4
Weight Management

According to recent estimates, more than one-third of the adult population in the United States is overweight (Kuczmarski et al., 1994), and the percentage of overweight individuals is increasing. Among those who are not overweight, a significant percentage of adult women are dieting to lose weight. Military personnel differ from the majority of civilian personnel in that while few civilian occupations are permitted by law to require employees to maintain their weight and body fat below an established maximum, military personnel, regardless of their individual occupational specialty, incur increasingly punitive administrative consequences for failing to "make weight." Because of the emphasis placed by the military on meeting standards for body weight and fat, and undoubtedly as a result of the same forces that have driven the increase in weight among civilians, the issue of weight management among military personnel has assumed considerable prominence. Enforcement of the body weight standards has led to the creation of programs for weight loss in each service. This chapter will describe the weight programs of each service, review existing data on the prevalence of weight problems among military personnel and on the outcomes of the weight programs, discuss the ramifications of weight standards in terms of what is known about dieting practices among military personnel, and finally, attempt to measure the current military programs against guidelines that have been established for successful civilian weight management programs.



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--> 4 Weight Management According to recent estimates, more than one-third of the adult population in the United States is overweight (Kuczmarski et al., 1994), and the percentage of overweight individuals is increasing. Among those who are not overweight, a significant percentage of adult women are dieting to lose weight. Military personnel differ from the majority of civilian personnel in that while few civilian occupations are permitted by law to require employees to maintain their weight and body fat below an established maximum, military personnel, regardless of their individual occupational specialty, incur increasingly punitive administrative consequences for failing to "make weight." Because of the emphasis placed by the military on meeting standards for body weight and fat, and undoubtedly as a result of the same forces that have driven the increase in weight among civilians, the issue of weight management among military personnel has assumed considerable prominence. Enforcement of the body weight standards has led to the creation of programs for weight loss in each service. This chapter will describe the weight programs of each service, review existing data on the prevalence of weight problems among military personnel and on the outcomes of the weight programs, discuss the ramifications of weight standards in terms of what is known about dieting practices among military personnel, and finally, attempt to measure the current military programs against guidelines that have been established for successful civilian weight management programs.

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--> Military Weight Management Programs If U.S. military personnel fail to comply with body composition standards, they are referred to a remedial weight management program. All military weight control program regulations implement Department of Defense (DoD) Directive 1308.1 (1981), which established a weight control program for all services. Each branch of the military has its own weight loss program, based on scientifically and medically accepted approaches for decreasing energy intake and increasing energy expenditure. Personnel participate in these programs until a weight within military standards is achieved. Army The Army Weight Control Program is the responsibility of the deputy chief of staff for personnel, with counseling and medical policies established by the surgeon general. Evaluation of weight and appearance, measurement of body fat, and assignment to the weight control program are the responsibility of commanders and supervisors. All personnel are weighed a minimum of every 6 months (at the time of the physical fitness test [PFT]); additional weighings and body fat measures are at the discretion of the commander or supervisor. Personnel who exceed the screening table weight maximum for their height, gender, and age undergo circumferential body fat measurement (see Army body fat standards in Appendix B). Those who exceed body fat standards receive medical evaluation; those found to have no underlying causative disease are entered into the weight control program by the unit commander, and their personnel records are flagged (this notation carries implications for travel, education, permanent change of duty station, and promotion). They must receive nutrition counseling (one visit with a counselor) and are required to meet a weight loss goal of 3 to 8 lb per month (AR 600-9, 1986). The nutrition counseling component of the Army Weight Control Program is provided by "qualified health care personnel," according to Army Regulation 600-9 (1986). Depending on the availability of such personnel, the counseling may be provided by registered dietitians, dietetic technicians, physicians' assistants, nurses, or physicians. Beyond the initial visit, there is no requirement regarding the number of visits, and an unlimited number of follow-up visits is permitted (Personal communication, LTC J. P. Warber, U.S. Army Research Institute of Environmental Medicine, Natick, Mass., 1997). The educational materials and counseling provided appear to vary from one facility to another (Personal communication, C. Baker-Fulco and LTC J. P. Warber, U.S. Army Research Institute of Environmental Medicine, Natick, Mass.; A. D. Cline, Pennington Biomedical Research Center, Baton Rouge, La., 1997). A general nutrition and weight management guide that emphasizes lower-fat food choices, sample menus, and advice on lifestyle and behavioral modification strategies appears as an appendix to Army Regulation 600-9, and may serve as a reference for Army health care personnel to provide counseling to personnel enrolled in weight control programs. Progress of personnel in the Weight Control Program is monitored on a monthly basis and evaluated at 6 months. Failure to show satisfactory progress for 2 consecutive months or at the 6-mo point may result in additional medical evaluation and ultimately separation from the Army.

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--> Air Force The Air Force Weight Management Program is described in Air Force Instruction 40-502 (1994) and implements Air Force Policy Directive 40-5 (1994), "Fitness and Weight Management." The Weight Management Program is the responsibility of each installation commander, with counseling and medical policies established by the deputy chief of staff for personnel, the surgeon general, and the Air Force Nutrition Committee. As in the Army, evaluation of weight and appearance, measurement of body fat, and assignment to the Weight Management Program is the responsibility of commanders and supervisors. All personnel are weighed, without notice, a minimum of every 12 months; additional weighings and body fat measures are at the discretion of the commander or supervisor. Personnel who exceed the screening table weight maximum for their height, gender, and age group or who appear to exceed body fat standards or who fail to present a "professional military appearance" undergo circumferential body fat measurement (see Air Force body fat standards in Appendix B). Those who exceed body fat standards receive medical evaluation; a 6-mo body fat standard adjustment may be made by the Medical Service if the person is deemed to be otherwise physically fit. Those personnel found to have no underlying causative condition or disease receive diet counseling and are entered into Phase I of the two-phase Weight Management Program and a 90-d exercise program by the unit commander. Such personnel are restricted from some travel; in addition, they are ineligible for education, permanent change of duty station, and promotion (AFI 40-502, 1994). Phase I of the Weight Management Program is administered by the Nutrition Medicine Service, with counseling provided by authorized diet counselors, who are defined as registered dietitians, authorized diet therapists, or other health professionals authorized by the Major Command (MAJCOM) consultant dietitian (AFI 40-104, 1994). While initial and follow-up counseling are specified in Air Force Instruction 40-502 (1994), the actual counseling may be conducted for various lengths of time, including a one-time class, a 4-wk program, or a 16-wk program (a mandatory program of quarterly diet counseling has been discontinued); some of the programs include a fitness component (Personal communication, MAJ J. M. Spahn, Elmendorf AFB, Alaska, 1997). Counseling is based on Air Force Instruction 44-135 (1994), "Clinical Dietetics," which in turn is based on the American Dietetic Association's Manual of Clinical Dietetics (Personal communication, MAJ J. M. Spahn, Elmendorf AFB, Alaska, 1997). Class materials are updated quarterly. Counseling sessions or classes cover the content of Air Force Pamphlet 44-132 (1994), "Dietary Information for Weight Loss." This 57-page booklet includes basic instruction on nutrition, physiology, foods and low-fat food choices, sample menus, portion guides, methods to chart progress, behavioral modification strategies, and references. In addition, individuals enrolled in the Weight Management Program receive the booklet Air Force Pamphlet 44-133, ''Improving Eating Habits," and Air Force Pamphlet 44-125, "Good Eating: A Dieter's Guide," as well as a food diary and exercise log (AF Form 3529, 1993) to teach self-monitoring of food intake and exercise. Individuals who complete Phase I of the program are enrolled in Phase II, a 6-mo observation period during which they are weighed monthly. This is followed by a 1-y probationary period, during which personnel can be weighed at any time. Personnel are encouraged at all times to return to the nutrition clinic for individual counseling and quarterly follow-up classes. Those who repeatedly fail to make satisfactory progress (defined as a decrease of at least 1 percent body

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--> fat per month or a weight loss of 3 lb per month for a woman) may be subject to increasingly severe administrative actions, culminating in discharge or separation, as described in Air Force Instruction 40-502 (1994). Navy and Marine Corps The Navy Weight Loss Program is described in Naval Operations Instruction 6110.1D (1990), "The Physical Readiness Program." Commanding officers are responsible for providing a conditioning program comprising fitness and nutrition education. The program is administered by certified fitness counselors. Navy and Marine Corps personnel undergo weighing every 6 months in conjunction with the physical readiness test (PRT). Those individuals who exceed the gender- and height-specific weight standards (Navy standards are not age specific) are subject to circumferential measurement. Those whose body fat exceeds the 30 percent standard may be referred to a counseling and assistance center rehabilitation program. Prior to 1995, this program comprised three tiers. Level I consisted of a command-directed, remedial, physical conditioning program lasting approximately 6 months and sometimes incorporating nutrition education and other elements; failure to progress in Level I resulted in assignment to Level II, which consisted of a 2- to 6-wk intense outpatient weight management counseling program. Level III was a 4- to 6-wk inpatient obesity treatment program and required a diagnosis of "compulsive overeating" (not recognized by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition [DSM-IV] or Naval Bureau of Medicine) for entry. In 1995, Level III was eliminated, because it was felt that the majority of overweight personnel need education rather than inpatient treatment and because the criterion for entry was not a true diagnosis. In 1996, a 2-wk outpatient weight management program was adopted, focusing on nutrition education and lifestyle behavior changes. The command-directed physical conditioning program consists of mandatory exercise sessions with regular monitoring of the individual's body composition; it is designed to motivate the development of regular exercise habits. The Navy Weight Loss Program now relies on the "Navy Nutrition and Weight Control Self-Study Guide: Forge the Future" (NAVPERS 15602A, 1996), which was developed to be the principal tool to enable service personnel to improve individual health and fitness. The study guide is used in conjunction with the command's physical conditioning program by every member of the Navy who exceeds body fat standards. The study guide was prepared by Navy personnel, including physicians, nurses, and registered dietitians. This guide provides an overview of nutrition, behavior modification, and exercise and includes recommended readings and references. The weight loss diet is based primarily on decreasing the dietary intake of fat and increasing the dietary intake of fiber from grains, fruits, and vegetables. Outcome Assessment for Military Weight Management Programs None of the military nutrition or personnel professionals contacted were able to identify any research to determine the availability of nutritionally trained health care professionals, the uniformity in implementation of weight control programs, or outcomes of these programs at military sites around the world. Data were not available on the numbers of individuals who were

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--> referred to weight control programs. It was agreed by those contacted that enforcement of the weight standards by referring individuals to weight control programs was entirely at the discretion of unit commanders and supervisors and was done on an individual basis. Regarding outcome analysis, no data were available on the rate of success or recidivism of the weight control programs except for a small study of Navy personnel. Trent and Stevens (1995) compared the 6-wk, 6-mo, and 12-mo outcome of patients enrolled in programs at approximately 20 different command sites and found that although maintenance of weight loss at 12 months was higher than civilian studies have reported, absolute loss was small. Interpretation of the results is complicated by the fact that the study compared personnel enrolled in three program levels. Whereas the most intense Level III (a 6-wk in-patient program) has since been abolished, the current program is most similar to the former Level II program. In addition, attrition was significant, and there was no control group. Nevertheless, based on their results, the authors recommended changing the Navy's approach to treatment of overweight, including adoption of a long-term, supportive, behaviorally based "aftercare" program. The 1992 Institute of Medicine (IOM) report, Body Composition and Physical Performance, recommended examining data compiled by the Army Medical Remedial Enlistment Program database to evaluate long-term health outcome and performance of program participants, as well as to perform a cost-benefit analysis of the program; however, these data were not available. The numbers of active-duty enlisted women separated from service in fiscal year 1996 for failure to adhere to the body composition standards are listed in Table 4-1. The Air Force was the only branch of service that separated female commissioned officers in fiscal year 1996 for failing to adhere to weight standards. Five women were separated, all between 26 and 40 years of age; three were minorities. According to one Air Force dietitian, the DoD is developing a software program to collect outcome data on weight reduction programs (Personal communication, MAJ Joanne M. Spahn, Elmendorf AFB, Alaska, 1997). At present, this software is being tested. TABLE 4-1 Active-Duty Enlisted Women Separated from U.S. Military Service in Fiscal Year 1996 for Failure to Meet Body Fat Standards Service Branch Total Number of Women Separated in FY1996 Separated Personnel as a Percentage of the Active-Duty Force (%) Percentage of Personnel Separated Who Were 17–25 Years Old (%) Percentage of Personnel Separated Who Were Minorities (%) Army 271 0.5 69 46 Air Force 144 0.3 60 26 Navy 419 0.9 58 44 Marine Corps 19 0.2 63 47   SOURCE: Defense Manpower Data Center (Rosslyn, Va., 1997).

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--> Summary The DoD mandates that the services maintain a weight management or body composition program for personnel who exceed the maximum gender-and age-defined percent body fat established by their service. Each service maintains its own program under the direction of the site commander but administered by authorized health care personnel (the Marine Corps refers personnel to the Navy program). In general, the programs require that personnel undergo a medical exam to rule out a medical cause for overweight, and that they attend a minimum of one meeting with a health professional designated as a nutrition counselor. Program participants are weighed periodically and must demonstrate a minimum weight loss each weighing period until their goal weight or body fat is met. Additional counseling sessions, classes, and remedial physical activity programs are sometimes provided or recommended. Referral to and participation in the weight management programs can result in personnel actions such as denial of travel, permanent change of duty station, further education, and promotion. Except for periodic weigh-ins, there is no mandatory long-term follow-up or ongoing counseling. The degree of uniformity with which these programs are administered from one site to another within the same service has not been studied, although it is acknowledged that the nutritional expertise of health care personnel varies among locations. In addition, long-term outcome studies have not been performed to determine the success of the overall programs, individual programs, or individual participants. Such studies are now under consideration. It is not possible to use data on numbers of personnel separated from service for failure to comply with body fat standards as an estimate of the success of the weight management programs because separation from service is at the discretion of the command. Prevalence Of Actual And Self-Perceived Weight Problems Data on the prevalence of overweight and eating problems among military women derive from three sources: (1) large self-report surveys of health status, (2) smaller surveys (self-report, sometimes with accompanying clinical measures) of women in basic combat training (BCT) classes or other training situations, and (3) personnel and medical databases that compile data on the percentages of personnel stratified by body mass index (BMI, weight in kilograms divided by the square of the height in meters), body fat, or weight for height as well as the incidence of separation for failure to meet body composition standards. Large Self-Report Surveys Data were requested from the Army, Navy, and Air Force that profiled the weight for height or BMI of all (or a representative sample of) active-duty women. These data are gathered annually or semiannually by each service during the mandatory routine medical exam. Data obtained from the Army Health Risk Appraisal database for 1995, the most recent year for which data are currently available, from a sample of 17,400 female soldiers (both active duty and those serving in the reserves) revealed a mean BMI of 22.7 ± 3.29 (SD) (Personal communication,

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--> V. R. Rao, U.S. Army Center for Health Promotion and Preventive Medicine, Aberdeen Proving Grounds, Md., 1996) with 13.9 ± 0.1 percent at a BMI of 27.3 or greater (the Healthy People 2000 [DHHS, 1991] definition of obesity for women age 20 and older). The prevalence of overweight by this definition increased with age, from 3.6 ± 0.1 percent for women under age 21 to 28.4 ± 0.2 percent for women over age 40. The prevalence of overweight was approximately twice as high for reservists as for active-duty women and tended to be higher for Hispanic women than for African American and Caucasian women. Comparable data were not available from the other branches of service. The 1995 Survey of Health-Related Behaviors among Military Personnel (Bray et al., 1995) reported the prevalence of overweight based on calculations of BMI from self-reported height and weight (Table 4-2) and on the definition of overweight used in Healthy People 2000 (DHHS, 1991), which is a BMI greater than or equal to 25.7 for women under age 20 and a BMI TABLE 4-2 Prevalence of Overweight among Active-Duty Personnel, by Age and Gender   Branch of Service       Gender/Age Group Army Navy Marine Corps Air Force Total DoD Males*           Under 20 19.3 (1.9) 20.8 (4.1) 23.9 (2.3) 20.2 (3.5) 20.8 (1.5) 20–25 12.8 (0.9) 17.3 (1.2) 8.9 (0.9) 10.3 (0.9) 12.8 (0.6) 26–34 16.7 (1.7) 24.1 (1.5) 11.1 (1.3) 19.2 (1.5) 19.3 (0.8) 35 and older 19.4 (1.6) 29.2 (0.9) 14.0 (1.5) 25.5 (1.5) 23.9 (0.8) Females†           Under 20 + (+) 14.1 (3.7) + (+) + (+) 10.5 (2.6) 20–25 5.0 (1.6) 9.2 (2.5) 1.1 (0.8) 4.6 (1.1) 5.6 (0.9) 26–34 11.8 (3.2) 12.0 (2.0) 2.7 (1.6) 5.2 (1.1) 9.1 (1.3) 35 and older 14.8 (2.2) 9.7 (2.1) 2.3 (1.4) 10.3 (3.4) 11.4 (1.7) Total DoD           Under 20 17.4 (2.1) 19.2 (3.4) 22.8 (2.2) 18.0 (2.5) 19.0 (1.4) 20–25 11.8 (0.9) 16.4 (1.2) 8.6 (0.9) 9.2 (0.8) 11.9 (0.6) 26–34 16.0 (1.7) 22.9 (1.3) 10.7 (1.2) 17.2 (1.4) 18.1 (0.8) 35 and older 18.8 (1.5) 27.5 (1.0) 13.6 (1.4) 23.5 (1.5) 22.6 (0.8) NOTE: Table entries are percentages of personnel meeting criteria for being overweight (with standard errors in parentheses). Overweight was defined in terms of body mass index (BMI), where BMI = (weight in kilograms) ÷ (height in meters).2 Estimates have not been adjusted for sociodemographic differences among services. +, low precision. DoD, Department of Defense. * Defined as being overweight if BMI > 25.8 for men under age 20 or BMI > 27.8 for men aged 20 or older. † Defined as being overweight if BMI > 25.7 for women under age 20 or BMI > 27.3 for women aged 20 or older. SOURCE: Survey of Health-Related Behaviors among Military Personnel (Bray et al., 1995).

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--> greater than or equal to 27.3 for women aged 20 or older. By this definition, 10.5 percent of military women under 20 years of age, 5.6 percent of military women 20 to 25 years of age, 9.1 percent of military women 26 to 34 years of age, and 11.4 percent of military women 35 years of age or older were overweight. Although these percentages for military women are well below the 15 percent goal recommended by Healthy People 2000, it is not possible to ascertain from them the proportion of active-duty women who exceed the weight standards at any one time because the current maximum weight-for-height standards correspond to BMIs of 25 or less, depending on service and age (see Table S-3 in Executive Summary). A recently completed survey of active-duty Army personnel by Warber and coworkers (in preparation) found that of 494 female respondents, 25.1 percent had a BMI of 25 or higher, while 2.4 percent had a BMI of 30 or higher (compared with 57.6% and 5.8% of men, respectively). Thus, 74.9 percent of women and 42.3 percent of men had a BMI less than 25. Nevertheless, an average of 59.3 percent of women reported that they were trying to lose weight (54% of women 29 years of age and younger, 64% of women 30–39 years of age, and 73% of women 40 years and over), compared with 37.4 percent of all men. The 1995 Sample Survey of Military Personnel, a cross-sectional survey of active-duty Army personnel, found that among 7,376 female respondents, 9 percent reported exceeding the Army's age-dependent body fat standards (30–36% body fat), although 20 to 28 percent reported difficulty meeting the weight standards (Verdugo, 1996). A self-report survey administered to 9,859 Navy and Marine Corps personnel (Perceptions of Wellness and Readiness Assessment, POWR'95, as reported by Graham, 1996 and Hourani, 1996) found that in response to the question "Do you consider yourself overweight?", 46 percent of Navy women and 31 percent of Marine Corps women reported they did consider themselves overweight; these percentages are considerably higher than the actual percentages of Navy and Marine Corps women who are overweight by published standards. Minority women reported a failure to meet the standards more often than Caucasians. Smaller Surveys A study by Rose and coworkers (1993) that examined methods of weight management by military personnel (both men and women) reported that 16.6 percent of soldiers were overweight by Army standards, although only 2.8 percent had participated in the Army Weight Control Program. In contrast to these data, the pamphlet "I Am the American Soldier" (issued by the Fort Benjamin Harrison Soldier Support Center in 1986 and cited by Rose et al., 1993) reported that between 21.1 and 34.5 percent of female soldiers exceed the maximum allowable weight and body fat standards. Of the soldiers in the Rose et al. study, 13.6 percent reported having attempted to lose weight beginning before the age of 18, which suggests lifelong weight concerns, and 85.9 percent of the soldiers were overweight according to their own personal standards. Approximately 66 percent of the soldiers reported having gained weight since accession. The data from the survey by Rose and coworkers indicate that a significant number of female soldiers who responded to the questionnaire had difficulty meeting the Army weight standards. Unfortunately, the response rate for this survey was low, only 26 percent (of a sample of approximately 4,000).

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--> In a study of women in Army BCT, Westphal and coworkers (1995) found that over 25 percent of new recruits exceeded the body fat standards, which suggests that a significant percentage of military women may enter the military with weight problems. Several studies have reported on the prevalence of overweight and weight concerns at the military academies. A study of U.S. Military Academy, West Point cadets by Friedl et al. (1990) conducted in 1990 found that 14 percent of female cadets were overfat according to Army standards (AR 600-9, 1986); however, by the Cadet Weight Management Program standards of the time, half of the women were classified as overfat. The study showed that 80 percent of female cadets were attempting to lose weight; no correlation was observed between attempting to lose weight and actual body fat level. The U.S. Military Academy has since incorporated the body composition standards of Army Regulation 600-9 (1986). A survey conducted in May 1995 at the U.S. Naval Academy (Drake, 1996) found that although the women had, on average, the same percent body fat and weight for height as their civilian college counterparts, 10 percent exhibited symptoms of disordered eating,1 according to their scores on the Eating Disorders Inventory (EDI, Garner and Olmstead, 1991). Finally, a self-report survey of Army Reserve soldiers (Sweeney and Bonnabeau, 1990) indicated that 38.5 percent of the respondents experienced difficulty with weight maintenance. Of these, almost half reported never having been in the weight control program, while the rest had been enrolled in the program at least once. The data were not stratified by gender. Data from Medical and Personnel Databases Data on BMI and on the prevalence of overweight (by military standards) for the entire military have not been reported. Although the numbers of active-duty enlisted personnel separated from service in fiscal year 1996 due to failure to comply with body composition standards appear in Table 4-1, these data are not indicative of the incidence of overweight in the military because, as described above, the decision to refer a soldier to the weight control program and to pursue separation is made on an individual basis. Low Body Weight Currently, the military maintains minimum weights-for-height for recruitment and retention, which for the Army correspond to a BMI of approximately 18.8 for women of short stature but to a BMI of 16.9 for a woman 70 in (1.8 m) in height. Although data on the prevalence of low body weight were not included in the published report (Bray et al., 1995) of the Survey of Health-Related Behaviors among Military Personnel, the prevalence rates for BMI less than 19 were obtained from the data set. Based on self-reported weights and heights, the prevalence rates 1   Disordered eating is a term used by the Women's Task Force of the American College of Sports Medicine in its position stand on the female athlete triad (ACSM, 1997) to refer to "a wide spectrum of harmful and often ineffective eating behaviors used in attempts to lose weight or achieve a lean appearance. The spectrum of behaviors ranges in severity from restricting food intake, to bingeing and purging, to the DSM-IV defined disorders of anorexia nervosa and bulimia nervosa" (p. i).

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--> for BMI less than 19.0 were 4.8 ± 0.9 percent (SEM) for Army women, 3.6 ± 0.4 percent for Navy women, 6.8 ± 0.7 percent for Marine Corps women, 4.7 ± 0.4 percent for Air Force women, and 4.7 ± 0.4 percent for all active-duty women (prevalence rates for BMI less than 19.8, stratified by service, age, ethnicity, and rank, are reported in Table 6-4). The highest prevalence of low BMI is observed among Marine Corps women, women less than 20 years of age, Hispanic women, and officers. The recently completed Army Food and Nutrition Survey (Warber et al., in preparation) also did not estimate the prevalence of underweight (low BMI); however, when asked whether they were trying to gain weight, 2.8 percent of female respondents reported that they were trying to gain weight (4.6% of women 29 years and younger, and 0.7% of women 30–39 years of age). No data were available on the prevalence of low body fat among active-duty women, as body fat assessments would be performed only on individuals who exceed the maximum weight for their height. According to NHANES III data, the percent of civilian women with BMI less than 18.5 is 5.6 percent of women 20 to 29 years of age, 3.8 percent of women 30 to 39 years of age, 3.0 percent of women 40 to 49 years of age, and 2.4 to 2.5 percent of women 50 to 79 years of age; the prevalence of underweight is higher among Caucasian women than among African American and Mexican American women in the sample population (Personal communication, A. Looker, National Center for Health Statistics, Hyattsville, Md., 1997). As suggested by data from the two military surveys and NHANES III, the prevalence of low BMI is more significant among younger women. Nevertheless, military dietitians and other personnel contacted were unaware of any formal program or intervention to rehabilitate underweight or underfat personnel. A study of women in BCT found that those whose body fat was below 25 percent at enlistment tended to gain weight, body fat, and fat-free mass throughout the 8-wk program (in contrast, women who entered BCT with greater than 25% body fat tended to lose body fat, and those who entered at greater than 35% body fat tended to lose both fat and weight). No follow-up data were available on these women. Summary Data on the prevalence of overweight among military personnel are difficult to obtain. Central medical and personnel databases do not appear to contain information that would permit a determination of the incidence of personnel exceeding the body fat standards. Data from two large self-report surveys that use self-reported height and weight to calculate BMI suggest that the prevalence of overweight among active-duty women is comparable to or less than that of a similar population of civilian women; however, these surveys use the definition of overweight established by the Healthy People 2000 report, which is significantly higher than the age- and service-specific cut-offs used by the military. Thus, it is not possible to estimate from these data the percent of women who are out of compliance with the standard to which they are required to adhere, but it is clear that this figure is higher than the percent defined as overweight by Health People 2000 standards. Data from several surveys demonstrate that the percentage of active-duty women who are dieting and/or dissatisfied with their weight is significantly higher than the percent of women who are actually overweight, suggesting that many women who are not overweight are trying to lose weight. As will be discussed below and in Chapter 5, this has serious implications for health, fitness, and performance.

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--> Issues In Weight Management Body Image and Weight Maintenance Evidence suggests that the percentage of active-duty women who perceive themselves to be overweight exceeds considerably the percentage who actually are overweight. The emphasis that is placed on meeting the body composition and appearance standards may contribute to this attitude and to the various means that are used to lose and maintain weight. Research has shown that women who perceive themselves to be fat are more likely to be dieting and to express weight dissatisfaction (Striegel-Moore et al., 1986). Davis and coworkers (1993a) reported that BMI, but not percent body fat, is significantly correlated with tendency to practice dietary restraint, which suggests that some anatomical factor other than fatness, per se, influences the tendency to diet. Subsequently, this group showed that among a population of normal to slightly overweight college women, frame size (as determined by several measures of skeletal structure) was a stronger predictor of weight dissatisfaction and dietary restraint than either BMI or body fat (Davis et al., 1993b). The implication of this finding is that a factor that is both unrelated to actual fatness and resistant to change by diet or exercise is the one most likely to drive the pursuit of thinness and unhealthy dieting. The implication for the military is that women with larger frame sizes and greater muscle, that is, those best suited to lifting and carrying tasks, may be the ones most likely to engage in unhealthy or unnecessary dieting. In the United States, obesity is increasing among the civilian population (Kuczmarski et al., 1994), with approximately one out of three Americans considered obese as defined by BMI greater than 25. However, there is a segment of the U.S. population whose focus on weight maintenance and ideal body weight results in an increased desire to minimize body weight. This focus is especially typical in women with inaccurate or negative body image, for whom the combination of internal and external pressure may lead to aberrant food intake or disordered eating (Rodin, 1993). Of concern in this group are those who are close to normal weight, for whom dieting can become pathological (Brownell and Rodin, 1994). Methods Used by Military Women to Lose and Maintain Weight The primary aim of the study by Rose and coworkers (1993) was to examine the techniques that soldiers use to lose weight following the enforcement of weight standards in the Army. Factors that motivated attempts at weight loss included appearance (42.8%), health concerns (32.6%), and upcoming weigh-in (20.9%). Diet and exercise were the primary methods used to meet the weight standards, but some soldiers used drugs (6.2%), saunas (5.2%), and bingeing-purging (behaviors that could be classified as bulimia) (2.7%). As mentioned above, fewer than 10 percent of the respondents were actually enrolled in the weight control program. Of those soldiers who attempted to lose weight, more than a fourth reported never reaching their ideal weight. The soldiers who reported reaching ideal body weight did so two, three, and four or more times, with 18 percent regaining the lost weight more than four times. The maximum length of time that these soldiers reported maintaining the lower body weight was 3 months or less.

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--> A survey conducted in May 1995 at the U.S. Naval Academy found that 9.6 percent of female and 2.8 percent of male midshipmen reported symptoms associated with disordered eating behaviors. This prevalence rate is less than for civilian college students (Holmes and Armstrong, 1995). A survey questionnaire administered to an Army Reserve unit (Sweeney and Bonnabeau, 1990) indicated that while 83 percent were within the weight standards, half of these soldiers wanted to lose weight, and 38.5 percent of all respondents reported difficulty with maintaining their weight. Almost half of these soldiers reported never having been on the Weight Control Program, while the rest had been placed in the Weight Control Program at least once. The reservists who were required to lose weight reported using multiple approaches to dieting including: low calorie diet (41.7%), popular diets (26.5%), self-induced vomiting (4.5%), taking laxatives (12.3%), taking diuretics (19.6%), and taking prescription and nonprescription diet pills (26%). The authors reported the frequency of "negative" behaviors in achieving weight loss: the percentage of reservists who used these negative behaviors twice per year, two to five times per year, and more than five times per year were 32.2, 40.7, and 27.1 percent, respectively. Unfortunately, these responses were not reported by gender, and the response rate for the survey was only 51 percent. These frequencies may suggest, however, that the concern for meeting the standards twice a year motivates negative behaviors throughout the year. As described in a clinical case report (Niezgoda et al., 1989), the use of diuretics by one male and one female soldier preparing for weigh-in caused fainting and nausea of sufficient severity to require admission to an emergency room. While this study is limited by its extremely small size, it indicates the need for further monitoring of weight loss practices within the military. A recent study quantitated the incidence of bulimic weight-loss behaviors in Air Force weight loss programs and compared the incidence with that in civilian programs. Using a modified version of the Stanford Eating Disorders Questionnaire (Agras, 1987), the investigators (Peterson et al., 1995) found that the military weight-management participants indicated a two to five times greater frequency of bulimic behaviors than did the civilian groups. Finally, a survey study by McNulty (1997) (with a response rate of 53%) to determine the prevalence of eating disorders among active-duty Navy nurses and to identify predisposing factors reported a prevalence of anorexia nervosa of 1.1 percent (similar to that in the female population), a prevalence of bulimia of 12.5 percent (six times that reported in the civilian literature according to a personal communication between the author and K. Vitousek), and a prevalence of eating disorders "not otherwise specified" (DSM-IV, 1994) of 36 percent (compared to 3–35% in the civilian literature according to DSM-IIIR, 1987). The percentage of respondents who reported practicing normal dieting behaviors was 50.4 percent, while the other half reported using one or more of what would be considered aberrant dieting behaviors. Factors associated with the onset of an eating disorder episode included body fat measurement, work stress, change of work schedule, and personal/professional motivation; rank and age were not factors (McNulty, 1997). The low response rate for military surveys of dieting practices is likely to be the result of a recently rescinded policy that specified the diagnosis of an eating disorder as cause for separation from military service, according to several speakers at the 1996 workshop. As a result, any attempts to estimate the prevalence of eating disorders in the military are likely to underestimate the problem, and studies suggest that the prevalence of subclinical forms of chronic disordered

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--> eating is likely to be even greater that that of full-blown eating disorders. Thus, it is not possible to assess the impact of disordered eating on military readiness. Negative Diet Behaviors in Civilian Populations The civilian literature is full of studies of the prevalence of body weight dissatisfaction and disordered eating among young adults. For example, Kurth and coworkers (1995) reported that among randomly selected female college freshmen, respondents to the Dieting and bingeing Severity Scale (DBSS, see Kurth et al., 1995) (N = 1,367), 9 percent could be classified as nondieters, 26 percent as casual dieters, 23 percent as moderate dieters, 21 percent as intense dieters, 19 percent as dieters at risk, and 2 percent as probably fitting the profile for bulimia nervosa. The authors suggested that their survey instrument can be used in other populations to identify risk factors associated with eating disorders. Using data from the 1992 Weight Loss Practices Survey, Biener and Heaton (1995) found that 47 percent of Caucasian women, 25 percent of African American women, and 16 percent of men who reported to be trying to lose weight had BMIs less than 25. Negative dieting behaviors (fasting, purging, using laxatives, diuretics, or diet pills) were reported by more than 13 percent of the dieters; African American women were more than twice as likely as Caucasian women to engage in such practices (Biener and Heaton, 1995). In a large survey of 16,486 university students with a mean age of 20.5 years in 21 European countries, only 8 percent of these students were overweight (based on BMI), and fewer than 1 percent were obese (Bellisle et al., 1995). In spite of this, 44 percent of the women were trying to lose weight and 14 percent were actively dieting, which demonstrates that the problem is not limited to the United States. The authors reported that dieting affected snack and meal patterns with twice as many dieters skipping breakfast as nondieters. Physical Consequences of Chronic Dieting Body weight variability throughout life is inevitable and can be divided into long-term and short-term changes in body weight. Weight cycling is defined as repeated weight loss followed by regain (Lissner et al., 1991). By far the majority of research that has examined the physical consequences of dieting has focused on two phenomena: (1) the syndrome known as the female athlete triad, the result of chronic energy deficit, and (2) weight cycling. The female athlete triad will be discussed in a later section. Weight Cycling and Body Composition Prentice et al. (1992) published a review of the effect of weight cycling on body composition. They addressed the popular view that during energy restriction, energy is mobilized and weight loss is from both the fat and lean compartments, while weight regain is primarily fat. Their review of data from small animal and human weight cycling studies in Great Britain and Gambia found no long-term effect of weight cycling on lean body mass. In British women who underwent a weight loss and regain, lean body mass loss and regain were entirely predictable

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--> from theoretical considerations (Forbes, 1987; Prentice et al., 1991). Prentice and colleagues (1992) concluded emphatically that weight cycling is not associated with negative effects on body composition. Weight Cycling and Resting Energy Expenditure In contrast to the popular belief that continued loss and gain of weight lowers resting energy expenditure, Saris (1989) and Wadden et al. (1992) reported no effect of weight cycling on resting energy expenditure. Weight Cycling and Risk for Disease Epidemiological studies provide the best evidence for the effect of weight cycling on overall health (Hamm et al., 1989; Lissner et al., 1989; Stevens and Lissner, 1990) In a study of Western Electric employees, one cycle of weight loss and regain in men was a risk factor for cardiovascular disease. In the Goethenburg study, body weight variability at three points in time was an increased risk factor for cardiovascular disease and for overall mortality in Swedish men and women. In the Dutch population described by the Zutphen Study, cardiovascular disease risk increased in those persons who had a high BMI and high variability in weight change during 10 years (cited as personal communication in Saris, 1989). More recently, the National Task Force on the Prevention and Treatment of Obesity (1994) reviewed the literature on weight cycling and found insufficient evidence to conclude that there was any adverse effect of weight cycling on body composition, energy expenditure, risk factors for cardiovascular disease, or the effectiveness of subsequent attempts to lose weight. Methods for Successful Weight Management Although a comprehensive review of the literature on methods for weight loss and management is beyond the scope of this report, several recent reports have reviewed and evaluated these methods (IOM, 1995; Levy and Heaton, 1993; NIH Technology Assessment Conference Panel, 1993). A summary is provided here of the pertinent points from the IOM report, Weighing the Options (1995) and the NIH Technology Assessment Conference Panel on methods for voluntary weight loss and control (1993). In the IOM report (1995), the purpose of which was to propose criteria for the evaluation of dieting programs, programs were divided into three categories: (1) do-it-yourself programs (any individual effort, including participation in a worksite program or support group, sometimes using advice from books or magazines), (2) nonclinical programs (often these are commercial programs that rely on trainers of varying skills and educational background), and (3) clinical programs. Five broad approaches to treatment were identified. These are diet (modifications with or without nutrition education), physical activity, behavioral modification, drug therapy, and gastric surgery. Except for procedures such as drug therapy and gastric surgery that are obviously limited

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--> to a clinical setting, the actual methods used to achieve weight loss may not differ from one category of program to another. Although the evaluation criteria were established for the purpose of evaluating programs or products that make claims regarding their success rates, these criteria can be applied to any program, including self-designed ones. The definition of success that was applied took into account recent evidence suggesting that the loss of small amounts of weight can reduce the risk for some chronic diseases and that weight management—that is, long-term maintenance of weight loss—rather than the weight loss itself, is the more important factor in reducing risk (USDA/DHHS, 1995). Three criteria were established by which all weight management programs can be evaluated. The first criterion is how well the program matches the needs of the individual. An extreme example of a poor match would be the prescription of gastric surgery for an individual with 10 lb to lose; a more typical and frequent example of a poor match is the provision of a rigid menu plan without assessment of the individual's health risks, lifestyle, dietary preferences, and nutrition knowledge and without ongoing or at least follow-up counseling. The second criterion is the soundness and safety of the program. An established weight management program performs a health evaluation that includes an assessment of readiness (Brownell, 1990) prior to formulating a plan with the individual. Do-it-yourself dieters with more than 5 to 10 lb to lose are advised by the media to obtain a medical evaluation before undertaking a diet or exercise program. Weight management programs are expected to employ staff trained in nutrition and dietetics to provide assessment of current dietary habits, instruction, and counseling. In addition, quality programs must emphasize fitness, evaluate the individual's current fitness level, and employ or refer to trained coaches for development of a fitness plan. The third criterion of a weight management plan is its outcome, that is the percentage of individuals who have been enrolled in or followed the plan and have maintained their weight loss long-term, had an improvement in their risk factors for chronic disease, and been monitored for any adverse consequences. Factors Associated with Successful Weight Management The low rate of success for participants in established weight management plans is well known. Because of this high recidivism, it has been difficult to use the experience of these participants to identify factors that predict successful weight management. Among the possible reasons for the high failure rate of weight management programs are that participants have often tried and failed repeatedly to lose weight on their own and are less predisposed to lose and maintain weight. Similarly, individuals drawn to such programs often have very large amounts of weight to lose (and thus large losses to maintain after years of practicing habits that led to weight gain). While it is known that many individuals lose weight on their own and successfully maintain the losses, until recently, few studies have attempted to document their success rates or strategies. Among the positive predictors cited have been self-monitoring, exercise, positive coping style, continuing contact with a counselor or other health monitor (sometimes referred to as a maintenance program), normalization of eating, and reduction of other comorbidities (Foreyt and Goodrick, 1994; Perri et al., 1992).

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--> Most of the recommendations in the Weighing the Options report (IOM, 1995) pertained to the need for additional research in the prevention, etiology, treatment, and long-term implications of obesity. However, one recommendation pertained to program planning, stating that a successful weight management program must include self-monitoring, goal setting, exercise, nutrition education, stress management, and social support. Implied in this recommendation is the idea that weight management is an ongoing process. The NIH Technology Assessment Conference Panel on methods for voluntary weight loss and control (1993) discussed the risks and benefits of various methods of weight management including dieting, exercise, behavior modification (which consists of identifying eating or related lifestyle behaviors to be modified, setting specific behavioral goals, modifying underlying precipitants of the behavior to be changed, and reinforcing the desired behavior), drug treatment, and combination therapies. Evidence suggests that the combination of changes in diet and exercise habits with behavior modification to reinforce those changes apparently extends the interval between weight loss and regain. Attributes of successful programs include a plan that results in slow, steady weight loss; development of an eating and exercise plan that can be maintained long term; education in emotional and social stress management and problem-solving strategies; self-monitoring; and maintaining contact with a health care professional. Thus, the emphasis of the NIH Technology Assessment Conference Panel statement is also on the need for a maintenance program. Prevention of Obesity In a recent review of obesity prevention research, Wing (1996) outlined times during the life span when a woman is at risk for weight gain. These include young adulthood (20–40 years), pregnancy, and the perimenopausal period (42–52 years). She suggested that it is at these critical times when preventive intervention would have the greatest effect. The vast majority of active-duty women fall into one of these categories. Weight gain prevention programs, although not widespread, tend to focus on populations or individuals at high risk for becoming obese or for developing obesity-related illnesses. For example, the Stanford Five-City Study (Taylor et al., 1991) conducted mass media campaigns and community organization interventions over a 6-y period to lower cardiovascular risk. Subjects in the two experimental cities gained only slightly less weight over time (+0.57 kg vs. 1.25 kg) than did the control cities, so effect on body weight was minimal. Wing (1996) also cites a similar study conducted in Minnesota to reduce the risk of coronary heart disease (Jeffery, 1995). Community outreach, worksite, and home (correspondence) prevention courses, as well as programs focusing on people who were already overweight in six communities over a 6-y period of time were unsuccessful in achieving a sustainable weight loss in the populations of these communities. Because these studies relied on education as the primary prevention intervention, the results indicate that education alone may not be sufficient. According to Weighing the Options (IOM, 1995), prevention programs that target certain high-risk groups with specific interventions (for example, working with families with overweight parents to build regular physical activity into their lifestyles) appear to have the highest record of success, at least in the short term. Because of the need to evaluate the outcome of such efforts in

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--> terms of long-term weight management, however, longitudinal studies must be conducted before their real success can be evaluated. Summary Research among civilian women has shown that women who perceive themselves as overweight are more likely to be dieting. Frame size is a stronger predictor of weight dissatisfaction and eating restraint than body fat or BMI, a finding of significance to the military population. It is difficult at this time to ascertain the methods used by active-duty women to lose weight or the prevalence of disordered eating among this group. Several small surveys that have attempted to assess the percentage of active-duty personnel who have engaged in disordered eating behaviors or other unhealthy weight management behaviors (such as use of diet pills, laxatives, and diuretics; purging; or excessive exercise) have reported incidences both similar to and significantly higher than those among comparable civilian populations. A potential health risk of chronic dieting is weight cycling. The prevalence of weight cycling, that is, repeated weight loss and regain, appears high among active-duty women. Although no convincing evidence has been found to support an association between weight cycling and risk for chronic disease, immediate effects of chronic dieting on readiness cannot be dismissed (see Chapter 5). Several national panels have examined existing civilian weight management strategies and established guidelines for successful weight loss and management programs. Programs were evaluated for how well they matched the needs of the individual, soundness and safety, and outcome. The long-term success of weight loss programs is notoriously poor. Nevertheless, factors found to be associated with positive outcome were self-monitoring, exercise, development of a positive coping style, and continuing contact with a counselor or other health monitor. The importance of a long-term approach to weight management is supported by civilian research, although data examining long-term maintenance programs in the military are extremely limited. A growing body of data supports the effectiveness of worksite weight management programs, which may provide a model for military programs. Finally, weight gain prevention efforts that target specific high-risk groups and employ specific interventions appear to have achieved some success among families. Concluding Remarks: Weight Management As A Military Readiness Issue Herrold (1996) defined readiness for a mission as maximizing performance, minimizing unplanned losses, and adapting to changing environments. Military personnel must be dependable, trained, healthy, physically fit, and well equipped. The weight management component of readiness includes a focus on the body as a tool for readiness. Therefore, one must maintain the tool in optimum condition. This type of maintenance approach includes preventing weight gain in those who currently meet the standards, administering an effective weight loss program based on current research, and implementing an exemplary weight maintenance program. Increased emphasis on maintaining fitness and the fitness program at all stages of a military career supports weight maintenance and decreases the need for efforts aimed at weight loss.

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--> References ACSM (American College of Sports Medicine). 1997. ACSM position stand. The female athlete triad. Med. Sci. Sports Exerc. 29:i–ix. Agras, W.S. 1987. Eating Disorders, Management of Obesity, Bulimia, and Anorexia Nervosa. New York: Pergamon Press. AF (Air Force) Form 3529. 1993. See U.S. Department of the Air Force. AFI (Air Force Instruction) 40-104. 1994. See U.S. Department of the Air Force, 1994. AFI (Air Force Instruction) 40-502. 1994. See U.S. Department of the Air Force, 1994. Air Force Instruction 44-135. 1994. See U.S. Department of the Air Force, 1994. Air Force Pamphlet 44-132. 1994. See U.S. Department of the Air Force, 1994. Air Force Policy Directive 40-5. 1994. See U.S. Department of the Air Force, 1994. American Psychiatric Association. 1987. Diagnostic and Statistical Manual of Mental Disorders, 3d ed. rev. (DSM-IIIR). Washington, D.C.: American Psychiatric Association. American Psychiatric Association. 1994. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) . Washington, D.C.: American Psychiatric Association. AR (Army Regulation) 600-9. 1986. See U.S. Department of the Army, 1986. Bellisle, F., M.O. Monneuse, A. Steptoe, and J. Wardle. 1995. Weight concerns and eating patterns: A survey of university students in Europe. Int. J. Obes. Relat. Metab. Disord. 19:723–730. Biener, L., and A. Heaton. 1995. Women dieters of normal weight: Their motives, goals, and risks. Am. J. Public Health 85:714–717. Bray, R.M., L.A. Kroutil, S.C. Wheeless, M.E. Marsden, S.L. Bailey, J.A. Fairbank, and T.C. Harford. 1995. Health behavior and health promotion. Department of Defense Survey of Health-Related Behaviors among Military Personnel. Report No. RTI/6019/06-FR. Research Triangle Park, N.C.: Research Triangle Institute. Brownell, K.D. 1990. Dieting readiness. Weight Control Digest 1:5–10. Brownell, K.D., and J. Rodin. 1994. The dieting maelstrom: Is it possible and advisable to lose weight? Am. Psychol. 49:781–791. Davis, C., J.V.G.A. Durnin, M. Gurevich, A. Le Maire, and M. Dionne. 1993a. Body composition correlates of weight dissatisfaction and dietary restraint in young women. Appetite 20:197–207. Davis, C., C.M. Shapiro, S. Elliott, and M. Dionne. 1993b. Personality and other correlates of dietary restraint: An age by sex comparison. Personality and Individual Differences 14(2):297–305. DHHS (U.S. Department of Health and Human Services). 1991. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. DHHS (PHS) Publ. No. 91-50212. Public Health Service, U.S. Department of Health and Human Services. Washington, D.C.: U.S. Government Printing Office. DoD (Department of Defense) Directive 1308.1. 1981. See U.S. Department of Defense, 1981. Drake III, A.J. 1996. Characteristics of female midshipmen: 1992 to 1996. Workshop on Assessing Readiness in Military Women: The Relationship to Nutrition. September 9–10, Irvine, Calif. DSM-IIIR (Diagnostic and Statistical Manual of Mental Disorders, 3d ed. rev.). 1987. See American Psychiatric Association, 1994. DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.). 1994. See American Psychiatric Association, 1994. Forbes, G.B. 1987. Lean body mass-body fat interrelationships in humans . Nutr. Rev. 45:225–231. Foreyt, J.P., and G.K. Goodrick. 1994. Attributes of successful approaches to weight loss and control. Appl. Prev. Psychol. 3:209–215. Friedl, K.E., L.J. Marchitelli, D.E. Sherman, and R. Tulley. 1990. Nutritional assessment of cadets at the U.S. Military Academy: Part 1. Anthropometric and biochemical measures. Technical Report No. T4-91. Natick, Mass.: U.S. Army Research Institute of Environmental Medicine.

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--> Verdugo, N. 1996. Overview of the military woman. Presentation at the workshop on Assessing Readiness in Military Women: The Relationship to Nutrition. September 9–10, Irvine, Calif. Wadden, T.A., S. Bartlett, K.A. Letizia, G.D. Foster, A.J. Stunkard, and A. Conill. 1992. Relationship of dieting history to resting metabolic rate, body composition, eating behavior, and subsequent weight loss. Am. J. Clin. Nutr. 56:2065–2115. Warber, J.P., S.M. McGraw, M. Kramer, L. Lesher, W. Johnson, and A.D. Cline. In preparation. The Army Food and Nutrition Survey. Technical Report No. T98-XX. Natick, Mass.: U.S. Army Research Institute of Environmental Medicine. Westphal, K.A., K.E. Friedl, M.A. Sharp, N. King, T.R. Kramer, K.L. Reynolds, and L.J. Marchitelli. 1995. Health, performance, and nutritional status of U.S. Army women during basic combat training. Technical Report No. T96-2. Natick, Mass.: U.S. Army Research Institute of Environmental Medicine. Wing, R.R. 1996. Prevention of obesity in adults. Prog. Obes. Res. 7:489–494.

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