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VVEIGHT MANAGEMENT State of the Science and Opportunities for Military Programs Subcommittee on Military Weight Management Committee on Military Nutrition Research Foocl and Nutrition Board INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES TH E NATIONAL ACADEMI ES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee re- sponsible for the report were chosen for their special competences and with re- gard for appropriate balance. Support for this project was provided by U.S. Army Medical Research and Ma- teriel Command through contract no. DAMD17-99-1-9478. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014, is the awarding and administering acquisition office. The views presented in this report are those of the Subcommittee on Military Weight Man- agement and are not necessarily those of the funding agency. International Standard Book Number 0-309-08996-4 (Pbk) International Standard Book Number 0-309-52681-7 (PDF) Library of Congress Control Number: 2003111596 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among al- most all cultures and religions since the beginning of recorded history. The ser- pent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"~(nowin,g is not enough; we must apply. Willin,g is not enough; we must do." Goethe _-- 'A INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineenng, ondMedirine The National Academy of Sciences is a private, nonprofit, self-perpetuat- ing society of distinguished scholars engaged in scientific and engineering re- search, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the fed- eral government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of out- standing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Acad- emy of Sciences to secure the services of eminent members of appropriate pro- fessions in the examination of policy matters pertaining to the health of the pub- lic. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engi- neering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academ ies.org

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SUBCOMMITTEE ON MILITARY WEIGHT MANAGEMENT RICHARD L. ATKINSON, JR. (chair), Obesity Institute, MedStar Research Institute, Washington, D.C. JOHN E. VANDERVEEN (vice-chair), San Antonio, Texas WILLIAM H. DIETZ, Division of Nutrition and Physical Activity, Centers for Disease Control and Prevention, Atlanta, Georgia JOHN D. FERNSTROM, UPMC Health System Weight Management Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania ARTHUR FRANK, Weight Management Program, The George Washington University, Washington, D.C. BARBARA C. HANSEN, Obesity and Diabetes Research Center, University of Maryland School of Medicine, Baltimore STEVEN B. HEYMSFIELD, Human Body Composition Laboratory and Weight Control Unit, St. Luke's-Roosevelt Hospital, New York ROBIN B. KANAREK, Graduate School of Arts and Sciences, Tufts Univer- sity, Medford, Massachusetts. BARBARA J. MOORE, Shape Up America!, Washington, D.C. Staff MARY I. POOS, Study Director LESLIE J. VOGELSANG, Research Assistant (from October 2001) HARLEEN K. SETHI, Senior Project Assistant (from February 2002) TAZIMAA. DAVIS, Senior Project Assistant (through November 2001)

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COMMITTEE ON MILITARY NUTRITION RESEARCH JOHN E. VANDERVEEN (chair), San Antonio, Texas BRUCE R. BISTRIAN, Department of Medicine, Harvard Medical School, Boston, Massachusetts JOHANNA T. DWYER, Frances Stern Nutrition Center, TuDs New England Medical Center, Boston, Massachusetts HELEN W. LANE, Johnson Space Center, National Aeronautics and Space Administration, Houston, Texas MELINDA M. MANORE, Department of Nutrition and Food Management, Oregon State University, Corvallis WILLIAM P. MORGAN, Sport Physiology Laboratory, University of Wis- consin, Madison PATRICK M. O'NEIL, Weight Management Center, Medical University of South Carolina, Charleston ESTHER M. STERNBERG, Neuroendocrine Immunology and Behavior Section, National Institute of Mental Health, Bethesda, Maryland BEVERLY J. TEPPER, Department of Food Science, Rutgers University, New Brunswick, New Jersey U.S. Army Grant Representative LTC KARL E. FRIEDL, USA, Military Operational Medicine Research Pro- gram, U.S. Army Medical Research and Materiel Command, Fort Detrick, Frederick, Maryland Stay MARY I. POOS, Project Director LESLIE J. VOGELSANG, Research Assistant HARLEEN K. SETHI, Senior Project Assistant V1

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FOOD AND NUTRITION BOARD CATHERINE E. WOTEKI (chair), College of Agriculture, Iowa State University, Ames ROBERT M. RUSSELL (vice chair), U.S. Department of Agriculture Jean Mayer Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland SUSAN FERENC, SAP Risk, LC, Madison, Wisconsin NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, D.C. PER PINSTRUP-ANDERSEN, Division of Nutritional Sciences, Cornell University, Ithaca, New York A. CATHERINE ROSS, Nutrition Department, The Pennsylvania State University, University Park BARBARA O. SCHNEEMAN, Department of Nutrition, University of California at Davis NICHOLAS J. SCHORK, Polymorphism Research Laboratory, University of California, San Diego JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison STEVE L. TAYLOR, Department of Food Science and Technology and Food Processing Center, University of Nebraska, Lincoln BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, The Pennsylvania State University, University Park Staff ALLISON ~4. YATES, Director LINDA MEYERS, Deputy Director GAIL SPEARS, Staff Editor GERALDINE KENNEDO, Administrative Assistant GARY WALKER, Financial Associate vii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Catherine M. Angotti, Occupational Health, National Aeronautics and Space Administration; George A. Brooks, Department of Integrative Biology, University of California, Berkley; Anthony G. Comae, Department of Genet- ics, Southwest Foundation for Biomedical Research; James L. Early, Depart- ment of Preventive Medicine, University of Kansas-Wichita; Esther F. Myers, Scientific Affairs and Research, American Dietetic Association; Janet Rankin, Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic In- stitute and State University. Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Shiriki Kumanyika, Center for Clini- cal Epidemiology and Biostatistics, University of Pennsylvania School of Medi- cine. Appointed by the Institute of Medicine, she was responsible for making certain that an independent examination of this report was carried out in accor- dance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring subcommittee and the institution. . . . vail

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Preface This publication is the latest in a series of reports based on reviews of the scientific literature and workshops sponsored by the Committee on Military Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), Institute of Medicine, the National Academies. A subcommittee of CMNR, the Subcommit- tee on Military Weight Management, was appointed to organize a workshop and prepare a report based on information presented at a workshop, a review of the scientific literature, and the subcommittee's expertise and deliberations. Other workshops or symposia conducted by CMNR have dealt with topics such as food components to enhance performance; nutritional needs in hot, cold, and high-altitude environments; body composition and physical performance; nutrition and physical performance; cognitive testing methodology; fluid replacement and heat stress; and antioxidants and oxidative stress. These workshops form part of the response that CMNR provides to the Commander of the U.S. Army Medical Research and Materiel Command (USAMRMC) regarding issues brought to the committee through the Military Operational Medicine Research Program at Fort Detrick, Maryland, and the Military N'utri- tion Division of the U.S. Army Research Institute of Environmental Medicine at Natick, Massachusetts. HISTORY OF THE COMMITTEE The CMNR was established in October 1982 following a request by the As- sistant Surgeon General of the Army that the Board on Military Supplies of the National Academy of Sciences set up a special committee to advise'the U.S. Department of Defense (DOD) on the need for and conduct of nutrition research and related issues. This committee was transferred to the oversight of FNB in 1983. The committee's primary tasks are to identify factors that may critically influence the physical and mental performance of military personnel under all environmental extremes; to identify knowledge gaps and recommend research 1X

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x PREFACE that would remedy these deficiencies; to recommend approaches for studying the relationship of diet to physical and mental performance; and to review and advise on military feeding standards. As a standing committee of IOM, the membership of CMNR changes peri- odically. However, the disciplines represented consistently have included human nutrition, nutritional biochemistry, performance physiology, food science, die- tetics, psychology, and clinical medicine. For issues that require broader exper- tise than exists within the committee, CMNR has convened workshops, utilized consultants, or appointed subcommittees with expertise in the desired area to provide additional state-of-the art scientific knowledge and informed opinion to aid in deliberations. BACKGROUND Following the release of the 1995 IOM report, Recommendations for Research on the Health of Military Women, CMNR was asked to review existing military policies governing body composition and fitness as part of the Defense Women's Health Research Program. In particular, the committee was asked to determine if existing body composition and appearance standards for women were in conflict with body composition requirements for task performance, and whether those same standards might actually interfere with readiness by encouraging chronic dieting, inadequate nutrient intake, or dangerous eating practices. In March 1998, the CMNR Subcommittee on Body Composition, Nutrition, and Health of Military Women released its report, Assessing Readiness in Military Women: The Relationship to Body Composition, Nutrition, and Health. This report made a number of key recommendations: . Incorporate the use of body mass index and fitness assessment into the current two-tiered body composition assessment procedures. Increase emphasis on fitness for readiness in military personnel. . Develop and validate a single service-wide circumference equation for the assessment of women's body fat. . Develop task-specific, gender-neutral strength and endurance tests and standards for use in determining placements in military occupational specialties requiring moderate and heavy lifting. . Encourage military personnel to achieve and maintain healthy weights through a continuous exercise and fitness program. goal. Provide nutrition education and ongoing counseling if weight loss is a Similar recommendations had been made in a 1992 CMNR report, Body Composition and Physical Performance, which first suggested that a military body composition standard should be based primarily on the ability to perform

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PREFACE x ~1 required physical tasks and secondarily on long-term health implications, and that all the services should develop job-related physical performance standards for accession into military service. THE COMMITTEE'S TASK In July 1999, CMNR was requested to review existing data on (1) optimal components of a weight-management program, (2) the role of age, gender, and ethnicity in weight management, and (3) current DOD activities in weight management; and to provide recommendations for military weight-management programs. This request for a review of effective military and civilian weight-loss and weight-management programs originated from the Director of Military Operational Medicine Research at USAMRMC. Subsequently, a subgroup of CMNR participated in a series of conference calls with USAMRMC and CMNR staff to identify the key areas that should be reviewed and to solicit suggestions for names of scientists who were active in the research fields of interest to serve as workshop speakers or as members of the subcommittee. The subcommittee was appointed in September 1999, and on October 24- 27, 1999, it convened a workshop in response to the request from the Army. The purpose of this workshop was to gather a group of experts to: . services, Share knowledge and experience in managing weight control within the Gain relevant knowledge and experience from industry and academia, Develop a consensus toward a more standard DOD-wide approach to weight management that utilizes state-of-the-art knowledge and practices, Examine current interventions and those under development, particu- larly in the pharmaceutical industry, and . Evaluate their appropriateness for military application or the need for further research. . The subcommittee was charged to identify the most effective interventions for weight loss and maintenance, particularly those most effective for the nonobese overweight individuals found in the military setting. Specifically, the subcommittee was asked to address the following questions: 1. What are the essential components of an effective weight/fat loss pro- gram, and the most effective strategies to sustain weight loss? 2. How do age and gender influence success in weight-management pro- grams? Should age be considered in weight/fat standards, and in weight- management programs and interventions? 3. Which strategies would be most and least effective in a military set- ting? Should military weight/fat loss programs involve direct participation inter-

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. . X11 PREFACE ventions, or only monitoring and guidance? Should military programs be more proactive in identifying and discouraging ineffective or dangerous weight-loss practices? Is a warning or cautionary zone prior to enrollment into a weight- control program an effective strategy? When should duty time be authorized for participation in intervention strategies for weight/fat loss? 4. To what extent should weight-control programs/policies be standard- ized across the services, versus tailored to the individual service, installation or unit? What are the advantages and disadvantages of standardization? Is the pro- vision of state-of-the-art techniques and knowledge a rationale for standardiza- tion? 5. How can diet be effectively dealt with as a weight-management com- ponent in the military setting? Should pharmacological treatment (anorexiants) be considered for use in the military? In what cases? What factors bear on this decision? 6. How should resistiveness for weight/fat control be dealt with? 7. What are the knowledge gaps in weight-management programs relative to the military? What research is needed? To accomplish this task, the subcommittee's workshop brought together the personnel responsible for both DOD-wide and service-specific weight-control program policies; a representation of military weight-control program leaders and innovators; and key military, academic, and industry researchers. The subcommittee reviewed the workshop presentations and the relevant scientific literature and developed a consensus statement on the optimal content for a weight-control program that could be utilized across the services. In the extensive interval since the workshop, the subcommittee has updated their report, incorporating recent references and military data where they were available. In November 2002, DOD released its revised Instruction 1308.3, DOD Physical Fitness and Body Fat Program Procedures, and has made some important changes, which the subcommittee applauds. These new guidelines are noted throughout the report as appropriate. ORGANIZATION OF THE REPORT Chapter 1 of this report provides background information on the current demographics of the U.S. population. It then describes the military's interest in body-weight and body-fat standards and the implications of these standards for health, performance, fitness, and appearance. Weight standards and weight- management programs currently provided by each of the services and issues of concern related to these programs are described in Chapter 2. Chapter 3 briefly reviews the factors that affect body weight, and Chapter 4 reviews the strategies for weight management. Chapter 5 provides the subcommittee's specific responses to the military's questions; Chapter 6 presents the subcommittee's

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PREFACE . . . X111 conclusions and recommendations and identifies research needs. The workshop agenda and speaker abstracts are presented in Appendix A, and the biographical sketches of the speakers and subcommittee members appear in Appendixes B and C, respectively. ACKNOWLEDGMENTS It is my pleasure as chairman of the Subcommittee on Military Weight Management to acknowledge the contributions of the ENB staff. Their dedication in the planning and organization of the workshop and the editing of this report made it possible for the subcommittee to respond to the Army's request. In particular, I wish to acknowledge the extensive efforts of Mary I. Poos, the senior staff officer for CMNR. She worked diligently with the subcommittee members in securing the expert panel of speakers and organizing the program for the workshop into coherent sessions, and she contributed substantially to the writing and final updating of the report in response to review. I also wish to acknowledge Ms. Leslie Vogelsang, research assistant to CMNR, for her diligence in checking references and finding missing references; and Ms. Harleen Sethi and Ms. Tazima Davis, senior project assistants to CMNR, and Ms. Gail Spears, staff editor to FNB, for their work in preparing the report drafts and final manuscript. I wish to commend the workshop speakers for their excellent contributions to the workshop: their abstracts, participation in discussions, and their willingness to take time from very busy schedules to prepare and deliver outstanding presentations made it possible for the subcommittee to conduct a review of the topic area and prepare this report. Their thoughtful responses to questions posed by subcommittee members and workshop participants also contributed immeasurably to the quality of the review. It would be neglectful not to mention the many experts who attended this open meeting at their own initiative and expense. Their questions and comments contributed in no small measure to broadening the exchange of scientific information. I express my deepest appreciation to the members of the subcommittee who participated extensively during the workshop and in discussions and preparation of the summary and recommendations in this report. RICHARD L. ATKINSON, Chair Subcommittee on Military Weight Management

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available. In November 2002, DOD released its revised Instruction ~ 308.3, DOD Physical Fitness and Body Fat Program Procedures, and has made some important changes, which the subcommittee applauds. These new guidelines are noted throughout the report as appropriate. ORGANIZATION OF THE REPORT Chapter ~ of this report provides background information on the current demographics of the U.S. population. It then describes the military s interest in body-weight and body-fat standards and the implications of these standards for health, performance, fitness, and appearance. Weight standards and weight-management programs currently provided by each of the services and issues of concern related to these programs are described in Chapter 2. Chapter 3 briefly reviews the factors that affect body weight, and Chapter 4 reviews the strategies for weight management. Chapter 5 provides the subcommittee's specific responses to the military's questions; Chapter 6 presents the Subcommittee's conclusions and recommendations and identifies research needs. The workshop agenda and speaker abstracts are presented in Appendix A, and the biographical sketches of the speakers and subcommittee members appear in Appendixes B and C, respectively. ACKNOWLEDGMENTS It is my pleasure as chairman of the Subcommittee on Military Weight Management to acknowledge the contributions of the FNB staff. Their dedication in the planning and organization of the workshop and the editing of this report made it possible for the subcommittee to respond to the Army's request. in particular, ~ wish to acknowledge the extensive efforts of ~ ~ T To . ~ . ^ ~ ~ _ I_ ~ ~ ~ ~ ~ ~ . ~ . ~ . ~ ~ . . Mary 1. Loos, the senior stall officer tor INK. fine worked ulllgently With the subcommittee members in securing the expert pane} of speakers and organizing the program for the workshop ---Cal --- - - r - ~ 1 - - c;J---~ --I ~-- - r - - no- ----- - ~ - --- - - - ~ ------ - r . . , . . . . , . . . . ~ .. . .. . ~ . ~ . . . ~ ~ .. mto coherent sessions, and she contnoutec sunstantla11y to the writing and ilna1 updating ot the report in response to review. ~ also wish to acknowledge Ms. Leslie Vogelsang, research assistant to CM~K, for her diligence in checking references and finding missing references; and Ms. Harieen Sethi and Ms. Tazima Davis, senior project assistants to CMNR, and Ms. Gail Spears, staff editor to FNB, for their work in preparing the report drafts and final manuscript. ~ wish to commend the workshop speakers for their excellent contributions to the workshop: their abstracts, participation in discussions, and their willingness to take time from very busy schedules to prepare and deliver outstanding presentations made it possible for the subcommittee to conduct a review of the topic area and prepare this report. Their thoughtful responses to questions posed by subcommittee members and workshop participants also contributed immeasurably to the quality of the review. It would be neglectful not to mention the many experts who attended this open meeting at their own initiative and expense. Their questions and comments contributed in no small measure to broadening the exchange of scientific information. ~ express my deepest appreciation to the members of the subcommittee who participated extensively during the workshop and in discussions and preparation of the summary and recommendations in this report. RICHARD L. ATKINSON, Chair Subcommittee on Military Weight Management x~v

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Contents EXECUTIVE SUMMARY 1 BACKGROUND AND CONTEXT OF THE OVERWEIGHT PROBLEM ~ 17 The Current National Situation, 17 Uniqueness of the Military Environment, 20 Previous Recommendations on Body Fat and Fitness, 25 The Current Task, 26 Summary, 28 2 MILITARY STANDARDS FOR FITNESS, WEIGHT, AND BODY COMPOSITION Introduction, 29 Fitness versus Fatness, 30 Weight Standards for Accession and Retention, 32 The Impact of Weight and Body-Fat Standards, 38 Meeting the Weight and Body-Fat Standards, 41 Weight-Management Programs, 43 Summary, 55 3 FACTORS THAT INFLUENCE BODY WEIGHT Developmental Determinants, 57 Genetic Determinants, 60 Age, 63 Race/Ethnicity, 65 Physical Activity, 67 Food, 69 Physiological Factors, 74 Environmental Factors, 75 Social Factors, 76 Summary, 78 xv .29

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xvl 4 WEIGHT-LOSS AND MAINTENANCE STRATEGIES Introduction, 79 Physical Activity, 80 Behavior and Lifestyle Modification, 82 Diet, 86 Support Systems, 93 Prescription and Over-the-Counter Drugs and Supplements, 96 Future Drugs for the Treatment of Obesity, 103 Surgery, 106 The Use of Structured Maintenance Programs, 107 Public Policy Measures, 1 10 Summary, 1 1 1 RESPONSE TO THE MILITARY'S QUESTIONS. Question 1, 1 13 Question 2, 1 17 Question 3, 1 18 Question 4, 121 Question 5, 123 Question 6, 124 Question 7, 124 6 113 PROGRAMMATIC AND RESEARCH RECOMMENDATIONS 125 Prevention, 125 Assessment, 130 Treatment, 133 Program Evaluation, 138 Training, 138 Research Recommendations, 139 Other Areas for Research, 140 REFERENCES APPENDIXES CONTENTS .79 ........... 143 A Workshop Agenda and Abstracts, 179 B Biographical Sketches ofthe Workshop Speakers, 241 C Biographical Sketches of the Subcommittee on Military Weight Man- agement, 249 D Acronyms, 255

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WIGS MELEE State of the Sclence and Opportunldes for ~llltary Programs

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