSFA se joint donc à moi pour souhaiter à chacun de bonnes fêtes de fin d’année que
ce soit en famille ou sur les terrains de guerre qui enflamment malheureusement notre Terre. J’émets le vœu que le respect des lois
humanitaires soit une préoccupation de tous les belligérants. Je tiens enfin à formuler à tous mes vœux de santé et de bonheur pour la
nouvelle année.
Médecin Général Inspecteur Prof. (2s)
Humbert BOISSEAUX
Rédacteur en chef de la RISSFA
Président du Conseil Scientifique du CIMM
International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées 5
ICMM 4_2022_Umbruch.indd 5 16.12.22 14:22
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Vitamin D deficiency: An often underestimated risk
Carence en vitamine D : Un risque généralement sous-estimé
E. Vits1, M. Staudt1, M. Berresheim1, U. Rohde1, T. Eger2, C. Bickel3, D. Leyk1,4. GERMANY
Summary
Vitamin D does not only play an essential role in calcium and bone metabolism, but also has numerous preventive and curative
effects in other organ systems. However, literature reviews show large differences regarding minimum vitamin D levels and
vitamin D supplementation. In this study, a systematic literature search was conducted to determine the background for these
divergent statements and to examine whether vitamin D supplementation is recommended for soldiers.
Various professional societies currently assume a vitamin D deficiency if serum vitamin D levels (calcidiol, 25-hydroxyvitamin
D3; 25(OH)D3) are below 20 ng/ml (= 50 nmol/l). Epidemiological studies, however, hint at higher levels for normal serum con-
centrations: Vitamin D serum levels of 30 ng/ml (= 75 nmol/l) are associated with lower cardiometabolic and inflammatory
biomarker levels. Newer studies provide supportive evidence that the different effects of vitamin D in the organism are con-
centration- and tissue related. Vitamin D levels in indigenous ethnic groups living close to the equator are markedly above 40
ng/ml (> 100 nmol/ml).
Roughly 60 % of the German population has an undersupply of vitamin D. More than 80 % of men and 90 % of women do not
reach the recommended daily vitamin D intake. Due to the low UV indices during the winter half year In Germany, vitamin D
production in the skin (the actual main source) is insufficient. There is an increased risk of vitamin D deficiency in numerous
population groups, which is further increased by staying behind window glass, in closed rooms, etc.
There are further restrictions of endogenous vitamin D production in military due to wearing of long-sleeved uniforms, protec-
tive equipment, and headgear. In a group of German Air Force personnel (> 2,000 persons) vitamin D deficiency was found in
over 70 %. In view of the new findings and the special circumstances in the military sector, targeted supplementation of vitamin
D in female and male soldiers is clearly recommended.
Key Words: supplementation, military; prevention; deficency; risk factors
Résumé
La vitamine D ne joue pas qu’un rôle essentiel dans le métabolisme du calcium et le métabolisme osseux. Elle a également de
nombreux effets préventifs et curatifs sur les autres fonctions de l’organisme. Cependant, une revue de la littérature montre de
grandes différences concernant les niveaux minimums de vitamine D pour une nécessaire supplémentation. A partir des élé-
ments de la littérature, nous avons donc mené une recherche systématique afin de déterminer le contexte de ces énoncés
divergents et d’examiner si une supplémentation en vitamine D apparaît nécessaire pour les soldats.
Diverses sociétés professionnelles considèrent actuellement qu’il y a carence en vitamine D si les taux sériques de vitamine D
(calcidiol, 25-hydroxyvitamine D3 ; 25(OH)D3) sont inférieurs à 20 ng/ml (= 50 nmol/l). Par ailleurs, des études épidémiologiques
indiquent que des niveaux plus élevés ( 30 ng/ml (= 75 nmol/l) sont associées à des niveaux plus faibles de biomarqueurs
cardiométaboliques et inflammatoires. Des études récentes apportent des preuves qui confirment que les différents effets de
la vitamine D dans l’organisme sont liés à leur concentration tissulaire.
Le taux de vitamine D dans les groupes ethniques indigènes vivant près de l’équateur sont nettement supérieurs à 40 ng/ml (>
100 nmol/ml). Par contre, 60 % de la population allemande est carencée en vitamine D et plus de 80 % des personnes âgées de
plus de 65 ans. Plus de 80 % des hommes et 90 % des femmes n’atteignent pas l’apport quotidien recommandé en vitamine D.
En raison des faibles indices UV pendant l’hiver en Allemagne, la production de vitamine D dans la peau (la principale source
actuelle) est insuffisante. Il existe donc un risque accru de carence en vitamine D dans de nombreux groupes de population,
carence qui est encore amplifiée par le fait de rester derrière une vitre, dans des pièces fermées, etc.
Chez les militaires, il existe des restrictions supplémentaires de production endog-
ène de vitamine D liée au port d’uniformes à manches longues, d’équipements
de protection et de casques. Ainsi, dans un groupe de personnels de l’armée de
l’air allemande (> 2 000 personnes) une carence en vitamine D a été trouvée dans
1
Bundeswehr Institute for Preventive Medicine,
Division A Health and Fitness Promotion,
plus de 70 % des cas. Compte tenu de ces résultats et de ces spécificités liées au
Andernach/Koblenz
milieu militaire, une supplémentation ciblée en vitamine D chez les soldats, hom- 2
Bundeswehr Central Hospital Koblenz,
mes et femmes, est clairement recommandée. Department XXIII Dentistry, Koblenz
Mots clés : Vitamine D, carence, facteur de risque, militaire, prévention, carence,
3
Bundeswehr Central Hospital Koblenz, Depart-
ment I Internal medicine, Koblenz
supplémentation. 4
German Sport University Colgone, Research
Group Epidmemiology of Performance, Col-
gone
International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées 7
ICMM 4_2022_Umbruch.indd 7 16.12.22 14:22
250 million euros in Germany alone [49].
While the multitude of vitamin D effects are
scientifically undisputed by now, there is
only a partial consensus regarding vitamin
D supply [71]. Thus, recommendations dif-
fer considerably with regard to vitamin D
levels, actual vitamin D requirements, and
the need of supplementation [53]. In litera-
ture, vitamin D serum levels are listed in
ng/ml or nmol/l (1 ng/ml = 2.5 nmol/l),
while the required amounts of vitamin D
are given in IU and µg (40 IU = 1 µg). The
Introduction eases (see Table 1). According to meta-anal- recommended minimum level of calcidiol
yses, vitamin D deficiency alone is a risk (25-hydroxyvitamin D3; 25(OH)D3)) varies
The interest in vitamin D has increased con- factor for various diseases in several organ from 10 ng/ml (= 25 nmol/l; [63]) to 30 ng/
siderably in the last 20 years. Only in 2020, systems. The Umbrella Review published in ml (= 75 nmol/l; [32]) depending on the
more than 5,100 scientific publications 2020 [44], for example, shows positive ef- professional society. The D-A-CH Nutrition
were released to PubMed (PubMed query fects of a vitamin D supplementation in the Society (Germany: Deutsche Gesellschaft
as of March 8, 2021). There is also more me- primary prevention of acute respiratory für Ernährung (DGE), Austria (ÖGE), Switzer-
dia coverage of vitamin D. Reasons for the tract infections, as well as in dementia, cog- land (SGE, SVE)) recommend minimum lev-
increased attention are new findings on vi- nitive decline, and depression. Among oth- els of ≥ 20 ng/ml (≥ 50 nmol/l) [48]. Much
tamin D effects that go far beyond the ers, curative effects exist in patients with higher minimum levels (40 ng/ml–60 ng/
known endocrine control of calcium ho- asthma and COPD [7, 44]. The outcomes of ml (= 100 nmol/l–150 nmol/l)) are men-
meostasis and bone metabolism [4, 15, 22, dental periodontitis and peri-implantitis tioned by the “VitaminD Society” [67],
31]. It is now well established that vitamin therapy show more favorable treatment re- among others. In this review, we present
D has additional autocrine and paracrine sults [42], and there is also evidence of a the background for the deviating reference
effects in most tissues. The activated and positive vitamin D influence in SARS-CoV-2 ranges and recommendations for the nor-
membrane-permeable steroid hormone infections [20, 36]. In Table 2 diseases mal vitamin D requirement. In addition,
calcitriol (1,25-dihy-droxycholecalciferol; showing positive effects from Vitamin D usefulness of vitamin D supplementation
1,25(OH)2D3) has multiple influences on, treatment are listed. for soldiers is assessed.
among others, gene expression [22, 58],
and epigenetics [14, 15, 71]. Recently published RCTs showed a 13 % re- Methodology
duction decrease in cancer mortality
Lowered vitamin D levels have been re- through vitamin D administration [38], A systematic literature search according to
ported in connection with numerous dis- which would lead to savings of more than the “preferred reporting items for system-
atic review and meta-analysis” (PRISMA rec-
Table 1: Diseases and medication frequently associated with low vitamin D levels (according to: [4, ommendations) was conducted in the
9, 21, 54, 59, 61, 70, 71]). PubMed database (https://pubmed.ncbi.
nlm.nih.gov/) in the period from 02/01/
2021 to 03/23/2021. The search term “Vita-
min D” was used to search for systematic
reviews published in German or English in
the last 10 years. In addition to an analysis
of the cited literature, a hand search was
carried out using the terms “Vitamin D &
physiology”, “Vitamin D & recommendation”,
“Vitamin D & status”, “Vitamin D & Germany”,
“Vitamin D & sport”, “Vitamin D & Armed
Forces”, and “Vitamin D & Bundeswehr”
(time-period: last 10 years). Current articles
were prioritized and other articles were
screened for substantially contradictory
opinions. Studies on adolescents (under 18
years), pregnant women, and seniors (over
65 years) as well as clinical reviews on spe-
cific diseases were excluded. Figure 1 shows
the PRISMA flow chart including literature
selection. From a total of 1262 articles, 168
studies were evaluated in the present publi-
cation.
8 International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées
ICMM 4_2022_Umbruch.indd 8 16.12.22 14:22Table 2: Diseases with confirmed positive effects of vitamin D administration. nation for the divergent study results and
recommendations on vitamin D.
Estimating the “normal” requirement
As previously shown, there are large differ-
ences in literature regarding normative
ranges for vitamin D values. The determina-
tion of normal vitamin D requirement is cru-
cial to the question of whether and how
much vitamin D should be supplemented.
The German Robert Koch Institute and other
internationally renowned institutions use
the classification of the US Institute of Medi-
cine [45] to assess the vitamin D status. Ac-
cording to this classification, a vitamin D
deficiency exists if calcidiol concentration is
below 20 ng/ml (= 50 nmol/l). The current
recommendations of the D-A-CH also men-
tion 20 ng/ml (= 50 nmol/l) as a threshold
value [19]. This serum level is based on the
* RCT = Randomized Controlled Study, OS = Observational Study/ Beobachtungsstudie occurrence of deficiency symptoms such as
rickets and other skeletal diseases.
Results or albumin (15 %, lower affinity) [8, 10]. However, more recent epidemiological
Mainly the unbound fraction (
60 %) has an undersupply of vitamin D. In
Figure 1: PRISMA flow chart of the literature search for systematic reviews; search term: “Vitamin D”, search
Europe, about 40 % of the population has a
timeframe: last 10 years serum calcidiol level below 20 ng/ml (= 50
International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées 9
ICMM 4_2022_Umbruch.indd 9 16.12.22 14:22nmol/l) [16]. The main reasons for the under-
supply are insufficient dietary vitamin D in-
take and reduced vitamin D production via
skin. Figure 2 shows the main factors influ-
encing vitamin D levels.
Nutrition
Only a small part (up to roughly 20 %) of the
required amount of vitamin D can be ob-
tained from dietary intake [52]. This is due
to the fact that only a few, almost exclu-
sively animal-based foods contain signifi-
cant amounts of vitamin D [33]. Vegetarians
and vegans therefore have an increased risk
of undersupply. Vitamin D is mainly found in
fatty sea fish (herring: 7.8—25 μg/100 g,
salmon: 16 μg/100 g), chicken eggs (2.9
μg/100 g). Trace amounts can be found in
dairy products and animal liver. Fungi and
lichens can produce high concentrations of Figure 2: Physiologically active forms of vitamin D and factors influencing vitamin D levels
vitamin D2 (ergocalciferol) under UV irradia-
tion, which is, however, less effective com- diation in Germany is too low for sufficient particularly often affected by a deficiency
pared to vitamin D3 [34, 40, 66]. The D-A-CH vitamin D production [12]. With regards to [17]. In addition, when spending time out-
now recommends a daily vitamin D intake the vitamin D levels stated above, it is obvi- doors, considerable areas of skin are usually
of 800 IU (= 20 µg) for adults [71]. According ous that the vitamin D supplies stored in fat, covered by lotions, sunscreen, and clothing
to the National Nutrition Survey II [46], over muscle tissue, and liver are insufficient to and thus insufficiently involved in vitamin
80 % of men and over 90 % of women do compensate for the reduced UVB radiation D production. For example, a sunscreen
not reach the daily recommended vitamin for 6 months. The typical wave-shaped an- with an UV protection factor of 8 reduces
D intake. Among senior citizens, this figure nual course of vitamin D levels for residents vitamin D synthesis by 93 % [71].
rises to over 95 %. in Germany is shown in Figure 3.
Female and male soldiers
Vitamin D production in the skin Population groups with increased
The main source of vitamin D is endoge- vitamin D requirements In the military, the wearing of uniforms,
nous synthesis, which takes place in the hu- protective equipment, and headgear as
man skin under influence of UVB radiation It is obvious that people with dark skin, well as indoor activities, and staying in air,
from the sun which depends on a variety of vegetarians, and vegans are at an increased land and water vehicles lead to a significant
factors [23] such as sun position (geograph- risk of vitamin D deficiency. Elderly (espe- restriction of endogenous vitamin D pro-
ical latitude, season, time of day, altitude), cially immobile) people, infants, young chil- duction. Therefore, a widespread and often
environmental factors (smog/weather, dren, and pregnant women are also among unrecognised vitamin D deficiency in sol-
shade or surface reflection of the environ- the risk groups. Overweight, obesity [50], diers may be assumed. So far, current fig-
ment), skin type, and age [23, 68]. Some of dental periodontitis, numerous diseases as ures on vitamin D supply in the Bunde-
these factors that can be influenced, includ- well as certain medical drugs can have a swehr are only available from a small and
ing exposed skin area, time of day, use of negative impact on vitamin D levels. Table non-representative collective of 2176 pilots
sunscreen/skin creams, duration of expo- 1 provides an overview of the correspond- and aircrew. Of these, 71.6 % showed vita-
sure, but also body fat percentage [69]. Sun- ing drugs and diseases. min D deficiencies [55].
burn should be avoided in any case because In contrast to the civilian sector, vitamin D
of the increased risk of skin cancer. Living environments may be even more important in military, po-
According to the Federal Office for Radiation lice, and fire services. Due to high additional
Protection [11], sunbathing of uncovered The problem of an adequate vitamin D sup- loads caused by protective clothing, equip-
face, hands, and arms (without sunscreen) ply is further exacerbated by modern life- ment, and armament, duty related activities
for 12 minutes 2 to 3 times a week leads to a styles and changes in lifestyles. When stay- may lead to acute or persisting situations
sufficient vitamin D production in the skin. ing in closed rooms, behind glass, and in with significantly increased risks of stress
These recommendations apply to a UV in- vehicles, UVB exposure is de facto almost fractures, among other things, especially if a
dex of 7, which is usually reached in Ger- nil – even in sunshine. However, merely vitamin D deficiency exists [18]. This is even
many under good weather conditions only spending time outdoors does not guaran- more relevant for female soldiers [47].
and around midday during the months of tee sufficient vitamin D production, as UVB
June and July [13]. In the remaining summer radiation in the morning and evening Conclusion and recommendation
months however, a much longer exposure is hours is only a fraction of the radiation
necessary due to lower UV indices. In the during midday. People who do not work A high vitamin D level provides numerous
winter half-year (October to March), UVB ra- outdoors and shift workers are therefore health benefits. More and more professional
10 International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées
ICMM 4_2022_Umbruch.indd 10 16.12.22 14:22opt/uv/uv-index/prognose/prognose_node.
html)>, last access on June 9, 2021.
14. Carlberg C: Nutrigenomics of Vitamin D. Nu-
trients 2019; 11 (3): 676.
15. Carlberg C, Haq A: The concept of the personal
vitamin D response index. J Steroid Biochem
Mol Biol 2018; 175: 12–17.
16. Cashman KD, Dowling KG, Škrabáková Z et
al.: Vitamin D deficiency in Europe: pandem-
ic? Am J Clin Nutr 2016; 103 (4): 1033–1044.
17. Coppeta L, Papa F, Magrini A: Are shiftwork
and indoor work related to D3 Vitamin defi-
ciency? A systematic review of current evi-
Figure 3: Typical seasonal course of vitamin D serum levels [24] and UVB indices (bar chart) [12] in Germa- dences. J Environ Public Health 2018; 2018:
ny. The physio- logical levels of vitamin D in indigenous ethnic groups living close to the equator never drop 8468742.
below 40ng/ml (> 100 nmol/l) [41] and are marked with +++.
18. Dao D, Sodhi S, Tabasinejad R et al.: Serum
25-Hydroxyvitamin D levels and stress frac-
organisations recommend vitamin D sup- References tures in military personnel: A systematic
review and meta-analysis. Am J Sports Med
plementation, ranging from 800 IU (= 20 µg)
2015; 43 (8): 2064–2072.
to 10,000 IU (= 250 µg). In some countries 1. Abdi F, Amjadi MA, Zaheri F, Rahnemaei FA:
Role of vitamin D and calcium in the relief of 19. Deutsche Gesellschaft für Ernährung e. V.: Ref-
(USA, Canada, India and Finland), foods erenzwerte Vitamin D (Calciferole)., last access June 9, 2021.
review of the role of vitamin D and calcium in 20. Deutsche Gesellschaft für Ernährung e. V.:
Although there is no representative data on
premenstrual syndrome. Obstet Gynecol Sci Vitamin D und COVID-19.
vitamin D levels in Bundeswehr soldiers, a , last access on June9, 2021.
male and female soldiers is highly likely, es- U: Evaluation of FGF-23 and 25(OH)D3 levels 21. Dietrich T, Joshipura KJ, Dawson-Hughes B, Bi-
pecially throughout the winter half-year. in peri-implant sulcus fluid in peri-implant schoff-Ferrari HA: Association between serum
health and diseases. Clin Implant Dent Relat concentrations of 25-hydroxyvitamin D3 and
Therefore, targeted supplementation with periodontal disease in the US population. Am
Res 2019; 21 (5): 1106–1112.
vitamin D seems to be appropriate. Studies 4. Amrein K, Scherkl M, Hoffmann M et al.: Vita- J Clin Nutr 2004; 80 (1): 108–113.
with soldiers from other nations show that min D deficiency 2.0: an update on the current 22. Dusso AS, Brown AJ, Slatopolsky E: Vitamin
daily doses of 2000 IU/d (= 50 µg/d) vitamin status worldwide. Eur J Clin Nutr 2020; 74 (11): D. Am J Physiol Renal Physiol 2005; 289 (1):
1498–1513. F8–28.
D in combination with calcium lead to an
5. Aoun A, Maalouf J, Fahed M, El Jabbour F: 23. Engelsen O: The relationship between ultravi-
improvement in bone health and a de- When and How to Diagnose and Treat Vitamin olet radiation exposure and vitamin D status.
crease in fracture rates [64]. The recently D Deficiency in Adults: A Practical and Clinical Nutrients 2010; 2 (5): 482–495.
published systematic review “Nonexercise Update. J Diet Suppl 2020; 17 (3): 336–354. 24. Francic V, Keppel M, Schwetz V et al.: Are sol-
6. Arslan IG, Dijksma I, van Etten-Jamaludin uble ST2 levels influenced by vitamin D and/
interventions for prevention of musculo-
FS, Lucas C, Stuiver MM: Nonexercise inter- or the seasons? Endocr Connect 2019; 8 (6):
skeletal injuries in armed forces” also ventions for prevention of musculoskeletal 691–700.
confirms a preventive effect of vitamin D, injuries in armed forces: A systematic review
25. Galior K, Grebe S, Singh R: Development of
calcium and protein supplementation [6]. and meta-analysis. Am J Prev Med 2021; 60
Vitamin D toxicity from overcorrection of Vi-
(2): e73-e84.
A common argument against vitamin D tamin D deficiency: A review of case reports.
7. Autier P, Mullie P, Macacu A et al.: Effect of
supplementation is the risk of overdosing. Nutrients 2018; 10 (8): 953.
vitamin D supplementation on non-skeletal
However, hypervitaminosis with vitamin D disorders: a systematic review of meta-anal- 26. Ganji V, Tangpricha V, Zhang X: Serum Vitamin
yses and randomised trials. Lancet Diabetes D Concentration ≥75 nmol/l Is Related to De-
is very rare. An elevated risk exists primarily creased Cardiometabolic and Inflammatory
Endocrinol 2017; 5 (12): 986–1004.
in the presence of an idiopathic infantile Biomarkers, Metabolic Syndrome, and Diabe-
8. Bikle DD, Schwartz J: Vitamin D binding pro-
hypercalcemia [62], which can, however, be tein, total and free Vitamin D levels in different tes; and Increased Cardiorespiratory Fitness in
easily diagnosed in suspected cases by de- physiological and pathophysiological condi- US Adults. Nutrients 2020; 12 (3): 730.
tions. Front Endocrinol (Lausanne) 2019; 10: 27. Gao W, Tang H, Wang D et al.: Effect of short-
termining the 24,25 : 25 vitamin D metabo-
317. term vitamin D supplementation after nonsur-
lite ratio in the blood [4]. Hypervitaminoses gical periodontal treatment: A randomized,
9. Botelho J, Machado V, Proença L, Delgado
in healthy individuals normally occur only AS, Mendes JJ: Vitamin D deficiency and oral double-masked, placebo-controlled clinical
in case of massive overdosing, such as in health: A comprehensive review. Nutrients trial. J Periodontal Res 2020; 55 (3): 354–362.
daily amounts exceeding 50,000 IU (= 2020; 12 (5): 1471. 28. Ghorbani Z, Togha M, Rafiee P et al.: Vitamin
10. Bouillon R, Schuit F, Antonio L, Rastinejad F: Vi- D in migraine headache: a comprehensive
1,250 µg/d), usually over months or years review on literature. Neurol Sci 2019; 40 (12):
tamin D binding protein: A historic overview.
[25]. There, toxic serum concentrations Front Endocrinol (Lausanne) 2019; 10: 910. 2459–2477.
measured ranged from 150 ng/ ml to 1,220 11. Bundesamt für Strahlenschutz: Konsentierte 29. Gregoriou E, Mamais I, Tzanetakou I, Lavranos
ng/ml (= 375 nmol/l–3,050 nmol/l) [25]. In Empfehlung zu UV-Strahlung und Vitamin G, Chrysostomou S: The effects of Vitamin D
D., diabetes tatients: systematic review of ran-
easily detected and prevented by determi- last access on June 9, 2021. domized controlled trials. Rev Diabet Stud
nation of vitamin D levels. In view of the 12. Bundesamt für Strahlenschutz: UV-Index welt- 2017; 14 (2–3): 260–268.
current state of studies and the specific de- weit. , of Vitamin D supplementation on rheumatoid
mands of the military sector, a targeted
last access on June 9, 2021. arthritis patients: A systematic review and
supplementation of vitamin D for soldiers is 13. Bundesamt für Strahlenschutz: UV-Prog- meta-analysis. Front Med (Lausanne) 2020;
clearly recommended. nose.< https://www.bfs.de/ DE/themen/ 7: 596007.
International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées 11
ICMM 4_2022_Umbruch.indd 11 16.12.22 14:2231. Holick MF: Vitamin D deficiency. N Engl J Med population in Germany has the cost-saving min D nutritional status and advised levels of
2007; 357 (3): 266–281. potential of preventing almost 30 000 can- vitamin D supplementation. Eur J Endocrinol
32. Holick MF, Binkley NC, Bischoff-Ferrari HA et cer deaths per year. Mol Oncol 2021; [Online 2013; 169 (4): R59–69.
al.: Evaluation, treatment, and prevention of ahead of print]. 61. Ross AC, Taylor CL, Yaktine AL, Del Valle HB
vitamin D deficiency: an Endocrine Society 50. Oliveira LF de, Azevedo LG de, Da Mota San- (ed.): Dietary reference intakes for Calcium
clinical practice guideline. J Clin Endocrinol tana J, de Sales, Luanna Pimenta Carlos, Perei- and Vitamin D. Washington (DC): National
Metab 2011; 96 (7): 1911–1930. ra-Santos M: Obesity and overweight decreas- Academies Press 2011.
33. Holick MF, Chen TC: Vitamin D deficiency: a es the effect of vitamin D supplementation in 62. Schlingmann KP, Kaufmann M, Weber S et al.:
worldwide problem with health consequenc- adults: systematic review and meta-analysis Mutations in CYP24A1 and idiopathic infan-
es. Am J Clin Nutr 2008; 87 (4): 1080S-1086S. of randomized controlled trials. Rev Endocr tile hypercalcemia. N Engl J Med 2011; 365
34. Houghton LA, Vieth R: The case against ergo- Metab Disord 2020; 21 (1): 67–76. (5): 410–421.
calciferol (vitamin D2) as a vitamin supple- 51. Perayil J, Menon KS, Kurup S et al.: Influence of 63. Scientific Advisory Committee on Nutrition:
ment. Am J Clin Nutr 2006; 84 (4): 694–697. Vitamin D & Calcium supplementation in the Vitamin D and health report. , last access
respiratory infections: systematic review 52. Pilz S, März W, Cashman KD et al.: Rationale on June 9, 2021.
and meta-analysis of aggregate data from and plan for Vitamin D food fortification: A 64. Sivakumar G, Koziarz A, Farrokhyar F: Vitamin
randomised controlled trials. Lancet 2021; 9 review and guidance paper. Front Endocrinol D supplementation in military personnel: A
(5):276–292. (Lausanne) 2018; 9: 373. systematic review of randomized controlled
36. Kazemi A, Mohammadi V, Aghababaee SK trials. Sports Health 2019; 11 (5): 425–431.
53. Pilz S, Zittermann A, Trummer C et al.: Vitamin
et al.: Association of Vitamin D status with 65. Spedding S, Vanlint S, Morris H, Scragg R: Does
D testing and treatment: a narrative review of
SARS-CoV-2 infection or COVID-19 severity: vitamin D sufficiency equate to a single serum
current evidence. Endocr Connect 2019; 8 (2):
A systematic review and meta-analysis. Adv 25-hydroxyvitamin D level or are different lev-
R27-R43.
Nutr 2021; nmab012 [Online ahead of print]. els required for non-skeletal diseases? Nutri-
37. Kennedy DA, Cooley K, Skidmore B et al.: Vi- 54. Pilz, S et al.: Vitamin D and mortality Antican-
ents 2013; 5 (12): 5127–5139.
tamin d: pharmacokinetics and safety when cer Res 2016 (36): 1379–1388.
66. Tripkovic L, Wilson LR, Hart K et al.: Daily sup-
used in conjunction with the pharmaceutical 55. Pippig T, Matthias O, Zahedi F: Erste Ergeb-
plementation with 15 μg vitamin D2 com-
drugs used in cancer patients: a systematic nisse: Vitamin-D-Versorgung bei Piloten und
pared with vitamin D3 to increase wintertime
review. Cancers (Basel) 2013; 5 (1): 255–280 Luftfahrtpersonal der Bundeswehr. Flug u
25-hydroxyvitamin D status in healthy South
38. Keum N, Lee DH, Greenwood DC, Manson JE, Reisemed 2019; 26 (04): 171–178.
Asian and white European women: a 12-wk
Giovannucci E: Vitamin D supplementation 56. Rabenberg M, Scheidt-Nave C, Busch MA et
randomized, placebo-controlled food-for-
and total cancer incidence and mortality: a al.: Vitamin D status among adults in Germa-
tification trial. Am J Clin Nutr 2017; 106 (2):
meta-analysis of randomized controlled trials. ny--results from the German Health Interview
481–490.
Ann Oncol 2019; 30 (5): 733–743 and Examination Survey for Adults (DEGS1).
67. VitaminD Society: The VitaminD Society.
39. Lips P, Chapuy MC, Dawson-Hughes B, Pols BMC Public Health 2015; 15: 641.
, last ac-
HA, Holick MF: An international comparison of 57. Rabenberg M, Scheidt-Nave C, Busch MA et
cess on June 9, 2021.
serum 25-hydroxyvitamin D measurements. al.: Implications of standardization of serum
68. Webb AR: Who, what, where and when-influ-
Osteoporos Int 1999; 9 (5): 394–397 25-hydroxyvitamin D data for the evaluation
ences on cutaneous vitamin D synthesis. Prog
40. Logan VF, Gray AR, Peddie MC, Harper MJ, of vitamin D status in Germany, including a
Biophys Mol Biol 2006; 92 (1): 17–25.
Houghton LA: Longterm vitamin D3 supple- temporal analysis. BMC Public Health 2018;
69. Wortsman J, Matsuoka LY, Chen TC, Lu Z,
mentation is more effective than vitamin D2 18 (1): 845.
Holick MF: Decreased bioavailability of vita-
in maintaining serum 25-hydroxyvitamin D 58. Ramasamy I: Vitamin D metabolism and
min D in obesity. Am J Clin Nutr 2000; 72 (3):
status over the winter months. Br J Nutr 2013; guidelines for Vitamin D supplementation.
690–693.
109 (6): 1082–1088. Clin Biochem Rev 2020; 41 (3): 103–126.
70. Zhou F, Zhou Y, Shi J: The association between
41. Luxwolda MF, Kuipers RS, Kema IP, Dijck-Brou- 59. Robien K, Oppeneer SJ, Kelly JA, Hamil-
serum 25-hydroxyvitamin D levels and den-
wer DAJ, Muskiet FAJ: Traditionally living pop- ton-Reeves JM: Drug-vitamin D interactions:
tal caries in US adults. Oral Dis 2020; 26 (7):
ulations in East Africa have a mean serum a systematic review of the literature. Nutr Clin
1537–1547.
25-hydroxyvitamin D concentration of 115 Pract 2013; 28 (2): 194–208.
71. Zittermann A, Pilz S: Vitamin D in Klinik und
nmol/l. Br J Nutr 2012; 108 (9): 1557–1561. 60. Romagnoli E, Pepe J, Piemonte S, Cipriani C,
Praxis. Dtsch Med Wochenschr 2017; 142 (8):
42. Machado V, Lobo S, Proença L, Mendes JJ, Minisola S: Management of endocrine dis-
601–616.
Botelho J: Vitamin D and periodontitis: A sys- ease: value and limitations of assessing vita-
tematic review and meta-analysis. Nutrients
2020; 12 (8): 12(8): 2177.
43. Mansourian M, Rafie N, Khorvash F, Hadi A, Reprint from Wehrmedizinische Monatsschrift 8/2021 (WMM 2021-65(8))
Arab A: Are serum vitamin D, calcium and
phosphorous associated with restless leg syn-
drome? A systematic review and meta-analy- MAJOR Emanuel VITS
sis. Sleep Med 2020; 75: 326–334.
44. Maretzke F, Bechthold A, Egert S et al.: Role of Major (MC) Dr. Emanuel Vits was called up for basic military service
Vitamin D in preventing and treating select-
in 2006. He served at the medical center of the Franco-German bri-
ed extraskeletal diseases-An umbrella review.
Nutrients 2020; 12(4): 969. gade in Müllheim. Due to his experiences during this time he
45. National Institutes of Health: Vitamin D. Sheet decided to start a career as a medical officer.
for health professionals., last access on June 9, 2021.
residency in surgery at the Bundeswehr Central Hospital (BwZKrhs)
46. Nationale Verzehrsstudie II. Ergebnisbericht
Teil 2. Karlsruhe, 2008. in Koblenz.
47. Nestler K, Tofaute KA, Leyk D: Frauen in der Due to his interest in research and sports, he became a scientist at the Bundeswehr Insti-
Bundeswehr. Wehrmed Wehrpharm 2016; 16 tute of Preventive Medicine in 2018. There he worked in the Department A “Health and
(4): 99–101. Performance Promotion” which is responsible for scientific evaluation of relevant issues
48. New reference values for vitamin D. Ann Nutr
in preventive medicine.
Metab 2012; 60 (4): 241–246.
49. Niedermaier T, Gredner T, Kuznia S et al.: Vi-
After 3 years in research, Major Vits in 2021 returned to BwZKrhs Koblenz as a resident in
tamin D supplementation to the older adult anesthesiology intending his specialization as an intensive care physician.
12 International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées
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ICMM 4_2022_Umbruch.indd
ERC Anz EMMS2022 A4.indd 13
1 16.12.22
06.05.22 14:22
13:09Nutritional requirements during training
for special operation forces
Besoins nutritionnels pendant l’entraînement des forces d’opérations spéciales
G. Rietjens,1,2 G. Plasqui,3 D. A.M.S.W. Frenken,3 J. Most3,4,5. THE NETHERLANDS
Summary
For special operation forces, low responses to training can hamper performance. In this study, we objectively measured strength
and fitness during special operation forces training, and assessed potential determinants of the training response in twenty
subjects.
Before and after a 9-week training, muscular strength was measured as one-repetition-maximum on four instruments, physical
fitness by the Cooper-test, body composition using deuterium dilution, physical activity by accelerometry and diet quality by
food records.
Body strength increased by 0.33±0.24 N/kg (+7%, PTo gain insight into the effect of special Table 1. Baseline anthropometrics and physical fitness assessments.
forces operations training and predictors of N Mean ± SD P
this response, we performed a study in 16 25.9 ± 3.6 0.95
which we assessed physical fitness and Age, years
10 26.3 ± 4.2 0.61
strength, as well as body composition, diet
quality, and physical activity in soldiers fol- 16 1.83 ± 0.05 0.28
Length, m
lowing an 9-week training. 10 1.83 ± 0.06 0.90
16 24.5 ± 1.7 0.26
Methods BMI, kg/m2
10 25.2 ± 1.4 0.20
16 82.4 ± 7.5 0.88
Experimental Approach to the Problem Body Weight, kg
Before and after the 9-week training pro- 10 84.3 ± 7.6 0.27
gram, measurements of strength, fitness, 16 4.95 ± 0.73 0.79
Strength, N/kg
and body composition were performed. 10 4.96 ± 0.73 0.88
During the training period, physical activity 16 54.3 ± 2.2 0.39
and diet quality were assessed. During the Fitness, mL/min/kg
10 54.5 ± 2.5 0.92
base training, recruits spend five days a
week at the military basis, performed their P-values refer to comparison of baselines values between participants with complete data and incomplete
data at follow-up (for cohort for primary outcomes: n=16 vs n=4, for cohort for secondary outcomes: n=10 vs
training and receive standard military diets.
n=10, data of drop-outs not shown). Strength and fitness are expressed per kg body weight.
During weekends, recruits were allowed to
travel, e.g. home, with no instructions for forces on four exercises divided by body using the energy intake-balance method
physical activity and diet. weight. (‘Calculated’). The intake-balance method
utilizes the first law of thermodynamics,
Subjects Physical fitness and calculates energy intake as the sum of
Participation in this study was offered to Physical fitness was assessed by the Coo- energy expenditure and changes in body
recruits who were to follow the base train- per-test (3). The Cooper-test assesses the energy stores. Total energy expenditure
ing of the Special Forces of the Royal Dutch distance participants are able to run in 12 was estimated using accelerometry.
Army. Twenty, healthy subjects volunteered minutes. Physical fitness is estimated as Changes in body energy stores were calcu-
to participate in this study between March age- and sex-specific function of the lated as the difference between fat mass
and May 2016. The participants were given achieved distance. and fat free mass in the first and last week
detailed information on the study proce- of the study, multiplied by their respective
dures. Informed consent was obtained be- Body composition energy densities of 9300 kcal/kg fat mass
fore the start of the study. This study was Anthropometrics of the subjects were ob- and 1100 kcal/kg fat-free mass (7).
approved by the Staff Joint Health Care Di- tained at the second day and at the last day
vision of the Dutch Ministry of Defence of their base training. Dietary quality
(“Vooropleiding2016”). Body weight was measured with minimal A daily food record was used to assess di-
Sixteen patients completed some measure- clothing (e.g. underwear) after an over- etary intake. Food records were completed
ments at follow-up. Two subjects left the night fast. Body composition was measured by the participants every weekday and
military training program, one subject quit using Deuterium dilution according to the during one weekend by the participants.
the study because of the experienced high Maastricht Protocol (22). Before the sub-
load of the study and one did not perform jects went to bed, they collected a baseline During week days, food and drinks were
fitness testing after the study. Ten out of 16 urine sample. Immediately thereafter, sub- supplied to the participants, allowing spe-
participants completed measurements of jects ingested 70 mL of the deuterium solu- cific knowledge about their diet composi-
body composition before and after train- tion. The following day, approximately 8 tion. During weekends, diets were ad libi-
ing. Among the 6 ‘partial’dropouts, one par- hours after consuming the isotope dilution, tum. Dietary intake was quantified as
ticipant did not collect the post-dose urine a sample of their second morning urine energy content, macronutrient composi-
sample before training, and 5 measure- was collected. In-between ingestion of the tion (as percentage of total energy), and
ments resulted in unreliable body water-es- deuterium solution and collecting the sec- adequacy of micronutrient and vitamin in-
timates. Anthropometrics, strength and fit- ond morning urine samples, the subjects take (as % of the Recommended Daily Al-
ness were not different between those who were not allowed to consume anything. To- lowance) using the NEVO-table.
completed measurements and those who tal body water was calculated by the Pla-
did not (Table 1). teau-Method, and fat-free mass was calcu- Physical activity
lated as total body water divided by 0.73, Physical activity was monitored using
Precedures assuming 73% hydration of fat-free mass. waist-worn accelerometers (ActiGraph
Fat mass was calculated as difference be- GT3X, Actigraph, Pensacola, FL, USA). Phys-
Muscular strength tween body weight and fat-free mass. ical activity was recorded during the entire
Muscular strength was measured as one- training period of nine weeks. To minimize
repetition-maximum on the chest press, leg Energy homeostasis burden, every participant wore the acceler-
press, vertical traction, and shoulder press. Energy intake was calculated from self-re- ometer for 4 out of 9 weeks; one week in
Strength was calculated as the sum of port by dietary records (‘Reported’), and each period: week 1-2, week 3-4, week 5-6-
International Review of the Armed Forces Medical Services Vol. 95/4 Revue Internationale des Services de Santé des Forces Armées 15
ICMM 4_2022_Umbruch.indd 15 16.12.22 14:227, and week 8-9. For each period, acceler- Results 31±6% (or -1380±275 kcal/d) less than cal-
ometers were randomly assigned to 10 par- culated (Figure 3).
ticipants; the remaining 10 wore the Strength and Fitness
accelerometer during the following week. During the 9-week training period, body Physical Activity
Data of non-wear weeks was linearly im- strength increased by 0.33±0.24 N/kg body Complete activity data was only available
puted from the week before and after. Ac- weight (+7%, PVous pouvez aussi lire
