Case Study: Post-Deployment Nutritional Considerations in

Military and Special Operations Forces

Brittnee A. Williams
Dietetic Intern 2017-2018
Deployment Conditions and Considerations

Military deployment to areas that are, or may potentially be, involved in war operations

poses many risks for the individuals involved. Rigorous training programs prepare service

members for harsh deployment conditions, yet it is not uncommon for returning service members

to experience difficulty readjusting1-8. Post-traumatic Stress Disorder (PTSD) may be a likely

diagnosis in some of these situations. It may also, however, be the symptom of another disorder

called Post-Deployment Syndrome (PDS). The constellation of symptoms associated with the

diagnosis of PDS include PTSD along with mild Traumatic Brain Injury (mTBI), chronic pain,

major depression and generalized anxiety disorder2.

Through training exercises and combat missions, service members are often exposed to

multiple debilitating injuries, not all of which are visible. In the decade following the September

11, 2001 terrorist attacks, 2.4 million military personnel were deployed to Iraq and Afghanistan

for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)3. These OEF/OIF

service members were often exposed to Improvised Explosive Devices(IEDs) and other blast

related events1,3-4. A recent study reported up to 60% of injured OEF/OIF soldiers presented

with symptoms of TBI5, making this the signature injury of OEF/OIF service members3.

Even with mild traumatic brain injury being one of the most common blast related

injuries3-5, the condition is often overlooked6. Symptoms may or may not be noticeable at the

time of the initial injury and sometimes can take days or weeks to appear6. Early in the OEF/OIF

conflict, service members were often diagnosed with mild TBI alone5. However, the high co-

prevalence of chronic pain and PTSD symptoms in this population led health care providers to

begin classifying these coexisting diagnoses by a number of names: combat stress, blast injury,

post-concussive syndrome, P3 or P4 (polytrauma, post-traumatic stress syndrome, pain, poly-

2
substance abuse) and Post-deployment Multi-Symptom Disorder (PMD)1,2. Military researchers

have reported that nearly one in five of the more than two million U.S. service members who

have been deployed to either Iraq or Afghanistan have returned with an array of signs and

symptoms2 that from here on will be referred to as Post-Deployment Syndrome or PDS.

A medical records review of 340 OIF/OEF veterans seen at a Department of Veterans

Affairs Polytrauma Network Site published in 2009 attempted to provide more insight into the

prevalence of PDS in this population7. The review reported pain to be the single most common

complaint reported and approximately 42% of the sample reported concurrent chronic pain,

mTBI and PTSD symptoms. Health care providers also began to realize this multi-symptom

presentation in blast injured patients demonstrated less symptom improvement after treatment3,5.

Several biological mechanisms have been suggested for interaction between mTBI and PTSD,

including processes associated with exposure to extreme stress, autonomic reactivity, immune

responses, and disturbed sleep physiology8.

Specific symptoms in addition to sleep disturbance include irritability and low frustration

tolerance; concentration, attention and memory problems; fatigue; hypervigilance; headaches and

musculoskeletal disorders; affective disturbance, apathy and personality change; substance

misuse; activity avoidance, relationship conflict and employment or school difficulties2.

Usual Medical Treatment Models and Prognosis

A history of concussion along with symptoms persisting greater than 30 or 60 days is

generally sufficient for diagnosis of PDS5,6. An MRI is usually unremarkable but done to test for

hematomas as well as to rule out head injury complications from more severe trauma6,9.

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Inflammatory mediators as biomarkers in TBI lack specificity and are therefore not currently

useful in identification of TBI or PDS10.

Traditional models of care have failed to meet clinical need and facilitate improved

quality of life5. Despite the recent literature detailing the resistance of PDS to current treatments,

there have been few resources that offer guidance toward how to best manage this problem1,5.

The Post-Deployment Rehabilitation Evaluation Program (PREP) is an inpatient

integrated mental health and rehabilitative treatment model offered at the James A. Haley

Veteran’s Hospital (JAHVH) in Tampa, Florida. It specializes in evaluation and treatment of

complex multifactorial symptoms associated with mTBI and post-deployment adjustment

difficulties. The Program was specifically designed to address the unique behavioral health needs

of OEF/OIF returnees, while ensuring that patients are provided population specific care to

decrease their functional disability and improve their coping ability related to their chronic pain,

PTSD, and post-concussive symptoms11. Vocational rehabilitation originally focused on

reintegration into the community, however, candidates for the program lately, have included

Active Duty Service members referred from Warrior Transition Units, United States Central

Command, and US Special Operations Command who are expecting these service members to

return to duty upon completion of the program.

The PREP program provides many coordinated services in an interdisciplinary setting

with specialty providers and treatment programs that are not readily available in military or

community settings. Therefore extension, and expansion, of these services, potentially to include

a nutritional component, may better equip these service members for improved health outcomes

and quality of life.

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Nutritional Considerations

Current data suggest that nutritional intakes for military personnel often do not align with

military reference intake standards12,13. For the general population, including military personnel

in a sedentary role, recommendations for the percentage contribution of each macronutrient to

the daily energy intake are 45-65% of calories from carbohydrate (or adequate intake of 130

grams per day), 10-35% from protein (or adequate intake of 56 grams for men, 46 grams for

women per day) and 20-35% from fat14,15. Military Dietary Reference Intakes (MDRI)

recommend 50-55% of calories from carbohydrates (or 4 to 8 grams of carbohydrates per

kilogram of body weight), 0.8 to 1.6 grams of protein per kilogram of body weight and 30% or

less from fat15. The Ministry of Defense reports the percent contributions for military personnel

in training or on operations, to be on the higher end of 60% of calories from carbohydrates, low

end of 10-15% from protein and fat similarly 25-30% of total intake16.

Special Operations Forces (SOF), however, are the service members that are at the

forefront of combat missions today and therefore are exposed to some of the most demanding of

environments that present some unique nutritional and metabolic challenges. Existing data

indicate that SOF operators routinely expend over 5000 kcals per day13,17. Additionally, neither

DRIs nor MDRIs consider the nutrient needs of SOF warriors.

The Special Operation Forces Nutrition Guide18 recommends estimating energy intake

using Mifflin St. Jeor with appropriate activity factors and adjustments for individual activities.

Protein is recommended to be 0.8 to 1.8 grams per kilogram of body weight (depending on

activity level), with the caveat that protein in excess of 3.5 grams per kilogram may compromise

muscle growth. Fat is recommended to be no more than 35% of total calories and the remainder

is to be consumed from carbohydrate sources. The SOF Guide considers vitamin and mineral

5
intake to be sufficient when consuming a good varied diet. Tactical performance nutrition

recommendations19 provide similar estimates depending on training goals. Energy intake can be

estimated to be 30-45 kcals per kilogram of fat free mass for weight loss or maintenance, and

greater than 45 kcals for weight gain or growth (or estimate using Mifflin-St. Jeor). Protein

recommendations range 0.8 to 2.0 grams per kilogram of body weight depending on performance

level. Carbohydrate intake can range from 3 to 4 grams per kilogram of body weight for light

training and up to 6 to 8 grams of carbohydrates for heavy training days. Fat recommendations

are 0.9 to 1.0 grams per kilogram of body weight for weight maintenance, with 0.2 gram

adjustments for weight loss or gain. Additional recommendations are provided to encourage

service members to exercise caution with supplement use.

The desire for human performance optimization in these elite athletes, contributes to

more prevalent use of nutritional supplements than the general population13,20 however their

beliefs and information are not always derived from evidence based recommendations13.

Nutrition Management Post-Deployment

There are a number of Human Performance Institutes that work with individuals to help

them achieve their optimum health and fitness or athletic training goals. These institutes often

staff performance or sports nutrition dietitians to optimize nutrition habits through strategic

nutrition planning, food service integration, and day-to-day guidance. The Tactical Human

Optimization, Rapid Rehabilitation and Reconditioning Program (THOR 3) is a Special Forces

human performance and exercise rehabilitation program out of Fort Bragg, North Carolina. The

THOR3 program claims to be building stronger, more resilient special operators with improved

health and longevity who are in peak physical shape for deployment, less likely to get injured,

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and are able to return to action faster from injury than ever before21. The program has its own

fitness center with strength and conditioning coaches, a physical therapy clinic and a sports

performance dietitian. The program focuses on optimizing physical and mental conditioning of

Special Forces Operators as well as elevating physical function, conditioning, and recovery of

injured Operators to peak physical and mental performance21.

An independent research study found 75% of the soldiers who participated in THOR3

reported improvements in physical fitness and being more physically fit for their mission. More

than half of the soldiers reported complete recovery from their injuries, with THOR3 group

having marginally lower self-reported injury rates when compared to the traditional physical

training group22.

Nutrition Assessment

Nutrition assessment for these service members should focus on body weight trends and

body compartment estimates to provide a more accurate nutritional picture in comparison to

traditional reference standards. Biochemical data, medical tests and procedures could include

standard visceral protein and hematological assessments along with liver and kidney function,

and inflammation and hydration status. Indirect calorimetry, when available, should be used to

determine estimated energy requirements. Otherwise, standardized prediction equations such as

Mifflin St. Jeor may be used in its place. Urine Urea Nitrogen tests can help determine protein

needs and nitrogen balance. An electrolyte and renal profile, along with additional vitamin and

mineral tests are also valuable tools for assessing adequacy of intake. A thorough food and

nutrition related history, including diet recall and supplement use can reveal knowledge, beliefs

and behaviors related to food, nutrition and intake. Client History can provide insights into

personal health, social history and deployments or occupational exposures. Nutrition focused

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physical findings should include an assessment of the eyes, skin, hair, nails and oral cavity for

physical symptoms of nutritional deficiencies along with assessing for symptoms of

gastrointestinal disturbance.

Nutrition Intervention

Nutrition education and counseling are likely the most appropriate interventions to be

provided based on assessment findings and nutritional diagnosis. Education could include

nutrition relationship to health/disease, reference standards for intake of specific nutrients, results

interpretation and recommended modifications. Nutrition counseling strategies could include

self-monitoring and goal setting based on service member’s desired outcomes. Collaboration

with other providers is central to this treatment model. Referral may be necessary if current

facility is not equipped to individually address the multi-dimensional treatment needs of these

service members.

Nutrition Monitors

Following initial assessment, nutrition monitoring may simply be related to intake of

energy and macronutrients compared to recommendations and monitoring for physical signs of

micronutrient deficiency and toxicity.

General Case Information

DT is a 33-year old Caucasian male. His height is 72 in [182.9 cm] and his weight is

233.8 lbs [106.3 kg]. He reports his usual body weight to be 233 lbs. He is an Active Duty Army

Ranger Platoon Sergeant. He obtained his Bachelor of Science in Political Science in 2009 and

would like to obtain his Master of Business Administration and start his own Gym. He is

dedicated to his wife of 7 years with whom he shares his 4-year-old son and 3-year old daughter

8
who are back home in Alabama until he is medically discharged so they can relocate to his

hometown of Arizona where his parents currently reside.

As a Ranger he has been exposed to multiple concussive events. He has sustained

forceful collisions with the ground during a static line jump, the roof of his vehicle in an IED

explosion, 16 block C4 blasts from a range of 20 feet, along with numerous other combative

training and mission events during Ranger school, Marine reconnaissance, and Special

Operations Force Reconnaissance.

In August 2016, DT sustained a head injury with loss of conscious from 160-pound crate

that fell 14 feet and landed on his head. There was no surgical intervention at that time. He began

to develop burning sensations that traveled down his left arm resulting in paralysis of arm. He

was deployed again in February 2017 whereupon his return, one of the paralytic events caused

him to have a near accident with his children in the car so he went for evaluation. In September

2017, after an unremarkable MRI of the brain, DT underwent C67 anterior cervical discectomy

& fusion with left iliac crest bone graft. DT reports damage from C5/6 to T1/2 however he states

his surgeon did not want to fuse that many vertebrate. The burning sensation in his arm did not

resolve and symptoms are still present. Following the surgery, DT was treated at EXOS Human

Performance Facility which he reports to have been very helpful.

Present Admission

On January 16, 2018 DT was screened and accepted to the PREP program at JAHVH.

The purpose of DT’s referral to PREP was to improve clinical symptoms of TBI, headaches,

dizziness/vertigo, memory loss, insomnia, anxiety and to improve overall ability to perform his

9
job as Ranger Squad Leader. The treating physician was Staff Physiatrist (Physical Medicine and

Rehabilitation physician) Bryan Merritt, M.D.

The primary diagnosis for DT was mild Traumatic Brain Injury. Additionally, he suffers

from chronic pain syndrome, tinnitus, hearing loss, inhalation exposures to burn pit, oil fields,

and shortly after admission he was diagnosed with Attention Deficit Hyperactivity Disorder. His

length of stay was estimated to be two to four weeks.

The treatment plan outlined for DT during this time included daily rehabilitative nursing,

physical therapy, occupational therapy and speech therapy 5 days per week along with social

welfare/recreation therapy. Consults placed upon admission included psychology,

neuropsychology, psychiatry, speech pathology, audiology, polytrauma optometry, recreational

therapy, physical therapy, occupational therapy, pain kinesiotherapy, respiratory therapy, along

with evaluations for electroencephalography and electrocardiogram. The medical team planned

to review DT at weekly team staffing conferences.

Upon review of his symptoms inventory, his team noted the following:

“Careful with his intake of food. Limits carbs and fat. Will have bowel movement (BM) 5 to 10

minutes after eating. If eats high fat or carbs will have to have BM immediately. Stool 5-6 times

a day. Diarrhea. No hematochezia/ Eats plain vegetable and 250 to 300 grams of protein a day.”

They placed a dietitian consult the following day. The reason for consult was described

as “32y/o Active Duty Ranger injured in 2015 by being impaled on stake during a parachute

jump. Surgeon removed seven feet of large intestine and six to seven feet of small intestine. He

has some very specific dietary needs. Eats a larger than usual amount of protein and fresh

vegetables; minimal carbohydrates and fat. Please evaluate.” A duplicate consult noted “Patient

has history of colostomy with reversal in 2015 due to being Impaled during training exercise.

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Would like high protein, low carbohydrate diet with minimally processed foods; has frequent

diarrhea approximately six times per day. Also works out six times per week and would like

double portions.”

The consult was received by the Rehab Dietitian who suggested DT as a potential case

study. Upon chart review, a follow-up assessment was conducted with DT that revealed on June

24, 2015 DT was impaled by a six-foot stake during a parachute landing in a field. The stake

went through his right buttocks, into his abdomen, and exited three inches to the left of his

umbilicus. He removed himself from the stake and was transported to a local Korean teaching

hospital for immediate medical attention and intestinal resection. He was given a temporary

colostomy, however, extra-intestinal fecal contamination caused him to go into septic shock two

to three weeks after the surgery.

During the procedure, however, the surgeons discovered DT had congenital intestinal

malrotation. People with chronic, uncorrected malrotation can have recurrent abdominal pain and

vomiting, however DT reports being asymptomatic.

DT is unlike most of the veteran population that Veteran hospital dietitians encounter on

a daily basis in many ways. His altered anatomy and gastrointestinal function combined with

multiple concussive events and a body composition of a warrior athlete made the potential for

this case study difficult to pass up.

Nutrition Assessment

Client History:

DT is a 33-year-old male Active Duty Army Ranger. He has a history of mild traumatic

brain injury and colon/small intestine trauma resection.

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Food/Nutrition-Related History:

DT reports restricting his carbohydrate and fat consumption and avoiding all processed

foods, bread and rice. He states he eats plain vegetables like broccoli, cauliflower, asparagus,

spinach, lettuce, onions, and bell peppers along with eight to ten ounces of meat each meal. He

reports drinking protein shakes between meals (pre- and post-workouts) along with other high

protein snacks like nuts. He estimates his total daily intake to be approximately 2600-3200

kilocalories (depending on activity level) and 250 to 300 grams of protein (or a goal of 1.5 grams

per pound of actual body weight). DT reports that he has been buying rotisserie chicken from the

grocery store because he has not been able to consume foods provided on the diet ordered for

him upon admission. DT also reports taking THORNE brand creatine supplement (20 grams per

day). Estimates from dietary recall total approximately 3000 calories and 311 grams of protein in

24 hours. He reports taking a multivitamin, fish oil, and probiotics daily and states he is lactose

intolerant. He has no known allergies and has no history of alcohol, tobacco or illicit drug use.

Anthropometric Measurements:

Prior to impalement, DT reports his usual body weight to be 256 pounds. One month

following the accident, he reports his weight dropped to 201 pounds (21.5% decrease in body

weight). Two months following the accident, he reports reaching his lowest weight of 188

pounds after which he states his appetite began to improve and he was able to start working out

again. He reports his usual body weight now to be 233 pounds, consistent with his admission

weight, which makes his current BMI 31.8.

Biochemical Data, Medical Tests/Procedures:

A 24-hour urine collection specimen revealed an elevated 21 grams of nitrogen (reference

range 10-20 grams). Creatinine, blood urea nitrogen, glucose, sodium, potassium, and chloride

12
were all within normal limits. Vitamin B12, serum folate and vitamin D status were also normal.

Complete blood count revealed low platelets, neutrophils, lymphocytes and total white blood cell

counts. Liver enzyme alanine aminotransferase (ALT) also noted to be elevated at

47U/L (Reference range: 11-44U/L) while Aspartate transaminase (AST) was normal. Glucose,

anion gap, calcium, albumin, and alkaline phosphatase all within normal limits.

Nutrition-Focused Physical Findings:

DT reports six to eight watery bowel movements per day with the first bowel movement

upon waking tending to be more formed stool. He states will very regularly have a bowel

movement five to ten minutes after eating throughout the rest of the day. He reports

gastrointestinal discomfort and fecal urgency with carbohydrate and high fat consumption; no

hematochezia. He reports undigested food particles in his stool (spinach, corn) and oily stools

with consumption of greasy foods. No nausea, vomiting or constipation.

There were no overt signs or symptoms of micronutrient deficiency such as skin

cracking, lesions, or dermatitis and no complaints of dry eyes, night blindness or corneal

alterations. DT reports occasional low energy levels with his restricted carbohydrate intake.

His hand grip strength indicates he is 8 standard deviations above the mean for his age and sex

with his dominant right hand. Bioelectrical Impedance Analysis (BIA) revels 8% body fat and

phase angle of 8.8 degrees (within average). Triceps skinfold measurement was in the 5-10th

percentile, mid arm circumference was in the 90-95th percentile and arm muscle area was

recorded to be greater than 95th percentile. See Appendix 1 for full Nutritional Assessment note.

Nutrition Prescription

Nutritional needs were assessed using indirect calorimetry and resting metabolic rate was

recorded as 2860 kilocalories per day. Based on a conservative activity factor of 1.5, his energy

13
needs were estimated to be 3800-4200 kilocalories per day. Protein was estimated to be 160

grams per day, based on 21 grams of nitrogen from urine urea analysis plus 4 grams for margin

of error.

Nutrition Diagnosis

The initial nutrition diagnosis was established as Altered GI function related to

colon/small intestine resection as evidenced by Service Member reports of frequent stools and

reports of oily stool when consuming high fat foods. After further assessment, the following two

nutrition diagnoses were added: 1)Imbalance of nutrients related to consumption of high-dose

nutrient supplements and food faddism as evidenced by diet recall estimating 40% of calories

from protein (2.8 grams/kg), 40% from fat and 20% from carbohydrates with inadequate intake

of potassium and fiber and 2) Food- and Nutrition-Related Knowledge Deficit related to lack of

prior nutrition-related education as evidenced by no prior education provided on how to apply

food and nutrition related information and reports of previous attempts to learn information.

Nutrition Interventions

The request for High Calorie, High Protein diet was honored. DT was educated on

recommendations for protein, carbohydrate and fat intake in relation to his current reported

intake. Education was provided on different fiber profiles and their relationship to intestinal

transit time and absorption. Interpretation of body compositions analyses were explained to DT

along with the benefits of adequate intake of vitamins and minerals through foods versus

supplements, and the relationship of nutrition to health and disease. An electronic summary of

the education was emailed to him. DT was determined to be in the preparation stage of the

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Transtheoretical Stages of change model and goal setting was used to allow DT the opportunity

to increase his carbohydrate intake to 35% and decrease his protein intake to 25% of total energy

intake to allow for realistic short term targeted intake goals. Long term goals for carbohydrate

and protein intake were established at 45%-60% of total energy intake and 1.6 grams per

kilogram respectively. Intervention goals of carbohydrate and protein intake were not

implemented during inpatient stay due to food preference and current facility offerings.

Nutrition Monitoring and Evaluation

DT was agreeable to tracking and reporting carbohydrate and protein intake compared to

goal. Levels of vitamin B12 were to be monitored for adequacy with potential reduced

absorptive capacity with intestinal (illeal) resection and recommended reduced protein intake

modifications. Other monitors were determined to be a nitrogen balance of no more than 20

positive short term (6 positive long term) and weight trends for overall sufficient energy intake.

Potential additional monitors could have been determined based on recommended fecal fat

analysis, PT/INR, and serum retinol tests, however, DT was deployed before further testing and

follow-up could be performed. His third diagnosis of Food- and Nutrition-Related Knowledge

Deficit however, did show immediate improvement as demonstrated through teach back method.

DT was receptive to the nutrition recommendations provided to him, however, because he was

not comfortable implementing them without sufficient menu offerings, his nutrition diagnosis of

Imbalance of Nutrients and Altered GI Function remained unresolved.

Discussion of Outcomes

Aside from his stay at EXOS, DT reports he had no prior contact with a dietitian. He was

eager to receive nutrition recommendations and was able to understand their relationship to

15
health and disease. He expressed a genuine interest not only from a performance standpoint but

also in respect to health and longevity. He reported many nutrition challenges in his military

career with a lack of access to nutrition advice. His present referral to a dietitian was for diet

needs that he felt were not met by the standard diet order or facility offerings. The standard

Healthy Diet ordered provided 2150 calories and 80 grams of protein per day. The dietitian

honored his high protein request by switching him to a High Calorie, High Protein Diet which

provided 3000 calories and 150 grams of protein per day. Even with access to additional

nourishments and snacks, DT reported not being able to meet his nutrient goals due to selection

and food preferences. Expanded menu offerings may have assisted in meeting intake goals

during inpatient stay. Continued protein supplementation and lack of variety in diet may cause

concern for inadequate intake of other macro- and micronutrients.

Follow Up Nutritional Care

Follow-up nutritional care should include assessments for the recommended

malabsorption tests such as serum retinol profile to rule out Vitamin A deficiency, prothrombin

time/ International normalized ratio (PT/INR) to assess Vitamin K status (with possible reduced

biosynthesis with intestinal resection) and qualitative fecal fat to assess for steatorrhea and

subclinical deficiencies of fat soluble vitamins. Multivitamin, mineral and probiotic

supplementation has likely assisted in preventing deficiency and continued use should be

monitored as intake and gastrointestinal adaptation improves. Follow-up care may also include

training level specific recommendations for intake as dietary adherence improves.

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Summary

Medical Prognosis

DT completed Phase I Evaluation and Treatment in the PREP program, but took a leave

of absence from Phase II Treatment to return to duty. He anticipates future participation in the

program to continue to improve symptoms of mTBI and overall ability to perform.

Nutritional Prognosis

DT was determined to be in the preparation stage of the Transtheoretical Stages of

change model. Although he was receptive to making changes to his intake, real-world operations

may limit his adherence to dietary recommendations in the field. Increased protein consumption

in the likely setting of caloric deficit may help to preserve lean body mass, however, muscle

protein synthesis is likely limited beyond 1.5 grams of protein per kilogram of body weight13.

Gastrointestinal adaptation following his intestinal resection may continue to improve and

further attempts at education can help to improve knowledge deficit and ensure adequate intake

of macro- and micronutrients.

Effectiveness and Other Considerations

For education to be effective in mTBI or PDS populations, educational materials must

consider the individual needs of the patient and any barriers to learning. Cognitive, hearing and

vision impairment could severely impact delivery and retention of information. Likewise,

method of dietary assessment may favor records over recalls. Early discharge from the PREP

program greatly shortened DT’s anticipated length of stay. Longer participation in the program

could have helped improve his memory and concentration issues and provide more opportunities

for evaluation and education reinforcements. High total body water from BIA suggested fluid

overload status, possibly from creatine supplementation. Therefore, a repeat BIA in the absence

17
of creatine supplementation may have provided more accurate results for body fat analysis and

other lab values in questions such as low white blood cell counts and borderline low sodium

levels. Although specific inflammatory markers are not useful in identification of mTBI, the

presence of inflammation could be useful in determining nutrition status. The dietitian working

with DT at EXOS was contacted for potential collaboration, however, DT was discharged before

any communication took take place. A barium swallow may be useful for a full gastrointestinal

evaluation due to lack of access to Korean medical records. The length of each remaining section

of the intestine is still unknown and could provide insight to individual nutrient absorption,

intestinal adaptability, and profile/energy contributions of short chain fatty acid production from

surviving microbiota. Responsible administration of hospital resources should, however, be

taken into consideration for the most effective care to be provided to the service member. The

lack of diet education following his intestinal resection begs for recommendation of nutrition

education following surgery, or ideally even before he was ever deployed.

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Appendix 1
Nutritional Assessment
Ht: 72 in [182.9 cm] (01/16/2018 08:00)
Weight History: LBS (KG) [BMI]
Measurement DT WEIGHT
LB(KG)[BMI]
01/16/2018 08:00 233.8(106.05)[32*]
01/08/2018 235
11/21/2017 230
11/02/2017 230
09/19/2017 230
09/06/2017 225
08/21/2017 225<-mTBI event
BMI: 31.8
Weight change:
2 months: up 3.8 LBS (1.7%)
5 months: up 8.8 LBS (3.9%)
Pertinent Labs:

---- CHEMISTRY (24 HR URINES) ----

24 HR URINE Jan 31 Units Reference Ranges

-----------------------------------------------------------------------------
CREAT 49.5 mg/dL Ref: >=20
CRE 24 2277 mg/24 hr 630 - 2500
BUN 448 mg/dL
UUN 24 21 H g/24 hr 10 - 20

----LAB CUMULATIVE SELECTED---

Collection DT Spec Creat BUN Glucose Sodium K CL

01/21/2018 18:00 URINE 25.7
01/17/2018 04:00 PLASM 1.1 20 97 136 4.1 103

---- VITAMINS - SERUM ----

SERUM Jan 17 Jan 17 Reference

2018 2018
Units Ranges
-----------------------------------------------------------------------------
VIT A mcg/dL
CAROTEN ug/dL
VI B12 990 pg/mL 218 - 1124
SER FOL 18.0 ng/mL Ref: >=5.4
HOMOCY umol/L 4.1 - 13.1
METHYLM nmol/L
VIT C
25-OH D 33 ng/mL 30 - 100

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 ---- CBC PROFILE ----
BLOOD Jan 17, 2018 Reference
Units Ranges
-----------------------------------------------------------------------------
WBC 3.36 L 10E9/L 3.9 - 9.9
RBC 5.3 10E12/L 4.1 - 5.7
HGB 15.5 g/dL 13 - 17
HCT 45.8 % 39 - 49
MCV 86.7 fL 81 - 98
MCH 29.4 pg 27 - 33
MCHC 33.8 g/dL 31 - 35
RDWSD 41.6 fL 38 - 50
PLT 156.0 L 10E9/L 167 - 378
MPV 10.3 fL 9.4 - 12.8
NRBC 0.0 %/WBC 0 - 0
IG # 0.00 10E9/L 0 - .05
NEUT # 1.41 L 10E9/L 1.73 - 6.37
LYMPH# 1.16 L 10E9/L 1.18 - 3.41

---- CHEM PROFILE (PLASMA) ----

PLASMA Jan 17 Reference
2018
Units Ranges
-----------------------------------------------------------------------------
NA 136 mEq/L 136 - 145
K 4.1 mEq/L 3.5 - 5.2
CL 103 mEq/L 98 - 109
CO2 26 mmol/L 22 - 32
BUN 20 mg/dL 8 - 23
CREAT 1.1 mg/dL .8 - 1.3
GLU 97 mg/dL 65 - 110
An Gap 7 5 - 18
Calcium 9.0 mg/dL 8.3 - 10.2
Mg mg/dL 1.5 - 2.6
PO4 mg/dL 2.3 - 4.3
TP 6.9 g/dL 6.8 - 8.7
Albumin 4.1 g/dL 4 - 4.9
ALT 47 H U/L 11 - 44
AST 39 U/L 10 - 46
ALKPHOS 90 U/L 25 - 125

Hand Grip CAMRY(STRONG):

Right (Dominant): 76.4 kg, 81.6kg, 82.5kg (8 SD above mean)
Left: 71.8, 74.6, 71.8
Bioelectrical Impedance Analysis(BIA):
Resistance: 286.1
Reactants: 44.1
Phase Angle: 8.8 degrees (within average)
Fat% of total weight: 8.0%
Total Body Water: 159.9 LBS
Extracellular Water: 71.3 LBS

Mid-point Arm: 8.5 in (Line below 'Harley' Tattoo)

Mid Arm Circumference: 41cm (90-95th percentile)
Triceps Skinfold: 5-7 mm (5-10th percentile)
Arm Muscle Area: 121.8 (greater than 95th percentile)

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Appendix 2

Diet Recall Corresponding to Urine Urea Nitrogen Analysis:

Breakfast: Double portion omelette (onions, ham, peppers), 1 sausage patty, 2
pieces bacon
Snack: Quest S'mores bar
Lunch: 2 Turkey patties, green beans, salad with balsamic vinegar
Snack: Myoplex Shred 42 gram protein shake, almond, cashew, craisin mix
Dinner: Chick-fil-a Southwest Salad (no cheese, tortilla strips or seeds),
chili lime vinaigrette, 12 grilled nuggets
Snack: Myoplex Shred 42 gram protein shake, almond, cashew, craisin mix
Estimated Intake from Recall: 3000 calories, 311 grams protein

Appendix 3

Education Material Provided

Kilocalories Carbohydrates Protein Fat

General 45%-65% 10%-35% 20%-35%

Recommendations

Current Intake ~150 grams (15- 311 grams (40%) (40-45%)

20%)

Short Term Goals 350 grams (35%) 250 grams (25%) Focus on
based on 4000 unsaturated,
kcals (2860 RMR) healthy fats
(avocado, nuts,
seeds, oils)

Long Term Goals 450 grams (45%) 160 g per UUN Focus on
based on 4000 unsaturated,
kcals (2860 RMR) healthy fats
(avocado, nuts,
seeds, oils)

21
References

1. Bosco M, Walker R, Clark M, Takagishi S. Post-deployment multi-symptom disorder: an

integrated behavioral health approach to treatment. J Pain. 2010;11(4).

2. Post-Deployment Syndrome: The Illness of War. BrainLine.

https://www.brainline.org/article/post-deployment-syndrome-illness-war. Published May

27, 2017. Accessed February 19, 2018.

3. Spelman J, Hunt S, Seal K, Burgo-Black A. Post Deployment Care for Returning Combat

Veterans. J Gen Intern Med. 2012;27(9):1200-1209.

4. Walker R, Clark M, Sanders S. The “Postdeployment multi-symptom disorder”: An

emerging syndrome in need of a new treatment paradigm. Psychol Serv. 2010; 7(3): 136-

147.

5. Lew H, Poole J, Alvarez S, Moore W. Soldiers with occult traumatic brain injury. Am J

Phys Med Rehab. 2005;84:393–398.

6. Mild TBI Symptoms. TraumaticBrainInjury.com. http://www.traumaticbraininjury.com/

symptoms-of-tbi/mild-tbi-symptoms/. Accessed February 19, 2018.

7. Lew H, Otis J, Tun C, Kerns R, Clark M, Cifu D. Prevalence of Chronic Pain,

Posttraumatic Stress Disorder and Postconcussive symptoms in OEF/OIF veterans: The

Polytrauma Clinical Triad. J Rehab Research Develop. 2009;46(6): 697–702.

8. Hoge C, Goldberg H, Castro C. Care of war veterans with tramatic brain injury: Flawed

perspectives. N Engl J Med. (2009;360:1588–1591.

22
9. Eierud C, Craddock RC, Fletcher S, et al. Neuroimaging after mild traumatic brain

injury: Review and meta-analysis. NeuroImage Clin. 2014;4:283-294.

10. Woodcock T, Morganti-Kossmann MC. The Role of Markers of Inflammation in

Traumatic Brain Injury. Front Neurol. 2013;4:18.

11. US Department of Veterans Affairs. Post Deployment Rehabilitation and Evaluation

Program. James A. Haley Veterans' Hospital, Tampa, Florida. https://www.tampa.va.gov/

services/PREP.asp. Published November 20, 2013. Accessed February 19, 2018.

12. Beals K, Darnell M, Lovalekar M, Baker R, Nagai T, San-Adams T, Wirt M. Suboptimal

Nutritional Characteristics in Male and Female Soldiers Compared to Sports Nutrition

Guidelines. Mil Med. 2015; 180(12):1239–1246.

13. Pasiakos D, Sepowitz J, Deuster P. US Military Dietary Protein Recommendations: A

Simple But Often Confused Topic. J Spec Op Med. 2015;15:4;89-95.

14. Institute of Medicine of the National Academies. Dietary Reference Intakes for Energy,

Carbohydrate. Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. National

Academies Press, Washington, DC. 2002/2005.

15. Department of Defense. Nutrition and Menu Standards for Human Performance

Optimization. 2017;AR 40–25:OPNAVINST 10110.1;MCO 10110.49;AFI 44–141.

16. Ministry of Defense. Defense Catering Manual: Catering Management Guidance.

December 2014. JSP 456;(1):2.

17. Tharion W, Lieberman H, Montain S, Young A, Baker-Fulco C, Delany J, Hoyt R.

Energy requirements of military personnel. Appetite. 2005 Feb;44(1):47-65.

23
18. Deuster P, Kemmer T, Tubbs L, Zeno S, Minnick C. Special Operations Forces Nutrition

Guide. 2012; 225.

19. United States Army Special Forces. Foundations in Sports Nutrition: Tactical

Performance Nutrition (THOR3). 2015; 24.

20. Austin KG, Mcgraw SM, Lieberman HR. Multivitamin and Protein Supplement Use Is

Associated With Positive Mood States and Health Behaviors in US Military and Coast

Guard Personnel. J Clin Psychopharmacol. 2014;34(5):595-601

21. Ragusa, P. THOR3 Program Building Modern Day Warriors. Special Ops Fitness. Gov

Rec Fit. 2012:3.

22. US Army Public Health Center: Clinical Public Health and Epidemiology Directorate

Injury Prevention Division. Evaluation of the Tactical Human Optimization, Rapid

Rehabilitation, and Reconditioning Program (THOR3). 2016; Technical Report No.

WS.0030636.3.

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