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Service-Specific Issues Related to Obesity and Overweight

The purpose of the workshop’s second session was to discuss how obesity and overweight affect each of the services, said session moderator Lieutenant Colonel Renee Cole, deputy of the Military Nutrition Division and director of the Healthy Eating Behavior Initiative at the U.S. Army Research Institute of Environmental Medicine. Speakers expanded on topics from Session 1, describing impacts on recruitment, retention, resilience, and readiness in each of the services, as well as impacts on retirement.

TRENDS IN WEIGHT CHANGE IN VETERANS WITH AND WITHOUT DIABETES

Margery Tamas, editorial manager at the Institute for Medical and Nursing Education, opened her presentation on trends in weight change among veterans with and without diabetes by reminding participants that weight gain is a risk factor for diabetes and may complicate its management. She began by noting that the Veterans Health Administration (VHA) is the largest integrated health care system in the United States. With an extensive collection of electronic medical records and a corporate data warehouse and analytical software platform, she explained, the informatics and computing infrastructure at the U.S. Department of Veterans Affairs (VA) permits analysis of weight trends in a large, national, contemporary veteran population.

Tamas described the two datasets that were constructed: (1) a primary dataset of approximately 4.7 million veterans born between 1915 and 1984 who had at least four weight measurements during 2000 to 2014, with at least one measurement per year performed in at least four consecutive years; and (2) a survivor dataset of nearly 860,000 veterans with weight data in the years 2000 and 2014, the endpoints of the study period. Consistent with the overall VA population, she continued, 92 percent of individuals in the primary dataset were male, and 70 percent were white; the mean age was 69; and 37 percent had diabetes. Overall, individuals with diabetes were older than individuals of the same sex without diabetes.

Tamas reported that patients were grouped into nonoverlapping 5-year cohorts according to their year of birth, and analysis of birth cohorts in the primary dataset indicated that the prevalence of diabetes varied from 4 percent to 44 percent. Beginning with the 1915 to 1919 cohort, in which the prevalence of diabetes was 29 percent, the prevalence steadily increased to a peak of 44 percent in the 1940 to 1944 cohort. Thereafter, Tamas continued, the prevalence steadily declined, falling to 4 percent in the 1980 to 1984 cohort. Diabetes was defined according to any of three criteria: (1) use

of a 250.xx code at a primary care visit, (2) any two uses of a 250.xx code, or (3) any use of a diabetes medication. Tamas observed that the variance in diabetes prevalence among birth cohorts likely reflects a combination of survivor bias and natural history: decreasing prevalence in the oldest cohorts is likely due to increased mortality (i.e., survivor bias), whereas low prevalence in the youngest cohort is likely due to natural history (i.e., insufficient age for expression of diabetes).

Cross-sectional trends, said Tamas, showed that men and women gained weight between 2000 and 2014 regardless of diabetes status. Individuals with diabetes were heavier than those without, and to the researchers’ surprise, she reported, women with diabetes were heavier than men without diabetes, a finding that differs from results of research done in the general population (Morgan et al., 2012). Findings across birth cohorts were not uniform, she added, with consistent weight gain in the youngest cohorts and weight loss in the oldest. Of concern, she noted, was that the youngest cohorts gained the most weight, with weight increase accelerating from the oldest to the youngest cohorts.

These patterns are not explained by survivor bias, Tamas pointed out. For the most part, she said, the pattern and the magnitude of the weight changes in the survivor set accord with those of the primary dataset, even though the former represents just 18 percent of the latter. She compared her results with those of the Normative Aging Study, a previous longitudinal study that examined weight change over 15 years, beginning in 1961, among a male veteran population without chronic diseases at baseline. Trends in net weight gain and loss were similar across birth cohorts in both studies, she observed, but baseline weight was consistently higher and younger cohorts gained weight more rapidly among veterans in her study relative to those in the earlier study (Grinker et al., 1995; Tamas et al., 2016).

Given the increased incidence of diabetes with increases in weight, Tamas cautioned that the prevalence of diabetes in the VA population may rise even more. She argued that this possibility highlights the need for efforts to prevent weight gain in this group, especially among women.

NAVY AND NAVY RESERVE

Captain Patricia McCafferty, commanding officer of the Expeditionary Medical Facility in Bethesda, Maryland, brought to bear the perspective of the Navy and Navy Reserve. She began by highlighting the mutual struggles of the Navy’s reserve and active components, including family needs and difficulty finding time for physical fitness. Within the older, mixed-age reserve population, she cited the need to balance military and civilian careers and the occurrence of dieting right before physical fitness testing. Among

the active component, she noted long working hours; evening shifts; and a younger, millennial population.

On the active component side, McCafferty highlighted what she said was a successful, dietitian-run program at Naval Medical Center San Diego. The program, she explained, incorporates individualized meal plans and exercise prescriptions with a focus on losing fat mass and limiting lean body mass. She added that primary care managers follow up with patients and may refer them to specialty clinics.

The Navy Reserve offers health promotion programs at every detachment, McCafferty continued, along with a unit command fitness leader who helps maintain physical fitness programs and manage the semiannual Physical Fitness Assessment (PFA). She also mentioned that nutrition and other health behaviors are evaluated in the Health Risk Assessment performed as part of the Periodic Health Assessment, a screening tool used to evaluate individual medical readiness.

McCafferty then listed a number of health programs and activities for members of the Navy Reserve:

• Crews into Shape, an annual team challenge in which each crew member earns points for exercising, maintaining or achieving a goal weight, eating fruits and vegetables, and engaging in other healthy behaviors;
• Soar into Shape, a 12-week program that begins with a baseline Body Composition Assessment (BCA) and includes incentives and weekly clinics, along with a repeat BCA;
• ShipShape, a 6-month course offered at six Navy medical treatment facilities that includes weekly sessions for the first 2 months, followed by monthly visits;
• Monthly mandatory Physical Readiness Test sessions, often incorporated as one of the two monthly drill sessions;
• The Navy Fitness Enhancement Program, a mandatory exercise and nutrition program for individuals who fail their PFA; and
• Navy One Source, a venue for phone-based health promotion counseling.

McCafferty concluded her presentation by noting that, as the Navy seeks to create a culture of lifelong fitness, it is exploring tactics such as use of wireless activity trackers and improved strategic communications via digital and social media platforms.

AIR FORCE

Lieutenant Colonel Heidi Clark, nutritional medicine flight commander at David Grant Medical Center, Travis Air Force Base, began by reporting that the percentage of Air Force members with a healthy body mass index (BMI) (18.5–24.9 kg/m²) decreased from 62 percent in 2009 to 35 percent in 2017. During the same period, she said, the percentage with a BMI in the obesity category increased from less than 10 percent to 16 percent.

Clark described the significant resource drain that unfit trainees impose on the recruiting pipeline: relative to their counterparts, they cost significantly more (about $4,000 compared with about $700) and make roughly four times as many clinic visits during training.¹ In addition, she continued, trainees with 1.5-mile run times in the bottom quartile are nearly six times more likely to sustain a stress fracture.² She speculated about underlying diet inadequacies within the general population from which trainees are recruited, and whether micronutrient deficiencies contribute to substandard bones.

Clark shared anecdotes about military members who drastically changed their dietary or physical activity behaviors to enter the military and then struggled to maintain similar habits throughout their careers, affecting both their home and work lives. Active duty service members who struggle with weight issues are more likely to sustain musculoskeletal injuries, she observed, citing data from a large retrospective cohort of Air Force personnel in which men and women with a waist circumference greater than 39 inches and 36 inches, respectively, were significantly more likely to sustain such an injury (Nye et al., 2014). She also cited a study that followed Air Force members from 2003 to 2015, finding that about 5,000 members had been diagnosed with type 2 diabetes while on active duty. She stressed that these are some of the most expensive health care users among Air Force members, both while they are in the service and when they retire. She also pointed out that “the health care dollars that are sucked away to treat individuals … are not available for new technology for training for making sure that we are the most fit and ready force.”

According to Clark, service members’ struggles to achieve and maintain weight loss and healthy lifestyle behaviors sometimes involve extreme, unproven, and/or potentially risky methods. She highlighted the tremendous amount of pressure experienced by individuals, explaining that “people become desperate” when faced with losing the weight or losing their job. Other opportunities, such as a promotion or a special assignment, may also hang in the balance, she added. These pressures are exacerbated, she

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¹ Personal communication, Neal Baumgartner, U.S. Air Force, May 3, 2018.

² Personal communication, Neal Baumgartner, U.S. Air Force, May 3, 2018.

observed, by long working hours, such common practices as “cake at every retirement ceremony, even in the medical group,” and families’ struggles to afford healthy foods.

Clark ended her presentation with an appeal to start from a foundation of strong health standards. She stressed the importance of having people enter the services with a healthy body weight and fitness appropriate to meeting the challenges they will face, thus advocating for establishing a foundation of health before talking about enhancing performance.

ARMY

Major Kayla Ramotar, command dietitian and Army holistic health and fitness action officer at the Army’s Training and Doctrine Command, described her experience working on a team tasked by the chief of staff and secretary of the Army in 2015 to examine underlying issues affecting the health and performance readiness of the force. The team identified three issues. First was soldiers’ lack of baseline knowledge about personal fitness and nutrition. This lack of knowledge, Ramotar reasoned, is potentially driven by decreases in health and physical education and home economics courses in the U.S. school system, compounded by reliance on unreliable information sources such as friends, family, and the Internet. In addition, she pointed out, a first source of education and knowledge in initial military training is the drill sergeant, from whom 70 percent of soldiers seek advice on nutrition and healthy eating. According to Ramotar, focus groups revealed that drill sergeants are confident in their ability to teach soldiers how to be physically active but are not as confident in their ability to teach them how to be healthy or eat healthfully. “We have a huge problem in that sense,” she maintained. While some individuals have the will to seek the right information, she said, they go to the wrong sources, which she declared “is the never-ending circle of misinformation and miscommunication.”

Ramotar also flagged the minimal nutrition education requirement in the military’s continuing education pathway. A 20-year professional military career, she lamented, includes only 1 hour of required nutrition education. On a positive note, she mentioned that the Drill Sergeant Academy is understanding the importance of nutrition and healthy eating and may seek to integrate more nutrition education and training into its program. However, she contended, there is a long way to go before drill sergeants will be prepared with enough knowledge and the ability to translate that knowledge into training.

A second issue cited by Ramotar is the military and broader U.S. Department of Defense (DoD) work environment, which often requires service members to adapt to new and different food environments in which they

may not know how to make healthy choices or may face other barriers to doing so. She noted, for example, that the operational environment during deployments generally entails less control over food choices, and that training exercises or other job-related travel can take soldiers out of their normal environments for an extended time. Thus, she stressed, they must have both the knowledge and the ability to apply it when options for food procurement, choices, and preparation are limited.

The third issue identified by Ramotar is the challenge of appropriately supporting service members’ genuine desires to be healthy, be fit, and enhance their performance. She cited data indicating that approximately 67 percent of the Army’s initial military training population wants to eat healthfully (U.S. Army Institute of Environmental Medicine, unpublished). But unfortunately, she said, negative reinforcement is often used to facilitate a desired change: “you stay fit or you get kicked out.” Moreover, she observed, negative reinforcement is not a viable method during military retirement, which underscores the need to use other methods to promote the desire for a healthy lifestyle regardless of whether a person is still serving in the military—a point that she identified as particularly important given that 80 percent of retirees become overweight or develop obesity (U.S. Army Institute of Environmental Medicine, unpublished). “How do we give them the actual desire to want to stay healthy no matter whether they are in the military or not? We have not figured that out,” she acknowledged.

To conclude, Ramotar stated that the Army Holistic Health and Fitness System, a coordinated, system-wide approach to improving health and performance readiness, will help address the three issues—limited nutritional knowledge, changing food environments, and inadequate supports—she had cited as inhibiting the health and performance readiness of service members. She stressed the importance of imparting knowledge and strategies for applying it throughout members’ military careers. According to Ramotar, accomplishing this will require training personnel throughout various units and levels to be informed messengers of the education and training provided by the armed forces’ limited health professional workforce.

MARINE CORPS

Brian McGuire, deputy director of the Force Fitness Division at the U.S. Marine Corps Training and Education Command in Quantico, Virginia, opened his presentation on a historical note. He cited a Marine Corps document from 1956 reporting that the biggest problem facing the Marine Corps was the poor state of fitness of America’s youth. “If they were saying that back then and we are saying it now,” he said, “it just gives me some perspective.”

On the other hand, McGuire asserted, obesity and overweight have had a minimal impact on the Marine Corps as a result of evidence-based high standards for body composition and physical fitness, as well as accountability. He reported that according to 2016 DoD data, the prevalence of obesity in the military as a whole is 7.9 percent, but just 1.6 percent among the Marine Corps.

Accountability begins with recruiters, explained McGuire, who do not get credit for recruits who fail to graduate from boot camp. Recruits must be within 5 percent of retention standards to attend boot camp, unless a waiver is granted. Even with a waiver, McGuire explained, applicants still must be no more than 11 percent above and no more than 7 percent below retention weight, and they must also pass an initial physical fitness test. He added that graduation from boot camp requires meeting retention standards.

McGuire pointed out that, related to the issue of underweight, Marines who achieve the specific physical standards for military occupational specialties are an average of 23 pounds heavier and 3 inches taller than those who do not. Size matters and in a very specific way, he argued, advocating for a careful determination of “how light we want somebody to be.”

McGuire went on to observe that in early 2017, the Marine Corps raised its Physical Fitness Test (PFT) and Combat Fitness Test (CFT) standards, which he said motivates members to challenge themselves to meet the new requirements. To incentivize and reward above-average physical fitness, he elaborated, the Marine Corps linked body composition standards to the PFT and CFT in a way that provides either flexibility in meeting the standards if those fitness test scores reach a certain threshold or an exemption from the standards in the presence of superior test results. A score of 250 points (achieved by 41 percent of service members in 2018) earns an additional 1 percent body fat. A score of more than 285 points (achieved by 6 percent of service members in 2018) earns an exemption from the maximum weight and body fat limits. Service members are still weighed and taped if necessary, said McGuire, “but we believe that in the battle between a static measurement of tape and a scale and a stop watch and physical performance, what should win? Physical performance.”

Although the Marine Corps is “in a good place with overweight and obesity,” McGuire continued, it still faces challenges. He provided two examples: first, it is monitoring a small increase in waiver requests, and second, it is trying to prevent unintended negative consequences from the readily available yet sometimes inaccurate health and fitness information that service members can access via smartphones and “Dr. Google.”

DISCUSSION

In the discussion period following the presentations summarized above, topics included strategies for implementing a holistic approach to healthier lifestyles and systematic, evidence-based approaches to the armed forces’ treatment of obesity and overweight.

Implementing a Holistic Approach to Healthier Lifestyles

Several speakers responded to a participant’s question about how the military plans to move toward a holistic approach to promoting healthy lifestyles among service members. McGuire emphasized the need to educate command leadership about the evidence supporting healthy lifestyle interventions, such as proper postworkout nutrition. Ramotar mentioned an upcoming effort to embed medical personnel, including a registered dietitian, physical therapist, and occupational therapist, in operational units where they can carry out the cognitive, physical, and nonphysical programming necessary to make a long-term impact on health and performance readiness. Clark suggested that an element of culture change is needed, so that people no longer think of exercise as a punishment and instead recognize that healthy behaviors will help them be successful during their military career and facilitate a long, enjoyable retirement. “I think it has to be an entire culture of owning your personal fitness and a desire to optimize your own performance all the way into retirement,” she said. McCafferty suggested making it fun and engaging people—starting with leadership at the top—throughout the year, not just on drill weekends. Tamas commented on potential challenges to fostering a culture of healthy lifestyles. Drill instructors have a certain self-image, she noted, and may perceive nutrition-related topics as inconsistent with that self-image and more consistent with “Betty Crocker … [whom] they have never in their life aspired to be.”

Evidence-Based Approaches to Treatment of Obesity and Overweight

A participant flagged the apparent lack of systematic, long-term, evidence- and guideline-based approaches to the armed forces’ treatment of obesity and overweight. Speakers acknowledged this discrepancy and suggested potential contributors. McGuire referenced a population consisting of a high proportion of young people without acute problems and thus a relatively limited need for intervention. Ramotar pointed out the disparate approaches to addressing the problem both within and across the services. McGuire added that each program has a champion who promotes its success, without much communication with other programs across the armed forces. Cole added that commanders often lack the patience to wait until

outcomes have been documented before implementing a program. Clark acknowledged that even when evidence-based programs exist, implementation challenges, such as an inability to hire or a lack of capable staff, can hinder their optimal use.

A participant asked how evidence-based interventions to change behavior are being translated from the civilian literature and disseminated to the military population, including those in the reserves and others who do not live on a military installation. Ramotar replied that, instead of relying on one health professional, the Army is working on training and equipping members down to the lowest unit levels to be “advocates and extenders” of information. As these members advance, she suggested, they can relay the information to the units they lead. She also noted that the Army is looking to engage the reserve component via mobile apps. Many such apps are in inventory but have not been well maintained, she said, and there is a need to consolidate them into a handful that work for various purposes or environments.