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http://nap.edu/25128
Understanding and Overcoming the Challenge of Obesity and
Overweight in the Armed Forces: Proceedings of a Workshop
(2018)
112 pages | 6 x 9 | PAPERBACK
ISBN 978-0-309-47676-8 | DOI 10.17226/25128
Emily A. Callahan, Rapporteur; Roundtable on Obesity Solutions; Food and
Nutrition Board; Health and Medicine Division; National Academies of Sciences,
Engineering, and Medicine
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. Washington, DC: The National Academies Press.
https://doi.org/10.17226/25128.

Understanding and Overcoming the Challenge of Obesity and Overweight in the Armed Forces: Proceedings of a...
Copyright National Academy of Sciences. All rights reserved.
Emily A. Callahan, Rapporteur
Roundtable on Obesity Solutions
Food and Nutrition Board
Health and Medicine Division
I N T H E A R M E D F O R C E S
U N D E R S TA N D I N G A N D OV E R C O M I N G
THE CHALLENGE OF
OBESITYAND OVERWEIGHT
PROCEEDINGS OF A WORKSHOP

Understanding and Overcoming the Challenge of Obesity and Overweight in the Armed Forces: Proceedings of ...
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
This activity was supported in part 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 Asso-
ciation; American Society for Nutrition; Bipartisan Policy Center; Blue Cross and
Blue Shield of North Carolina Foundation; The California Endowment; ChildObe-
sity180/Tufts University; Chobani; Edelman; General Mills, Inc.; Greater Rochester
Health Foundation; HealthPartners, Inc.; 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 In-
ternational, Inc.; and YMCA of the USA. Any opinions, findings, conclusions, or
recommendations expressed in this publication do not necessarily reflect the views
of any organization or agency that provided support for the project.
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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. Washington, DC: The National
Academies Press. doi: https://doi.org/10.17226/25128.

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v
PLANNING COMMITTEE ON UNDERSTANDING
AND OVERCOMING THE CHALLENGE OF OBESITY
AND OVERWEIGHT IN THE ARMED FORCES1
BERNADETTE MARRIOTT (Chair), Professor and Director, Nutrition
Section, Division of Gastroenterology and Hepatology, Department
of Medicine and Military Division, Department of Psychiatry and
Behavioral Sciences, Medical University of South Carolina
CAPT. HEIDI MICHELS BLANCK, Chief, Obesity Branch, Division of
Nutrition, Physical Activity, and Obesity, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention
RENEE COLE, Director, Healthy Eating Behavior Initiative; Deputy,
Military Nutrition Division, U.S. Army Research Institute of
Environmental Medicine
PAMELA GREGORY, Navy Nutrition Program Manager, Physical
Readiness Program
KARI HARRIS, Deloitte Consulting, LLP
JENNIFER B. HARWARD, Deputy Chief, Air Force Health Promotion,
Air Force Medical Support Agency
JEFF HILD, Policy Director, Sumner M. Redstone Global Center for
Prevention and Wellness, Milken Institute School of Public Health, The
George Washington University
LISEL LOY, Vice President, Programs, Bipartisan Policy Center
ESTHER MYERS, CEO, EF Myers Consulting, Inc.
DONNA RYAN, Professor Emerita, Pennington Biomedical Research
Center, Louisiana State University
ANNE UTECH, Acting National Director, Nutrition and Food Service,
U.S. Department of Veterans Affairs
Health and Medicine Division Staff
LESLIE J. SIM, Roundtable Director
HEATHER DEL VALLE COOK, Senior Program Officer
ELLE ALEXANDER, Associate Program Officer
AMANDA NGUYEN, Associate Program Officer
MEREDITH YOUNG, Research Assistant
CYPRESS LYNX, Senior Program Assistant
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees
are solely responsible for organizing the workshop, identifying topics, and choosing speak-
ers. The responsibility for the published Proceedings of a Workshop rests with the workshop
rapporteur and the institution.

vii
ROUNDTABLE ON OBESITY SOLUTIONS1
BILL PURCELL III (Chair), Farmer Purcell White & Lassiter, PLLC,
Nashville, Tennessee
RUSSELL R. PATE (Vice Chair), University of South Carolina, Columbia
MARY T. STORY (Vice Chair), Duke University, Durham, North
Carolina
SHARON ADAMS-TAYLOR, The School Superintendents Association,
Alexandria, Virginia
KATIE ADAMSON, YMCA of the USA, Washington, DC
ANDREA M. AZUMA, Kaiser Permanente, Oakland, California
CAPT. HEIDI MICHELS BLANCK, Centers for Disease Control and
Prevention, Atlanta, Georgia
JEANNE BLANKENSHIP, Academy of Nutrition and Dietetics,
Washington, DC
DON W. BRADLEY, Duke University, Durham, North Carolina
CEDRIC X. BRYANT, American Council on Exercise, San Diego,
California
HEIDI F. BURKE, Greater Rochester Health Foundation, Rochester,
New York
DEBBIE I. CHANG, Nemours, Newark, Delaware
JOHN COURTNEY, American Society for Nutrition, Bethesda,
Maryland
ANNE DATTILO, Nestlé Nutrition, Florham Park, New Jersey
MERRY DAVIS, Blue Cross and Blue Shield of North Carolina
Foundation, Durham, North Carolina
CHRISTINA ECONOMOS, Tufts University, Boston, Massachusetts
IHUOMA ENELI, American Academy of Pediatrics, Columbus, Ohio
JENNIFER FASSBENDER, Reinvestment Fund
GARY FOSTER, Weight Watchers International, Inc., New York,
New York
DAVID D. FUKUZAWA, The Kresge Foundation, Troy, Michigan
MARJORIE INNOCENT, National Association for the Advancement of
Colored People, Baltimore, Maryland
SCOTT I. KAHAN, The George Washington University, Washington, DC
AMY KULL, Edelman, San Francisco, California
SHIRIKI KUMANYIKA, Drexel University, Philadelphia, Pennsylvania
CATHERINE KWIK-URIBE, Mars, Inc., Germantown, Maryland
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables
do not issue, review, or approve individual documents. The responsibility for the published
Proceedings of a Workshop rests with the workshop rapporteur and the institution.

viii
THEODORE KYLE, The Obesity Society, Pittsburgh, Pennsylvania
LISEL LOY, Bipartisan Policy Center, Washington, DC
KELLIE MAY, National Recreation and Park Association, Ashburn,
Virginia
MYETA M. MOON, United Way Worldwide, Alexandria, Virginia
JOSEPH NADGLOWSKI, Obesity Action Coalition, Tampa, Florida
BARBARA PICOWER, The JPB Foundation, New York, New York
SUE PECHILIO POLIS, National League of Cities, Washington, DC
ROBERT C. POST, Chobani, New York, New York
AMELIE G. RAMIREZ, Salud America!, San Antonio, Texas
OLIVIA ROANHORSE, Notah Begay III Foundation, Santa Ana Pueblo,
New Mexico
NANCY ROMAN, Partnership for a Healthier America, Washington, DC
KEVIN R. RONNEBERG, HealthPartners, Inc., Minneapolis, Minnesota
SYLVIA ROWE, S.R. Strategy, LLC, Washington, DC
JAMES F. SALLIS, University of California, San Diego
EDUARDO J. SANCHEZ, American Heart Association, Dallas, Texas
MARION STANDISH, The California Endowment, Oakland, California
MAHA TAHIRI, General Mills, Inc., Minneapolis, Minnesota
KATHLEEN TULLIE, Reebok International, Canton, Massachusetts
MONICA HOBBS VINLUAN, Robert Wood Johnson Foundation,
Princeton, New Jersey
HOWELL WECHSLER, Alliance for a Healthier Generation, New York,
New York
JAMES R. WHITEHEAD, American College of Sports Medicine,
Indianapolis, Indiana
TRACY ZVENYACH, Novo Nordisk, Washington, DC
Health and Medicine Division Staff
LESLIE J. SIM, Roundtable Director
HEATHER DEL VALLE COOK, Senior Program Officer
ELLE ALEXANDER, Associate Program Officer
AMANDA NGUYEN, Associate Program Officer
MEREDITH YOUNG, Research Assistant
CYPRESS LYNX, Senior Program Assistant
ANN L. YAKTINE, Food and Nutrition Board Director
Consultant
WILLIAM (BILL) H. DIETZ, The George Washington University,
Washington, DC

ix
This Proceedings of a Workshop was reviewed in draft form by indi-
viduals chosen for their diverse perspectives and technical expertise. The
purpose of this independent review is to provide candid and critical com-
ments that will assist the National Academies of Sciences, Engineering, and
Medicine in making each published proceedings as sound as possible and
to ensure that it meets the institutional standards for quality, objectivity,
evidence, and responsiveness to the charge. The review comments and draft
manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
LTC. RENEE COLE, U.S. Military-Baylor University
CAPT. KIMBERLY ELENBERG, U.S. Department of Defense
JEFF HILD, The George Washington University
HANNAH MARTIN, Bipartisan Policy Center
Although the reviewers listed above provided many constructive com-
ments and suggestions, they were not asked to endorse the content of the
proceedings, nor did they see the final draft before its release. The review
of this proceedings was overseen by NICOLAAS PRONK, HealthPartners,
Inc. He was responsible for making certain that an independent examina-
tion of this proceedings was carried out in accordance with standards of the
National Academies and that all review comments were carefully consid-
ered. Responsibility for the final content rests entirely with the rapporteur
and the National Academies.
Reviewers

xi
1 INTRODUCTION 1
Organization of This Proceedings, 3
2 DEFINING THE PROBLEM AND ITS EFFECTS ON
RECRUITMENT, RETENTION, RESILIENCE, AND
READINESS 5
The Basis of Current U.S. Department of Defense Body Fat
Standards, 6
Recruitment, 10
Retention, 13
Resilience, Readiness, and Deployment, 15
Families and Communities, 18
Discussion, 19
3 SERVICE-SPECIFIC ISSUES RELATED TO OBESITY AND
OVERWEIGHT 23
Trends in Weight Change in Veterans with and Without
Diabetes, 24
Navy and Navy Reserve, 25
Air Force, 27
Army, 28
Marine Corps, 29
Discussion, 31
Contents

xii CONTENTS
4 EXPLORING INNOVATIVE STRATEGIES 33
Policy and Office of Secretary of Defense Strategy, 34
Joint Nutrition Initiatives, 36
Service-Specific Initiatives, 39
U.S. Department of Veterans Affairs Programs, 45
Discussion, 48
5 PERSPECTIVES FROM OUTSIDE THE ARMED FORCES 51
Centers for Disease Control and Prevention, 52
Memphis Healthy U, 53
Academy of Nutrition and Dietetics, 54
U.S. Department of Agriculture’s National Institute of Food and
Agriculture, 55
6 POTENTIAL FUTURE OPPORTUNITIES FOR THE ARMED
FORCES, MILITARY FAMILIES, AND THEIR
COMMUNITIES 57
Moderators’ Reflections, 57
Discussion, 58
REFERENCES 61
APPENDIXES
A WORKSHOP AGENDA 65
B ACRONYMS AND ABBREVIATIONS 71
C INNOVATIVE STRATEGIES: ABSTRACTS 73
D SPEAKER AND FACILITATOR BIOGRAPHIES 81

xiii
BOX
1-1 Workshop Statement of Task, 2
FIGURES
2-1 Body fat limits are key to military appearance, combat readiness,
and health, 7
2-2 Nomogram of the equation used to calculate male body fat
percentage in the armed forces, 8
2-3 Comparison of Army and U.S. Department of Defense body fat
standards, 9
2-4 Percentage of military-age Americans that exceed service-specific
weight-for-height and body fat standards (2008), 11
2-5 Navy Physical Fitness Assessment (PFA) separation analysis showing
total enlisted active component PFA losses by zone, 14
2-6 Injury incidence by 2-mile run time and body mass index for
women and men in basic combat training, 17
4-1 Total force well-being: Enhancing individual readiness and
resiliency, 35
4-2 Results of an outcome evaluation of Army Wellness Center clients
with at least one follow-up (conducted at least 30 days after initial
assessment), 41
4-3 Example of an Air Force Commander’s Health Scorecard, 43
4-4 Weight outcomes at the 6-month mark for new participants in the
MOVE!® program, 47
Box and Figures

1
Introduction
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 com-
munities. The consequences of obesity and overweight in the armed forces
influence various aspects of their operations that are critical to national se-
curity, including recruitment, retention, resilience, readiness, and retirement.
A workshop titled Understanding and Overcoming the Challenge of
Obesity and Overweight in the Armed Forces was held on May 7, 2018,
in Washington, DC.1 The workshop was convened by the Roundtable on
Obesity Solutions, which is part of the Health and Medicine Division of the
National Academies of Sciences, Engineering, and Medicine. The goals of
the workshop were to examine the challenges posed by obesity and over-
weight for the armed forces and explore opportunities to overcome these
challenges. The workshop’s full Statement of Task is in Box 1-1.2
Bill Purcell, currently with Farmer Purcell White Lassiter, PLLC,
and former mayor of Nashville, Tennessee, welcomed participants with an
1 The workshop planning committee’s role was limited to planning the workshop, and this
Proceedings of a Workshop was prepared by the workshop rapporteur as a factual summary
of what occurred at the workshop. Statements, recommendations, and opinions expressed are
those of individual presenters and participants, and are not necessarily endorsed or verified
by the National Academies of Sciences, Engineering, and Medicine, and they should not be
construed as reflecting any group consensus.
2 The workshop agenda, presentations, and other materials are available at http://www.
nationalacademies.org/hmd/Activities/Nutrition/ObesitySolutions/2018-MAY-07.aspx (ac-
cessed July 13, 2018).
1

2 OBESITY AND OVERWEIGHT IN THE ARMED FORCES
overview of the roundtable. He explained that the roundtable, established
in 2014, engages leaders from multiple sectors to help solve the nation’s
obesity crisis. Through meetings, public workshops, background papers,
and ad hoc convening activities, it fosters an ongoing dialogue about critical
and emerging issues in obesity prevention and treatment. It also provides
a trusted venue for inspiring, developing, and examining multisector col-
laborations as well as policy, environmental, and behavioral initiatives that
will increase physical activity, reduce sedentary behavior, and improve the
healthfulness of foods and beverages to reduce the prevalence and adverse
consequences of obesity and its related health disparities.
Purcell then introduced the workshop by remarking on the aptness of
its topic in relation to the history of the National Academies. It was in the
midst of the Civil War in 1863, he informed the audience, that President
Lincoln signed the Act of Incorporation establishing the National Academy
of Sciences (NAS). The NAS’s dominant purpose was service to the nation,
he continued, and at the request of President Wilson, it expanded during
World War I to keep pace with the demand for advice regarding military
preparedness. Subsequent executive orders have affirmed the importance of
the NAS and further broadened its charter (NASEM, 2018).
Following Purcell’s remarks, Bernadette Marriott, professor at the
Medical University of South Carolina and chair of the workshop planning
BOX 1-1
Workshop Statement of Task
An ad hoc committee will plan and conduct a 1-day public workshop that will
examine the challenges posed by obesity and overweight in the armed forces and
explore opportunities to overcome those challenges. The workshop will investigate
what is known about the prevalence of obesity and overweight in members of
the armed forces (including active duty, guard, and reserve components), their
families, veterans, and retirees. Presentations and discussions will highlight the
effects of obesity and overweight on recruitment, retention, readiness, and retire-
ment, and their implications for the military health care and retirement systems.
Discussion topics will highlight existing programs, practices, and policies that
support healthy weight of the armed forces, military families, and communities;
and the advantages and barriers in designing, implementing, maintaining, and
scaling them. The workshop agenda will also explore potential future opportunities
for innovative programs and partnerships inside and outside of the military sector,
such as leveraging linkages between military installations and their surrounding
communities.

INTRODUCTION 3
committee, took the podium to outline the workshop’s five sessions. She
added to Purcell’s historical overview by noting that the Roundtable on
Obesity Solutions is an activity of the National Academies’ Food and Nu-
trition Board (FNB), whose organization in 1940 was spearheaded by the
Council on National Defense. Also in 1940, she said, President Franklin D.
Roosevelt established the National Defense Research Council, which asked
the new FNB in 1941 to develop recommended dietary allowances to in-
form the feeding of American troops in the field. Since then, she observed,
the FNB has continued to partner with the U.S. military on research related
to many aspects of diet, nutrition, and health.
ORGANIZATION OF THIS PROCEEDINGS
This proceedings follows the order of the workshop agenda (see Ap-
pendix A), chronicling its five sessions in individual chapters. Chapter 2
examines how obesity and overweight are measured in the armed forces
and how the problem of obesity and overweight affects recruitment, reten-
tion, resilience, and readiness. Chapter 3 then details service-specific issues
related to obesity and overweight. Chapter 4 highlights innovative strate-
gies for addressing obesity and overweight through improved nutrition,
physical activity, and stress management. Chapter 5 describes perspectives
from outside of the armed forces on approaches to preventing and treating
obesity and overweight. Finally, Chapter 6 summarizes the last session of
the workshop, during which the moderators of the preceding four sessions
reflected on the speakers’ presentations and discussed the challenges and
opportunities entailed in overcoming the concerns posed by obesity and
overweight among the armed forces, military families, and their commu-
nities, including potential cross-sector opportunities. The acronyms and
abbreviations used throughout this proceedings are listed in Appendix B,
supplemental abstracts related to information presented in the workshop’s
third session appear in Appendix C, and the biographies of the speakers
and planning committee members are included in Appendix D.

2
Defining the Problem and Its
Effects on Recruitment, Retention,
Resilience, and Readiness
The first session of the workshop, moderated by Esther Myers, chief
executive officer of EF Myers Consulting, Inc., examined the methods used
for measuring obesity and overweight in the armed forces and discussed
how these conditions affect recruitment, retention, resilience, and readiness.
Highlights from the Presentations of Individual Speakers
• The body fat standards of the U.S. Department of Defense were
established to motivate regular physical activity and nutrition
behaviors that would ensure a high level of readiness for de-
manding military missions at any time. (Karl Friedl)
• These body fat standards are related to three key outcomes:
military appearance, health, and job performance. The em-
phasis on abdominal circumference in the standards addresses
the primary site of modifiable fat deposition related to each of
these outcomes. (Karl Friedl)
• The armed services spend about $1.5 billion annually on
obesity-related health care expenses and the costs of replacing
unfit military personnel. (Tracey Smith)
• Approximately one-third of Americans aged 17 to 24 do not
qualify for military service because of their excess weight.
(Tracey Smith)
5

• Existing military recruitment and accession standards are ap-
propriate, although the view that the standards are not posing
challenges to recruitment goals could change should recruit-
ment demands increase. (Tracey Smith)
• In early 2018, the U.S. Navy changed its physical readiness
separation policy. Members who want to stay in the Navy
now have the opportunity to change their behaviors and fitness
levels to return to good standing by passing a future Physical
Fitness Assessment within the remaining timeframe of their ser-
vice contract (enlisted) or rotation date (officers). (Jay Heaney)
• If the U.S. Army desires the most physically ready soldiers, it
may need to institute standards that consider physical fitness
and body composition simultaneously. (Bruce Jones)
• In the Military Health System, 13 percent of children aged 6
to 17 are overweight, and another 17 percent are at risk for
becoming overweight. (Karen Hawkins)
THE BASIS OF CURRENT U.S. DEPARTMENT
OF DEFENSE BODY FAT STANDARDS
Karl Friedl, senior research scientist in physiology at the U.S. Army
Research Institute of Environmental Medicine, set the stage with a pre-
sentation on the rationale and methods for measuring body fatness among
service members. He argued for the importance of defining the problem
because of the many “misconceptions about why we have the composi-
tion standards that we try to enforce in the DoD [U.S. Department of De-
fense].” Body composition standards exist to sustain and support military
performance, he explained, because it is imperative to ensure consistent
readiness to perform missions that often require intense physical effort in
harsh environments.
The development of enforced standards for fitness and body fat began
in 1980, Friedl recounted, sparked when national news cameras panned
down the “relatively wide gut line” of an Honor Guard in Washington, DC.
Each service was represented, he noted, and “the national commentary was,
‘Do these guys look like they are fit to defend you?’” As a result, President
Carter asked DoD to convene a panel of experts to develop an approach
for instituting enforceable fitness standards. According to Friedl, the expert
panel’s recommendations led to a DoD directive for all the services to adopt
enforceable body fat standards based on abdominal circumference, not just
body weight, which would make it possible to distinguish individuals who
may be overweight but not overfat. The Marines had already adopted a

RECRUITMENT, RETENTION, RESILIENCE, AND READINESS 7
circumference-based standard, he noted, and now the other services would
follow.
Abdominal circumference (and not just body weight) is key to three
important outcomes related to the standards: military appearance, combat
readiness, and health, Friedl elaborated. He added that the expert panel rec-
ognized that standards based on military appearance would be most strin-
gent, while those based on health would be least stringent (see Figure 2-1).
He also noted that the health-based standards would have to apply to all
adult males and females, regardless of age, and have upper limits more ap-
propriate for older than for younger adults, who are likely to gain weight
as they age. According to Friedl, the panel realized that it would need to
“meet in the middle” to account for all three outcomes.
Friedl explained that the panel considered the average body fat of a
fit, young man or woman (15 percent and 25 percent, respectively), then
allowed for a small statistical window and set a reasonable upper limit that
would be consistent with maintaining fitness and also help drive healthy
eating and physical activity habits to prevent excess weight gain. The panel’s
recommended upper body fat limit was 20 percent for men and 30 percent
for women, he reported. He noted that an explanation of sex-specific dif-
FIGURE 2-1 Body fat limits are key to military appearance, combat readiness, and health.
NOTE: BF = body fat; NHLBI = National Heart, Lung, and Blood Institute.
SOURCES: Presented by Karl Friedl, May 7, 2018. See References chapter for citations listed
at the bottom of the figure. Friedl, 2012, p. S89. Reprinted with permission.

ferences in body composition was important to help DoD understand that
the higher upper limit for women was appropriate, and that assigning them
the same upper limit as men could push them to anorexic levels.
Next, continued Friedl, the services were told to develop a circumfer-
ence standard, and each service had a different proposal. He explained
that the services ultimately converged on the best standard, which was
developed by the Naval Health Research Center. He described the resulting
standard as focused on key sites reflecting chronic underexercise and over-
nutrition habits: abdominal (navel) circumference for males, and abdominal
(waist) and hip circumference in females. Measurements for both sexes are
corrected for neck circumference and for stature, he added. Friedl argued
that, while this is not necessarily a method that one would use in a research
study requiring a precise measure of percent body fat, it is “a very practical
and pragmatic method.”
Friedl then showed a nomogram to illustrate how the equation works
(see Figure 2-2). The figure compares the difference between abdominal cir-
cumference and neck circumference plotted against stature, demonstrating
the difference in body fat computation for a 69-inch-tall male with either
FIGURE 2-2 Nomogram of the equation used to calculate male body fat percentage in the
armed forces.
SOURCES: Presented by Karl Friedl, May 7, 2018. Lukaski, 2017. Reprinted with permission
of Taylor and Francis.

a small or large waist. For females, hip circumference would be added to
abdominal circumference, Friedl noted.
Friedl clarified that using a body composition assessment method such
as dual-energy X-ray absorptiometry (DEXA) or underwater weighing
does not accord with the intent of this regulation, which is to enforce an
abdominal circumference standard that is then corrected for height and
other relevant variables. Measuring total body fat, he explained, begins to
pick up ethnic differences and considers fat in other body regions where it
is less responsive to changes in energy input and expenditure.
To summarize, Friedl showed a comparison of the standards of the
Army and DoD (see Figure 2-3). In the Army, he observed, acceptable
measures range from an ideal of 15 percent to up to 26 percent for men,
and from an ideal of 25 percent to up to 36 percent for women. He further
explained that the upper limits for young men and women are 20 and 30
percent, respectively, with a graduated adjustment to the upper limits as
one ages. This adjustment, he elaborated, accounts for age-related changes
in body composition, as well as the tendency of senior service members to
have desk-bound jobs. By comparison, in DoD, the standards are 18 to 26
percent for men and 26 to 36 percent for women.
Friedl went on to describe the kind of aerobic and strength performance
that the standards are intended to ensure. “Neither a sumo wrestler nor a
marathoner is an ideal soldier,” he maintained, suggesting that for DoD, the
ideal is probably between these two, incorporating an agility component.
In discussing efforts to validate the standards against the type of aerobic
and strength performance they are intended to enforce, Friedl said that in
the future, the current standards could give way to an assessment based on
FIGURE 2-3 Comparison of Army and U.S. Department of Defense body fat standards.
NOTE: BMI = body mass index; DoD = U.S. Department of Defense; WC = waist circumference.
SOURCES: Presented by Karl Friedl, May 7, 2018. Lukaski, 2017. Reprinted with permission
of Taylor and Francis.

a combination of body mass index (BMI) and fitness testing. He noted that
the Army may approve a new fitness test that could be used as part of such
a combination assessment.
Turning to the changes in soldiers’ body composition over time, Friedl
pointed to data on average height, weight, and circumference (chest, waist,
and hips) collected in 1864 from nearly 1 million soldiers in Union camps,
which could be used to estimate body fat. When compared with data from
the year 2000, those early data show a 30-pound increase in lean mass
and little change in body fat or adiposity for young men accepted into the
military (Friedl, 2004). Friedl noted further that in the middle of the 20th
century, there were many young men in the general population who were
underweight, and now “we have a lot of young men [who are overweight]
that we are turning away at the gate.”
Finally, Friedl claimed that the standards were successful in their intent
to modify behavior, as they were correlated with an end to big lunches
and an increase in individuals’ physical activity. He also mentioned three
large trials that attempted to examine weight management approaches in
the Army but were complicated by job-related migration. “We cannot give
up,” he said in conclusion. “But it shows you that these are the realities of
working with the military population.”
RECRUITMENT
Tracey Smith, a nutrition scientist at the U.S. Army Research Institute
of Environmental Medicine, opened her presentation on recruitment by
reporting that in 2007, the armed services spent about $1.5 billion for
obesity-related health care expenses and the costs of replacing unfit military
personnel (Voss et al., 2018). Moreover, she added, this number may un-
derestimate the true figure, as it does not include long-term disability costs.
She noted that obesity also leads to lost work days, degraded readiness and
resilience, and higher need for aeromedical evacuation.
About one-third of U.S. adults are overweight and almost 40 percent
have obesity, Smith continued, figures she said are relevant to DoD because
it recruits its members from the general population. Indeed, she observed,
according to DoD’s analysis of national height and weight data collected in
2014, approximately one-third of Americans aged 17 to 24 do not qualify
for military service because of their weight (based on a BMI ≥27.5, the
military’s upper limit for most age and sex groups). When this statistic is
combined with other disqualifying factors, including criminal history and
lack of adequate education, 71 percent of 17- to 24-year-olds are ineligible
for military service, she reported (Council for a Strong America, 2018). She
pointed out that these figures are based on height and weight data only,
whereas assessing eligibility also requires circumference measurement to

determine whether an individual meets the military’s body fat standards
(see the summary of Friedl’s presentation above).
Smith went on to discuss the proportion of military-age American civil-
ians who, based on 2008 data, exceed service-specific standards for both
body fat and weight-for-height. The figures range from 5 to 12 percent for
men and 13 to 35 percent for women, she reported, depending on each
service’s enlistment age requirements and standards (see Figure 2-4).
Moving on to examine statistics for individuals who apply for military
service, Smith referred to 2014 data on applicants who underwent a physi-
cal at a military entrance processing station. Among first-time applicants for
active component enlisted military service, approximately 9 percent were
medically disqualified because of obesity based on International Classifica-
tion of Diseases, Ninth Revision (ICD-9) coding.1 Smith reported that this
figure represented a decrease from 13 percent for the prior 5-year period.
She added that, based on other medical failure codes provided by the U.S.
1 For the ICD-9 codes used to classify clinical diagnoses of obesity, see https://www.health.
mil/Reference-Center/Publications/2016/10/01/Overweight-Obesity (accessed August 23,
2018).
FIGURE 2-4 Percentage of military-age Americans that exceed service-specific weight-for-
height and body fat standards (2008).
NOTES: The eligible age ranges for enlistment in active duty for each of the services are
17–42 (Army), 17–34 (Navy), 17–27 (Air Force), and 17–28 (Marine Corps). BMI = body
mass index.
SOURCES: Presented by Tracey Smith, May 7, 2018 (data from Cawley and Maclean, 2010).
Reprinted with permission.

Military Entrance Processing Command, about 16 percent of applicants in
2014 were disqualified because of weight and body build (Accession Medi-
cal Standards Analysis and Research Activity, 2015). For all the services, the
average rate of disqualification due to weight and body build had decreased
by 3 percent in 2014 compared with the prior 5-year period. Smith noted
that weight status is a temporary disqualifying condition that can be reme-
diated by an applicant without the need for an accession (initial military
entry) medical waiver.
According to a 2013 technical report from the Defense Health Board,
Smith continued, existing recruitment and accession standards are not
posing challenges for recruitment goals (Defense Health Board, 2013).2
For context, she noted that recruitment targets have decreased since 2007
because of the drawdown of troops, and recruiters are reporting that it has
become easier to recruit healthy individuals.
Smith then turned to demographic characteristics associated with obe-
sity and overweight at the time of accession into the Army. Overall, she
reported, the prevalence of exceeding the Army’s screening table weights
increased from 1989 to 2012, from a low of 5.7 percent to 25 percent, and
peaking at 31 percent in 2006 and 2007. From 2008 to 2012, she added,
women were less likely than men to exceed the guidelines, and women be-
low age 20 were less likely to do so than women aged 20–29 and 30–39.
The odds of exceeding the screening table weights showed no consistent
trends with respect to educational attainment, marital status, or geography
(Hruby et al., 2015).
Next, Smith shared data indicating the long-term impact of excess
weight at accession on lower-extremity musculoskeletal injury and dis-
orders and cardiometabolic risk factors. Relative to soldiers with normal
BMI at accession, she said, those who were underweight, overweight, or
had obesity had a 7, 11, and 33 percent, respectively, higher risk of injury
(after adjusting for a number of sociodemographic factors). The risk of
injury was lowest in soldiers with a BMI of 21–23 km/m2 at accession, she
pointed out (Hruby et al., 2016), adding that studies with shorter follow-up
periods have yielded similar results. “Taken together,” Smith stated, “BMI
at accession certainly has important implications for injury risk and does
support the importance of upper limits of BMI at accession.”
Furthermore, Smith continued, relative to soldiers with normal BMI
at accession, those who were overweight or had obesity had a higher risk
for developing each of the following cardiometabolic risk factors: meta-
2 The recruitment targets presented at the workshop are recommendations from the 2013
Defense Health Board report Implications of Trends in Obesity and Overweight for the De-
partment of Defense, published November 22, 2013. See http://www.dtic.mil/dtic/tr/fulltext/
u2/1027323.pdf (accessed August 22, 2018).

bolic syndrome, glucose/insulin disorder, hypertension, and dyslipidemia.
Soldiers with obesity at accession, for example, had three times the risk of
hypertension relative to those with normal weight (Hruby et al., 2017).
These elevated risks, she noted, were detected despite a generally low inci-
dence of these risk factors in this young population, as well as a relatively
brief (3.2 years) follow-up time.
Smith closed by citing four practical ways in which the information
on national trends in overweight and obesity and implications for military
personnel provided in the Defense Health Board’s 2013 report can be ap-
plied to advance efforts to recruit and retain fit armed forces:
• The report indicates that existing recruitment and accession stan-
dards are appropriate, although the indication that the standards
are not posing challenges to recruitment goals could change should
recruitment demands increase. As noted in the report, this issue
should be revisited periodically.
• Recruitment centers should collect data on the number of people
that are turned away from recruitment stations, given that some
prospective applicants do not undergo an initial medical exam and
thus cannot be factored into calculations of actual recruitment
losses related to classification as overweight or obese.
• DoD should assess the feasibility of training recruiters to calculate
BMI and collect circumference measurements to identify applicants
who may not meet the weight standards but may meet the body fat
standards.
• Current accession standards for weight-for-height and body fat
should be maintained as minimal requirements for all military
personnel to ensure an agile and responsive fighting force, with
stricter standards for certain military occupational specialties, such
as Special Forces.
RETENTION
Jay Heaney, deputy for the Warfighter Performance Department at the
Naval Health Research Center, began by observing that the military’s Body
Composition Assessment (BCA), performed on service members twice per
year, influences retention and separation from service. The Navy follows
the DoD’s upper limits for body fat of 26 percent for males and 36 percent
for females, he said, reiterating Friedl’s explanation of the graduated ad-
justment to the upper limit with increasing age—as members become more
senior in service, they “are probably not on the front line doing the physical
labor that [they] used to do.”
Heaney shared the Navy’s BCA scorecard for 2017, which detailed the

pass/fail rate for male and female enlisted members and officers in three
areas: height and weight (upper limit = BMI of approximately 27 kg/m2),
abdominal circumference (upper limits = 39 inches for males, 35.5 inches
for females), and age-adjusted body fat percentage by circumference. The
pass rate for the BCA was 99.2 percent that year, although, he pointed
out, that rate still left nearly 2,500 service members failing in both assess-
ment cycles. He added that the pass rate for the Physical Readiness Test
(PRT), which includes a 1.5-mile run and other components, was just under
99 percent. Thus, he observed, the average pass rate for the total Physical
Fitness Assessment (PFA) process in the Army that year was slightly below
99 percent; the pass rate for height and weight was approximately 97.7
percent and for physical fitness was about 97.5 percent. To summarize,
Heaney stated that most active duty service members pass their PFA, which
puts them in good standing for advancement and retention.
Heaney went on to present data representing the number of enlisted
sailors who separated because of PFA failure from 2013 through 2017 (see
Figure 2-5). He explained that the majority of the Navy’s separations due
to PFA failure occur among early-career sailors: “We are losing our service
members in their first tour. We are not holding on to them.”
Heaney pointed out that for 2013 and 2014, the administrative policy
FIGURE 2-5 Navy Physical Fitness Assessment (PFA) separation analysis showing total en-
listed active component PFA losses by zone.
NOTES: Zone A represents a sailor’s first 4-year term, Zone B represents a sailor’s second
4-year term, etc. For 2013 and 2014, failing three out of four PFA cycles led to separation.
A “reset period” preceded a new policy in 2017 that led to separation after failing two out
of three PFA cycles.
SOURCE: Presented by Jay Heaney, May 7, 2018. Reprinted with permission.

was that failing in three out of four PFA cycles led to separation. In
2016, he explained, the administrative policy changed, resulting in a “reset
period,” and in 2017, a new policy was enacted that required separation
after two out of three failed PFA cycles.
Another change in policy went into effect on January 1, 2018, Heaney
continued. The Navy is currently short 8,000 shipboard sailors, he ex-
plained, and rather than changing physical readiness standards, it changed
its physical readiness separation policy. The new policy, he elaborated, is
more flexible, allowing sailors who fail two or more consecutive PFAs to
serve until the end of their obligated term (enlisted) or projected rotation
date (officer), during which time they have an opportunity to resume good
standing by passing a PFA. However, he noted, individuals are not eligible
for promotion or reenlistment during that time.
Heaney illustrated the new policy with the theoretical example of an
officer who fails two consecutive PFAs but has 2 years remaining before his
or her projected rotation date. The officer would be allowed to continue
serving and would have four more cycles (two per year) to pass a PFA.
For service members who want to remain in the Navy, Heaney elaborated,
the policy gives them the time to change their behaviors and fitness levels
to resume good standing. He added that sailors with nuclear training and
those with a medical specialty or other special training may be granted an
exception from the new policy. “We seem to find a way to give an exemp-
tion to keep that highly trained person in the service,” he remarked.
Heaney went on to report that sailors who exceed age-adjusted body
fat standards are enrolled in the Fitness Enhancement Program. This pro-
gram mandates nutritional counseling and 3 days per week of physical
fitness training, and includes routine weight and body composition moni-
toring and other supportive resources. Sailors’ participation in the program
continues for a minimum of 6 months until they pass the next PFA or BCA.
The Army has a similar program, Heaney noted. He elaborated briefly on
the other services’ separation policies related to BCA, which are fairly simi-
lar to that of the Navy and have their own nuances.
Heaney closed by emphasizing the critical role of the standards in en-
suring military performance and execution of job responsibilities, asserting
that “we cannot be … relaxing standards because our civilian population
that we are recruiting from is coming in heavy.” He noted that while service
members’ health is a concern, in the military, “it is really about being able
to perform your job.”
RESILIENCE, READINESS, AND DEPLOYMENT
Bruce Jones, chief of the Injury Prevention Division at the U.S. Army
Public Health Center, discussed resilience, readiness, and deployment

through the lens of the complex interrelationships among BMI, percent
body fat, physical fitness, and injury risk.3
BMI, Physical Fitness, and Injury Risk Among Army Recruits
Jones began by reporting that among males and females in the Army’s
basic combat training, the risk of injury is slightly higher at both extremes
of the BMI quintiles and lowest in the average BMI group (middle quintile)
(Jones et al., 2017). He went on to cite a consistent finding since the 1980s
of the association for both men and women between decreasing aerobic
endurance (based on 2-mile run time) and increasing injury risk. Risk
increases steadily from the fastest to the slowest run times, he said, from
about 10 to 24 percent for men and from about 27 to 56 percent for women
(Jones et al., 2017). Taking BMI into consideration as well, he continued,
the highest risk of injury occurs among the leanest individuals with the
slowest run times, and “oddly enough,” the lowest risk is seen among those
with the highest BMIs who also run the fastest. Across all fitness levels, he
summarized, the highest injury risk occurs among those with the lowest
BMIs (Jones et al., 2017) (see Figure 2-6).
BMI, Physical Fitness, and Age of Soldiers in Operational Units
Next, Jones shared data on soldiers in operational units, where he said
age becomes a factor, as compared with basic training, where all trainees
are relatively young. Presenting data for men, he pointed out a progressive
increase in both BMI and 2-mile run time with age, adding that the data
also show a progressive increase in BMI with increasing 2-mile run times.
When age groups are stratified by BMI, he noted, the groups with the
highest risk for injuries are those with the highest BMIs in the older age
groups (25+ years) and those in the oldest age group (35+ years). When
run times are stratified by BMI, the groups with the highest injury risk are
those with the lowest and highest BMIs and the slowest run times (Rappole
et al., 2017).
Correlations of BMI and Height with Physical
Fitness and Military Performance
Moving on to BMI, height, physical fitness, and military performance,
Jones observed that as BMI increases, aerobic fitness (as measured by 2-mile
3 The views expressed in this presentation are those of the speaker and do not necessarily
reflect the official policy of DoD, the Department of the Army, the U.S. Army Medical Depart-
ment, or the United States.

FIGURE 2-6 Injury incidence by 2-mile run time and body mass index for women (top) and
men (bottom) in basic combat training.
SOURCES: Presented by Bruce Jones, May 7, 2018 (data from Jones et al., 2017). Reprinted
with permission.
Women
Men

run time) decreases for both men and women. On the other hand, increas-
ing BMI is associated with increasing upper-body muscle endurance for
men, and with increasing lower-body muscle endurance as well as increas-
ing upper- and lower-body strength for both men and women. He added,
however, that according to the data, overall combat fitness (as measured
by time to complete a warrior task and battle drill obstacle course with
a fighting load) does not change with increasing BMI for either men or
women. There are no apparent differences across levels of BMI, he contin-
ued, suggesting that completing the obstacle course requires a combination
of muscle strength, muscle endurance, and aerobic endurance. The picture
is a little different with height, he said, displaying data indicating that the
tallest men and women completed the obstacle course more quickly relative
to those of shorter stature. Height made a bigger difference for women, he
noted, with an improvement of several minutes for the tallest compared
with the shortest women, versus an improvement of about 1 minute for the
tallest men (Pierce et al., 2017).
Effects of Deployment on Body Composition and Physical Fitness
Jones then presented data on two groups of male soldiers, one on a
9-month deployment to Afghanistan and the other on a 13-month deploy-
ment to Iraq. In both cohorts, postdeployment body weight and BMI had
increased, and in the 13-month group, body fat was measured and had also
increased. Physical fitness had not changed in the 9-month group (Knapik
et al., 2008), but several other fitness measures indicating muscle strength
and power had increased in the 13-month group (Lester et al., 2010).
Closing Remarks
Jones closed by asserting that taken together, these findings suggest it
may be misleading to think that increased BMI is associated with decreased
military readiness, because soldiers with higher BMIs and higher fitness
have shown greater musculoskeletal resilience in terms of being less injury-
prone. Injuries are the leading cause of medical nonreadiness, he informed
the audience. “If the Army desires the most physically ready soldiers,” he
argued, “they may need standards that take into consideration both physi-
cal fitness and body composition simultaneously.”
FAMILIES AND COMMUNITIES
Obesity and overweight affect children and families throughout the
military community said Karen Hawkins, a registered dietitian in the Of-
fice of Military Family Readiness Policy. In the Military Health System, she

said, 13 percent of children aged 6 to 17 are overweight, and another 17
percent are at risk for becoming overweight (Bencio et al., 2004). Many
military children will wish to join the military once they grow up, she said,
and DoD is trying to address the finding that as many as 30 percent of
military children may not be eligible to do so because of weight.
Hawkins reported that a DoD Childhood Obesity Working Group ap-
pointed in 2012 had developed an educational campaign encouraging fami-
lies to lead healthy lifestyles. She described the 5-2-1-0 Healthy Military
Children Campaign, a partnership with the U.S. Department of Agriculture
(USDA) and universities. The numbers in the campaign’s title refer to rec-
ommended healthy food and beverage consumption, hours of screen time,
and physical activity: 5 or more daily servings of fruits and vegetables, no
more than 2 hours of daily screen time, at least 1 hour of daily physical
activity, and 0 sweetened beverages per day. While the concept may appear
simple, said Hawkins, data support its effectiveness throughout the popula-
tion and the public health community, both within and outside DoD. She
described the campaign materials, which include a website, a newsletter,
and toolkits for both civilian and military communities. The toolkits ex-
plain how to work with various facilities on a military installation, such as
the commissary and child development centers, to support the campaign.
She highlighted a recent example from April 2018 in which students on
military installations created artwork illustrating the 5-2-1-0 message and
how they use it in their daily lives.
Next, Hawkins touched on her work with the Military Family Learning
Network, which provides research and continuing education for military
family service providers and educators to enhance their professional growth
and impact. She works with the network’s Nutrition and Wellness concen-
tration area, determining the continuing education and resources needed
for dietitians and other service providers to address nutrition needs in the
military community successfully. The network develops and conducts about
10 educational webinars per year, she reported, with an average of 200–400
participants on a monthly basis.
Finally, Hawkins mentioned Military OneSource, a free resource avail-
able 24 hours per day, 7 days per week to connect service members and
their families with a wide range of individualized consultations, coaching,
and counseling for many aspects of military life. She highlighted in particu-
lar Military OneSource’s health and wellness coaching opportunity.
DISCUSSION
During a discussion period following the five presentations summarized
above, speakers addressed questions from the audience on topics including

fitness measures, recruitment quotas, risk of injury among women, and use
of the standards to maintain the appearance of military readiness.
Fitness Measures
Responding to a question on the practicality of measures to predict
fitness, performance, and injury, Jones emphasized that BMI is a very good
preliminary screening tool. However, he maintained, a combination of
both fitness and body composition is needed, given that high and low BMI
values are associated with different kinds of fitness. Friedl added that while
BMI could play a role, a good fitness test should perhaps be the ultimate
determinant of whether a person can do the job. He predicted that a new
approach to fitness may be on the horizon, with a different test that is more
job related. Jones concurred that fitness “may trump body composition if
you are looking for soldiers that can do their job.”
The discussion then shifted to fitness tests for high school students and
whether one standard could be used for that age group as well as in the
armed forces. Jones argued that the military’s tests should not only measure
military fitness but also encourage individuals to improve their own physi-
cal fitness, and should consist of simple, practical activities that can be done
in normal, everyday settings. “If we come up with a good test, it could be
something that high school kids could do too,” he suggested. Heaney added
that the test should assess how well a person is able to carry his or her body
weight to execute a job. Friedl mentioned that the Army has developed
basic tests with components that assess one’s capacity to perform different
jobs in the Army, which are in turn used to classify people for different
demands in various jobs.
Recruitment Quotas
Referring to Smith’s report that recruitment commands are meeting
their numbers, a participant asked whether there could be a point at which
a surge in recruitment needs would require recruiting unfit individuals.
Smith responded that specific numbers of recruitment needs have not been
calculated, but the situation should be reassessed every 3 years based on the
Defense Health Board’s 2013 report. In terms of how better to prepare so-
ciety to help the military meet a possible surge in recruitment needs, Friedl
mentioned a potential initiative in Switzerland to provide a fitness tracking
system to all prospective male recruits of high school age to provide guid-
ance during the year before they would enter basic training.
Citing the high percentage of age-eligible individuals who do not meet
military recruitment standards, another participant argued that the military
should advocate for society’s shared responsibility for raising awareness

of the importance of and cultivating a healthy population, starting during
pregnancy and infancy. Jones emphasized that the problem is a readiness
issue, which he said adds an incentive for the public to take more interest
in the health and physical fitness of young people.
Risk of Injury Among Women
A participant noted that Jones’s data indicate that regardless of BMI,
women’s risk of injury is almost three-fold higher than men’s. Jones re-
sponded that this is a consistent finding in basic training, where everyone
is doing the same thing on a daily basis. The relationship is not observed
in operational units, he continued, explaining that when one controls for
physical fitness in basic training, the relative risk “goes from 2.5 to 3 times
higher to almost 1 to 1 … maybe 1.2 or 1.3. Our suspicion is that it is
mostly related to physical fitness.” Asked about the nature of the injuries
observed in basic training, Jones responded that 70 to 80 percent are
lower-extremity injuries, due mostly to overuse. Friedl added that the first
women who complete rigorous training successfully are those who appear
to have higher bone density, which he said appears to protect against stress
fractures. Jones also noted that soldiers with the lowest BMIs are at the
highest risk for stress fractures, and that overweight individuals appear to
be protected against this type of injury.
Use of the Standards to Maintain the Appearance of Military Readiness
Participants briefly discussed how the perception of military members’
appearance can serve as a deterrent to conflict. If service members look
flabby and out of shape, said Friedl, it is “not much of a threat to anybody.”
Heaney added that in some services with a greater reliance on unmanned
vehicles, “the appearance factor is not quite what it was for the infantry of
old.” But even cyber warriors need daily physical activity for optimal brain
function, Friedl argued, and chronic diseases affect cognition and mental
health. Heaney agreed that appearance is still a relevant standard, but may
not be as important as it was in earlier times.

3
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 Re-
search 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.
• Analysis of a contemporary veteran population revealed in-
creased weight in male and female veterans regardless of dia-
betes status during 2000 to 2014, with an acceleration in the
magnitude of weight change from the oldest to the youngest
birth cohorts. (Margery Tamas)
• When faced with losing weight or losing one’s job, service
members sometimes resort to extreme, unproven, and/or po-
tentially risky methods. (Heidi Clark)
• Three underlying issues affect the health and performance read-
iness of the armed forces: (1) the lack of baseline knowledge
about personal fitness and nutrition among soldiers and of a
minimal nutrition education requirement in the military’s con-
tinuing education pathway, (2) a dynamic work environment
that often forces service members to adapt to new and different
23

food environments, and (3) challenges in appropriately sup-
porting service members’ genuine desires to be healthy. (Kayla
Ramotar)
• Eighty percent of military retirees become overweight or de-
velop obesity. (Kayla Ramotar)
• Obesity and overweight have had minimal impacts on the U.S.
Marine Corps as the result of evidence-based high standards
for body composition and physical fitness, as well as account-
ability. (Brian McGuire)
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 manage-
ment. 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 con-
tinued, 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

SERVICE-SPECIFIC ISSUES RELATED TO OBESITY AND OVERWEIGHT 25
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. Indi-
viduals with diabetes were heavier than those without, and to the research-
ers’ 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 longitudi-
nal 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 ef-
forts 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 re-
serve 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 detach-
ment, McCafferty continued, along with a unit command fitness leader who
helps maintain physical fitness programs and manage the semiannual Physi-
cal 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, fol-
lowed by monthly visits;
• Monthly mandatory Physical Readiness Test sessions, often incor-
porated 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 signifi-
cantly 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 person-
nel 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 in-
dividuals … 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, un-
proven, 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
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 po-
tentially 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 mili-
tary career, she lamented, includes only 1 hour of required nutrition educa-
tion. 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. De-
partment 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 dur-
ing 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 facili-
tate 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 serv-
ing 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 Fit-
ness System, a coordinated, system-wide approach to improving health and
performance readiness, will help address the three issues—limited nutri-
tional 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 strat-
egies for applying it throughout members’ military careers. According
to Ramotar, accomplishing this will require training personnel through-
out 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 account-
ability. 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 spe-
cialties 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) stan-
dards, 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 exemp-
tion 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 inter-
ventions, such as proper postworkout nutrition. Ramotar mentioned an up-
coming 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 readi-
ness. 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 sug-
gested 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 instruc-
tors 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 sug-
gested 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 suc-
cess, 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, implementa-
tion 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 be-
havior 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.

4
Exploring Innovative Strategies
The third session of the workshop included 10 speakers who presented
innovative strategies for addressing obesity and overweight in specific popu-
lations within the armed forces. Session moderator Anne Utech, acting
national director of nutrition and food services at the U.S. Department of
Veterans Affairs, explained the speakers had been instructed to describe
their program’s largest impact, contributors to its success, and outcomes
achieved, as well as future initiatives. Noting that speakers would not have
enough time to provide complete information about their programs, she
directed participants to a handout of abstracts for more details (see Ap-
pendix C).
• Support for service members in navigating the challenges of
military life requires a comprehensive approach to well-being
throughout their career—through a broad enterprise-level as-
sessment of readiness and policy at the level of the Office of
the Secretary of Defense. (CAPT. Andy Vu)
• The U.S. Army accounts for 64 percent of the total force, and
10 percent of the Army (or 100,000 soldiers) is nondeployable,
mainly because of medical conditions. (CAPT. Andy Vu)
• Joint nutrition initiatives provide support for food and nu-
trition needs across the military environment. The Military
Nutrition Environment Assessment Tool is used to evaluate
policies and environmental factors at the community level that
33

support healthy eating, and the Joint Services Buyer’s Guide,
currently in development, is intended to establish a subsistence
quality baseline for all food purchases across the services. Go
for Green® 2.0 uses stoplight color labeling, choice architec-
ture strategies, and performance-based marketing messages
to nudge patrons in military dining facilities toward healthier
choices. (Tammy Lindberg, Beth Moylan)
• A number of initiatives exist to address obesity and overweight
among service members and their families in the Army, Air
Force, Marine Corps, and Navy; their respective reserve and
guard components; and veterans. These initiatives highlight
current accomplishments and challenges, as well as opportuni-
ties for future success. (Anne Utech)
POLICY AND OFFICE OF SECRETARY OF DEFENSE STRATEGY
CAPT. Andy Vu, deputy director, Operation Live Well, opened the
session with a leadership perspective on policy, data, and strategic plan-
ning. Vu’s office supports the Office of the Under Secretary of Defense for
Personnel and Readiness in aligning policies and programs along the Total
Force Fitness Framework across the U.S. Department of Defense (DoD),
said Utech.
The Office of Joint Force Fitness is positioned for success, said Vu,
because in 2016 the portfolio of Operation Live Well migrated from the
Defense Health Agency, which focuses primarily on the clinical aspect of
readiness, to Personnel and Readiness, which focuses more broadly on the
readiness aspect of obesity and other disease and nonbattle injury condi-
tions. Furthermore, said Vu, the office is ideally situated to work collab-
oratively to influence policy, doctrine, materiel, personnel, and facilities
because of the broad, enterprise-level scope of its mission to assess readiness
issues for military service members.
Supporting military service members in navigating the challenges of
military life requires a comprehensive approach to well-being throughout a
service member’s career, Vu declared. He described this support as including
a holistic assessment of well-being and readiness based on a Total Force Fit-
ness Framework that encompasses eight domains of fitness—social, physi-
cal, environmental, medical and dental, nutritional, spiritual, psychological,
and behavioral—that together best portray the readiness level of military
service members across the deployment cycle (see Figure 4-1). A key chal-
lenge, Vu remarked, is that 64 percent of the total force is the U.S. Army,
10 percent of which (or 100,000 soldiers) is nondeployable, mainly because
of medical conditions.

EXPLORING INNOVATIVE STRATEGIES 35
According to Vu, his office is prototyping the development of a Readi-
ness Prediction Model (RPM), a machine learning model with the capability
to quantify individual readiness, predict and report the level of deploy-
ability DoD can achieve, 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.
Min Yi, lead data scientist for the initiative, explained that the initial
outcomes of this model indicate the Army programs that may help mitigate
the root causes of nondeployability or incomplete deployments. He gave the
example of Army Wellness Centers, which help service members stay fit and
mitigate musculoskeletal-related injuries, explaining that the RPM analysis
identified these types of injuries as a frequent medical point of failure for
service members who return home early from deployment. Moreover, he
added, the RPM was able to suggest that the use of wellness care appoint-
ments at Army Wellness Centers decreased deployment incompletion rates,
that is, the likelihood of premature return from deployment.
According to Yi, the Office of the Under Secretary of Defense for
Personnel and Readiness has also leveraged open public and other federal
datasets to understand readiness risk factors. He referenced an internal
assessment indicating that data from the Centers for Disease Control and
Prevention (CDC) on health-related quality of life were a good proxy for
individual readiness. A model was then built using 19 different community-
level readiness risk factors (including such obesity-related risk factors as the
food environment index, physical inactivity, and the prevalence of adult
FIGURE 4-1 Total force well-being: Enhancing individual readiness and resiliency.
SOURCES: Presented by CAPT. Andy Vu, May 7, 2018. U.S. Department of Defense (DoD).
Reprinted with permission.

Military Obesity 2018

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