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6 Programmatic and Research Recommendations Knowledge gaps concerning weight-management programs relative to the military are extensive. Much published research has been derived from studies on middle-class, middle-aged or perimenopausal, Caucasian women in clinical settings. This data may have little 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. Research recommendations are focused on those areas that are of specific concern to the military community. This chapter provides recommendations on the structure and content of military weight-management programs and highlights research needed under each of these areas. In addition, recommendations are provided for other poten- tial areas of relevant research. PREVENTION National health survey data from the U.S. general population clearly demonstrate that a significant percentage of individuals are overweight or obese. This is true for both adolescents and adults. The existence of the Department of Defense's (DOD) weight-for-height and body-fat standards currently means that an estimated 13 to 18 percent of young men between the ages of 17 and 20 and 17 to 43 percent of young women in this age group would fail to meet military standards for accession (Nolte et al., 2002~. While this situation will-certainly have a negative impact on DOD's ability to meet recruitment goals, the fact that accession standards exist also offers an extremely unique opportunity to develop and study interventions to prevent weight gain. Since the majority of military recruits will have met the DOD weight-for- height and body-composition standards at the time of entry into the service, the 125

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126 WEIGHT MANAGEMENT need for combat readiness (Robbing et al., 2001), optimal health, and economics (Robbing et al., 2002) dictate that the prevention of weight gain should be a major focus of military health programs and research. Research is needed on interventions at the individual, group, worksite, and community levels to prevent overweight and obesity. Most of the studies that have evaluated prevention efforts in communities, in the workplace, or in schools have shown modest or no effect on body weight (Atkinson and Nitzke, 2001; Taylor et al., 1991~. However, intervention studies in targeted individuals have been more positive (Angotti and Levine, 1994; Angotti et al., 2000; Latner et al., 2000; Perri et al., 2001~. There is a general consensus that preventing the onset of obesity with appropriate interventions is likely to produce a better success rate than attempting to treat overweight or obesity after it develops; however, solid clinical research has not yet verified this assumption. Evidence from a large body of literature indicates that once an individual becomes overweight, loss of the excess weight is difficult to accomplish and the fre- quency of regain is high. Early Education of Initial Entry Trainees Almost uniquely in American society, the military has the ability to mold belief systems and behaviors of large groups of young people. This is apparent in the ability of the military to take people in their late teens and early twenties and instill in them character issues of discipline, honor, integrity, and hard work. If the military made a commitment to nutrition education and physical activity as part of the "military lifestyle," generations of young people would have a high possibility of adopting good nutrition and exercise habits as a part of expected behavior. The military currently expects and demands a commitment to physical fitness that far surpasses that which is customary in the civilian population, and recruits change behavior dramatically in regard to physical fitness. Initial entry training is a time of learning for individuals entering the military. Just as these individuals learn military tasks (e.g., how to fire a weapon), they could also learn nutritional principles and to adopt physically active lifestyles. It is recommended that classes be included in initial entry training that deal with appropriate nutrition behavior, eating patterns (such as consumption of ample quantities of fruits, vegetables, and whole grains and limiting portions of saturated fat), portion sizes, and the basic human biology of nutrition and energy balance. An early training effort can provide large benefits, including decreased loss of time from the job, reduced administration cost of weight-control programs, and improved morale. Military mess halls have a long history of closer adherence to recommended dietary allowances than is usual in the civilian population. Educating recruits on why this is appropriate and expected may produce life-long eating habits that are healthier than that of the civilian population. The effectiveness of such a pro-

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PROCRAMMATICAND RESEARCH RECOMMENDATIONS 127 gram, including its specific components, should be evaluated. Controlled studies of pilot programs could be conducted at selected bases to determine if behavior changes are observed in response to the nutrition and healthy lifestyle education and to identify the most appropriate methods of nutritional training. Large-scale, randomized trials with alternate classes of recruits, followed over time, could be highly useful in evaluating the efficacy of the preventive efforts and whether they prove to be helpful in preventing overweight and obesity later in military service. Positive results would encourage expansion of the program to the entire military. Particular attention should be paid to the concept that, as daily physical activity declines with time in the service due to more administratively oriented duties, energy intake needs to decline in order to maintain energy balance, even if the level of fitness training remains unchanged. Education of Families Spouses and families of new military inductees should be included in instruction on nutrition and healthy lifestyle habits, just as they are in classes on military etiquette. Classes should also be set up for military spouses to learn appropriate nutrition, cooking skills, shopping skills, and the importance of a high level of exercise and activities of daily living. Evaluation of the effective- ness of these programs should be carried out as described above (for the initial entry trainees). Exercise/Activity As indicated in Chapters 3 and 4, there is much evidence to indicate that activity is an important factor in preventing excess adipose tissue gain. Activity may be divided into two categories: structured exercise and unstructured exercise (or activities of daily living). Both of these provide opportunities for research that could be of benefit to the military. Structured Exercise Current DOD policy dictates regular exercise as part of duty time, but this policy is routinely ignored due to time pressures. Enforcement of these policies by DOD or, for example, by holding commanders accountable for their units' achieving a minimum average level of performance on the physical fitness test, would engage commanders in the quest for routine exercise and attainment of physical fitness. The use of exercise as entertainment, as competition, and as games can play an important role, especially among men. It is particularly valuable in military facilities in which personnel are often organized into units around which compe-

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128 WEIGHT MANAGEMENT tition can be developed. Scheduling competitions that involve unit fitness could be tested as a method to improve overall fitness and activity. The competitions should require participation by the entire unit and could include activities such as comparisons of the unit-wide average performance on annual physical fitness tests. Competition among companies or battalions would necessitate that all individuals take part and would require nonmar~dated exercise to attain peak performance. Activities of Daily Living Structured exercise requires time and may impinge on the performance of other military duties. It usually is confined to a very limited period each day or to several times per week. Increasing the activities of daily living to increase unstructured exercise has been proposed as a way to help prevent overweight and obesity. This could be studied in the military environment in a number of ways, such as: . Comparisons of environmental changes that might promote increased activity. Changes to the design of military facilities that encourage increased activity (a model that has been recommended but not tested in civilian life) include prohibiting the use of cars in the center of bases (or cities), thus increasing the likelihood of walking or biking, and designing (or renovating) buildings so that stairs are readily available and that elevators or escalators are not the first option for movement between a few floors. Such changes could only be introduced gradually, but would provide an opportunity for evaluating the effect on the prevalence of overweight or the average performance on physical fitness tests. The military setting provides a unique environment in which to examine the potential role of such features. DOD-wide competitions for model activity programs. A DOD-wide competition, held periodically, could stimulate innovative individuals to develop programs locally that could be tested and, if found to be effective, then applied on a broader scale. Awards for the most innovative, effective program locally, by region, by service, and throughout all services would bring attention to the possibilities, stimulate creative solutions, and take advantage of the huge range of talents of military personnel. Diet and Nutrition Recent research by the Air Force (Fiedler et al., 1999) showed that provid- ing "heart-healthy" menus in base dining facilities was not only possible, but also that these menus improved body mass index (BMI) for women recruits with no detrimental effects on physical conditioning or visits to the doctor. Another study by the Army found that women consuming more than 14 reduced-energy

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PROGRAMMA TIC AND RESEARCH RECOMMENDATIONS 129 foods per week had a lower BMI, exercised more, and had significantly higher intakes of dietary fiber, folate, calcium, and iron. (Arsenault and Cline, 2000~. Environmental Factors Current theories to explain the epidemic of obesity point to an increased availability of foods, particularly energy-dense foods. Vending machines are a ubiquitous presence in both military and civilian life. The majority of foods in these machines are snack items containing high amounts of fat, calories, or both. Careful studies could be undertaken to determine the roll of vending machines~in promoting obesity or overweight. For example, studies could be conducted that compare the presence or absence of vending machines with the hypothesis that severely limiting their availability might reduce impulse eating. Also, offering alternatives such as fiuit, low-calorie snacks, meal replacement bars and drinks, should be evaluated. It is possible that the availability of vending machines is important for morale on military bases, but the effect of removing these machines on the prevalence of overweight and on military morale are appropriate questions for well-designed studies. In addition, studies could be conducted to determine if increasing the price of high-energy and high- fat foods and reducing (or subsidizing) the price of fresh fruit and other low- calorie snacks encourages healthier eating behavior. RECOMMENDATIONS ON PREVENTION - Each service should provide its members training on diet and health, in- cluding the fundamentals of energy balance, the caloric content of common foods, portion sizes, and the importance of maintaining high levels of daily activity even after intensive training periods (e.g., initial entry training) to prevent weight gain. An education program on maintaining healthy weight should include com- ponents directed at the entire military family. Programs to reinforce the concept of exercise and activity as part of the military lifestyle should be developed, along with ones to encourage the re- duction of alcohol consumption, which contributes to excess energy intake. Particular emphasis should be placed on providing or upgrading physical fitness facilities and equipment that encourage exercise. Creating bicycle paths and sidewalks, making community-owned bicycles available to per- sonnel, discouraging the use of automobiles, and organizing competitions should be given high priority.

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130 WEIGHT MANAGEMENT The use of rewards for exercise achievement should be reinforced. More tangible and immediate benefits in recognition, awards, and personnel and performance ratings should be developed within military facilities. The military services should make the incorporation of"heart healthy" menus a standard for base dining facilities, with continued emphasis on training all military cooks in low-fat cooking techniques. In addition, low- calorie and low-fat food items should be offered in vending machines and at base exchange facilities. Lowering the costs of these items could be an incentive to increase their consumption. Priority consideration should be given to commercial eating establishments that routinely offer reasonable portion sizes and low-fat dining options when these establishments are competing for base contracts. ASSESSMENT The reissued instruction, DOD Physical Fitness and Bow Fat Program Procedures, states that "service members shall maintain physical readiness through appropriate nutrition, health, and fitness habits," and that "aerobic capacity, muscular strength, muscle endurance and desirable body-fat compo- sition" form the basis for the military's relevant programs (DOD, 2002~. This policy also mandates that all service members, regardless of age, will be formally evaluated and tested for the record at least once annually unless under medical waiver. If the prevention of weight gain is an appropriate goal (as it should be), annual or semi-annual evaluations are clearly inadequate to aid in achievement of this goal. Individuals have ample opportunity to increase their weight and body composition to levels above standards over a 6- to 12-month period. They will have a much better chance of returning to standards if their problems are identified early. Thus, more frequent evaluations, while potentially costly, may be less costly than remedial programs. In addition, more frequent evaluations may decrease the number of disordered eating behaviors that have been documented to occur in military personnel within 3 months of their annual assessments (McNulty, 1997a, 1997b, 2001; Peterson et al., 19951. Ideally, evaluations (at least weigh-ins and body-fat assessments, if not physical fitness) should be performed quarterly. Early Identification of Personnel at Risk Many obesity experts believe that preventing obesity or treating it at the initial stages of overweight is more effective than individuals' attempting to lose

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PROGRAMMA TIC AND RESEARCH RECOMMENDATIONS 131 significant amounts of weight. Inviting individuals at risk (e.g., those who have gained weight or body fat since their last assessment but are still within stan- dards) and those who have only recently become overweight to enroll In weight- management programs may reduce the prevalence of personnel who later become significantly overweight. This deserves careful study. The Air Force has recently modified its weight-management program to include a 3-month cautionary zone prior to enrollment in the program itself (with its administrative consequences). Research is recommended on the impact of this program change on weight-management efforts before instituting such a change in the other services. Identifying potential risk factors for weight gain (e.g., overweight at time of accession, family history of obesity, poor initial performance on physical fitness test, a weight gain of more than 5 percent over initial entry training weight) may help identify individuals who are at risk. Educating these individuals during initial entry training, or whenever risk factors are identified, about their risk of becoming overweight might allow self-directed preventive measures. An evaluation of the usefulness of these efforts should be undertaken as there is a potential for negative consequences: individuals identified as potentially at risk may be singled out for attention or suffer discrimination by their commanders. The military appearance policy raises several concerns. Individuals differ anatomically and some accumulate adipose tissue in the abdomen (upper-body adiposity), while others tend to have a more even distribution of fat over several regions of the body. However, from an appearance perspective, an individual with abdominal fat may attract negative attention, while an individual with an even distribution of fat may not. Age, gender, and ethnic background (e.g., Hispanic, African-American) may exacerbate the disproportionate accumulation of abdominal adipose tissue, but the available data are insufficient to support these associations (IOM, 1998~. Implementation of the appearance policy may unfairly penalize some individuals due to their demographics. In addition, an individual who has been accused of violating the appearance standard but is later found to be within the height and weight standards may suffer some loss of self- esteem. Also, the use of the appearance standard by unit commanders has frequently been criticized as being flawed because it is not uniformly applied to all personnel. DOD is to be commended for the recent changes in procedure instructions relative to body fat that mandate the use of a single abdominal circumference- based equation for men and one for women to be used by all the services (DOD, 20021. The emphasis on abdominal circumference is appropriate as it is the site of human body-fat deposition most strongly associated with health risks and it corresponds most closely with military goals on appropriate appearance.

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132 WEIGHT MANAGEMENT Underweight and Eating Disorders One of the negative aspects of military enforcement of weight-for-height and body-fat standards is the possibility that such efforts may provoke the onset of eating disorders (e.g`, bulimia, binge eating, anorexia nervosa). Questions that need research attention include: What is the prevalence of bulimia, binge eating, and anorexia nervosa in military personnel? Some research has been conducted in this area, primarily by the Navy (McNulty, 1997a, 1997b, 2001~. One study of Air Force weight- management program participants has been conducted (Peterson et al., 1995), but this information needs to be collected in both men and women across all the services. 2. Does the military lifestyle promote disordered eating behavior in military personnel? 3. Does the diagnosis of an eating disorder preclude retention in the military? 4. What are the effects of disordered eating on performance? Performance It is recognized that implementation of the new DOD policy requires that specific physical fitness standards for occupation specialties be established, and that once these standards are identified, physical fitness training and testing would be linked to occupational requirements. This should benefit personnel needs as performance can not always be linked to compliance with standards. For example, Sharp and colleagues (1994) found that in female Army recruits in initial entry training, women who exceeded the weight-for-height standards or the percent body-fat standards before initial entry training performed as well as or better than women who initially passed the standards. Thus, the standards at that time tended to eliminate stronger women. Implementation of the new DOD weight-for-height standards should alleviate this problem, but it merits investi- gation. RECOMMENDATIONS ON ASSESSMENT - Assessments for weight-for-height (BMI) and percent body fat should be conducted quarterly rather than annually or semi-annually to facilitate identifying personnel at risk of exceeding standards and to allow for early intervention. More frequent assessments should be evaluated to determine they reduce disordered eating and other risky behaviors.

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PROGRAMMA TIC AND RESEARCH RECOMMENDS TIONS . 133 I Individuals at risk of increased weight gain or body fat (e.g., those entering the service over the standard or those with a family history of obesity) should be identified at the time of accession 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. TREATMENT Military personnel who are identified as exceeding body composition stan- dards are mandated to enter a military weight-management program for treatment. A good weight-management program must include two phases: weight loss and weight maintenance. Details of each are provided below. There are however, two overarching recommendations for military weight-management programs: (1) the critical components of the programs should be uniform across the services so that all personnel who are referred to such programs obtain equal assistance, and (2) the personnel administering these programs should have training in weight- management principles with respect to diet, physical activity, and counseling on behavior modification. The particular problems of establishing these services for military personnel are immediately obvious. Treatment programs are based on the concept of long- term care. Military personnel are rarely stationed at one facility long enough to be able to take advantage of continuing services, even if they are available. The problem is compounded still further by the instability of the staff. Even if staff were available for a continuing care program, there would be no expectation that these personnel would be continuously assigned at one facility. These environ- mental factors make it more urgent that each service strive to have a uniform program that will allow the individual to continue to progress in weight control regardless of assigned duty station. Furthermore, where possible, the programs of all the services should be coordinated to the maximum extent to assist individuals who receive medical care from another service and to facilitate fairness across the services. It may be possible to reorganize aspects of care to permit patients to maintain contact with individual service providers through e-mail, regardless of the location of patient or provider. This will only be useful, however, if com- puters are generally available to all service personnel and if resources are locally available for the patient to be able to follow-up on recommendations developed through this system.

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134 WEIGHT MANAGEMENT Essential Components of Military Weight-Loss Programs The key components of military weight-loss programs are diet, physical ac- tivity, behavior modification, and structured follow-up. Recommendations on each of these components are discussed in detail below. Diet General criteria for a diet that provides reasonable and steady weight loss are based on the principle of a hypocaloric-balanced diet. However, there is re- cent evidence that in obese individuals, use of very-low-calorie diets, coupled with behavior modification, may be more successful in initial weight loss and maintenance of weight loss than the hypocaloric-balanced diet. Although there is still considerable controversy over the ideal macronutrient distribution of a hypocaloric-balanced diet, recent evidence suggests that there may be some benefits to diets with a higher ratio of protein to carbohydrate in terms of stabilization of blood glucose, maintenance of lean body mass during weight loss, and better satiety. In a recent comprehensive review, Astrup and coworkers (2002) examined four meta-analyses of weight change occurring on intervention trials with ad libitum low-fat diets and found that these diets consistently demonstrated significant weight loss both in normal-weight and overweight individuals. On the other hand, Kris-Etherton and colleagues (2002) found that a moderate-fat diet (20 to 30 percent of energy from fat) was more likely to promote weight loss because it was easier for patients to adhere to this type of diet than to one that was severely restricted in fat (< 20 percent of energy). Thus, the macronutrient distribution of a recommended diet could be tailored somewhat to individual preferences. The most important dietary considerations are that: . The diet must be deficient in energy, as determined by comparing its energy value with an estimate of the individual's energy expenditure. Energy intake should be sufficient, and the level of other essential nutrients adequate, to allow individuals to pursue their regularly scheduled activities and to maintain appropriate levels of fitness. The diet program should promote a new set of eating habits that can help to maintain weight loss over time and should emphasize changes in what, how much, and how often one eats. . The diet should include at least five servings of fruits and vegetables a day and should be able to be readily incorporated into an individual's life style. It must be one that can be followed for a sufficient period of time to achieve desired weight loss.

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PROGRAMMA TIC AND RESEARCH RECOMMENDA TIONS 135 . The diet should contain sufficient volume to promote feelings of satiety. It should also be palatable and familiar, with the foods reflecting the food preferences ofthe individual, if possible. The foods in the diet must be readily available and affordable. Additionally, given that personnel may be living in barracks or at home, married or single, in the United States or abroad, the diet must be easily adaptable to a variety of situations, including mess halls and other group feeding environments, restaurants, and home. . An appropriate weight-loss diet would be one that incorporates the points above and is energy deficient by 350 to 1,000 kcal/day (with intakes no lower than 800 kcal/day). For women, protein intake should be no less than 60 g/day, and for men, no less than 75 g/day. Fat content should be no greater than 30 percent of total calories and carbohydrate intake no less than 130 g/day. A daily multivitamin and mineral supplement may be useful. Low-Car60hydrate Diets. Use of low-carbohydrate diets by military personnel should be discouraged. These diets have been associated with a number of potential side effects such as physiological dehydration, nausea, hyperuricemia, ketosis, and fatigue incidental to the depletion of glycogen stores, which could comprise performance (Phinney et al., 1980~. Furthermore, the recently released Dietary Reference Intakes for macronutrients (IOM, 2002) concluded that the adult requirement for carbohydrate to supply adequate glucose for proper brain function is 100 g/day, with a recommended daily intake of 130 g/day. Thus, it is recommended that under no circumstances should weight-loss diets recommended for military personnel contain less than 130 g/day of carbohydrate. Dietary Supplements. Little or no information is available to guide medical providers on possible interactions between weight-loss drugs and medications, herbals, or supplements taken for other purposes. Because military personnel must be combat-ready and side effects and interactions of supplements are largely unknown, personnel should be advised against the use of weight-loss supplements. Physical Activity A weight-reduction strategy based solely upon an increase in~physical activity (in the absence of calorie restriction) is likely to yield only a modest weight loss of no more than 5 to 6 lb (Blair, 1993; Wadden and Sarwer, 1999~. Weight-loss outcomes are optimized when physical activity is combined with dietary intervention (Dyer, 1994; Pavlou et al., 1989a, 1989b; Perri et al., 1993; Wing and Greeno, 19941. Finally, physically active dieters are far more likely to

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136 WEIGHT MANAGEMENT be successful in maintaining lost weight as compared with dieters who do not embrace physical activity (Kayman et al., 1990; Klem et al., 1997~. It should be kept in mind that persons who include bouts of structured physical activity in their weight-reduction regimen may inadvertently reduce their activities of daily . . Irving. It is difficult to develop specific physical activity recommendations for weight loss that may be appropriate for military programs. The amount of activity needed in conjunction with decreased energy intake will depend on whether the individual is genetically and phenotypically obesity-prone or obesity-resistant, and how much weight or body fat needs to be lost to bring them into compliance with military standards. There are few data available for physical activity requirements for predominantly young (< 50 y), male, over- weight (as opposed to obese) individuals. Recent recommendations for normal- weight individuals are 60 min/day of moderately intense physical activity to maintain healthy weight (IOM, 2002~. Data also indicate that the threshold of energy expenditure as physical activity needed to minimize weight regain in previously obese women is 47 kJ/kg body weight/day, which equates to an average of 80 min/day of moderate activity or 35 min/day of vigorous activity added to a sedentary lifestyle (Schoeller et al., 1997~. In a thorough review of the literature, Jakicic and colleagues (2001) developed a consensus statement for the American College of Sports Medicine that recommends an initial physical activity goal for overweight and obese individuals as a minimum of 150 min/wk of moderately intense exercise. To enhance weight loss and maintenance of this loss, exercise should be gradually increased to 200 to 300 min/wk (3.3-5 fur). Similar results may also be achieved through the expenditure of > 2,000 kcaVweek through activities of daily living (Dunn et al., 19999. The physical activity component of a weight-loss program should include both structured and unstructured exercise (e.g., aerobics, strength training, increased activities of daily living). Behavior Modif cation The behavior modification component of a weight-loss program should in- clude instructions on stimulus control, cognitive restructuring, relapse preven- tion, and self-monitoring, and it should provide mentoring. The primary goals of behavioral strategies for weight control are to increase physical activity and to reduce energy intake by altering eating habits (Brownell and Kramer, 1994; Wilson, 19959. Self-monitoring of dietary intake and physical activity, which enables the individual to develop a sense of accountability, is one of the cornerstones of behavioral treatment (Jeffery and French, 1999~. Patients are asked to keep a daily food/activity diary in which they record what and how much they have eaten, when and where the food was consumed, the context in which the food was consumed (e.g., what else they

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PROGRAMMA TIC AND RESEARCH RECOMMENDS TIONS 137 were doing at the time, what they were feeling, who else was there), and the types and amount of physical activity. The information obtained from the diary can also be used to identify personal and environmental factors that contribute to overeating and sedentary behavior, which helps in selecting and implementing appropriate weight-loss strategies for the individual (Wilson, 19951. Self- monitoring also provides a way for therapists and patients to evaluate which techniques are working and how changes in eating behavior and activity are contributing to weight loss. The Use of Structured Follow-Up/Maintenance Once individuals have achieved their weight-loss goals, systematic contact and follow-up from the weight-loss program staff is crucial to maintain the weight loss. This structured follow-up should include monitoring of body weight and weigh-ins weekly during the weight-loss phase and at least monthly during the weight-maintenance phase. Contact with program staff via phone or the Internet every 1 to 2 months, depending on the individual's difficulty in main- taining a stable weight, would facilitate continuity of care. RECOMMENDATIONS ON THE SPECIFIC CONTENT OF WEIGHT- LOSS PROGRAMS Diet. A weight-loss diet should be energy deficient by 350 to 1,000 kcal/day, with a minimum intake of 800 kcal/day. It should provide a mini- mum of 60 g of protein/day for women and 75 g of protein/day for men. Fat should provide no more than 30 percent of total energy and carbohydrate content should be no less than 130 g/day. In addition, the daily use of a mul- tivitamin-mineral supplement may help to ensure adequate micronutrient in- take. Exercise. A combination of aerobic and strength training exercise, along with increased activities of daily living, is recommended. Energy expended in physical activity should be at least 200 to 300 min/wk of moderate inten- sity exercise (3.5-5 fur), or greater than 2,000 kcal/wk. Behavior Modif cation. Training and support in behavior modification should include stimulus control, relapse prevention, self-monitoring, cogni- tive restructuring, and mentoring. Structured Follow-up. Follow-up should include regular contact with weight management counselors, routine self-monitoring, and ongoing sup- port that could be provided via the Internet.

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138 WEIGHT A~1NAGEMENT PROGRAM EVALUATION An important aspect of implementation of any weight-management program is an evaluation of the program results. The effectiveness of a weight-manage- ment program is determined by the success of the participants in losing the nec- essary amount of weight and being able to maintain that weight loss. This re- quires long-term tracking of these individuals. While this may be inherently more difficult in the military setting because of frequency of relocation and terms of enlistment, a minimum period of tracking would be 2 years. Because of the high rate of weight regain documented in many civilian settings, 5 and even 10 years of follow-up data would be optimal for program evaluation. TRAINING If one assumes a shortage of personnel Gained to assist in weight manage- ment, it may be advantageous for the military services to establish weight- control training programs for professionals as a military occupational specialty. The development of a specialty skill in administering weight-management programs may be useful for personnel otherwise trained as nurses, dietitians, physician assistants, nurse practitioners, counselors, and psychologists and would aid in developing uniform quality of weight-loss programs across the services. Special efforts will be needed to develop these programs in an effective way and to recruit personnel with sufficient interest in, and understanding of, the problems in losing and maintaining weight loss, so that they can be effective in the delivery of services. RECOMMENDATIONS ON A WEIGHT-MANAGEMENT MILITARY OCCUPATIONAL SPECIALTY Weight-control training programs should be established to train a multidis- ciplinary team of personnel associated with implementing weight-loss and weight-maintenance programs. Training standards for a weight-management military occupational specialty should include training in the principles of: - Nutrition - Physical activity/exercise - Behavior modification - Weight-loss aids (e.g., counseling, mentoring, psychological support). The program should include mandated continuing education requirements.

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PROGRAMMA TIC AND RESEARCH RECOMMENDS TIONS RESEARCH RECOMMENDATIONS 139 The modest success of weight-management endeavors in the civilian world sends a signal that losing weight and maintaining weight loss will not be easy and research on weight management in the military is sorely needed. Further suggestions for military research on overweight are presented in the following sections. Use of the Internet Internet-based programs could be developed using models already being used by the military (James et al., 1999a) in which participation may be completed during off-duty time. 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 even though overall response is not consistent. The concept of web-based programs may be very fruitful. Also, with a few resources put into development, a program could be created that followed military personnel regardless of where they were stationed. Classes could be conducted on line and even live (with current technology, two-way video can be inexpensive). Individuals could do this on their own time at home. Since members of the military risk losing their job if they exceed standards, it may not be too much to expect them to spend some off-duty time working at a weight- loss or weight-management program. The military could develop its own pro- gram with its own personnel or it could contract to one or more of the outstanding civilian obesity-treatment programs (Brownell, 1999; Foreyt and Goodrick, 1994; Jakicic et al., 1995; McGuire et al., 1999; Wadden et al., 1989~. These computerized weight-loss interventions optimize staff time (Wylie-Rosett et al., 2001) and could be used as a model for weight-reduction education in the military. Evaluation of Existing Military Initiatives and Programs for Effectiveness Evaluation of military weight-management programs is essential to deter- mine their effectiveness. Recommendations provided in this report are based almost exclusively on data collected in civilian populations; effectiveness may be quite different in military populations. This type of evaluation research will require the identification and long-term monitoring of personnel who have completed military programs.

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140 WEIGHT MANAGEMENT Computerized Follow-Up of Personnel at Risk It is necessary to create an independent computerized database that can be used to identify individuals with risk factors for weight gain or overweight as described above, to maintain routine contact with these individuals to check on their weight and physical fitness status, and to identify problems early and inter- vene as needed. Such computerized information should be centrally maintained and used as a source of data for longitudinal studies on He 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. Evaluation of Pharmacological Treatments Pharmacological treatments compatible with military performance need to be identified. Some military operational specialties preclude the use of central nervous system-active agents, but other types of Food And Drug Administra- tion-approved drugs could be considered. For all other operational specialties, obesity drugs could be used on a long-term basis. Studies of individual weight- loss drugs and combinations of drugs to determine their effects on mental and physical performance of military duties, as well as on their success in reducing body weight, need to be carried out. Most current drugs have been evaluated as single agents, so research on the effects of drug combinations should receive special attention. Evaluation of the Use of Dietary Supplements and Herbal Remedies Many nonprescription preparations are being used for weight loss by the civilian population and are undoubtedly being used in the military population. Very little is known about their effects on body weight, body composition, overall health, and physical performance. It may be particularly important to assess their effects on military performance. Of particular importance is evaluation of the prevalence of the use of ephedrine/caffeine preparations and their effects. Although DOD has followed Food and Drug Administration warnings and removed this compound from post exchanges and base establishments, personnel may still obtain ephedrine/caffeine preparations from civilian establishments. OTHER AREAS FOR RESEARCH The military environment affords an excellent opportunity to conduct important research needed to fill gaps in knowledge about weight control and treatment for overweight. It is recognized that some of this research may not

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PROGRAMMA TIC AND RESEARCH RECOMMENDA TIONS 141 have a direct or apparent need in military operations and, therefore, may have lower priority in military research fimd~ng. However, in keeping with the current policy that encourages increased leveraging of resources for research in the federal government, the areas described below should be considered. Body Weight and Aging Little is known about developmental aspects of fat deposition or the effects of early attempts at weight control on later propensity for obesity. Because most personnel enter the military during late adolescence or young adulthood, and because the military has the capability to follow its personnel longitudinally, the military is in a unique position to follow a large population of young adults from the time of accession into retirement to examine the following questions: How do the mechanisms of fat deposition change with aging? Do individuals who remain in strenuous (heavy lifting or very physical- ly active) occupations throughout their careers increase their proportion of body fat at a lower rate as they age than do those in low-activity occupations? Do they preserve lean body mass as they age? Do they remain healthier as they age? Do they cost the military less money as they age? Is bone mass/bone density better preserved as they age? Gender Information is needed on whether there are differences in gender responses to the various components of weight-management programs (e.g., do men and women respond differently to diet, physical activity, and behavioral change interventions). In addition, gestational weight gain is a major risk factor for overweight in women of childbearing age. Little is known about the factors responsible for postpartum weight retention or the effects of pregnancy and breastfeeding on military performance. Research is needed to answer the following questions: Does a program of regular physical activity throughout pregnancy (and/or beginning early in the postpartum period) reduce postpartum weight retention? Does weight loss at the rate that is required to return to within body composition standards in the recommended time frame (180 days) (IOM, 1998) permit adequate breastfeeding? Does competency in estimating portion sizes lead to less maternal weight gain and more rapid return to prepregnancy body weight and body composition?

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142 WEIGHT MANAGEMENT Is improved fitness when one becomes pregnant and throughout pregnancy associated with better outcomes (assessed by infant birth weight as well as by lower perinatal mortality and morbidity)? Does breastfeeding (which needs to be measured carefully and defined in terms of frequency and duration of feedings) lead to a more rapid return to prepregnancy body weight and body composition? Genetic Screening Currently, there are about 250 genes and gene markers that have been identified as associated with human obesity (Rankinen et al., 2002~. As science progresses, common patterns of genes or gene markers may be identified that correlate with the development of obesity. While it would be an extremely sensitive area of research, the military could address the question of whether genetic screening for obesity-prone individuals is appropriate for its mission. Role of Infectious Disease in Obesity A provocative hypothesis that has been proposed as an explanation for at least some of the increase in the prevalence of obesity is that one or more viral infections may produce obesity. Several animal viruses produce obesity in animals, and both animal and human viruses have been associated with obesity in humans (Dhurandhar et al., 1997, 2000.~. Although the current committee was not constituted to evaluate this particular issue, it was presented at the committee's workshop and thus is mentioned here as an area where numerous research questions exist on the role of viruses in the etiology of obesity. Both basic and clinical studies are needed to identify whether human adenoviruses that have been demonstrated to produce obesity in animals are associated with obesity in humans.