Naval Submarine Medical Research Laboratory

NSMRL REPORT 1201 27 JUNE 1996

NUTRITION EDUCATION AND DIET MODIFICATION

ABOARD SUBMARINES

Caron L. Shake, LCDR, MSC, USN

Christine L. Schlichting, PhD

19960904 001

Released by

R G. Walter, CAPT, DC, USN

Commanding Officer

Naval Submarine Medical Research Laboratory

DTIC QTJMJTYINSPBG^^1

Approved for public release; distribution unlimited
Nutrition Education And Diet Modification Aboard Submarines

Caron L. Shake, LCDR, MSC, USN*

Christine L. Schlichting, Ph.D.*

Naval Submarine Medical Research Laboratory

NSMRL Report 1201

Naval Medical Research and Development Command

Work Unit 63706N 0096.002-5206

Approved and Released by

R. G. Walter, CAPT, DC, USN

Commanding Officer

NAVSUBMEDRSCHLAB

Approved for public release; distribution unlimited
Summary Page

Problem

To determine whether nutrition education and a menu designed to decrease the percentage of

caloric intake from saturated fats and cholesterol would improve coronary heart disease (CHD)

risk.

Findings

Regardless of nutrition education or menu intervention, submariners showed some reduction

in CHD risk factors during deployment. There was an additional beneficial effect for those submariners who received the education and menu intervention.

Application

The use of nutrition education and menu intervention in the reduction of coronary heart disease risk factors.

Administrative Information

This work was conducted under NMRDC Work Unit 63706N 0096.002-5206, Nutrition education and diet modification aboard submarines. Both authors contributed equally to the report;

order of authors does not reflect degree of involvement. The views expressed in this report are

those of the authors and do not reflect the official policy or position of the Department of the

Navy, Department of Defense, or the U. S. Government. This report was approved for publication on 27 June 1996 and designated NSMRL Report 1201.

li
Abstract

During a one year period, 534 male, US Navy submariners participated in a nutrition research project designed to reduce coronary heart disease (CHD) risk. The research was carried

out on board USN Trident Submarines before, during, and following actual patrols. Subjects

from six submarine crews were assigned to either the education / diet group (E) or the control

group (C). Group E was provided nutrition education and a modified 5 week cycle menu which

focused on decreasing the percentages of caloric intake derived from fat and high cholesterol

food. Group C received NO intervention. Measurements of cholesterol (TC), high density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG), Ratio

(TC/HDL), blood pressure (BP), and body fat (BF%) were taken before and after deployment

and again after the off crew period. Age, height, and weight data were also gathered. The data

were analyzed with the MANOVA procedure using a mixed multivariate model with repeated

measures on the two groups. Following the patrol one of the three control crews demonstrated

statistically and clinically significant decreases in TC, HDL, LDL, and Ratio and another crew

showed a significant decrease in BP (systolic). Within the education group (3 crews) several significant decreases occurred during deployment: TC declined (3 crews), LDL and HDL declined

(2 crews), ratio declined (one crew), and TG declined (2 crews). All six crews demonstrated a

statistically significant decrease in BF% during deployment. Changes were noted following the

off crew period. Both groups demonstrated increases in most variables.

The experiment demonstrated that regardless of education or menu intervention, subjects

showed some reduction in CHD risk factors during deployment.

The results also demonstrated that the nutrition education and diet modification intervention

had a greater beneficial effect on reducing CHD risk factors when compared to no intervention.

m
[Blank Page]

IV
Nutrition Education and Diet Modification Aboard Submarines

In the United States, cardiovascular disease

is the leading cause of death, with coronary

heart disease (CHD) accounting for two thirds

of all heart disease (Kannel, Dawber, Kagan,

Revotskie, & Stokes, 1961; Klang, et al.,

1993; Garber, Sox, & Littenberg, 1989).

Epidemiological studies indicate that both genetic and acquired factors increase the risk for

CHD (Garber, et al., 1989; Manson, et al.,

1992; Ornish, et al., 1990). Some of these,

such as age, gender, and familial predisposition are irreversible risk factors. However,

many of the other risk factors for CHD are reversible (e.g. elevated serum cholesterol, elevated low density lipoprotein cholesterol, low

level of high density lipoprotein cholesterol,

smoking, high blood pressure, obesity) (Kannel, et al., 1961; Klang, et al, 1993; Garber,

et al., 1989).

For instance, there is overwhelming evidence that identifies hypercholesterolemia as

a major risk factor for CHD (Kannel, et al.,

1961; Klang, et al., 1993; Garber, et al., 1989;

Schuler, et al., 1992). Both dietary cholesterol

and saturated fats raise serum cholesterol and

other lipid fractions (Kannel, et al., 1961;

Klang, et al., 1993; Garber, et al., 1989;

Schuler, et al., 1992; Stehbens, 1990). In

most cases, abnormal or unhealthy levels of

these lipids can be modified with a diet outlined for sound nutrition (Thorn, Kannel, &

Feinleib, 1985; Banta, 1979; Hoiberg, Bernard, & Watten, 1980; Graham & Good,

1987). Research suggests that improving dietary habits and consequently reducing percent

body fat (%BF) may improve cardiovascular

health, physical performance, and job productivity (Thorn, et al., 1985; Banta, 1979;

Hoiberg, et al., 1980; Graham & Good, 1987).

Improvement or maintenance of health and

physical fitness of military personnel is a major concern of the US Navy as they impact on

performance and it reduces the risk for CHD.

Because excess %BF incurs a health risk, the

Department of Defense (DOD) has set a maximum acceptable %BF level of 22% for males

(using the circumference method). Excess

body fat has been shown to be associated with

high blood pressure, diabetes, and heart disease as described by the National Institute of

Health Conference on Obesity (National Institute of Health [NIH], 1985). Therefore, the relationship between risk factors and coronary

heart disease is of importance to the DOD and

the U.S. Navy from both a health and financial standpoint.

U.S. Navy shipboard conditions such as

confinement, lack of exercise equipment, and

the lack of time to exercise are barriers to increasing cardiovascular health in the operational Navy (Marcinik, Hodgdon, & O'Brien,

1988). In general, the lack of physical activity

is related to CHD (Paffenberger, 1985). Due

to confinement, this lack of activity is frequently the case aboard submarines. Reduced

physical activity, coupled with the usual 35-

percent-of-calories from fat and high cholesterol diet typically served onboard

submarines, may put submariners at higher

risk for CHD while on active submarine duty

(Carson, 1986; Tappan, Mooney, Jacey, &

Heyder, 1979). These circumstances suggest

that nutritional modification and/or an exercise program could be beneficial.

Very few studies on submariners are available in the open literature; however, significant results are reported in Navy publications.

In a study of CHD risk on crew members on

one submarine, Carson (1986) examined the

nutrient intake of the submariners and the implications for CHD. He reported that the crew
members subsisted on a highly atherogenic

diet.

Carson (1986) states that the submarine

fleet has seen increased incidence of CHD in

highly trained members. Missions have been

jeopardized in order to conduct highly dangerous and expensive medivac operations (Tansey, Wilson, & Schaefer, 1979). These

occurrences could be reduced with an increase

in physical activity, modification of the diet,

and implementation of preventive medicine

measures (Carson, 1986; Trent & Conway,

1988).

The purpose of this research is to demonstrate that a nutrition education program combined with improved menu choices during

submarine deployment can have a beneficial

effect on CHD risk factors by reducing serum

cholesterol, other lipid fractions, blood pressure, and percent body fat.

Method

Subjects

The research was carried out on board U.S.

Navy Trident Submarines before, during, and

following actual patrols. Subjects were male,

U.S. Navy submarine volunteers (N=534)

from six Trident submarine crews stationed at

either of two Naval submarine bases (Kings

Bay, GA or Bangor, WA). Some subjects did

not complete all phases due to transfer of

crew members off the submarine and scheduling conflicts with mission related training.

Procedure

Data were collected before (pre-patrol) and

after a deployment (post-patrol) of at least 60

days, and immediately before a second deployment (final). Three submarine crews

were assigned to the control group (C) and

three crews to the education/diet group (E).

One submarine participated in both groups (C

first, E last). The control group was provided

a diet consisting of menus prepared as usual

by their cooks (Mess Management Specialists) who were not given any additional nutrition education. The experimental crews

received nutrition education and were offered

a modified diet which was lower in fat and

cholesterol than the normal menu. The experimental menu offered meals which were approximately 30% fat, while the control

submarines provided meals which ranged

from 34-36% fat.

Time of year varied for the patrol. Two of

the control submarines began the study in the

winter of 1992 and finished in the summer of

1993. The third control submarine had the

first set of measurements taken in early May,

1993, post-patrol measurements in August,

and final measurements in November 1993.

All three experimental submarines began prepatrol measurements in the summer of 1993

and completed post-patrol and final measurements in the winter of 1993 -1994.

Education. The food service personnel in

the experimental group attended two days of

nutrition education lectures several weeks

prior to deployment. They received specific

instructions on how to order foods, prepare

menus, and prepare foods which are nutritionally and medically sound.

Prior to deployment, the experimental submarine crew members also attended 4 hours

of nutrition education lectures and were further provided with nutrition education via lectures and video media during deployment.

The education provided during the patrol was

presented by a hospital corpsman from the

NSMRL research staff who acted also as a research monitor during the patrol.

During the educational lectures, the crews

of the experimental group received specific instructions on how to decrease their risk for

CHD by choosing foods which are nutritionally and medically sound. They also received
information regarding the specific risk factors

associated with CHD, and how to modify

their own particular risk.

Modified menu. The modifications to the

submarine menu were planned under the supervision of a registered dietitian (RD). The

experimental menu focused on decreasing the

percentage of caloric intake that was derived

from fat and high cholesterol food. The menu

was intended to provide menu choices with an

overall percentage of fat of 30% and to include nutritionally sound recommendations

such as modifying cooking methods, keeping

fat content to a minimum, offering low calorie

desserts, and using whole wheat flour. All

subjects were allowed to choose what and

how much they wanted to eat.

Cost comparisons for the menus were

made between the control and the experimental groups. No appreciable difference was

found between the lower fat menu and menus

typically used by each submarine.

Analysis

With few exceptions, two measurements of

total cholesterol (TC), high density lipoprotein

cholesterol (HDL), low density lipoprotein

cholesterol (LDL calculated), triglycerides

(TG), and blood pressure (BP) were made at

each of the three time periods (pre-patrol,

post-patrol, and final). At each time period,

blood was drawn with the subject in a sitting

position in the morning after a 12-hour fast

(Segal, et al., 1984). Analyses for TC, HDL,

LDL, and TG, were performed at the Naval

Hospital Groton, CT using the Boehringer

Mannheim Corp Hitachi 911 clinical analyzer

(Diagnostic Laboratory Systems Division, Indianapolis, IN). Low density lipoprotein cholesterol was derived from a standard

calculation (TC-HDL-(TG/5)) (Bakermann,

1984). Any measurements with greater than

14% difference between the two measurements were re-analyzed (National Institute of

Health [NIH], 1990). A single measurement

for percent body fat (%BF) was made at each

time period using the Navy's body circumference measurement method (Beckett & Hodgdon, 1984).

Investigators gathered initial data on

height, weight and age. Height was recorded

and rounded to the closest half-inch while

weight was recorded to the closest half-pound

using scales available on the submarines.

The data were analyzed with the MANOVA procedure using a mixed multivariate

model with repeated measures on the two

groups. All physiological data were analyzed

in this manner. A calculation of percent

change was then performed for each group followed by a paired Mest to compute the differences in percent change for the control group

versus the experimental group. Pre-planned

apriori Mests were conducted separately for

each group (C&E) across time, for all variables. Except where noted, all comparisons

were significant at the .01 level or greater.

Other factors (e.g. family history of CHD,

diet, exercise, alcohol, and nicotine habits)

were included and will be summarized in a

subsequent report.

A concern in a study of this magnitude is

the probability of Type I errors (rejecting

the null hypothesis, when in fact it is true)

due to the large number of significant tests

conducted. In particular, the family wise error rate for the experiment must be considered. Two common ways of addressing this

issue are using significance tests which take

into account the number of comparisons being made or secondly, to simply adopt a

more stringent a level when performing

the tests (Howell, 1993).

In the present design, for each variable,

there are nine comparisons that will be made.

Within each group there are three compari-
Table 1

Pre-Deployment:

members

Mean physiological valuesfor male US Navy submarine crew

Control Experimental

Variable Mean SD CV Mean SD CV

Age (yrs) 27.0 5.6 .20 27.6 5.7 .20

Height (in) 69.7 2.7 .04 70.1 2.6 .04

Weight (lbs) 182.5 27.8 .15 181.1 27.0 .15

TC (mg/dl) 182.1 34.3 .19 187.5 38.5 .20

HDL(mg/dl) 45.1 10.3 .23 41.3 11.4 .28

LDL (mg/dl) 113.5 29.4 .26 119.5 33.4 .28

TG 122.6 76.8 .63 137.4 79.0 .57

Ratio (TC/HD) 4.3 1.4 .32 4.9 1.9 .39

Systolic BP

(mmHg)

121.7 9.1 .07 121.9 8.7 .07

Diastolic BP

(mmHg)

76.3 7.7 .10 77.9 7.8 .10

BF (%) 19.1 6.0 .31 18.8 5.7 .30

Table 2

Comparison ofcontrol (C) and experimental (E) groupsforpre-patrol, postpatrol, andfinal measurement

Variable C/E

C

E

n

Pre

Mean SD

Post

Mean SD

Final

Mean SD

TC

(mg/dl)

296

238

182.1

187.5

34.3

38.5

174.5

176.6

31.9

37.3

187.4

193.1

35.3

34.3

HDL

(mg/dl)

C

E

285

236

45.1

41.3

10.3

11.4

42.9

37.9

9.4

8.3

49.3

43.4

14.6

9.1

LDL

(mg/dl)

C

E

287

234

113.5

119.5

29.4

33.5

107.8

112.2

28.7

34.5

111.8

120.0

31.7

30.5

TG

(mg/dl)

C

E

285

233

122.6

137.4

76.8

79.0

126.7

125.8

69.3

70.0

136.8

143.8

83.4

89.8

Ratio

(TC/HDL)

C

E

285

236

4.3

4.9

1.4

1.9

4.3

4.9

1.2

1.5

4.2

4.6

1.3

1.2

Systolic BP

(mm Hg)

C

E

281

246

121.7

121.9

9.1

8.7

121.6

114.9

10.1

10.1

120.0

118.3

9.0

9.2

Diastolic BP

(mm Hg)

C

E

280

246

76.3

77.9

7.7

7.8

75.1

71.8

8.0

7.9

76.2

74.7

7.0

7.1

BF

(%)

C

E

266

244

19.1

18.8

6.0

5.7

17.9

17.8

5.3

5.7

18.9

18.8

5.5

6.0
sons for the interval (pre to post, post to final,

pre to final), a total of six for the two groups.

Between groups there are comparisons at each

interval (three comparisons). For each variable, therefore, there are nine comparisons of

simple effects being made in the MANOVA.

Since the degrees of freedom in the numerator

for the F tests is 1 for each of these comparisons, the resulting F value is equal to t

squared. This relationship permits the use of

the Bonferroni t (Dunn's test) to control the

family-wise error rate (Howell, 1993). The

critical value of t for nine comparisons and df

> 100 is 2.77. An F value (t2), therefore,

must be above 7.7 to control for family wise

error at thep < .05 level.

Another way to control family wise error is

to use a more conservative level of a, such

as .01, .005, or .001. This is equally acceptable as the Bonferroni adjustment of t (Howell, 1993), but may yield slightly different

results. In the tables that follow, we have included the F value and the level ofsignificance resulting from the MANOVAS. We

have noted in the test instances in which the

Bonferroni correction would alter the significance of a comparison.

Results

Table 1 presents the mean physiological

values and standard deviations (SD) pre-patrol for each group. It includes columns for

the coefficient of variation (CV - standard

deviation divided by mean), which is a scaled

measure of the relative variability. Table 2

shows the physiological values for both

groups across the three time periods. Figures

1,2, and 3 show the direction of change for interval comparisons for the physiological measures. "Better" means the change was in the

direction of reduced risk, "worse" is toward increased risk. Significant changes are depicted

with arrows, an equal sign indicates no

change across the time interval.

PRE-PATROL TO POST PATROL

MEASURE:

TC, LDL, %BF

HDL

RATIO, TG

SYS, DIA BP

CONTROL GROUP EXPERIMENTAL GROUP

WORSE BETTER VTORSE BETTER

o

4>

Figure 1

POST PATROL TO FINAL PERIOD

CONTROL GROUP EXPERIMENTAL GROUP

MFA^IIRP WORSE BETTER WORSE BETTER

TC, LDL, %BF ^m 4*

HDL

TRIGLYCERIDES ^m\ ^

SYSTOLIC BP E|> ^

DIAST0LICBP = ^B

RATIO = c^>

Figure 2

PRE-PATROL TO FINAL PERIOD

CONTROL GROUP EXPERIMENTAL GROUP

MFA9IIRF' WORSE BETTER WORSE BETTER

LDL, %BF = =

HDL c|>

TRIGLYCERIDES ^1

SYSTOLIC BP E&>

RATIO, DIA BP = Ep>

Figure 3
Appendix A shows the results of the repeated measures MANOVAs and simple effects tests for each variable. It also includes

the paired t tests for within group comparisons for the three intervals. Table 3 shows

percent changes for each group from pre- to

post-patrol and Table 4 the post-patrol to final

measurement.

Appendix B displays individual crew results from pre- to post-patrol and from postpatrol to final measurement. The number of

subjects included in the various means differs

throughout because not all subjects completed

all phases.

In the following sections, pre- to post-patrol results are discussed first, then post-patrol

to final measurement results follow.

Total Cholesterol (TC) (mg/dl)

Means and standard deviations for both

groups at each time interval are shown in Table 2 and statistical results are shown in Appendix A. There was no difference between

groups in pre-patrol TC values or at the other

two intervals (Appendix A-2). Both groups

showed a significant lowering of total cholesterol from pre- to post deployment, followed

by an increase during the off-crew period (Appendix A-3). There was no significant difference found between groups for percent change

in TC (Table 3). One control boat (crew 3)

showed a significant decrease in TC, while all

three experimental crews had significant decreases in TC during the patrol (Appendix B).

From post-patrol to the final measurement,

both groups had significant increases in TC

(Appendix A-3), and no significant difference

was found in the percent change in TC values

between groups (Table 4). Final TC values

were significantly higher than pre-patrol values for both groups (Appendix A-3). All six

crews demonstrated significant increases in

TC during the off crew period (Appendix B).

HDL (mg/dl)

Means and standard deviations for both

groups at each time interval are shown in Table 2 and statistical results are shown in Appendix A. Values for HDL were significantly

different between the two groups and across

the three measurement intervals (Appendix

A-l). The difference between groups was

significant at each of the three time intervals

(Appendix A-2). Both groups showed similar

decreases in HDL values from pre- to post-deployment, followed by an increase during the

off crew period to a level higher than pre-deployment values (Appendix A-3).

From pre- to post-patrol measurement,

each group showed significant decreases in

HDL values (Table 2 and Appendix A-3), and

no difference was found in the percent change

between the two groups (Table 3). Two control crews (1 and 3) and two experimental

crews (4 and 5) displayed significant decreases in HDL during the patrol period (Appendix B).

During the off crew period, each group

demonstrated significant increases in HDL

and there was no difference in percent change

found between the groups (Tables 2 and 4).

Individually, four of the crews (2,3,4,6)

showed significant increases (p < .05) in HDL

levels during the off crew period (Appendix

B).

LDL (mg/dl)

Means and standard deviations for both

groups at each time interval are shown in Table 2 and statistical results are shown in Appendix A. The results for LDL revealed a

significant difference in low density lipoproteins across time and between groups (Table 2

and Appendix A-l). There were no differences between groups in LDL values at the

pre- or the post measurement intervals, only at

the final (Appendix A-2). The effect of interval was significant for the experimental
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group, while for the control group, the effect

of interval was not significant by the Dunn's

test criteria ofF = 7.7.

Each group demonstrated a significant decrease in LDL during deployment (Table 2),

and no difference in percent change between

the groups was evident (Table 3). One control crew (2) showed a significant increase in

LDL while crew 3 showed a significant decrease (Appendix B). Two of the experimental crews (4 and 5) showed significant

decreases in LDL during deployment (Appendix B).

During the off-crew period, each group

demonstrated a significant increase in LDL

(Appendix A-3). There was a difference in the

percent change between the groups, but final

LDL values were not different than pre-patrol

values for either group (Table 4 and Appendix

A-3). There was a significant difference between groups at the final interval with the control group showing lower LDL values

(Appendix A-2). One control crew (1) and

two experimental crews (4 and 5) had significant increases in LDL during the off-crew period, while one experimental crew (6)

displayed a significant decrease (Appendix B).

Ratio

Means and standard deviations for both

groups at each time interval are shown in Table

2 and statistical results are shown in Appendix

A. Significant differences were noted in the

ratio of TC to HDL across time and between

groups (Appendix A-l). The differences between groups were significant at the pre- and

the post interval with ratios higher in the experimental group (Table 2 and Appendix A-2).

From pre- to post-patrol, no significant

change in Ratio occurred in either group (Table 2 and Appendix A-3) and no difference in

percent change was noted (Table 3). Two of

the control crews showed significant changes

in ratios during deployment (crew 2 increased, crew 3 decreased). One experimental

crew (6) showed a significant decrease in Ratio (Appendix B).

During the post-patrol period, the experimental group displayed a significant decrease

in Ratio (Table 2) and no difference was

found between groups when comparing percent change (Table 4, and Appendix A-3).

The final ratio measure was lower than the

pre-patrol value for the experimental group

only. Specifically, one control crew (1) and

one experimental crew (5) displayed increases

in Ratios during off-crew while one control

crew (3) and one experimental crew (6)

showed significant decreases (Appendix B).

Triglycerides (mg/dl)

Means and standard deviations for both

groups at each time interval are shown in Table 2 and statistical results are shown in Appendix A. Triglycerides measures showed

more variability than the other measures.

This is evidenced by the coefficient of variation, which for TG is twice as large as that of

any other variable (Table 1). The basic MANOVA on TG data revealed a significant difference across time for both groups

(Appendix A-2); only the experimental group,

however, met the significance level on the

Dunn's test (Appendix A-2).

During deployment, neither group revealed

a significant change in TG values, but the direction of change was an increase for the control

and a decrease for the experiment (Table 2

and Appendix A-3). There was a significant

difference between the two groups for percent

change in TG values (Table 3). While no

changes were noted for any of the control

crews during deployment, two of the experimental crews (5 and 6) displayed significant

declines in TG values (Appendix B).
During the off-crew period, both groups

displayed significant increases in TG values

with no difference in percent change between

groups (Table 4). For the control group only,

the final TG measure was significantly higher

than the pre-patrol value (Appendix A-3). Individually, one control crew (2) and two experimental crews (4 and 6) demonstrated

significant increases in TG values during off

crew (Appendix B).

Blood Pressure (mm Hg)

Systolic (SBP). Means and standard deviations for both groups at each time interval

are shown in Table 2 and statistical results are

shown in Appendix A. The MANOVA (Appendix A-l) revealed significant differences

across interval and between groups. An interaction was also found for interval by group.

The change over intervals was significant for

the experimental group, but not the control

group by the Dunn's criteria (Appendix A-2).

During the patrol period, only the experimental group showed a decrease in SBP (Appendix A-3). A significant difference was

found between the two groups for percent

change in SBP during the patrol (Table 3)

with the experimental group showing an 8%

decrease in SBP. Individually, a significant

decrease in SBP was demonstrated by one

control (1) and one experimental (4) crew (Appendix B).

Both groups showed a significant change

in SBP during the off-crew period with the

control group demonstrating a decrease and

the experimental group displaying an increase. Both groups showed significantly

lower final SBP than pre-patrol, but the

magnitudes of these differences were small

(Table 2 and Appendix A-3). A significant

difference was found between the groups for

percent change in SBP during this time with

the larger increase found for the experimental

group (Table 4). Whereas one control crew

(3) demonstrated a significant decline in SBP,

two of the experimental crews (4 & 6) displayed significant increases (Appendix B).

Diastolic (DBP). Means and standard deviations for both groups at each time interval

are shown in Table 2 and statistical results are

shown in Appendix A. The results for DBP

were somewhat similar to those for SBP. As

with SBP, there was a significant difference

found for DBP across time. There was, however, no difference between groups. An interaction was revealed for interval by group

(Table 2 and Appendix A-l). There was no

difference in diastolic BP between groups at

the pre-patrol or final measure, but there was

for the post-patrol measure (Appendix A-2).

During the deployment, only the experimental group showed a decrease in DBP

(7%), and a significant difference was found

between groups for percent change with the

experimental group showing a larger decrease

(Table 3). One control crew (1) and two experimental crews (4 and 6) demonstrated a significant decline in DBP during the

deployment (Appendix B).

The experimental group demonstrated significant increases (p < .05) in DBP during the

off-crew period. The difference in percent

change found between the groups was also

significant with the experimental group

change, again, larger (Table 4). Final DBP

measure was lower than pre-patrol for the experimental group only (Appendix A-3). Two

control (1 and 3) and two experimental crews

(4 and 6) displayed significant increases in

DBP during the off-crew period while one experimental crew (5) showed a decrease. (Appendix B)

Body Fat (%)

Means and standard deviations for both

groups at each time interval are shown in

Table 2 and statistical results are shown in
Appendix A. Multivariate analysis of variance showed no overall difference between

groups in BF % levels (Table 2 and Appendix

A-l). There was a significant difference

among the three time periods for BF%.

During the patrol cycle, both groups demonstrated significant declines in BF% and no

difference in percent change was evident between groups (Tables and Appendix A-3).

Each of the six crews demonstrated a significant decline in BF%.

Both groups displayed significant increases

in BF% during the off crew period and again

no difference between groups was found in

percent change (Tables and Appendix A-3).

Percent body fat at the end of the patrol was

not different than the pre-patrol for either

group (Appendix A). Four individual crews

revealed significant increases in BF% during

the off crew, two from each group (1 and 3; 4

and 5) (Appendix B).

Within Submarine Comparison of the Effect

of Education and Menu Modification

One of the submarines participated in the

study first as a control crew and then as an experimental crew. The control crew had the

first set of measurements taken in March, the

second set in May, and the final set in August

of 1993. The experimental crew had the first

set of measurements taken in August of 1993,

the second set in December 1993, and the final set in February 1994. During the research, several subjects were lost and some

were gained due to rotation of men off and

onto submarine duty. Following are results

for comparison of those subjects who completed both patrols (Control and Experimental).

Control Patrol

Lipid Profiles Immediately following the

control patrol, subjects showed a significant

increase in total cholesterol (6.1 mg/dl) and

LDL cholesterol (6.5 mg/dl) above pre-patrol

values. This change was also reflected in a

small increase in the TC/HDL ratio (.17).

There were no changes in triglycerides or

HDL cholesterol. At the final measurement,

LDL levels were the same as those of the postpatrol. Total cholesterol levels were further

increased over the post-patrol levels (6.3

mg/dl) at the final measurement, but there was

no accompanying change in ratio.

Blood pressure and percent body fat. The

only significant change in any blood pressure

measure was a 6.0 mm Hg mean rise in systolic pressure from pre-patrol to post-patrol.

There was also a significant drop in percent

body fat (.8%) from pre-patrol to post-patrol.

Experimental Patrol

Lipid Profiles. When these same subjects

participated in a patrol including menu modification and nutrition education, a different pattern of change was observed. Both total

cholesterol (11.2 mg/dl) and LDL cholesterol

(5.6 mg/dl) decreased at the post-patrol measurements.

These values both increased over the postpatrol values at the final measurement (cholesterol 17.7 mg/dl; LDL 15.1 mg/dl). HDL

values decreased from pre-patrol to post-patrol by 4.7 mg/dl and rose again by 2.5 mg/dl

for the final measurement. This final measurement was 4.6 mg/dl lower than the pre-patrol

level. There was no change in ratio from preto post-patrol, but there was a significant increase from post-patrol to the final measurement (.46). Triglyceride levels did not

change.

Blood pressure and percent body fat.

There were no changes in any of the blood

pressure measurements for the experimental

patrol. Percent body fat decreased by .7% during the patrol and increased again by .8% at

the final measurement. Pre-patrol percent

10
body fat was no different from the final measurement.

Within Submarine Comparison Across

Control and Experimental Conditions

Because these are the same men, it is possible to compare the initial measurements taken

before the first control patrol to the final measurements taken following the experimental patrol to determine any lasting changes for these

men. Final measurements for total cholesterol

were 18.9 mg/dl greater than the pre-patrol

measures for the control patrol, 17.4 mg/dl for

LDL and 17.2 mg/dl for triglycerides. HDL

levels were 2.3 mg/dl lower at the final measurements across the same time period. Percent

body fat was .7% lower at the final measurement. Note that these sets of samples were all

taken after approximately 3 months ashore, in

a non-deployed status.

Discussion

The experiment demonstrated that both

groups showed some degree of decrease in

CHD risk factors from pre- to post-patrol.

Specifically, the control group displayed

significant decreases in three variables (TC,

LDL, BF%), while the experimental group displayed significant decreases in five (TC, LDL,

SBP, DBP, BF%). Concurrently, both groups

also demonstrated significant declines in HDL

values during deployment, typifying an increase in CHD risk (Garber, et al., 1989; Hunninghake, et al., 1993). Decreases in the

levels of all CHD risk related variables (except HDL) are considered positive with respect to lowering CHD risk (Manson, et al.,

1992; Stehbens, 1990).

During the off-crew period, both groups

demonstrated significant increases in four variables (TC, LDL, TG, BF%). Increases in

these levels are associated with greater risk

for CHD (Garber, et al., 1989; Manson, et al.,

1992; Stehbens, 1990). Systolic blood pressure was the only variable for which the two

groups showed opposite changes. The control

group displayed a decline, and the experimental group showed an increase. There was no

change in DBP for the control group while

there was an increase for the experimental

group. The experimental group demonstrated

significant declines in Ratio (TC/HDL) during

the off-crew, but there was no difference in

perent change between the groups.

Some of these results demonstrate that nutrition education and diet modification had a

small additional beneficial effect on reducing

CHD risk when compared to no intervention.

When considering CHD risk factors, the results also demonstrate that the deployment cycle was healthier for all submarine crews than

was the off crew period.

Percent Change

Comparison of the percent changes that occurred during deployment provided a clearer

view of what occurred between the two

groups (Table 3). No differences were found

between the two groups for five variables

(TC, HDL, LDL, Ratio, BF%). The control

group fared better when comparing changes

in HDL values, because, although both groups

displayed statistically significant decreases,

the control group's decline (3.6% = 2.2

mg/dl) was significantly less than that of the

experimental group (5.0% = 3.4 mg/dl). Data

suggest that a 2 to 3 percent increase in CHD

risk is associated with a 1 mg/dl decrease in

HDL for an individual (NIH, 1992). Therefore, these results might be considered clinically important even though the decline in

HDL appears small for both groups.

The experimental group, however, did much

better during deployment than the control

group with respect to percent difference (preand post-patrol) for SBP, and DBP. The experimental group had a significant decrease

in both variables, while the control group

11
showed no change. Similarly, the experimental group had a smaller increase in TG level

than shown by the control group. This suggests less risk for CHD in the experimental

group (Garber, et al., 1989; Manson, et al.,

1992; Stehbens, 1990).

Of the three control submarines, crew 3

had by far the best pre- to post-patrol results

with respect to lowering CHD risk. This crew

lowered their TC, LDL, Ratio, and BF% significantly during deployment, thereby decreasing overall risk for CHD.

Subjectively, it appeared that crew 3 was

definitely more nutrition and health conscious

prior to their participation than other crews.

This observation is based on several pre-study

interviews and briefings with the Commanding Officer, Food Service Officer, and Mess

Management Specialists. It is also based on

reviews and nutrition analysis of their menu

used during the study. If this is true, this variable confounds the results.

Crew 6 was the only submarine crew to

demonstrate an improvement (4.6% increase)

in HDL values during deployment. This

change, ifsignificant, would be considered

clinically important. In the Lipid Research

Clinic's Coronary Primary Prevention Trial, a

3% increase in HDL was correlated with a 2%

decline in CHD risk (NIH, 1992). Crew 6

also displayed significant improvement with

decreases in five other variables (TC, Ratio,

TG, DBP, BF%). Overall, crew 6 demonstrated the best results with respect to lowering CHD risk. This crew, in particular, had

an extremely involved nutrition educator/research monitor on board during the patrol.

This individual played an integral part in furthering the subjects' education while deployed. He was a working member of the

Food Service Division and was involved in

preparing and serving food. This allowed him

daily one-on-one contact with all test subjects

as they came through the serving line and

asked for advice on choosing lower fat foods.

Research monitors on the other two experimental boats were not actively involved with

the preparation or serving of food.

Only one of the control crews showed improvement from pre- to post-patrol. However, all three of the experimental crews did

as well or better and appear to have benefited

from the intervention.

In general, CHD risk increased for both

groups during the off-crew period, since values for six variables increased during this

time. A significant difference was noted between groups for only three variables (LDL,

SBP, DBP) during the off-crew interval. Possible reasons for this pattern of results: a) the

diets of the experimental group during the off

crew period were worse than with the experimental menu, and/or b) nutrition education

had no lasting effect on subjects' dietary

choices.

It appears that the off-crew period was less

conducive to maintaining or improving risk

factors for CHD compared to the patrol period.

The results from the single within boat

comparison indicate that the men benefited

from the study intervention when comparing

values for CHD risk factors displayed from

their control deployment period to their experimental deployment period. The results

suggest a positive temporary effect of diet

modification but no lasting effect of nutrition

education.

Risk Factors

The hypothesis of this study was that nutrition education and diet modification would

have a beneficial effect on CHD risk factors.

The mechanisms underlying these effects,

12
however, vary. They are discussed below in

relation to the findings of this study.

Lipids

It has been stated that a 10% to 15% reduction in serum cholesterol level resulting from

the diet modification should reduce CHD risk

by 20 to 30%, especially for those who have

levels in the 250-300 mg/dl range (NIH,

1988). In light of this information, the 7.6%

decline of TC observed in the experimental

group during deployment would be considered beneficial. This decline in TC values,

however, could also have been caused in part

by the decrease in BF% observed (NIH, 1992).

In addition, decreases in HDL levels are

also encountered, both following weight loss

and in response to diets which are lower in total fat, saturated fat, and cholesterol. These

decreases in HDL levels brought about by

lower total fat intake, however, can be prevented or attenuated by aerobic exercise

(NIH, 1992; Hunninghake, et al., 1993;

Miller, Seidler, Kwierovich, & Pearson,

1992). It is also known that exercise increases HDL values and decreases plasma TG

and the risk of CHD (NIH, 1990; Manson, et

al., 1992; NIH, 1992; National Cholesterol

Education Program [NCEP], 1993). Active

smoking decreases HDL and is itself a risk

factor for CHD. The Consensus Development

Conference Statement on triglyceride, high

density lipoprotein and CHD reported that recent data suggests that passive smoking also

decreases HDL levels (NIH, 1992). Use of

alcohol increases HDL levels in some individuals (NIH, 1992).

In this study, HDL values declined during

deployment in all but one of the crews. These

decreases may have been caused by: a) decreases in the amount of aerobic exercise performed, b) exposure to second hand smoke,

c) lower total fat or saturated fat intake, or

d) a combination of the above.

Other factors besides exercise can also

cause changes in TG values. It is known that

alcohol increases plasma TGs in some people.

On the other hand, plasma triglycerides will

decrease in response to a lower intake of total

fat and saturated fat, and frequently weight

loss will help to lower plasma TG values

(NIH, 1992).

The decreases in TG observed following

deployment may be related (at least partially)

to the prohibition of alcohol consumption during deployment. The effect of a lack of alcohol during patrol on HDL values is unclear

since HDL actually declined in 5 crews. All

crews lost BF% during the patrol, and this may

have been what brought about the decreased

in TG observed.

The results revealed that LDL values decreased in five of the crews during deployment which is an improvement since

decreases in LDL levels are associated with

decreased CHD risk. However, HDL values

also decreased during this time which increases CHD risk. Both declines could have

been caused by the change in diet, yet the net

effect on the risk of CHD of reduction of both

LDL and HDL levels is still not clear (Sacks

& Willet, 1991).

Blood Pressure:

Hypertension is a consistent and modifiable cause of CHD (Stokes, Kannel, Wolf,

D'Agostino, & Cupples, 1989). Data confirm

that systolic blood pressure is a better predictor than is diastolic pressure. This finding is

consistent with the fact that isolated systolic

blood pressure can predict the incidence of

CHD, stroke, and coronary heart failure for

those with a diastolic pressure less than 90

mm Hg (Stokes, et al., 1989).

In this study, SBP declined significantly

during deployment in one control and one experimental crew. DBP declined significantly

13
in three crews (one control, two experimental). For CHD risk level, these changes are

considered positive. During the off-crew period, however, no consistent changes were observed within groups or between groups for

either SBP or DBP, therefore it is difficult to

assess whether risk for CHD was affected for

either group.

Seasonal Variations of Lipids

To make matters more complicated, not

only are lipid levels affected directly by factors such as diet and exercise, it is known that

seasonal variations in cholesterol of approximately 3-5% exist. Cholesterol tends to be

higher in the winter and lower in the summer

months. Levels for HDL follow a similar pattern. Researchers believe that seasonal

changes in physical activity, diet, and/or other

factors may contribute to some extent to these

changes (NIH, 1990). Ideally, pre-, during-,

and post- patrol data should have occured at

the same time(s) of year. This could be a confounding factor in the present results.

Summary

In summary, this study reveals that CHD

risk factors appear to be favorably modified

during at sea periods, even in the absence of

dietary change or education. U.S. Navy submarine personnel benefit from nutrition education and diet modification by decreasing risk

for CHD. Nutrition education and dietary

changes during a submarine patrol had a small

additional benefit on CHD risk by lowering

triglycerides and blood pressure.

What remains unclear is the relative roles

of diet modification and the nutrition education in reducing or modifying the CHD risk

factors.

Our findings show that submariners are at

somewhat greater risk for CHD during the offcrew period than they are during deployment.

We were unable to find any reports that addressed how long term cyclic increases and decreases (like those observed) in CHD risk factors affect the health of the general population

and specifically of submariners. To improve

CHD risk, lasting changes in personal health

and eating habits are required; education may

assist in this process.

The total cost of CHD in the U.S. is staggering, costing the nation between $50 and

$100 billion each year for medical treatment

and lost wages (NCEP, 1993). Prevention of

CHD, therefore, could reduce this economic

burden (Garber, et al., 1989; NCEP, 1993).

One inexpensive way to reduce CHD may be

through education targeted at preventing or reducing the major risk factors for CHD, especially high blood cholesterol, lack of exercise,

high blood pressure, and smoking (NCEP,

1993).

Conclusions

1. Coronary heart disease risk factors appear to be favorably modified during at-sea periods.

2. A nutrition education program followed

up by dietary modification during submarine

deployment had a small additional beneficial

effect on CHD risk factors.

3. Broader use of the nutrition education

program throughout the U.S. Navy and Department of Defense is not strongly supported

by these results.

4. Implementation of a low fat menu and

storage of the required food aboard TRIDENT

submarines can be easily accomplished with

no additional expense and with strong crew

acceptance.

14
Acknowledgments Graham, C, & Good, D. (1987). Nutrition.

The authors are indebted to the Command- In: R. J. Donateile (Ed.), Heart at work

ing Officers and their crews from the USS trainer's manual. Portland, OR: Ameri-

• MICHIGAN (SSBN 727) (B), USS PENN- can Heart Association, Oregon Affiliate.

SYLVANIA (SSBN 735) (B), USS HENRY

M JACKSON (SSBN 727) (B), USS WEST Hoiberg, A., Bernard, S. P., & Watten, R. H.

VIRGINIA (SSBN 727) (B), and the USS (1980). Correlates of obesity. Journal of

KENTUCKY (SSBN 737) (G) for their sup- Clinical Psychology, 36(4), 983-91.

port and cooperation. It is also a pleasure to

acknowledge HM1 Rick Garstenshlager, Howell, D. C. (1992). Statistical methodsfor

HM1 Todd Brewer, MSCS Mark Martin, psychology. Belmont, CA: Duxbury Press.

HMCS Edsel Wright, Ms. Carol Mergen, LT

Joel Smithwick, CDR Sandra House, Ms. Hunninghake, D. B., Stein, E. A., Dujovne, C.

Michelle Stallworth, and Ms. Sue Monty for A., Harris, W. S., Feldman, E. B., Miller,

their excellent technical assistance. V. T., Tobert, J. A., Laskarzewski, P. M.,

Quiter, E., & Held, J., Taylor, A., Hopper,

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17
18
APPENDIX A
Table A-l

Multiple analysis ofvariance for CHD risk variables

Source df F

Between Subjects - Group

TC (mg/dl) 1,532 2.50

HDL (mg/dl) 1,519 40.00**

LDL (mg/dl) 1,519 6.44*

TG (mg/dl) 1,516 1.30

Ratio (TC/HDL) 1,519 27.70**

SBP (mmHg) 1,524 18.31**

DBP (mmHg) 1,524 4.52

BF (%) 1,508 .09

Within Subjects - Interval (Pre, Post, Final)

TC (mg/dl) 2,1064 85.50**

HDL (mg/dl) 2,1038 78.49**

LDL (mg/dl) 2,1038 20.92**

TG (mg/dl) 2,1032 13.38**

Ratio (TC/HDL) 2,1038 8.55**

SBP (mmHg) 2,1048 34.43**

DBP (mmHg) 2,1048 46.98**

BF (%) 2,1016 74.61**

Within Subjects - Group x Interval

TC (mg/dl) 2,1064 1.59

HDL (mg/dl) 2,1038 2.51

LDL (mg/dl) 2,1038 1.52

TG (mg/dl) 2,1032 3.90

Ratio (TC/HDL) 2,1038 1.16

SBP (mmHg) 2,1048 32.68**

DBP (mmHg) 2,1048 24.44**

BF (%) 2,1016 .90

* p < .01

**p<.001

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Table A-3

T test results for within group comparisonsfor the control and experimental groupsfor

three intervals (pre to post, post to final, pre to final)

Pre to Post Patrol Post to Final Pre to Final

Variable Control t

4.96**

Exp t Control t Exp? Control t

-3.67**

Expt

TC (mg/dl) 6.38** -9.14** -8.31** -3.43**

HDL (mg/dl) 5.55** 6.22** -7.87** -8.71** -5.39** -2.96*

LDL (mg/dl) 4.14** 4.95** -3.06* -3.87** 1.14 -.31

TG (mg/dl) -1.17 2.98 -2.61* -3.92** -4.02** -1.44

Ratio (TC/HDL) -.14 .7 2.21 -2.50* 1.76 2.62*

SBP (mmHg) -.14 10.07** 2.63* -5.31** 3.26** 5.72**

DBP (mmHg) 2.36 9.15** -2.11 -5.31** .27 5.74**

BF (%) 7.80** -794** -7.08** -7.09** 1.86 -.06

** p < .001

* p < .01

Appendix A-3
Appendix A-4
APPENDIX B
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UNCLAS5IFIED

TCATIOWOFTHIS"

REPORT DOCUMENTATION PAGE Form Approved

OMB No. 074-0188

1a. REPORT SECURITY CLASSIFICATION

UNCLASSIFIED

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NSMRL Report 1201

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6a. NAME OF PERFORMING ORGANIZATION

Naval Submarine Medical

Research Laboratory

6b. OFFICE SYMBOL

(IfApplicable)

7a. NAME OF MONITORING ORGANIZATION

Naval Medical Research and Development

Command

6c. ADDRESS (City, State, Zip Code)

Box 900, Naval Submarine Base

NLON,

Groton, CT 06349-5900

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11. TITLE (Include Security Classification)

(U) Nutrition education and diet modification aboard submarines

12. PERSONAL AUTHOR(S)

C. L. Shake & C. L. Schlichting

13a. TYPE OF REPORT

Technical

13b. TIME COVERED

FROM TO

14. DATE OF REPORT (Year, Monti, Darf

1996 June 27

15. PAGE COUNT

27

16. SUPPLEMENTARY NOTATION

17. COSATI CODES

FIELD GROUP SUB-GROUP

18. SUBJECT TERMS (Continue on reverse ifnecessary and identify by block number)

Nutrition education, diet modification, submarines, CHD risk

19 ABSTRACT (Continue on reverse if necessary and identify by block number)

During a one year period, 534 male, US Navy submariners participated in a nutrition research project

designed to reduce coronary heart disease (CHD) risk. The research was carried out on board USN Trident

Submarines before, during, and following actual patrols. Subjects from six submarine crews were assigned to

either the education / diet group (E) or the control group (C). Group E was provided nutrition education and a

modified 5 week cycle menu which focused on decreasing the percentages of caloric intake derived from fat

and high cholesterol food. Group C received NO intervention. Measurements of cholesterol (TC), high

density lipoprotein cholesterol (HDL), low density lipoprotein cholesterol (LDL), triglycerides (TG), Ratio

(TC/HDL), blood pressure (BP), and body fat (BF%) were taken before and after deployment and again after

the off crew period. Age, height, and weight data were also gathered. The data were analyzed with the

MANOVA procedure using a mixed multivariate model with repeated measures on the two groups.

Following the patrol one of the three control crews demonstrated statistically and clinically significant

decreases in TC, HDL, LDL, and ratio and another crew showed a significant decrease in BP (systolic).

Within the education group (3 crews) several significant decreases occurred during deployment: TC declined

(3 crews), LDL and HDL declined (2 crews), ratio declined (one crew), and TG declined (2 crews). All six

20. DISTRIBUTION/AVAILABILITY OF ABSTRACT

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22a. NAME OF RESPONSIBLE INDIVIDUAL

Susan D. Monty, Ed.

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(860) 449-3967

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19. cont.

crews demonstrated a statistically significant decrease in BF% during deployment. Changes were noted

following the off crew period. Both groups demonstrated increases in most variables.

The experiment demonstrated that regardless of education or menu intervention, subjects showed some

reduction in CHD risk factors during deployment.

The results also demonstrated that the nutrition education and diet modification intervention had a great©

beneficial effect on reducing CHD risk factors when compared to no intervention.

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