Proceedings of a Workshop
Understanding and Overcoming the Challenge of Obesity and Overweight in the Armed Forces
Proceedings of a Workshop—in Brief
Obesity and overweight pose significant challenges to the armed forces in the United States, affecting service members (including active duty, guard, and reserve components), veterans, retirees, and their families and communities. The consequences of obesity and overweight in the armed forces influence various aspects of its operations that are critical to national security.
On May 7, 2018, the Roundtable on Obesity Solutions, a part of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, held a workshop titled “Understanding and Overcoming the Challenge of Obesity and Overweight in the Armed Forces.” Speakers examined how obesity and overweight are measured in the armed forces and how they affect recruitment, retention, resilience, and readiness; discussed service-specific issues related to these problems and highlighted innovative strategies to address them through improved nutrition, physical activity, and stress management; and offered perspectives from outside of the armed forces on approaches to prevent and treat obesity. Reflecting on the speakers’ presentations, the moderators of the sessions discussed the challenges and opportunities related to overcoming the concerns posed by obesity and overweight in the armed forces, military families, and their communities, including potential cross-sector opportunities.
This Proceedings of a Workshop—in Brief summarizes views made by workshop participants during the presentations and discussions and is not intended to provide a comprehensive summary of information shared during the workshop.1 The information summarized here reflects the knowledge and opinions of individual workshop participants and should not be seen as a consensus of the workshop participants, the Roundtable on Obesity Solutions, or the National Academies of Sciences, Engineering, and Medicine.
DEFINING THE PROBLEM AND THE EFFECTS ON RECRUITMENT, RETENTION, RESILIENCE, AND READINESS
The workshop’s opening session described how obesity and overweight are measured in the armed forces and how they affect recruitment, retention, resilience, and readiness. Karl Friedl, senior research scientist in physiology at the U.S. Army Research Institute of Environmental Medicine, explained the rationale and methods for measuring body fat among service members. Body composition standards exist to sustain and support military performance, he explained, because consistent readiness to perform the mission is imperative and intense physical efforts in harsh environments are often required. In 1980, the Department of Defense (DoD) issued a directive specifying that all services adopt enforceable circumference-based body fat standards. Abdominal circumference (and not just body weight) is key to three important outcomes related to the standards: military appearance, combat readiness, and health, Friedl said.
In DoD, the body fat standards range from 18 to 26 percent for men and from 26 to 36 percent for women. Friedl mentioned the consideration given to sex differences and age-related changes in body composition when
1 The workshop agenda, presentations, and other materials are available at http://www.nationalacademies.org/hmd/Activities/Nutrition/ObesitySolutions/2018-MAY-07.aspx (accessed June 20, 2018).
determining the body fat standards. He gave the example of the graduated increase to the maximum allowable level that occurs as one ages, which is granted in part because of the tendency of senior service members to be in desk-bound jobs. Friedl explained that the standards are intended to enforce a combination of agility and aerobic and strength performance, noting that in the future the current standards could give way to an assessment based on a combination of body mass index (BMI) and fitness testing.
Tracey Smith, a nutrition scientist at the U.S. Army Research Institute of Environmental Medicine, opened her presentation about recruitment with a statistic that the armed services spent about $1.5 billion for obesity-related health care expenses and costs to replace unfit military personnel in 20072—which may underestimate the true figure, she noted, as it does not include long-term disability costs. Obesity also leads to lost work days, degraded readiness and resilience, and higher need for aeromedical evacuation, she continued.
Approximately one-third of Americans ages 17 to 24 do not qualify for military service because of their weight (BMI ≥27.5, the military’s upper limit for most age and sex groups), based on 2014 national height and weight data. Combined with other disqualifying factors, including criminal history and a lack of adequate education, 71 percent of 17- to 24-year-olds are ineligible for military service, she cited.3
Smith also referenced the proportion of military-age American civilians who exceed service-specific limits for both weight-for-height and body fat standards. The figures range from 5 to 12 percent for men and 13 to 35 percent for women, depending on the branch of service and each service’s different enlistment age requirements.4
Among first-time enlisted active duty applicants for military service, approximately 9 percent were disqualified because of obesity (based on ICD-9 code) and about 16 percent were disqualified because of weight and body build (based on other medical failure codes).5 Nonetheless, a 2013 Defense Health Board technical report6 indicated that existing recruitment and accession standards are not posing challenges for recruitment goals, Smith said. Existing recruitment and accessions standards are appropriate, though the indication that they are not posing challenges to recruitment goals could change if recruitment demands increase, she relayed. As noted in the report, current physical accession standards should be maintained as a minimal requirement for all military personnel to ensure an agile and responsive fighting force, she described, with stricter standards for certain military occupational specialties.
The military’s body composition assessment, which is performed on service members twice per year, plays into retention and separation from service, said Jay Heaney, deputy for the Warfighter Performance Department at the Naval Health Research Center. Most active-duty service members pass their physical fitness assessment (PFA)—approximately 98 percent in both the Army and the Navy in 2017—which puts them in good standing for advancement and retention, he affirmed.
The Navy is short 8,000 shipboard sailors, and it changed its physical readiness separation policy in early 2018, Heaney reported. The policy became more flexible, he explained, by allowing sailors who fail two or more PFAs in a row to serve through their obligated term, during which time they can resume good standing by passing a PFA. Sailors who exceed age-adjusted body fat standards are enrolled in a program of nutritional counseling, increased physical training, and routine weight and body composition monitoring, he said.
Heaney closed by emphasizing the critical role of the standards in ensuring job performance, asserting that “We cannot be going and relaxing standards because our civilian population that we are recruiting from is coming in heavy.” Service members’ health is a concern, he assured, but in the military, “It is really about being able to perform your job.”
Bruce Jones, chief of the Injury Prevention Division at the U.S. Army Public Health Center, discussed resilience, readiness, and deployment. Injuries are the leading medical cause for medical nonreadiness, he said, and among Army recruits, risk of injury is slightly higher at both extremes of BMI quintiles and lowest in the middle quintile (average BMI group).7 A consistent finding for both sexes, he continued, is the association between decreasing aerobic endurance
2Voss, J. D., G. Pavela, and F. C. Stanford. 2018. Obesity as a threat to national security: The need for precision engagement. International Journal of Obesity. Published online March 9, 2018. doi: 10.1038/s41366-018-0060-y.
3Mission: Readiness, Council for a Strong America. 2018. Many young Americans are ineligible to serve in the military. https://www.strongnation.org/articles/414-map-many-young-americans-are-ineligible-to-serve-in-the-military (accessed May 23, 2018).
4Cawley, J., and J. Maclean. 2010. Unfit for service: The implications of rising obesity for U.S. military recruitment. Cambridge, MA: National Bureau of Economic Research.
5Accession Medical Standards Analysis and Research Activity. 2015. 2015 Annual Report. Silver Spring, MD: Walter Reed Army Institute of Research. http://www.amsara.amedd.army.mil/Documents/AMSARA_2015%20Report/AMSARA%20AR%202015.pdf (accessed May 23, 2018).
6Defense Health Board. 2013. Implications of trends in obesity and overweight for the Department of Defense. http://www.dtic.mil/dtic/tr/fulltext/u2/1027323.pdf (accessed May 23, 2018).
7Jones, B. H., K. G. Hauret, S. K. Dye, V. D. Hauschild, S. P. Rossi, M. D. Richardson, and K. E. Friedl. 2017. Impact of physical fitness and body composition on injury risk among active young adults: A study of Army trainees. Journal of Science and Medicine in Sport 20(4):S17–S22.
(based on a 2-mile run time) and increasing injury risk.8 The highest risk of injury occurs among the leanest individuals with the slowest run times, and the lowest risk occurs among those with the highest BMI who also ran the fastest. Across all fitness levels, the highest injury risks are among those with the lowest BMIs, he summarized.
Moving on to BMI, physical fitness, and military performance, Jones said that as BMI increases, aerobic fitness decreases for men and women. On the other hand, he stated that increasing BMI is associated with increasing upper body muscle endurance (for men) and increasing lower body muscle endurance as well as increasing upper and lower body strength (for men and women). However, he said that according to the data, as BMI increases there is no change in overall combat fitness (for men and women), which requires a combination of muscle strength, muscle endurance, and aerobic endurance. He added that for male service members, postdeployment BMI and percent body fat appear to increase, while muscle strength and muscle endurance appear to increase or remain the same.
Taken together, these findings suggest that it may be misleading to think that increased BMI is associated with decreased military readiness, concluded Jones. “If the Army desires the most physically ready soldiers, they may need standards that take into consideration both physical fitness and body composition simultaneously.”
Obesity and overweight affect children and families throughout the military community, said Karen Hawkins, a registered dietitian in the Office of Military Family Readiness Policy. In the military health system, she said, 13 percent of children ages 6 to 17 are overweight and another 17 percent are at risk for becoming overweight.9
Hawkins described examples of how DoD has addressed this issue for service members and families: the 5-2-1-0 healthy military children campaign that encourages healthy food and beverage consumption, physical activity, and recommended screen time behaviors; the Military Family Learning Network, which provides continuing education and resources for professionals working with military families; and health and wellness coaching offered through Military OneSource.10 All of these resources are tailored to the unique needs of the military community, she said.
The second panel of speakers expanded on the topics from Session One, discussing how obesity and overweight affect each of the services.
Margery Tamas, editorial manager at the Institute for Medical and Nursing Education, presented research on longitudinal weight trends among veterans with and without diabetes. Overall, both 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, said Tamas, women with diabetes were heavier than men without diabetes, a finding inconsistent with research done in the general population. Patients were grouped into nonoverlapping 5-year cohorts according to their year of birth, which showed consistent weight gain in the youngest cohorts and weight loss in the oldest. Of concern, she noted, was that weight increase accelerated progressively from the oldest to the youngest birth cohorts. Based on the results, Tamas suggested that the prevalence of diabetes in the veteran population may increase even more, highlighting the need for efforts to prevent weight gain in this group.
Captain Patricia McCafferty, commanding officer of the Expeditionary Medical Facility in Bethesda, Maryland, brought a perspective from the Navy and Navy Reserve Corps. She highlighted health promotion programs and practices available for those two groups, noting that the Reserve Corps has health promotion programs at every detachment. In addition to programs that are completed individually, such as ShipShape, there is an annual team challenge, Crews Into Shape, in which each crew member earns points for exercising, maintaining or achieving a goal weight, eating fruits and vegetables, and engaging in other healthy activities. As the Navy seeks to create a culture of lifelong fitness, it is exploring tactics such as wireless activity trackers and improved strategic communications via digital and social media platforms, she said.
Lieutenant Colonel Heidi Clark, nutritional medicine flight commander at the David Grant Medical Center at the Travis Air Force Base, began by describing the significant resource drain that unfit trainees exert on the recruiting pipeline. They cost about four times as much and have about four times as many clinic visits during training as their control counterparts, she explained.
According to Clark, service members’ struggles to maintain weight loss and healthy lifestyle behaviors sometimes involve extreme, unproven, and/or potentially risky methods. A tremendous amount of pressure is put on individuals, she
8Jones, B. H., K. G. Hauret, S. K. Dye, V. D. Hauschild, S. P. Rossi, M. D. Richardson, and K. E. Friedl. 2017. Impact of physical fitness and body composition on injury risk among active young adults: A study of Army trainees. Journal of Science and Medicine in Sport 20(4):S17–S22.
9Overweight children in the military health system. HCSDB (Health Care Survey of DoD Beneficiaries) Issue Brief. http://www.tricare.mil/survey/hcsurvey/BMI_0127.pdf (accessed June 6, 2018).
10This text has changed since release.
said, 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. Long working hours, common practices such as cake at every retirement ceremony, and families struggling to afford healthy foods are “definitely not making matters better,” concluded Clark.
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 of the Army and the Secretary of the Army in 2015 to examine underlying issues affecting health and performance readiness of the force.
The team identified three issues, starting with a lack in soldiers’ baseline knowledge about personal fitness and nutrition. This is potentially driven by decreases in health and physical education and home economics courses in the U.S. school system and compounded by reliance on unreliable sources, Ramotar reasoned. She also flagged the minimal nutrition education requirement in the military’s continuing education pathway. A second issue is the military and broader DoD work environment, which often forces service members to adapt to new and different food environments in which they may not know how to make healthy choices or face other barriers to doing so, she explained. A third issue is the challenge of appropriately supporting service members’ genuine desires to be healthy, be fit, and enhance their performance.
Unfortunately, negative reinforcement is often used, said Ramotar: “You stay fit or you get kicked out.” Upon retirement, even the negative reinforcement is gone, which she said underscores the need to instill other methods to support the desire for healthy lifestyles whether or not the person is currently enlisted. This is particularly important given that 80 percent of retirees become overweight or develop obesity, she added. Ramotar emphasized the importance of imparting knowledge and the strategies to apply it throughout the spectrum of one’s military career, which she said will help address these three compounding issues.
Obesity and overweight have had minimal impact on the U.S. Marine Corps owing to high evidence-based standards for body composition and physical fitness, as well as accountability, said Brian McGuire, deputy director of the Force Fitness Division at the U.S. Marine Corps Training and Education Command in Quantico, Virginia. According to 2016 DoD data, the prevalence of obesity in the military as a whole is 7.9 percent, whereas among the Marine Corps it is 1.6 percent, he said.
Accountability begins with recruiters, explained McGuire, who do not get credit for recruits unless they 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, he 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 (PFT). Graduation from boot camp requires meeting retention standards, McGuire said.
In early 2017, the Marine Corps raised its PFT and Combat Fitness Test (CFT) standards, which McGuire said motivate members to challenge themselves to meet the new requirements. To incentivize and reward above-average physical fitness, the Marine Corps linked body composition standards to the PFT and the CFT in a way that provides flexibility in meeting the standards if fitness test scores reach a certain threshold, or an exemption from the standards in the presence of superior test scores.
Though the Marine Corps is “in a good place with overweight and obesity,” observed McGuire, it still faces challenges. He provided two examples; first, it is monitoring a small increase in waiver requests, and second, it is also 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,” he said.
The third session included 10 speakers who presented innovative strategies to address obesity and overweight in specific populations within the armed forces. Each speaker was instructed to describe the strategy’s largest impact, contributors to its success, and outcomes achieved, as well as future initiatives that have been identified.
Captain Andy Vu, deputy director, Operation Live Well, which supports the Office of the Under Secretary of Defense for Personnel and Readiness, opened the session with a leadership perspective on policy, data, and strategic planning. Helping military service members to navigate the challenges of military life requires a comprehensive approach to well-being throughout a service member’s career, he declared. He said that this support includes a holistic assessment of well-being and readiness based on a Total Force Fitness Framework that encompasses eight domains: social, physical, environmental, medical/dental, nutritional, spiritual, psychological, and behavioral. A key challenge, he remarked, is that 64 percent of the total force is the U.S. Army, of which 10 percent (or 100,000 soldiers) is nondeployable, mostly owing to medical conditions.
Vu said that development of a Readiness Prediction Model is under way, which is a machine learning model that
will quantify individual readiness, predict the level of deployability for service members, and identify the root causes of nondeployability. “We are partnering with the services to essentially consume their data and develop machine learning algorithms that are going to help us identify these three metrics,” he explained.
Vu emphasized the need for an “enterprise approach” to address the drivers of the armed forces’ weight problems, such as nutrition. This requires attention to how food is procured, prepared, and promoted, and even includes practices for the timing of lunch and recess in DoD schools. He also mentioned a pilot program to support reserve component military service members in achieving the same access to care and facilities as active duty members. Fifty percent of service members are reservists, who increasingly live away from military installations but are expected to deploy at a similar rate to active duty members, he explained.
Lieutenant Colonel (retired) Tammy J. Lindberg, nutrition program manager at the Headquarters Air Force Medical Operations Agency, and Beth Moylan, director of performance nutrition for the Consortium for Health and Military Performance at Uniformed Services University of the Health Sciences, described joint nutrition initiatives that affect the feeding environments in all branches of the military.
Lindberg discussed two initiatives that she said have led to a culture change, improved communication of food and nutrition needs in the military environment, and spurred collaboration by breaking down the silos in which the armed forces’ food programs operate. The Military Nutrition Environment Assessment Tool (m-NEAT) assesses environmental factors and policies that support healthy eating in military installation communities. The Joint Buyer’s Guide, a tool that establishes a subsistence quality baseline for all food purchases for the Army, Air Force, Navy, and Marine Corps, leverages the purchasing power of the joint forces. These two tools have led to increased availability of healthy options on military installations and to the use of commanders’ leadership and service members’ feedback to drive solutions to challenges, Lindberg said. In the future, she said, m-NEAT will begin implementing the U.S. Department of Health and Human Services’ (HHS’s) Food Service Guidelines for Federal Facilities, which address the placement, pricing, and promotion of healthy options, and the Joint Buyer’s Guide will expand to include more food categories.
Go for Green® 2.0 is designed to improve the performance, readiness, and health of military service members through nutrition, said Moylan. Based on evidence from behavior change research, it uses the tactics of stoplight color food labeling and placement to nudge diners toward better food and beverage selections in military dining facilities, without restricting their personal choice and with a focus on performance outcomes as the core of its message.
Keys to the program’s success, said Moylan, are its standardized dissemination across all services and staff training at all levels in the dining facilities implementing the program. Pilot testing of the initiative resulted in the increased availability and promotion of healthy food options and the increased presentation of nutrition information, she reported. Qualitative feedback suggested the beginning of a culture shift among soldiers as they began to pay more attention to their food choices and how they affect performance. Future efforts will address implementation challenges, such as the need for improved technical and operational support, and evaluate the initiative’s effect on soldiers’ food choices and knowledge and attitudes around nutrition, Moylan said in closing.
Major Tamara Osgood, division chief, Health Education and Application at the U.S. Army Public Health Center, was the first of four speakers who discussed service-specific initiatives. She emphasized that coordinated, holistic, evidence-based approaches at multiple levels of the social ecological model are essential to change behavior and improve health outcomes.
Osgood described four initiatives targeting the “total Army family”: active duty, National Guard, Army Reserve, and Department of the Army civilians, retirees, and family members. The first, Fit for Performance, is an evidence-based, standardized, clinically based six-session lifestyle and behavior modification program with acute targets of weight loss and achievement of body fat standards at the individual level. The second, Army Wellness Centers, provides standardized primary prevention programs and health coaching services designed to build and sustain good health through changes in lifestyle behaviors. Both of these initiatives have helped soldiers lose weight, reported Osgood, and they also share common challenges: participants’ failure to attend all sessions and follow-up appointments, and difficulty maintaining the consistent staffing that is needed for effective implementation. The third initiative, the Performance Triad, is a campaign designed to improve sleep, activity, and nutrition. Osgood explained that a lesson learned from the initiative was that increased awareness and knowledge are not always enough to change behavior, and that adjusting the environment is critical to making the healthy choice the easy (and likely) choice. That led to her fourth initiative, Healthy Army Communities: a coordinated, Army-wide effort, involving multiple entities working together to improve food environments to facilitate healthier choices, in addition to their focus on tobacco and improving physical activity.
Lieutenant Colonel Jennifer Harward, deputy chief, Air Force Health Promotion at the Air Force Medical Support Agency, presented five initiatives that the Air Force is testing at different locations to improve health behaviors among active duty service members, dependents, and retirees. Tele-Medical Nutrition Therapy connects registered dietitian
nutritionists (RDNs) at “hub” sites with patients at both hub and “spoke” sites via video teleconferencing and telephone, which she said fills gaps in medical nutrition therapy services at locations that do not have an RDN or have limited capacity. Harward cited the success of setting up three spoke sites to date, though this involved logistics challenges, she said.
Healthcare to Health is a second initiative and has two components: a campaign to educate families and increase their awareness of healthy behaviors to prevent childhood obesity, and a group lifestyle balance program aimed at preventing or delaying diabetes. Participants in the latter program achieved a 6.7 percent weight loss at 1 year, said Harward, but attrition is a challenge. Health Coaching is a new initiative for 2017, said Harward, which allows primary care providers to refer patients to face-to-face or telephone-based behavior change counseling for weight management, physical activity, nutrition, tobacco cessation, and stress management. Gaps in service caused by contractor turnover challenge health coaching as well as Healthcare to Health, Harward said. Another relatively new effort is the Air Force Smart Fueling Initiative, which collaborates with stakeholders who manage various food access points across the military installation to improve the availability and accessibility of healthier foods. Finally, Harward briefly described a newly developing health promotion program that will target high-risk squadrons with a standardized, holistic program to improve behaviors related to sleep, weight, physical activity, and tobacco use.
McGuire returned to discuss the service’s physical fitness initiatives. McGuire began by sharing that the Marine Corps is training members to be Force Fitness Instructors, unit-level fitness experts who will help develop programs and refer individuals to dietitians and other health professionals. Alongside cultivating a desired “density” of these instructors, the Marine Corps observed success with decreased injury and assignment to body composition programs and increased general and occupational fitness among service members, reported McGuire.
Next, McGuire said that the strong science supporting performance nutrition as a strategy to increase endurance, improve muscle recovery, and reduce injuries has facilitated the practice of providing postexercise nutritional supplements following rigorous activity at recruit depots at Officer Candidate School in entry-level training. In addition, “performance nutrition packs” are provided to help bridge the gap between the evening meal and the following morning’s early exercise session. Though it was a challenge for some people to change their thinking, said McGuire, a case was made that nutrition does not have to occur only in the dining facilities and that it was possible to “bring the chow hall out to the [physical training] field.” Data showing the benefits of these tactics, such as decreased sick call visits, decreased injuries, and increased physical performance, “wins our leadership over,” McGuire stated.
James Sherrard, head of Health Promotion and Wellness at the Naval Hospital Pensacola, highlighted three of the Navy’s health promotion initiatives to target the obesity and overweight concerns of active duty and reserve sailors, their families, and DoD civilian staff. ShipShape is the Navy’s weight management program, starting with eight weekly sessions that focus on nutrition, physical activity, and mindset, followed by several weeks of follow-up to encourage continued adherence to a healthy lifestyle. A challenge, he said, is getting people to complete all 8 weeks of the program.
One success of ShipShape is that its trained facilitators need not have health or medical backgrounds, stated Sherrard, though they should model healthy personal lifestyles. Sherrard shared that surveys of program participants revealed a 97 percent positive response to the statement, “I now have the knowledge, skills, and abilities necessary to maintain my weight for the long term.”
The second initiative Sherrard discussed is a Health Promotion Toolbox on the Navy and Marine Corps Public Health Center’s website. The toolbox offers a repository of health and wellness information, divided topically into monthly campaigns for command-level health promotion staff to use to plan health promotion education and events.
Third, continued Sherrard, is a new Health Promotion Interactive Map that provides a snapshot of health promotion resources such as walking paths, cooking classes, tobacco cessation classes, and weight management classes close to every Navy and Marine Corps treatment location. The map is updated as new resources are identified and is particularly useful, he suggested, when service members deploy or travel and want to know what healthy lifestyle supports will be available at their destination.
The session’s final two speakers discussed Department of Veterans Affairs (VA) programs. Susan Raffa, national program director for Weight Management for the Veterans Health Administration, described its MOVE!® Weight Management Program for Veterans, an evidence-based, population-focused approach that is integrated into the health care system.
The program has demonstrated effectiveness in three areas, observed Raffa: near-universal screening and referral for obesity and overweight, a broad reach (more than 800,000 veterans participating since its 2005 launch), and provision of co-pay exempt, standardized care at every VA medical center, delivered as comprehensive lifestyle intervention education. Data collected since 2008 indicate that 15 to 20 percent of new participants achieve clinically significant weight loss (≥5 percent of body weight) by the 6-month mark, she reported, and about 70 percent are at least maintaining weight
or achieving some degree of weight loss at that point in time. Approximately 30 percent of participants achieve clinically significant weight loss with intense and sustained program participation, Raffa reported, defined as attending at least eight sessions within 4 months.
Raffa suggested that the program’s success is underpinned by its evidence-based programming, national program office support, and measurement of key performance indicators. The program could be even more successful, she suggested, with better integration and coordination with other elements of care, such as pharmacotherapy and bariatric surgery. Raffa also noted an effort to make program materials more interactive as well as plans for a national telephone survey to assess veterans’ satisfaction with programming.
Veterans and their families across the country can be exposed to new foods and learn healthy cooking skills through the VA’s National Healthy Teaching Kitchens program, said Sean Walsh, a registered dietitian and certified sous chef who co-leads the program. Depending on the facility, participants get hands-on cooking experience or observe cooking demonstrations that teach the skills to help them progress toward their personal health goals. By demystifying the cooking process and appealing to personal and regional food preferences, the program helps redefine healthy foods as tasty foods that people want to eat, he explained. It also helps veterans stretch their food dollars by showing them how to reduce waste and use leftovers. An enabler of success is a resource toolkit with lesson plans, recipes, and administrative guidelines for implementing the program in other VA sites, said Walsh. Evaluation data help tailor the program to better serve individual goals and different ethnicities and geographic areas where food cultures and regional specialties vary, Walsh noted in closing.
PERSPECTIVES FROM OUTSIDE THE ARMED FORCES ON APPROACHES TO PREVENT AND TREAT OBESITY
In the workshop’s fourth session, four speakers from organizations outside of the armed forces offered perspectives on initiatives to address obesity and overweight, sharing success stories and suggesting opportunities to inspire future action. Captain Heidi Michels Blanck, chief of the Obesity Branch in the Division of Nutrition, Physical Activity, and Obesity (DNPAO) at the Centers for Disease Control and Prevention, said the division’s goal is to lead the nation’s fight against the health and economic burden of chronic disease by promoting good nutrition, regular physical activity, and healthy weight for all Americans across the life span. The division works with other federal partners to speed up research, identify best practices, disseminate evidence-based guidelines, and provide implementation training and assistance. As opposed to traditional clinical prevention efforts such as screening, counseling, and weight clinics, she clarified that the DNPAO focuses on policy, systems, and environmental change in communities and institutions in order to improve the healthfulness of places where people live, work, play, and pray.
Blanck highlighted the DNPAO’s use of scientific data and evidence to inform what communities and states can do to address obesity, as well as its engagement in cross-agency communication to learn what others in HHS are doing. Regarding collaboration, the Food Service Guidelines for Federal Facilities are an example of a cross-sector initiative with a high potential for having a large impact, “because if we can improve food procurement in child care, schools, work sites, and DoD, we can change the demand for healthy foods and, over time, the crops that are grown in America,” Blanck explained.
Marian Levy, associate dean in the School of Public Health at the University of Memphis, described Memphis Healthy U, an initiative to provide environmental and normative support for healthier eating and increased physical activity on campus. This effort warranted campus-wide collaboration, she said, particularly with the university’s food service vendor. Support from campus leadership such as the President’s Office and the Provost’s Office drove the involvement of other departments and student groups on campus. The initiative featured group fitness activities, promotional deals for healthier foods, and signage to encourage healthier behaviors. Levy listed a few of the initiative’s success factors: support from top-level administration; promotion of healthier foods while maintaining cost-neutrality to the food service vendor; and meeting people where they are, welcoming diverse perspectives, and tailoring activities accordingly. She also encouraged partnering with university ROTCs to create a culture of health “pipeline” that can make its way into the military.
Jeanne Blankenship, vice president of policy initiatives and advocacy at the Academy of Nutrition and Dietetics (AND), began by urging continued collaboration: “What we can do as an organization is really limited compared to what we can do when we partner with others.” Blankenship drew attention to the roles that RDNs hold in various clinical and community settings where they can affect obesity and overweight issues, highlighting certification programs offered by AND to help train its membership to address obesity and weight management issues in adult and pediatric populations. Blankenship discussed opportunities to provide nutrition education through federal food and nutrition assistance programs, such as the Supplemental Nutrition Assistance Program (SNAP) and the Special Supplemental Nutrition Program
for Women, Infants, and Children, which count many military members and families as recipients. She described AND’s involvement in national efforts related to improving access to care, developing standards of care and obesity competencies, and addressing the weight bias and stigma that can be a barrier to providing quality care. Lastly, Blankenship proposed that it would be helpful to hear from military personnel who struggle with weight and thus face possible discharge and separation. Their perspective on potential barriers to successfully using the programs and services that were shared by other speakers can help identify opportunities for improvement going forward, she said.
Jane M. Clary Loveless, national program leader for nutrition/extension at the National Institute of Food and Agriculture at the U.S. Department of Agriculture, discussed two grant programs funded by the Farm Bill: the Community Food Projects (CFP) and the Food Insecurity Nutrition Incentive (FINI). CFP aims to meet the food needs of low-income individuals through food distribution, outreach to increase participation in federally assisted nutrition programs, and improved access to food; and to promote comprehensive responses to local food access, farm, and nutrition issues, she said. CFP successfully distributed nearly $50 million to 200 organizations in 47 states between 2008 and 2016. Examples of grantee projects include community food assessments, community gardens with market stands, and mobile markets.
The FINI grant program’s primary goal, said Clary Loveless, is to support projects to increase the purchase and consumption of fruits and vegetables among low-income SNAP participants by providing point-of-purchase incentives, including vouchers, coupons, and tokens for fruits and vegetables; direct point-of-sale discounts on fruits and vegetables; or providing other SNAP-eligible items in response to fruit and vegetable purchases.
POTENTIAL FUTURE OPPORTUNITIES FOR THE ARMED FORCES, MILITARY FAMILIES, AND THEIR COMMUNITIES
The workshop’s final session provided time to reflect on the day’s discussions about promising strategies, challenges, and future opportunities to overcoming the challenges posed by obesity and overweight in the armed forces, military families, and their communities—including potential cross-sector opportunities. Four speakers, who each moderated one of the workshop’s sessions, shared their reflections and engaged in discussion with participants.
Lieutenant Pamela Gregory, Navy nutrition program manager, spoke about the close collaboration among stakeholders across the armed forces to address obesity and overweight. Because sharing resources and assets can build collective power toward achieving common objectives, she noted the importance of reaching out to other sectors to identify and leverage additional opportunities to collectively address the problem.
Anne Utech, acting national director of nutrition and food service at the VA, remarked on the large number and wide variety of programs that exist across the armed forces to address health and weight issues. Based on the “incredible amount” of data that have been generated by these programs, “we may be sitting on a gold mine of knowledge,” she speculated. She suggested partnering with educational institutions to mine the data and disseminate it throughout the scientific community and government agencies.
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, drew attention to the relative lack of information about service members’ eating behaviors compared to their physical fitness, and speculated about the potential to survey service members on a wider range of health-related behaviors. She noted that this information could help tailor efforts to address the needs of members of different rank and occupational specialties.
Esther Myers, CEO of EF Myers Consulting, said that she was struck by the culture and attitude change that has occurred since her early military service in 1976. It is wonderful, she proclaimed, that people now recognize that healthy eating is a shared responsibility across all parts of the military, not just the hospital. She also noted the positive shift to applying a systems thinking, community-wide lens to promoting healthy living among the military community. Finally, she emphasized the need to identify solutions to overcome the attrition that affects many health promotion and weight control programs, given that multiple touch points are needed for success.
In closing, Bernadette Marriott, professor at the Medical University of South Carolina, assessed that the day’s discussions “have shown how complex it is to look at the issues related to obesity and overweight within the military.” Highlighting a few statistics that speakers shared about the negative consequences of excess weight among service members, she concluded that “these are pretty staggering pieces of information as we think about meeting this challenge.” ♦♦♦
DISCLAIMER: This Proceedings of a Workshop—in Brief was prepared by Emily A. Callahan as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.
*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Cedric Bryant, American Council on Exercise. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.
SPONSOR: This workshop was partially supported by the Academy of Nutrition and Dietetics; Alliance for a Healthier Generation; American Academy of Pediatrics; American College of Sports Medicine; American Council on Exercise; American Heart Association; American Society for Nutrition; Bipartisan Policy Center; Blue Cross Blue Shield of North Carolina Foundation; The California Endowment; ChildObesity180/Tufts University; Chobani; Edelman; General Mills, Inc.; Greater Rochester Health Foundation; HealthPartners; The JPB Foundation; Kaiser Permanente; The Kresge Foundation; Mars, Inc.; National Recreation and Park Association; Nemours; Nestlé Nutrition; Novo Nordisk; Obesity Action Coalition; The Obesity Society; Partnership for a Healthier America; Reebok, International; Reinvestment Fund; Robert Wood Johnson Foundation; Salud America!; Weight Watchers International, Inc.; and YMCA of the USA.
For additional information regarding the meeting, visit nationalacademies.org/obesitysolutions.
Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Understanding and overcoming the challenge of obesity and overweight in the armed forces: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25213.
Health and Medicine Division
Copyright 2018 by the National Academy of Sciences. All rights reserved.