1. Please give a brief overview of what your session will cover at Medical Innovation 2018?

The endocrine effects of arduous military training on women: evidence from Antarctica and  Sandhurst

High rates of adverse reproductive, psychological and bone health-related outcomes have been reported in military women, compared with men or civilian women. While the reasons for this are poorly understood, hormones are thought to be responsible, since they mediate differences in sex.  Sqn Ldr Gifford will present data from two observational studies which have attempted to understand the nuances of female hormone physiology in arduous training and their impact on reproduction, stress and bone.

The Army Ice Maidens were the all-female first team to complete an Antarctic ski traverse unassisted. The expedition provided a unique investigation of the absolute extremes of exercise, with detailed dynamic hormone testing, body composition measurement and high resolution bone architecture scans to explore the impact of the expedition on women and the rates of recovery.

The Commissioning Course at the Royal Military Academy, Sandhurst is an arduous, year-long basic military training course undertaken by male and female Officer Cadets. The Female Endocrinology in Arduous Training (FEAT) Study’s objective is to understand the reproductive, stress, bone health and nutritional changes in 60 women in military training ab initio. The preliminary findings compare a subgroup with a cohort of 10 men.

The session will describe the studies from Antarctica and sex comparator aspects of the FEAT Study and discuss their findings, before exploring the implications for women entering arduous training.

2. What do you think understanding the future of such an unexplored topic looks like, and how will it shape the way medical practices develop?  

 From what is already known, women and men experience different medical outcomes during military training and employment. By understanding the biological underpinning these differences we aim to develop evidence-based mitigation strategies to promote training equity (rather than just equal opportunities). As well as protecting our women from injury and illness, an improved understanding of the aetiology will equip policymakers and individuals to make evidence-based decisions about training and employment. Furthermore, studies like these may allow medical practice and military training design to become more closely aligned. Emerging technologies like mobile health applications and sensors can enable long term data collection, allowing doctors to assess and improve training outcomes. Using these data we could ultimately generate tailorable training programmes to avoid undue risk to Defence personnel without compromising combat effectiveness.

3. What is your understanding of ‘prolonged care’ and ‘preparedness’ and its relevance to the wider medical community? Any recently publicised events are welcome examples.

The causes of many psychological and musculoskeletal injuries are related to individual physiology, however the precise causal pathways are poorly understood. Our research aims to understand the features of arduous military training and employment which cause physiological strain. Understanding risk factors will allow prolonged field care (PFC) providers to identify and manage risk, allow medical operations to be planned and commanded with a better expectation of risks to individuals, and identify ‘left of bang’ interventions, by describing and mitigating individuals’ injury risks during selection and training.

The Ice Maidens recently demonstrated exceptional biological resilience during an exceptionally arduous exercise exposure – far greater than has been seen in specialist military training. The reasons for this could be simple factors, for example they had an incremental training package rather than an abrupt-onset one, and they were afforded appropriate rest, where possible. These may be salutary lessons for preventing injury in the field.

Through the FEAT Study, we aim to validate and deliver mobile health applications which we hope could facilitate data collection across meaningful durations of training and deployment, and implement positive behavioural change to mitigate against illness or injury. Such platforms could also have great benefits to PFC delivery, allowing data collection from PFC providers.

4. What developments have been made in medical innovation in the last 12 months that particularly stand out, and why?

A study using mobile apps for research data collection has recently been published in the Canadian Armed Forces (Ahmed et al. Nutrients, 2017). The results are promising, and mobile health applications may represent a force multiplier for prolonged field research and behaviour change interventions, from prevention of injury and illness to delivery of military healthcare. However, significant concerns have been raised about data security with commercial health apps. We have therefore commenced the development of an app to coincide with the completion of the FEAT Study, to implement the behaviour changes highlighted or as a platform for further research that will be indicated.

5. What, in your opinion, present the biggest challenges to the development of ‘prolonged care’?

The PFC environment is largely undescribed, therefore prolonged field research is necessary to understand the challenges this environment provides. Such research could take place in training or operations. It should combine qualitative and quantitative approaches, to create a provider-centred depiction of the potential challenges and how these can be managed.

In area of interest, the critical factor not to miss is that prevention is better than cure, and ‘left of bang’ interventions begin at selection and training. The sex-differential in a variety of pertinent conditions, such as heat illness, stress fracture, post-traumatic stress disorder and infertility highlights that more can be done to understand and optimise physiology in order to develop mitigation strategies.

6. What are your priorities for the next year ahead?

Following the completion of the FEAT study, we aim to highlight the findings to policymakers, in order to implement effective preventative measures. It will be necessary to involve non-medical stakeholders and approach this creatively to avoid degrading the quality of training. Further research will also be required to better understand potential mitigating factors, such as the beneficial effects of sleep and strategies for coping with stress.

Medical Innovation attracts attendees from the military and civil healthcare community, from trainees to surgeons and scientists to policy makers, as well as industry suppliers of medical equipment and services. In your view, who/which professions will your session appeal to?

I very much hope policy makers, scientists with an interest in sports and nutrition physiology, trainees, and industry partners involve in mHealth might be interested in the session.