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Executive Summary
The primary purpose of fitness and body composition standards in the
military has always been to select individuals best suited to the physical
demands of military service based on the assumption that proper body weight
supports good health, physical readiness, and appropriate military appearance.
Prior to the Korean Conflict, these standards were used primarily to exclude
underweight candidates. Advances in health care and improved nutrition over
the past 75 years have resulted in increases in mean height, weight, and fat-free
mass of soldiers, and in the U.S. population as a whole. However, increases in
food consumption and decreases in daily activity have raised new concerns
about the impact of overnutrition and fatness on overall health, physical fitness,
and military performance.
BACKGROUND AND CHARGE TO THE COMMITTEE
Considerable attention has been given to the alarming rise in the incidence
of overweight and obesity in the U.S. population. The most recent national data
(]999-2000 National Health and Nutrition Examination Survey) show the
prevalence of overweight and obesity (defined as a body mass index tBMI] of >
25 for overweight and > 30 for obesity) in adults 20 years of age and older is
64.5 percent overweight and, of these, 30.5 percent are obese. Furthermore, the
prevalence of overweight in adolescents (ages 12-19 years) is 15.5 percent.
The epidemic of overweight and obesity affects the military services of the
United States in several ways. For example, it decreases the pool of individuals
eligible for recruitment into military services, and it decreases the retention of
new recruits. Almost 80 percent of recruits who exceed the military accession
weight-for-height standards at entry leave the military before they complete their
first term of enlistment. This in turn increases the cost of recruitment and
training. These issues threaten the long-term welfare and readiness of U.S.
military forces.
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2
WEIGHT MANA GEMENT
-
To aid in developing strategies for the prevention and remediation ot
overweight in military personnel, the U.S. Army Medical Research and Materiel
Command (USAMRMC), through its director of Military Operational Medicine
Research Programs, requested the Committee on Military Nutrition Research
(C MAR) to review existing data on: optimal components of a weight-manage-
ment program; the role of age, gender, and ethnicity in weight management; and
current Department of Defense (DOD) activities in weight management in order
to provide recommendations for military weight-management programs. In
response to this request, the Subcommittee on Military Weight Management was
appointed in September 1999.
The subcommittee was charged to identify the most effective interventions
for weight loss and weight maintenance, particularly those most pertinent to the
nonobese overweight individuals (BMI 25.~29.9) found in the military setting,
to evaluate the interventions' appropriateness for military application or the need
for further research, and to develop a consensus toward a more standard DOD-
wide approach to weight management that utilizes state-of-the-art knowledge
and practices. Specifically, the military requested guidance on the appropriate
degree of standardization of programs across the services, whether specific aids
for weight loss (e.g., drugs) should be considered, how dietary changes would
impact successful weight loss, and whether resistiveness to weight loss and
maintenance are genetically controlled to the extent that individuals with genetic
predispositions for obesity should be identified and automatically excluded.
METHODS
As part of the response to the military request, the subcommittee convened
a workshop to bring together a group of experts to share knowledge and
experience in managing weight-control programs within the services, to gain
relevant knowledge and experience from industry and academia, to examine
current interventions and those under development (particularly in the pharma-
ceutical industry) for their appropriateness for military application, and to
identify needs for further research. In addition, the subcommittee performed an
extensive review of the scientific literature for data on optimal components of a
weight-management program; the role of age, gender, and ethnicity in weight
management; and current DOD activities in this arena. From this review,
recommendations were developed on the optimal components of a weight-
management program that could be utilized across the services.
CURRENT MILITARY WEIGHT STANDARDS AND
WEIGHT-MANAGEMENT PROGRAMS
There are significant demographic differences between the military popula-
tion and the general U.S. population. The general population is almost evenly
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EXECUTIVE SUMMARY
split with respect to gender (49.1 percent men and 50.9 percent women), while
the military population is approximately 85 percent men and 15 percent women.
There are also significant age differences in the two populations. Approximately
31.5 percent of the U.S. population is between the ages of 18 and 40 years,
while approximately 80 percent of the military population is in this age range.
The military also has a higher percentage of ethnic minorities than the general
population, especially among women.
The weight-for-height and body-fat standards of the military services were
predicated on the need for the highest level of physical performance in adverse
environments-, to maintain a high level of readiness at all times, and to present a
trim military appearance (e.g., the image that the individual may convey of the
military). These standards theoretically take precedence even when individuals
demonstrate an ability to perform their assigned tasks in an exceptional manner.
Typically, the various branches of the military service have had two sets of
weight/fat standards: one set to be met by potential recruits for accession into
initial entry training and another equivalent or more stringent set to be retained
in the service once admitted. The initial body composition screen consists of a
weight-for-height assessment. Historically, maximum allowable weight-for-
height tables are used.
When only two anthropometric measurements are used to estimate body
composition, height and weight have the highest level of association with the
percentage of body fat. Height and weight can also be used to compute BMI, a
widely accepted index that correlates with percent body fat. A substantial body
of evidence shows that BMI is positively associated with both morbidity and
mortality. Each of the services screens active duty personnel at least annually or
semiannually for fitness and compliance with weight-for-height standards.
Typically, the maximum allowable weights-for-height varied across ser-
vices for individuals of the same height, age, and gender, and individual service
standards were uniformly more stringent than the DOD recommendations. The
disparity in maximum BMI between men and women was marked. For example,
prior to 2002, the maximum allowable retention weight-for-height for women in
any service corresponded to a BMI of 25.1 (Army), for men it corresponded to a
BMI of 28.2 (Air Force).
The military uses circumference measurements to estimate body composition.
Until the early 1990s, each service employed its own set of measurement
equations for estimating body composition. More recently, a single equation for
use across all the services has been mandated by DOD. In November 2002, DOD
reissued its reference document on implementation policy and procedures for
physical fitness and weight/body-fat standards. This policy mandates that the
weight-for-height tables for all the service branches will be based on BMI, and that
no service may have a standard more stringent than a BMI of 25 or more liberal
than a BMI of 27.5. In addition, all branches of the service must use a single,
validated equation based on abdominal and neck circumference and height for men;
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4
WEIGHT MANAGEMENT
and one based on abdominal, neck, and hip circumference and height for women to
estimate percent body fat. Body-fat standards for men shall not be more stringent
than 18 percent and not more liberal than 26 percent. For women, the fat standards
shall not be more stringent than 26 percent and not more liberal than 36 percent.
Individuals who exceed these limits must be referred to a weight-management
program
A review of the weight-loss programs across the military services highlighted
significant deficits that could affect success. All of the programs have a strong
motivating component that is highly disciplinary in nature, and the penalties for
exceeding the body-fat limits are significant. With exception of those in the Air
Force program, the majority of participants receive only minimal counseling by a
qualified dietitian. The same appears to be true throughout the services in the area
of behavior modification. With the exception of the Air Force and some specific
sites in the other services, data collection for program evaluation is lacking.
FACTORS THAT INFLUENCE BODY WEIGHT
Maintaining a healthy body weight is an extremely complex issue. Main-
tenance of fitness and appropriate body-fat standards by military personnel is
affected by each individual's genetics, developmental history, physiology, age,
physical activity level, diet, environment, and social background. Some of these
factors are biologically programmed (e.g., physiology, genetic makeup, age).
Other factors can be manipulated by the individual (e.g., physical activity level,
diet), while still other factors may require institutional, systemic, or environ-
mental changes (e.g., worksite and community design, availability of facilities).
Genetics
Individuals appear to show significant heterogeneity in their body weight
and body fatness responses to altered energy balance, dietary components, and
changing activity levels, although little is yet known about the specific causes of
heterogeneity.
There is a group of at least 20 Mendelian syndromes in which obesity is a
component; these genetic disorders are rare, however, and family studies do not
suggest that the genes responsible for these syndromes are involved in the
common forms of human obesity. For more than 99 percent of obese individ-
uals, the genetic basis of their obesity is unknown, and genetics may or may not
be a causal factor.
The strongest evidence for genetic weight-regulating mechanisms is the
recent elucidation of single gene defects that are associated with excessive
weight gain in animals. Of the five gene products identified to date as being
associated with weight regulation, leptin is the best characterized. Genetic
defects in leptin have been associated with extreme obesity in humans. Although
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E,YECRJTI HE SUMMARY
extensive efforts have been made to identify mutations in the genes identified as
obesity-associated in rodents and in humans, only a handful of individuals have
been identified with mutations in any of the genes that have produced obesity in
rodents.
Physiology
A number of phenotypic characteristics have been associated with risk of
weight gain, notably alterations in nonvolitional components of energy expendi-
ture. Energy expenditure can be divided into three main components: resting
'metabolic rate (RMR), the energy expended at rest, under thermoneutral
conditions, and in a postabsorptive state; thermic elect of feeding, the
incremental increase in energy expenditure after a meal is consumed, associated
with absorption and transport of nutrients and the synthesis, storage, and
breakdown of protein, fat, and carbohydrate; and the energy expended for
physical activity, primarily voluntary movement, but also including the
involuntary movements associated with shivering, fidgeting, and postural
control. The RMR accounts for 60 to 75 percent of total energy expended in
most adults. A number of studies have been performed to evaluate the effect of
exercise, particularly resistance training, on RMR. Results have been inconsis-
tent, and thus whether exercise training increases RMR remains controversial.
Age
Many weight-management experts agree that body weight becomes pro-
gressively more difficult to maintain with age. Some research has indicated that
body weight and associated circumferences increase with advancing age unless
food intake is significantly reduced or physical activity is substantially
increased. However, health risk associated with BMI remains unchanged in
older individuals. Thus, there appears to be little rationale for increasing the
upper BMI range consistent with good health as individuals become older.
A large number of cross-sectional studies, however, do demonstrate that
body fat increases with age. In contrast to body fat, skeletal muscle mass
declines with age beginning around the third decade, and losses of skeletal
muscle parallel decreases in bone mass. The mechanisms of body composition
changes that accompany aging are multifactorial and include physical inactivity,
diet, and hormonal alterations. This loss of lean mass and the gain in fat mass
occur even with no apparent change in body weight. Since lean mass contributes
the larger share of metabolic activity, total energy expenditure decreases pro-
portionally with loss of lean mass.
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6
WEIGHT MANAGEMENT
Physical Activity
The rapid rise in the prevalence of overweight and obesity in the last 20
years likely reflects major environmental shifts in eating habits and exercise,
both of which can be controlled. Some of these shins include changes in the
food supply, food availability, food composition, palatability, and affordability,
as well as numerous technological advances that have removed the need for
physical labor or physical movement (e.g., elevators, escalators, riding lawn
mowers, remote controls for televisions and stereos). Physical activity represents
an important component of volitional energy expenditure. Reductions in physi-
cal activity over the past several decades have likely contributed to the evolution
of positive energy balance and the weight gain characteristic of all industrialized
societies.
Exercise, especially in bouts of 30 minutes of activity or more, can promote
fat oxidation because the substrate that is preferentially oxidized by muscle
tissue switches from carbohydrate to fat. Thus, chronic extended bouts of
exercise may, in effect, substitute for expansion of the adipose tissue, allowing
the physically active individual to achieve fat balance while maintaining a lower
body-fat mass than the sedentary individual.
Food Intake
A high energy intake (i.e., energy intake in excess of energy expenditure) or
an energy intake that is not adjusted downward with age and declining physical
activity is associated with the development of overweight or obesity in suscep-
tible individuals. In addition to total energy intake, the character of the diet may
clay a role in the etiology of obesity, with high-fat diets potentially promoting
~ · ~} ~ ~ ~ · _ ^4 · —A A _ _ ~^ ~ A _ =~ _ ~ ~ ~
increased body weight.
Social and Environmental Factors
Other factors that contribute to overweight both in the military and in civil-
ian populations include meal patterns and eating habits, familial and ethnic fac-
tors, cultural norms, socioeconomic status, smoking, alcohol consumption, use
of certain common drugs such as anti-allergens, and the use of antidepressants,
hypoglycemic agents, and certain antihypertensive agents. Members of the mili-
tary population with unusually sedentary job responsibilities and a work envi-
ronment that promotes a combination of high-pressured, hasty, and thoughtless
overeating along with inactivity are likely to be particularly at risk for weight
gain. Thus, the social and environmental context of the overweight individual
needs to be carefully evaluated.
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E,YECUTI HE SUMMARY
7
RECOMMENDATIONS
After careful review of the information presented at the workshop and the
scientific literature, the subcommittee makes the following specific recommen-
dations.
Prevention
· Each service should provide training on diet and health, including the
fundamentals of energy balance, the caloric content of common foods, portion
sizes, and the importance of maintaining high levels of daily activity after inten-
sive training periods (e.g., initial entry training) to prevent weight gain.
· An education program on maintaining healthy weight should also in-
clude components directed at military spouses and family.
· Programs to reinforce the concept of exercise and activity as part of the
military lifestyle should be developed, along with programs to encourage the
reduction of alcohol consumption.
Particular emphasis should be placed on providing or upgrading physi-
cal fitness facilities and equipment that encourage exercise.
The use of rewards for exercise achievement should be reinforced.
The services should make the incorporation of"heart-healthy" menus a
standard for base dining facilities, with continued emphasis on training all mili-
tary cooks in low-fat cooking techniques.
· Priority consideration should be given to commercial eating establish-
ments that routinely offer reasonable portion sizes and low-fat dining options
when these establishments are competing for base contracts.
Assessment
· Assessments for weight-for-height and percent body fat should be con-
ducted quarterly rather than annually or semi-annually. More frequent assess-
ments should be evaluated to determine if they reduce disordered eating and
other risky behaviors.
.
Individuals at risk of increased weight or body-fat gain should be iden-
tified at the time of accession (e.g., those entering service over the standard,
those with a family history of obesity) and their evaluations monitored so that
interventions may be instituted as soon as adverse changes are identified.
· The incidence of disordered eating behaviors needs to be documented
and addressed across all branches of the military.
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8
WEIGHT MANAGEMENT
Weight-Loss Programs
. A weight-loss diet should be energy deficient by 350 to 1,000 kcal/day;
should provide a minimum daily intake of at least 800 kcal/day; should provide
a minimum of 60 g of protein/day for women and 75 g of protein/day for men;
should provide no more than 30 percent of total energy as calories from fat; and
should have a carbohydrate content of no less than 130 g/day (excessively low
carbohydrate intake can cause dehydration and impact both physical and cogni-
tive function). The daily use of a multivitamin-mineral supplement may be
included.
. A combination of aerobic and strength training exercise, along with in-
creased activities of daily living, is recommended. Energy expended in physical
activity should be at a minimum of 2,000 kcal/wk, which amounts to 200 to 300
m~n/wk of moderate-intensity exercise (3.5-5 fur). In keeping with other recent
recommendations, 60 min/day of moderate-intensity activity in addition to ac-
tivities of daily living is suggested.
. Training and support in behavior modification should include stimulus
control, relapse prevention, self-monitoring, cognitive restructuring, and men-
toring.
.
Follow-up should include regular contact with weight-management
counselors; routine self-monitoring of diet, weight, and physical activity; and
ongoing psychological support that could be provided via the Internet or by tele-
phone.
.
.
Training programs should be established for all personnel associated
with implementing weight-control programs. Training standards for a weight-
management military occupational specialty should include training in principles
of nutrition, portion control, physical activity/exercise, behavior modification,
psychological support, and the use of weight-loss aids. The program should also
include mandated continuing education requirements.
Research
Internet-based programs should be developed using models already in
use by the military. Emphasis should be given to the development of a number
of options, testing their effectiveness overall, and identifying those with high
response rates. Also, the range of individual responses of military personnel
should be evaluated since there may be subpopulations that respond well to a
given intervention when overall response is not consistent.
.
An evaluation of military weight-management programs is essential to
determine their effectiveness. This evaluation would require following personnel
who have completed the program for 2 to 5 years, and perhaps throughout their
military career. Recommendations provided in this report are based almost ex-
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EXECUTIVE SUMMARY
9
elusively on data collected in civilian populations, and effectiveness may be
quite different in military populations.
· Many nonprescription preparations are undoubtedly being used in the
military for weight loss. Very little is known about their effects on body weight,
body composition, overall health, and physical performance. It is particularly
important to assess the use of such preparations as well as their effects on mili-
tary performance.
RESPONSE TO THE MILITARY'S QUESTIONS
What are We essential components of art effective weight/fat loss program,
and We most effective strategies for sustaining weight loss?
Years of research have demonstrated that a program for weight/fat loss can
only be effective when it is closely integrated with a program for sustaining
weight loss.
Essential Components of an Effective Weight/Fat Loss
Program
.
Exercise. For overweight adults who are otherwise healthy, increased
physical activity is an essential component of a comprehensive weight-reduction
strategy.
.
Behavior modif cation. The use of behavior and lifestyle modification
in weight management is based on a body of evidence that people become or
remain overweight as the result of modifiable habits or behaviors and that by
changing these behaviors, weight can be lost and weight loss can be maintained.
Net dietary energy def cit. Energy expended must exceed energy
consumed on a consistent basis over an extended period of time, the length of
which depends on the degree of overweight.
· Education. Information on nutrition principles, food portion control,
and the need for energy balance is essential for individuals to develop
appropriate eating behaviors.
· Psychological support and counseling Any weight-management
program is likely to be more successful if it is accompanied by structured
support mechanisms (e.g., Dom professional counselors, commanders,
coworkers, family).
Environmental changes. Restructuring the individual's environment to
remove factors that promote overeating and underactivity is also a significant
part of weight loss and management. The environment includes the home, the
workplace, and the community.
· Structured monitoring. The long-term success of weight management
appears to depend on a specific and deliberate follow-up program. This struc-
.
.
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10
WEIGHT MANAGEMENT
tured follow-up should include monitoring body weight with regular weigh-ins
at least weekly during the weight-loss phase and monthly during the mainte-
nance phase.
Sustaining Weight Loss
An integrated program that combines the weight-loss procedures described
above with weight-maintenance strategies is essential to achieve the best long-
term benefits. The use of maintenance strategies with the strong incentive that is
provided by the military regulations on weight control should enhance the
chances for successful weight maintenance.
.
Physical activity. An expenditure of at least 2,000 to 3,000 kcal/wk
from exercise is essential.
.
Permanent lifestyle and behavior modifications. Balancing customary
daily energy intake with appropriate habitual levels of physical activity is also
necessary. This includes portion control, selecting foods lower in fat and
calories, and consistently sustaining higher levels of daily physical activity.
Self-monitoring. Individuals need to record their body weight a
minimum of once weekly. They also need to periodically keep a 3-day food
diary (about every 3 months) and a physical activity diary or use an activity
monitor (e.g., a pedometer) to help maintain weight loss.
· Continuous structured support. It is also necessary to have follow-up
visits or counseling via phone or the Internet every 2 to 4 weeks for the first 3
months and every 1 to 2 months thereafter, depending on the difficulty in
maintaining a stable, healthy weight.
How do age and gender influence success in weight-management programs?
*could age be considered in we~ght/fat standards and in weight-marlagement
programs and interventions?
Age
Although weight gain with age is a frequent occurrence, it is not inevitable.
Increases in weight with age can be avoided if energy intake is adjusted to
compensate for decreases in activity and the loss of lean body mass, or if
physical activity is increased (including strength or resistance exercises) to
maintain lean body mass. For the benefit of long-term health, there should not
be age-related increases in weight-for-height standards.
Research indicates that percent body fat increases with age even if weight
does not change. The current upper limits of DOD standards of 26 percent fat in
men and 36 percent fat in women, however, is well within the limits of the
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,YECUTI HE SUMMARY
11
healthy percent body fat range even for those 60 to 79 years of age. While
individual services have upper limits of percent body fat that are uniformly more
stringent than the DOD maximum, increases in percent body fat with age are
appropriate.
Gender
On average, women have a higher percent body fat than men. Weight gain
and lifestyle changes during the childbearing and childrearing years, as well as
the hormonal and metabolic changes that accompany pregnancy and menopause,
are associated with higher body fat. Thus, the gender-specific fat standards are
appropriate.
Wl~ic/, *irategies would he most and least effective in a military setting?
*Gould military weigl't/fat loss programs involve direct participation inter-
ve'?tion, or only monitoring and guidance? Should military programs be more
proactive ir' identifying and discouraging ineffective or dangerous weight-loss
practices? Is a warring or cautionary zone prior to enrollment in a weigl~t-
control program an effective strategy? When should dud time be authorized
for participation in inierver~tion strategies for weight/fat loss?
The Most and Least Effective Strategies of a Weight/Fat
Loss Program in a Military Setting
The effective strategies for a weight/fat loss program would be the same re-
gardless of whether the setting is military or civilian. However, the implementa-
tion of some of these strategies could be facilitated in the military environment,
particularly physical fitness, exercise, and behavior modification.
The primary difficulty in the military setting would be in providing
structured follow-up due to the mobility of the military population. Other diffi-
culties include remoteness or isolation of some work locations, the paucity of
low-fat food selections in vending machines and dining facilities, the availability
and affordability of foods with low energy density (e.g., fruits and vegetables,
low-fat or nonfat milk), and high-pressure environments with short meal breaks
that may promote inappropriate dietary patterns.
Direct Participation Interventions versus Monitoring and
Guidance
Direct participation interventions have been demonstrated to improve com-
pliance, increase the success rate of weight/fat loss, and support an improved
level of weight maintenance.
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12
WEIGHT MANAGEMENT
Identifying and Discouraging Ineffective or Dangerous
Weight-Loss Practices
Military weight programs should collect information on weight-loss practices
of overweight individuals as a component of their medical evaluation. Military
individuals found to be using ineffective or dangerous weight-loss practices such as
extensive fasting, purging, He use of diuretics, and Me use of commercially
available herbal supplements arid diet pills, should be counseled on the risks of
these practices and strongly encouraged to adopt standard weight-loss practices.
One method to reduce the incidence of dangerous practices is more Dequent weigh-
ins and emphasis on appropriate diet and physical activity patterns at all times as
part of a military lifestyle.
Is a Warning or Cautionary Zone Prior to Enrollment into
a Weight-Control Program an Effective Strategy?
The warning zone that is now in effect for the Air Force program (3
months) appears to be an excellent strategy. It gives individuals a chance to
manage their overweight/body-fat problem by themselves in a timely manner
without assignment to a weight control program, with its accompanying career
implications.
Authorizing Duty Time for Participation in Intervention
Programs for Weight/Fat Loss
Any medical examination and tests that are appropriate before being
assigned to a program for weight/body-fat loss, as well as counseling and
monitoring, should be accomplished during duty time. A weight-loss program
should be viewed as treatment for a medical condition and be given comparable
priority as treatment for other medical conditions.
Since current DOD policy dictates regular exercise as a part of duty time,
unit commanders should provide (or require) time for regular exercise to ensure
a high level of fitness and readiness.
To what extent should weight-control programs/policies be standardized
across the services versus tailored to the individual service, installation or
unit? Bleat are the advantages and disadvantages of standardization? Is the
provision of state-of-the-art techniques and knowledge a rationale for stan-
dardization?
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EXECUTI HE SUMMARY
13
Extent of Standardization Across the Services versus
Tailored to an Individual Service
The specifics of implementation of weight-control programs and policies
may need to be tailored for each service due to the different environments in
which the programs will be carried out (e.g., aboard ships, on CONUS military
bases, or on overseas bases). However, they could be standardized across the
services to a significant extent as indicated below. A limited number of military
health centers should be identified to provide scientifically validated body
composition evaluations.
.
Standard methodology. New technologies for measuring body compo-
sition should be adopted service-wide as they become available, once they are
validated for accuracy and ease of use.
Appearance standard. A waist circumference standard of no more than
40 inches for men and 35 inches for women should be used as an objective
measure for appearance standards as these standards are known to be related to
long-term health.
Weight-management counselors. Those responsible for weight-control
programs should be certified and their training should be standardized.
· Internet-hased weight-management programs. A standardized program
across all services would be more efficient and could be easily accessed by
military personnel regardless oftheir duty assignment.
.
The advantages of standardization of weight-control programs and policies
are that all military personnel would have access to equivalent weight-manage-
ment assistance and that the incorporation of new technologies for body
composition assessment and the adoption of Internet-based services would be
facilitated. In addition, the costs of producing education materials (e.g., portion
size models, brochures) would be reduced. The disadvantage of standardization
is that it might limit innovation within the branches ofthe armed forces. There is
no scientific disadvantage.
Is the Provision of State-of-the-Art Techniques and
Knowledge a Rationale for Standardization?
Standardization of weight-control program components would facilitate the
incorporation of new technologies and provide a stronger base for program
evaluation, which would in turn protect DOD investments in each individual. To
date, none of the existing military weight-control programs have been
sufficiently evaluated to justify adoption DOD-wide.
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14
WEIGHT MANAGEMENT
How can diet be effectively dealt with as a weight-management component in
the military setting? Should pharmacological treatment (ar~ore~ciants) be
considered for use in flee military? In what cases? What factors bear on this
decision?
Diet counseling needs to be administered by individuals who are fully
trained in weight-management strategies, and it should be supported by
appropriate professional personnel. For those military personnel who are on
ships or are dependent on mess halls, more healthy, low-fat food choices and
sufficient time for meal consumption are imperative. Providing choices of foods
(both snack and full-meal foods) that are less energy-dense; increasing the price
of foods high in calories, fat, and refined carbohydrates; and subsidizing the
price of fresh fruits and low-calorie snacks in vending machines and exchange
service facilities should be considered. In any case, nutrition and lifestyle
education is paramount and should be provided early in the initial entry training
period and reinforced periodically. The development of distance-based educa-
tion in nutrition and lifestyle modification may prove useful.
Pharmacological treatments should be considered for those who meet the
standard criteria for the use of such compounds (i.e., a BMI of 2 30 or > 27 with
comorbidities such as hypertension or high cholesterol). These individuals
would have to be in military occupational specialties that do not preclude the use
of drugs that affect the central nervous system.
How should resistiveness to weight/fat control be dealt with?
Resistiveness, as defined by the military, is a condition that generally refers
to a genotype and/or a phenotype that is obesity-prone. These individuals can
lose weight, but they usually have to work harder and may need additional assis-
tance in a weight-management program and with structured follow-up.
Bleat are flee knowledge gaps in weight-management programs relative to the
military? What research is needed?
Knowledge gaps concerning weight-management programs relative to the
military are extensive. Most published research has been derived from studies on
middle-aged men and women or perimenopausal, Caucasian women in clinical
settings. These data have limited relevance to the military population where: (1)
only about 25 percent of officers and warrant officers and about 6 percent of
enlisted personnel are over the age of 40, (2) only 15 percent are women, and (3)
approximately 40 percent are minorities. Considerable research is needed in the
primary areas of prevention, treatment, and program evaluation. In addition to
the research needs highlighted in the recommendations, research should also be
conducted on the following topics.
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EXECUTIVE SUMMARY
Prevention
Early Identif cation of Personnel at Risk
15
To identify those at risk of overweight or obesity, a set of potential risk
factors for weight gain (e.g., overweight at the time of accession, family history
of obesity, initial performance on the physical training test, a gain of more than
5 percent over initial entry training weight) should be developed. The effective-
ness of educating these individuals during initial entry training or whenever they
are identified as being at risk of becoming overweight should be evaluated.
Early Education of Initial Entry Trainees and Families
Initial entry training is a time of learning for individuals new to the military.
Just as these individuals learn military tasks (e.g., how to fire a weapon), they
could also learn nutritional principles, particularly the importance of energy
balance, appropriate portion sizes, and the caloric content of frequently
consumed foods. Spouses and other family members could also be included in
instruction on nutrition, just as they are in classes on military etiquette. Large-
scale, randomized trials with alternate classes of recruits, followed over time,
would be useful in determining if such preventive efforts are effective.
Exercise (Structured and Unstruct2'red~
All the services should adopt the strategy of promoting physical fitness as a
way of life from the first day of initial entry training. Mandating exercise during
the duty day regardless of time pressures is one strategy. Scheduling competi-
tions that require participation by the entire unit and that require unstructured
exercise to attain peak performance could be tested as a method to improve
overall fitness and activity. The usefulness of resistance or strength training and
the optimum mix of aerobic and strength training for the purpose of weight
management needs to be evaluated among military personnel.
Reduction of Environmental Factors That Promote Overweight
Research is needed that: evaluates the effectiveness of eliminating high-
calorie and high-fat snacks in vending machines, or of offering alternatives such
as fruit and low-calorie snacks and meal replacements; evaluates the effects of
different time allotments for meal consumption; and evaluates the effectiveness
of altering the environment to promote physical activity, such as the creation of
walking and bike trails on military bases.
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Evaluation of Treatment Methods and Programs
Evaluation of Local Initiatives for Effectiveness
WEIGHT MANAGEMENT
Research is needed to identify and evaluate local weight-loss programs,
both military and civilian, for effectiveness. A military-wide competition could
be established for the most innovative weight-reduction programs, with recog-
nition and meaningful rewards for the most successful.
Evaluation of Ineffective or Dangerous Weight-Loss Practices
Research from the Navy has demonstrated that unhealthy eating and purg-
ing behaviors are more prevalent among military personnel compared with the
civilian population. Information is needed on the impact of such dangerous or
ineffective weight-loss practices on physical and mental performance among
military personnel. The prevalence of bulimia, binge eating disorder, and ano-
rexia nervosa in military personnel and whether the military lifestyle and stan-
dards promotes such behavior needs to be determined.
Computerized Follow-Up of Personnel at Risk
An independent, computerized database is needed to identify individuals
with risk factors for weight gain or overweight as described above, and to
maintain routine contact with these individuals to check on their weight or
physical fitness status, to identify problems early, and to intervene as needed.
Such computerized information should be centrally maintained and used as a
source of data for longitudinal studies on the effectiveness of prevention and
treatment innovations. This data should not be available to unit commanders to
avoid the possibility of discrimination against individuals at risk.
Other Areas for Research
Information is needed on whether there are differences both in gender re-
sponses to the various components of weight-management programs (e.g., do
men and women respond differently to diet, physical activity, or behavioral
change interventions) and in race/ethnicity responses to various weight-
management strategies.
Representative terms from entire chapter:
weight management
