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Military Standards for Fitness, Weight, and Body Composition "The physical characteristics of the U.S. fighting soldier have long proved to be a significant factor in the maintenance of a strong military force. Through- out history it has been demonstrated that the stronger, more fit, mentally sound soldier is better able to perform his or her assigned duties at optimal levels of proficiency. This proficiency has been measured in various ways, by quality of work, productivity, promotion success, and test scores. It may also have been measured, at times simply by survival (Wheeler, 1965~. Measurable attributes affecting performance include physical characteristics, medical and mental ill- ness, behaviors of risk, intelligence level (Altus, 1949), athletic ability, and en- durance (Gould, 1979~" (Johnson, 1997~. This chapter provides a brief background on the relationship of body fat and fitness and the current policies of each branch of the military with respect to weight and body composition standards and weight-management programs. INTRODUCTION The primary purpose of fitness and body composition standards in the mili- tary has always been to select soldiers 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. The idea of a strong, trim military soldier is certainly not a new concept. Weight-for-height has been used as a key measure of a potential recruit's fitness for military ser- vice for almost 150 years. The first height and weight tables for the U.S. military were created during the Civil War. Anthropometric measurements of Civil War draft recruits were collected at the end of the war by Colonel Jedediah H. Bax- ter, chief medical officer in the Office of the Provost Marshall General (Johnson, 1997~. These data were later published in Statistics, Medical and Anthropologi- cal (1875, as reported by Love et al., 195 8~. 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 in- creases in mean height, weight, and fat-free mass of soldiers. However, the like- 29

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30 WEIGHT MANAGEMENT lihood of overnutrition leading to overweight and obesity and increases in inac- tivity have raised new concerns about the impact of fatness on health and mili- tary performance. FITNESS VERSUS FATNESS Assessing Fitness versus Fatness One of the considerations most relevant to the issue of fitness in the military is how fitness should be assessed. As described in the recently revised Depart- ment of Defense (DOD) Physical Fitness and Body Fat Program Procedures (DOD, 2002), the four components of fitness assessment are: (1) aerobic capac- ity, (2) muscular strength, (3) muscle endurance, and (4) body composition, which is influenced by other measures of fitness. Fatness, as defined by DOD, means a body-fat content in excess of 26 percent of total weight for men and 36 percent of total weight for women. Fitness and fatness are frequently confused due to the methods used to ex- press data related to fitness. For example, the definitive measure of cardiorespi- ratory (i.e., aerobic) fitness is the determination of maximal oxygen consump- tion (VO2,nax). VO2max is usually measured while the subject is exercising on a treadmill, according to a defined protocol that gradually increases speed and incline, until voluntary exhaustion and maximal heart rate are achieved. Maxi- mal heart rate is usually estimated as a heart rate of 220 minus the subject's age. The most appropriate expression of VO2ma,` is as ml O2/min, or as ml O2/kg fat- free mass/mint The effects of training on cardiovascular endurance may increase VO''naX by approximately 20 percent. Unfortunately, however, in many studies VOW is expressed as ml O2/kg body weight. Because this expression includes fat, which does not increase oxygen consumption in response to exercise, VOW, expressed as ml O2/kg body weight may reflect differences in perform- ance, but does not allow comparisons of cardiovascular fitness. Fitness, Fatness, and Injury Jones and colleagues (1992) studied the relationship of fitness and fatness (percent body fat) on injury rates of recruits during entry training at Fort Jack- son, South Carolina, in 1984 and 1988. Fitness was defined on the basis of l- or 2-mile run times and the number of sit-ups and push-ups completed during a 2- minute interval. All three fitness measures were highly correlated to fatness in both men and women. In men, percent body fat, determined from four skin-fold measures, was significantly and positively correlated with 1- and 2-mile run times and inversely correlated with the number of sit-ups and push-ups. Fitness was positively correlated with body mass index (BMI) as well, except no sig- nificant relationship was found for number of push-ups. Among women, the results of the three fitness tests were also positively correlated with percent body fate although the strength of the relationships was weaker. BMI was positively,

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MILITARY STANDARDS 31 but weakly, correlated with 1-mile run and weakly, but inversely, correlated with push-ups. However, in a subsequent study of female Army initial entry trainees, Sharp and colleagues (1994) found that women who failed the percent body fat standard performed significantly better on physical performance meas- ures of strength. For men, injury rates were directly correlated with percent body fat; for women, the highest rates of injury occurred in the leaner groups. Among both men and women, faster run times were associated with increased injury rates. In a multivariate analysis, the odds ratio for injuries to women was 2.5 times those for men. In analyses stratified by gender, both fatness and fitness independently accounted for significant proportions of the variance in injury rates. Fitness, Fatness, and Mortality Fitness may be an independent predictor of mortality. In a series of studies, Blair and coworkers (1989) have shown that fitness, defined as maximal tread- mill time, was inversely associated with mortality, even after control for a vari- ety of other variables linked to early mortality, such as serum cholesterol, blood pressure, and blood glucose. However, the highest mortality rates occurred in the least fit individuals with the lowest BMIs. In subsequent studies, Caucasian men who maintained or improved adequate levels of fitness had lower mortality rates than men who were persistently unfit (Blair et al., 1995~. In more detailed studies of the relationship of obesity and fitness, low fitness appeared to increase mortality rates among men in all weight categories and carried a risk comparable to other cardiovascular risk factors (Wed et al., 1999~. In another study (Lee et al., 1999), men who were lean and unfit had a higher mortality rate than men who were obese and fit. These results suggest that fatness and fitness may have independent effects on mortality. Caution is needed, however, in applying the data related to fitness and fat- ness reviewed above. First, the most comprehensive studies derive from a single patient population (Caucasian men). Therefore, the generalizability of these ob- servations to other populations may be limited. Second, in many of the earliest papers, VO2max was measured during submaximal exercise, but it was expressed as ml O2/kg body weight. Because obesity was defined on the basis of BMl, individuals with increased BMIs may have been spuriously classified as obese. This difficulty was only partially addressed by the analyses of the effect of fit- ness within BMI categories. A more recent study examined the relationship of BMI, cardiorespiratory fitness, and all-cause mortality in women (Farrell et al., 2002~. After adjusting for age, smoking, and baseline health status, the authors found that compared with normal-weight women, overweight and obesity did not significantly increase all-cause mortality. However, women with moderate and high cardiorespiratory fitness had significantly lower mortality risk com- pared with those with low cardiorespiratory fitness. These highly promising

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32 WEIGHT MANAGEMENT TABLE 2-1 U.S. Army Maximum Weight (lb)-for-Height Accession Standards by Age Height Men (y) (in) 58 59 60 61 61 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 SOURCE: U.S. AImy (1998). Women (y) 17-20 21-27 28-39 40+ 17-20 21-27 28-39 40+ 122 126 130 135 139 144 148 153 158 162 167 172 177 182 188 193 198 204 209 215 220 226 232 112 116 146 120 151 124 156 129 161 133 166 137 171 141 177 146 182 149 187 154 193 158 199 163 204 167 210 172 216 177 222 183 228 188 234 194 240 199 247 204 253 209 259 214 139 144 148 153 158 163 168 174 179 184 189 194 200 205 211 217 223 229 235 241 247 141 146 150 155 160 165 170 176 181 186 192 197 203 208 214 220 226 232 238 244 250 143 148 153 158 163 168 173 179 184 189 195 201 206 212 218 224 230 236 242 248 255 115 119 123 127 132 137 141 145 150 154 159 163 168 172 177 182 189 194 200 205 210 215 220 119 123 127 131 137 141 149 154 159 164 168 173 177 183 188 194 200 206 211 216 222 227 results suggest that the military focus on the physical fitness of personnel is ap- propriate not only for performance, but also for overall health. WEIGHT STANDARDS FOR ACCESSION AND RETENTION Typically, the various branches of the military have had two sets of weight standards: one set of standards to be met by potential recruits for accession into initial entry training, and another equivalent or more stringent set of standards in order to be retained in the service.

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MILITARY STANDARDS TABLE 2-2 Maximum Body Mass Index (BMI) (kg/m2) for Height for Accession 33 Men Women Height Marine Air Marine Air (in) Army Navy Corps Force Army Navy Corps Force 64 28.0 27.5 27.5 28.2 24.9 26.8 25.1 25.1 65 28.0 27.5 27.5 28.0 24.8 26.7 25.0 25.0 66 27.9 27.5 27.5 28.1 24.9 26.4 25.1 25.1 67 28.0 27.6 27.5 28.1 24.9 26.2 25.1 25.0 68 28.0 27.6 27.6 28.0 24.9 25.9 25.0 25.0 69 27.9 27.5 27.5 28.0 24.8 25.7 25.0 24.9 70 28.0 27.6 27.6 27.9 24.8 25.4 25.0 24.9 71 28.0 27.5 27.5 27.8 24.7 25.3 25.0 24.7 72 27.9 27.6 27.6 27.9 24.8 25.1 25.0 24.7 73 28.0 27.5 27.6 27.9 24.8 25.0 25.0 24.9 74 28.0 27.5 27.5 28.0 24.9 25.0 25.1 25.0 75 28.0 27.6 27.4 28.1 25.0 25.0 25.0 24.9 76 28.0 27.6 27.4 28.1 25.1 25.0 25.0 25.0 77 28.0 27.6 27.3 28.0 25.0 25.1 25.1 25.0 78 28.0 27.6 27.2 28.0 25.0 25.0 25.0 24.9 79 27.9 27.5 27.2 28.0 25.0 25.1 25.1 24.9 80 28.0 27.5 27.2 28.0 24.9 25.0 25.1 24.9 NOTE: Navy, Marine Corps, arid Air Force accession standards are the same as their retention standards. Army BMI was calculated from age group 28-39 y weight-for- height accession standards. The new Department of Defense Instruction 1308.3 (DOD, 2002) sets BMI standards between a lower limit of 25 and art upper limit of 27.5. SOURCE: USAF (2002~; U.S. Army (1998~; USMC (2002~; U.S. Navy (2002~. Accession Standards Each of the services maintains gender-specific, weight-for-height and body- fat standards for accession (entry) into active military service in order to prevent the entry of overfat individuals. In the Army and Navy, accession standards are more liberal than retention standards, and the Army accession weight-for-height standards change with increasing age (see Table 2-1~. Accession standards for all the services, based on BMI, are presented in Table 2-2. Body-fat standards for accession and retention are presented in Table 2-3. Currently, the Navy's body-fat accession standard is 1 percent higher than its retention standard. The Army accession standard is more liberal relative to the retention standard for men than it is for women. This is based on evidence that male recruits lose weight during initial entry training and early in their enlistment and maintain the weight loss, while women may lose weight during initial entry training, but tend

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34 TABLE 2-3 Maximum Body Fat (TO) for Accession and Retention WEIGHT MANA GEMENT Age (y) Service Gender 17-20 21-27 28-39 40+ . Army Male 20 22 24 26 Female 28 30 32 34 Navya Male 22 22 22 23 Female 33 33 33 34 Marine Corps Male 18 18 18 18 Female 26 26 26 26 Air Force Male 20 (17-29 y) 24 (30+ y) Female 28 (17-29 y) 32 (30+ y) NOTE: The body fat % is dependent upon age group, except for the Marine Corps, which does not distinguish between age groups. " The Navy accession standard for body fat is 1 % higher than retention standards. Spe- cifically~ the Navy accession standard for women is 34 percent body fat with a retention standard of 33 percent, for men the accession standard is 23 percent body fat and the retention standard is 22 percent. SOURCE: GAO (1998~; Singer et al. (2002~. to regain some of it (Friedl et al., 1989~. Accession standards for the Air Force and Marine Corps are the same as their retention standards. Because an accurate measurement of height and weight is considerably eas- ier than an accurate measurement of percent body fat, the initial body composi- tion screen for accession consists of a weight-for-height assessment using ser- vice-specific maximum allowable weight-for-height tables. Height and weight can be used to compute BMI, a widely accepted surrogate index of percent body fat (Gurrici et al., 1998; IOM, 1992a; NHLBI, 1998; Strain and Zumoff, 1992; Wang et al., 1996~. It should be noted, however, that the military standards for maximum weight-for-height were established long before the science supporting the use of BMI was developed. When only two measurements are used, height and weight have the highest level of association with the percentage of body fat. However, each service has conducted extensive anthropometric measurements of service personnel and used these data, together with data on body composition, to assess the best sin- gle additional measurement for estimating body fat (Fried!, 1992; Hodgdon, 1992~. Until quite recently (DOD, 2002), none of the services had adopted the BMI per se as an alternative to maximum weight-for-height standards. However, the Air Force has considered BMI as part of the evaluation process before as- signing an overweight individual to a weight-control program. The maximum allowable weights-for-height have varied across services for individuals of the same height, age, and gender. The individual service standards were uniformly more stringent than the DOD recommendations. For example, as

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MILITAR Y STANDARDS 35 reviewed by the General Accounting Office (GAO, 1998), in 1998 the maxi- mum allowable weight-for-height corresponded to a BMI of 25.1 for women in the Army, whereas for women in the Marine Corps, it corresponded to a BMI of 23.8. The disparity in maximum BMI between men and women was marked: while the maximum allowable weight-for-height for women in any service cor- responded to a BMI of 25.1 (Army), for men it corresponded to a BMI of 28.2 (Air Force) (GAO, 1998~. However, in the recent revision of DOD Instruction 1308.3 (DOD, 2002), the weight-for-height tables have been revised to correspond to an upper-limit BMI of 27.5 and a lower limit BMI of 25, and it specifies that no service shall set more stringent screening weights than those corresponding to a BMI of 25. Thus, the Marine Corps had to raise its previous standard of 23.7 for women, while the Air Force had to decrease its previous standard of 28.2 for men. Prospective recruits who exceed the accession weight limit for their height must undergo a body-fat assessment. The maximum allowable percentage of body fat for women on entry into the service ranges from 26 percent to 34 per- cent, depending on the service and for the Army, age. The maximum allowable percentage of body fat for men on entry into the service ranges from 18 percent to 26 percent depending on service and age (USAF, 2002; U.S. Army, 1987; U.S. Navy, 2002; USMC, 2002) (see Table 2-3~. Each service uses circumfer- ence measurements to estimate body composition and, until recently, each em- ployed its own set of measurement equations. However, as of November 2002, DOD has mandated a single circumference equation to be used across all the services for assessing percent body fat in men, and a different equation to be used in women. In 1998, the Navy adopted a maximum standard of 23 percent body fat for men and 34 percent for women (Hodgdon, 1999~. In setting these standards, the Navy consensus panel recognized that measures of height and weight "only ap- proximate the precise magnitude of fatness," and that lack of a strong relation- ship may lead to inaccurate classifications. However, height and weight were the only measurements for which a great deal of epidemiological data were avail- able (Hodgdon, 1999~. Ideally, more sophisticated body-fat measurements should augment the weight-for-height indices. Setting accession standards has implications for recruiting. When the ser- vices set restrictions on recruitment eligibility based on weight-for-height and estimated percent body fat, they eliminate a portion of individuals who might otherwise qualify for service. In the Third National Health and Nutrition Exami- nation Survey (NHANES III), 59 percent of the men and 51 percent of the women in the survey over age 20 years exceeded recent guidelines- (NHLBI, 1998) that suggest that men and women are overweight when they exceed a BMI of 25 (Flegal et al., 1998; Kuczmarski et al., 1997~. Nolte and coworkers (2002) recently examined NHANES III data to deter- mine the percentage of the U.S. population between the ages of 17 and 20 years that would meet the military weight-for-height standards that were in effect at

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36 WEIGHT MANAGEMENT TABLE 2-4 Maximum Permissible Body Mass Index (BMI) (kg/m2) for Given Height for Retention Men Height (in) DOD Army Navy Marine Corps Air Force 64 27.5 26.5 27.5 27.5 28.2 65 27.5 26.5 27.5 27.5 28.2 66 27.5 26.4 27.5 27.5 28.1 67 27.5 26.5 27.5 27.6 28.1 68 27.5 26.5 27.6 27.6 28.0 69 27.5 26.5 27.5 27.5 28.0 70 27.5 26.6 27.5 27.6 27.9 71 27.5 26.4 27.4 27.5 27.8 72 27.5 26.5 27.3 27.6 27.9 73 27.5 26.4 27.2 27.5 27.9 74 27.5 26.5 27.1 27.5 28.0 75 27.5 26.6 27.0 27.5 28.1 76 27.5 26.5 27.0 27.6 28.1 77 27.5 26.5 26.9 27.6 28.0 78 27.5 26.5 26.8 27.6 28.0 79 27.5 26.5 26.6 27.5 28.0 80 27.5 26.4 26.5 27.5 28.0 NOTE: Navy, Marine Corps, Air Force, and Department of Defense (DOD) standards are the same as their accession standards. Army BMI was calculated from age group 28-39 y weight-for-height retention standards. the time the study was conducted. Their analysis indicated that 13 to 18 percent of men and 17 to 43 percent of women in this age range exceeded the military standards. The authors concluded that these data indicated a need for the mili- tary to reassess their standards. Perhaps a more appropriate conclusion (particu- larly for long-term health) would be to highlight the need for weight-gain pre- vention strategies targeted towards adolescents, particularly minority women. Data from the 1999-2000 NHANES indicate that BMI continues to increase, with the most recent data indicating that the prevalence of overweight and obe- sity in all men over the age of 20 years has now increased to 67.2 percent, while prevalence in women over the age of 20 years has risen to 61.9 percent (Flegal et al., 2002~.

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MlLlTARY STANDARDS Women DOD Army Navy Marine Corps Air Force 27.5 23.6 26.8 25.1 25.1 27.5 23.5 26.7 25.0 25.0 27.5 23.6 26.4 25.1 25.1 27.5 23.4 26.2 25.1 25.0 27.5 23.5 25.9 25.0 25.0 27.5 23.4 25.7 25.0 24.9 27.5 23.4 25.4 25.0 24.9 27.5 23.3 25.3 25.0 24.7 27.5 23.4 25.1 25.0 24.7 27.5 23.4 25.0 25.0 24.9 27.5 23.5 25.0 25.1 25.0 27.5 23.5 25.0 25.1 24.9 27.5 23.7 25.0 25.0 25.0 27.5 23.6 25.1 25.1 25.0 27.5 23.6 25.0 25.0 24.9 27.5 23.6 25.1 25.1 24.9 27.5 23.6 25.0 25.1 24.9 SOURCE: DOD (2002); USAF (2002); U.S. Army (1987); USMC (2002); U.S. Navy (2002). Retention Standards 37 The retention standards are the maximum weights-for-height and percent body fat that military personnel are allowed to avoid referral to a weight- management program (DOD, 1995~. The current BMI retention standards for men and women for each military service are presented in Table 2-4. The maxi- mum allowable percentage of body fat for men ranges from 18 to 26 percent depending on service and age, while for women it ranges from 26 to 34 percent (See Table 2-3~. Each of the services screens active duty personnel either annually or semi- annually for fitness and compliance with weight-for-height standards. Personnel may be screened several times a year in the course of medical examinations, physical fitness tests, or training school examinations. Thus, personnel receive regular feedback on how well they meet the standards of weight-for-height. The consequences of these practices are clear. In the NHANES III study, 34 percent of civilian men and 36 percent of civilian women over age 20 years exceeded a

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38 WEIGHT MANAGEMENT BMI of 27 (NCHS, 1998~. In contrast, in a 1998 worldwide survey of active duty military personnel from all four services (n = 17,264), only 21 percent of active duty men and 9 percent of active duty women exceeded a BMI of 27. Additionally, 57 percent of active duty men and 25 percent of active duty women exceeded the newer overweight standard of 25, compared with 59 per- cent and 51 percent of civilian men and women, respectively (Bray et al., 1999; Flegal et al., 1998~. Because the data from Bray and coworkers (1999) are self-reported rather than actual measurements, some bias may exist. However, investigators who collected both self-reported data and actual measurements concluded that such biases were small. They found that correlation between self-reported data and actual measurements was high (R > 0.82), and that self-reported data enabled investigators to classify weight category correctly 94 percent of the time (Jeffery, 1996; Strauss, 1999~. Moreover, the data of Bray and coworkers (1999) were taken from surveys completed anonymously and collected by personnel who were outside the military chain of command of the respondents. Thus, these data most likely accurately portray the scope of the problem of overweight in the military services. THE IMPACT OF WEIGHT AND BODY-FAT STANDARDS One way to assess the impact of body-fat standards on the military is to look at the cost in terms of personnel management, namely the proportion of personnel enrolled in weight-management programs at any given time. Assign- ment to these programs requires paperwork and other administrative costs and may involve lost duty time. As of December 1999, 0.5 percent of male officers, 1.3 percent of female officers, 1.6 percent of male enlisted personnel, and 3.0 percent of female enlisted personnel were enrolled in the Air Force Weight Management Program. Data on weight-management programs recidivism or long-term success are not systematically compiled by any of the services, a situation that is, at least in part, intentional. The services attempt to minimize the stigma associated with participation in these programs by purging records. The Impact on the Health Care System Another way to assess the impact of body-fat standards on the military is to estimate their cost to the health care system. In 1998, according to the Defense Medical Epidemiology Database (DMED)l, active duty personnel made 9.1 mil- lion visits2 to ambulatory care clinics. Just over 40,000 of those visits were for a ' http://www.amsa.army.mil. The Arrny maintains the database, but it contains data from all four services. 2 International Classification of Disease, 9th revision (ICD9) codes 001 through V99.

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MILITARY STANDARDS 39 primary diagnosis of"obesity" or "localized adiposity."3 An additional 2,700 visits were for a primary diagnosis of"anorexia," "bulimia," or other "eating disorder."4 That is, less than one-half of 1 percent of all ambulatory visits made by active duty personnel were recorded as being primarily for concerns about body weight, body composition, or dysfunctional weight-loss practices. A dif- ferent approach was reported by Robbins and colleagues (2002), who examined anthropometrics, demographics, and health behaviors of 4,974 active duty Air Force men and women. This analysis found that more than 20 percent exceeded their maximum allowable weights and that this was associated with an increased cost of $22.& million per year for medical care and lost workdays (especially among men). Unfortunately, the statistics on visits to military clinics for weight- related matters do not provide a complete picture. Military personnel are likely to enroll in commercial weight-reduction programs or to self-treat with supple- ments or over-the-counter medications rather than call attention to their weight, which invites possible disciplinary action or separation from the service with loss of benefits. Diabetes, hypertension, and ischemic heart disease accounted for less than 1 percent of the visits made to ambulatory care clinics by active duty personnel in 1998. Taken together, all visits for "endocrine, nutritional, and metabolic dis- eases and immune disorders" and "diseases of the circulatory system" accounted for 4.5 percent of the total visits (in contrast, musculoskeletal disease and inju- ries/poisonings accounted for 26 percent and 16 percent of all visits, respec- tively). Thus, since the military is made up predominately of young, healthy individuals who exercise with some regularity, it appears that they are far more likely to suffer musculoskeletal injuries than they are to present health problems associated with obesity. The Impact on Weight-Loss Behavior and Disordered Eating Eating disorders have been widely studied among civilian women and among select groups of men (e.g., athletes, wrestlers). Gross disturbances in eating behavior characterize the conditions of anorexia nervosa currently seen in 1 to 2 percent of females in the general population, and bulimia nervosa, which has a prevalence of 1 to 3 percent in this population. Both disorders have a fe- male-to-male ratio of occurrence of 10:1. Another category of eating disorders, known as not otherwise specified (NOS), has been reported in the literature to occur in 3 to 35 percent of the population. The need to maintain weight-for-height and body composition standards does place pressure on military personnel, particularly those who may find themselves in more sedentary occupations after completing initial entry and ad- vanced individual training. The military policy of testing personnel annually or 3 ICD9 codes 278-0 and 278-1, respectively. 4 ICD9 codes 307-l, 307-51, and 307-51, respectively.

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MILITARY STANDARDS 53 "heart-healthy" dining hall menus (Fiedler et al., 1999). A recent Army study (Arsenault and Cline, 2000) reported the positive effects of the regular consump- tion of reduced-fat food items on total nutrient consumption and BMI in 50 women in a U.S. Army Medical Department Officer Basic Course. Each of the services performs medical evaluations to rule out possible medical causes of overweight before referring an individual to a weight- management program. A medical officer evaluates the individual's records and physical health to ensure that participation in a weight-management program will be safe. However, the extent of this medical evaluation is not well defined, except by the Air Force. In some programs, specific tests are conducted for un- derlying disease; the Air Force also assesses psychosocial factors such as readi- ness and stress levels. Army The Army program, "Weigh to Stay," is managed by physical fitness train- ers who must complete a course on weight loss and weight-control counseling. The Army also runs a number of hospital weight-loss and weight-management programs that are overseen by physicians as part of preventive medicine re- search efforts. The Hawaii-based program is highly innovative in its reliance on behavior modification and use of the Internet to maintain support of individuals at remote locations (James LC et al., 1997; James et al., l999b). Monthly weigh- ins are required, and those who fail to make satisfactory progress (loss of 3 to 8 lb/mo) for 2 consecutive months can face separation. Exemptions from the pro- gram are granted for prolonged illness, pregnancy (up to 180 d postpartum), hospitalization, or a medical profile waiver (U.S. Army, 1987~. Navy According to the Physical Readiness Program (U.S. Navy, 2002) the Navy's Command-Directed Physical Conditioning Program (CDPCP) is required for all individuals who fail the physical fitness test or who do not meet body fat standards. It is a 6-month program managed by a command-trained, physical- fitness coordinator (an enlisted person who has undergone 2.5 days of training). The program includes mandatory supervised exercise three times per week. Each individual who exceeds body-fat standards is issued a self-study nutrition and weight-control guide. A more rigorous, second phase program is the Bureau of Medicine-Approved Weight Management Program, an intensive 2-week out- patient program that requires the commanding officer's endorsement and 6- months prior participation in the CDPCP. Individuals with three fitness or body fat failures are not eligible (three failures in 4 years results in administrative action and although individuals are no longer separated from the service, they are not permitted to reenlist and are not eligible for promotion for the duration of their enlistment term). Successful completion of the Bureau of Medicine pro-

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54 WEIGHT MANAGEMENT gram and 1 year of follow-up in which progress continues toward meeting body fat standards result in a clear record. The Navy also conducts a 2-day course on recipe modification for mess specialists. The Navy has some innovative, small- scale weight-control programs to which selected individuals can be assigned. These include a 10-week program on nutrition, behavior modification, and exer- cise, with monthly support-group follow-up at the Norfolk Navy Environmental Health Center; a shipboard weight-control program (Dennis et al., 1999~; and a program at San Diego Naval Medical Center that is regarded as a model for pro- grams used at other locations (Carlson and Burman, 1984; Trent and Stevens, 1993, 19951. The challenge for the Navy has been to devise a single program that would address the needs of personnel at diverse duty stations and that could be taught by minimally trained personnel (Hoiberg and McNally, 1991~. Marine Corps The Marine Corps' physical fitness/weight-control program, "Semper Fit," similar to that of the Army, is managed by physical fitness trainers. Diet coun- seling is administered by self-study or by a dietitian if the individuals are close to an installation with an available dietetic service. Individuals who fail to meet the body fat standards and who do not receive a medical waiver are enrolled for an initial period of 6 months. If the individual is progressing but has not yet reached the target weight or percent body fat at the 6-month point, he or she may be allowed to continue for another 6 months. If after reaching the goal, the indi- vidual fails again during the rest of his or her career, he or she is allowed an- other 6 months to achieve compliance or face separation (USMC, 2002~. Air Force The Air Force Weight and Body Fat Management Program (WBFMP) op- erates from a health and wellness center (HAWC) located on each base, which is responsible for assessment of weight, body fat, fitness, and data recording. Per- sonnel who exceed the body-fat standards undergo clinical, laboratory, and psy- chological assessment to determine their qualification for the WBFMP. Those deemed unqualified are sent to an appropriate practitioner for care. The program consists of three phases. Medically cleared personnel are admitted to a 3-month initial program that provides counseling on diet and behavior modification by an Air Force dietitian or other authorized medical personnel, as well as exercise instruction provided by the HAWC staff. All individuals assigned to the pro- gram must attend a series of four classes concerning diet, behavior modification, and exercise. Personnel enrolled in the initial program are not penalized by ad- ministrative actions during the 3-month enrollment, although they are restricted from some professional activities. Personnel who meet their weight/body fat standard after completion of the 3-month program proceed to Phase II, a 6- month maintenance/monitoring program. Following successful completion of

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MILITARY STANDARDS 55 Phase II, the individual's WBFMP records are expunged. Personnel who fail to meet their goal within the first 3 months of the initial program are enrolled in Phase I, a more intense weight-management program in which monitoring is conducted monthly and the individual is subject to significant administrative restrictions relating to assignments, training, and promotions. Each Air Force installation has the authority to select programs approved by the Major Com- mand dietitian for use in counseling on diet and exercise (USAF, 2002), for ex- ample, "The Sensible Weigh" or "Shape Your Future Your Weigh." SUMMARY Accession and retention weight-for-height and percent body fat standards vary across the four services, as does the comprehensiveness of weight-loss pro- grams. A review of the weight-loss programs across the military services high- lights some significant deficits that could affect success. All of the programs have a strong motivating component that is highly disciplinary in nature the penalties for exceeding the body fat limits are significant. The majority of par- ticipants receive only minimal counseling by a qualified dietitian (with the ex- ception of those in the Air Force program). The same appears to be true throughout the services for the area of behavior modification. With the excep- tion of the Air Force (Spahn, 1999) and some specific sites in the other services, data collection for program evaluation is lacking.

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fast fooct restaurants now offer "super-size" portions for a minimal increase in cost. For example, a "jumbo super-size" order of a large hamburger, french fries, and soft drink at a fast-food restaurant may now contain more than 1,500 kc al for a single meal. These dramatic increases in portion size have recently been documented (Nielsen and Popkin, 2003; Young and Nestle, 2002. 2003~. One of the distinguishing features of dining out in Europe compared with the United States is the difference in restaurant portion sizes, a factor that may contribute to the lower prevalence of obesity in Europe. A recent trenc! analysis of portion size was conducted by Nielsen and Popkin (2003~. Data was taken from four national fooct-consumption surveys covering the perioc! 1977 to 1996. Food consumption was estimated as energy intake in kcal and as average portion sizes using food moclels to assist respondents in identifying portion size. Results clemonstrated that for foods eaten both inside and outside the home, portions sizes have increased for salty snacks, desserts, soft drinks, fruit drinks, French fries, hamburgers, cheeseburgers, ant! Mexican food. Meal Patterns and Eating Habits Eating patterns that are appropriate for an active lifestyle may continue after the individual changes to a more sedentary lifestyle. individuals for whom this observation has been made inclucle athletes and a large percentage of people with increasing age and changing occupational responsibilities. Athletes who are in training expend! large amounts of energy each day and, for many organized sports, are encouraged to eat large quantities to maintain their weight at an artificially high level. When activity declines, the eating pattern established during training may not be adjusted to meet the new lower energy needs. The same is true of military personnel. During basic training, advanced individual training, and special forces training, large amounts of energy are expended on a daily basis. By the time training is completed, individuals have been habituated to consume large amounts of food over a very short period of time. In many occupations, tasks that require more physical activity are assigned to younger workers. As these workers age and acquire more responsibility, their work may become more sedentary, but eating patterns may not change. This pattern of decreased occupational energy expenditure with promotions may be common in the military as well. Privates, airmen, and junior noncommissioned officers are more active than senior officers and noncommissioned officers. Despite strong commitments to engage in daily physical fitness, which may be unchanged or even increased in more senior indivicluals, the decrease in activities of daily living and job performance can lead to a positive ener~v balance unless particular care is taken to reduce ener~v intake O. The ubiquitousness of vending machines and fast-food outlets ensures constant access to foods at work usually foods with a high caloric content largely contributes! by fat or by refined CHO. A major contributing factor to the epidemic of obesity in recent years is likely to be the rise in the proportion of meals eaten away from home (eating out), along with the increase in access to boosts in virtually all locations. These changes have contributed in several ways to promoting obesity. Because more families include two-wage earners, adults spend more time out of the home and do not have time to prepare meals as they customarily did in the past. Meals consumed at restaurants tend to be larger and have a higher caloric content than those consumed at home, mainly because of higher fat content and larger portion sizes (Young and Nestle, 2003~. In addition, a high percentage of meals eaten away from home are eaten in fast-food restaurants or consist of fast-food take-out. The presence of fooct in virtually every circumstance of daily 3-~4