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The Army Eating Environment: Current Nutritional and Behavioral Concerns Adrienne Hatch, MS, RD, CSSD MAJ Julianna Jayne, PhD, RDN, CHES

U.S. Army Research Institute of Environmental Medicine Military Nutrition Division

The opinions or assertions contained herein are the private views of the author(s) and are not to be construed as official or as reflecting the views of the Army or the Department of Defense.

UNCLASSIFIED

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Disclaimer

Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Army or the Department of Defense. Any citations of commercial

• rganizations and trade names in this report do not constitute an official

Department of the Army endorsement of approval of the products or services of these organizations

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Outline

• The Army as a population
• Dietary guidelines for military personnel
• Military feeding today and current challenges
• Body weight concerns
• Military‐specific eating behaviors
• Eating behavior research efforts and findings
• Conclusion

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Army Demographics

Race

White 69.7% 16.8%

Black or African American Data taken from the 2017 DoD Demographics Report 5

Army Demographics

45.7 37.6 39.3 16.7 60.7

10 20 30 40 50 60 70

Men Women Men Women Men Women Combat Arms Combat Support Combat Service Support

Occupational Specialty

% of Army Population

Data taken from Stanford Military Data Repository, 2011-2014 6

Soldiers Eat in Many Places

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Dietary Guidelines for Military Personnel

Nutrition Standards for Military Feeding to Support Human Performance Optimization

• Defines nutritional responsibilities of the Army, Navy,

Air force

• Includes recommended nutrient standards = Military

Dietary Reference Intakes (MDRI’s)

• Implements DoD menu standards
• Nutritional standards for rations
• Energy expenditure under various environmental

conditions (cold, hot, high altitude)

• Establishes basic nutrition education standards for

initial military training programs across Services

Army Regulation 40-25

Military Dietary Reference Intakes (MDRI’s)

• Energy Requirements Take

into Consideration:

– MDRI calculation – Body size – Physical activity – Environmental factors – Clothing and equipment – Terrain – Metabolic adjustments

• Nutrient requirements

listed include:

– Carbohydrate – Protein – Fat – Fiber – Iron

• Water, sodium, & CHO

electrolyte beverages

– Fluid requirements for various work intensities, temperatures, altitudes, clothing worn – Guidance on sodium requirements

Past US Military Field Feeding

• Group – special purpose

− Mountain & Jungle Rations − 10 in 1 & 5 in 1, Squad/Crew − Air Crew Lunch − Lifeboat WW2 – expanded catalog of 23 different combat rations R&D Innovations

• Packaging – shelf stability, safety
• Weight/Cube reduced
• Situationally specific rations
• Nutrient requirements as per 1941 RDAs
• Individual

− C Ration – 1 day (3 meals, ~ 3,800 Kcal/d) − D Ration – 600 Kcal survival bar − K Ration – 1 meal (~ 2,800 Kcal/d), compact, easy-to-carry, for paratroopers Ration, Type C Ration, Type K Ration, Type D

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Under‐consumption with Field Feeding: Recommendations vs Reality

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Committee on Military Nutrition Research

1995

• Eating behavior

− Consumer preferences, menu fatigue − Limited time & unappealing places to eat

• Food availability constraints

− Remote operations & austere logistics/resupply − Size & Weight limit amount of rations carried 1 MRE ~ 1 lb 3 MRE / day

• 3900 Kcal
• Carb: 507 g
• Protein: 137 g
• Fat: 147 g

6 days for 10 Soldiers

Expedient solution: field stripping MREs

Hard to Match Energy Intake to High Warfighter TDEEs

Tharion et al. Appetite 2005

3 MREs (3,900 kcal)

Warfighters in high-intensity combat operations unlikely to consume > 3 MRE/day

Military Dietary Reference Intake Standard Energy Allowance (3400 Kcal/d)

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Physiological Analysis of Marines During Mountain Warfare Training

Purpose: To better understand the physiological impact of Marines training in summer and winter mountain operations by measuring:

– Calorie expenditure and intake

• Doubly labeled water, combat ration intake logs, dietary recalls

– Body weight and muscle mass

• Bioelectrical impedance

– Anabolic hormones, inflammation, and nutrition-health status

• Blood draws

– Physical performance testing

• Beep test, sprint test, vertical jump

Data collected before (PRE), during (MID), after (POST) 30 day training in summer and winter

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Current Field Feeding Options

First Strike Ration ~2900 kcals/day Meal, Ready to Eat Unitized Group Ration‐ Express ~1300 kcals/meal ~1300 kcals/meal

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Current Field Feeding Options

Special Purpose Rations

Long Range Patrol MORE Pack Carbo Pack Cold Weather ~380 kcals/pack, 75 g CHO ~4620 kcals/day ~1540 kcals/day ~1050 kcals/pack

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Garrison feeding

• Approximately 74% of non-deployed military personnel consume at least 1

meal/day in military dining facilities (DFAC)1

• Labelling “healthy” entrees in an Army DFAC did not effectively increase sales
• f those items, but taste and food quality did2
• Soldier intake is less than ideal with low fruit, vegetable, nutrient-rich food

consumption in an ad lib environment1,3

• Modest menu enhancements in a DFAC intervention showed reductions in

energy intake, total fat, % energy from fat and saturated fat4

1Bray et al. 2008 DoD Survey of Health Related Behaviors Among Active Duty Military

Personnel; 2009

2Sproul et al. Military Medicine; 2003 3Smith et al. J. Acad Nutr Diet; 2013 4Crombie et al. J Acad Nutr Diet; 2013 5Tharion et al. Appetite 2005

Particular challenge in feeding Special Operations Forces that expended 140% energy expended by typical garrison soldiers5

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Influencing Nutritious Behaviors in the Garrison Environment

Cole et al., J Nutr Educ Behav; 2018 17

Implementing a Performance‐Based Menu Improved Diet Quality

Healthy Eating Index Score

Based upon energy density at 1000 kcal Higher Score is Better >80 pts = a good diet 51‐80 pts = needs improvement <50 pts = a poor diet National Average ranges from 48‐57 pts

Cole et al., J Nutr Educ Behav; 2018

* p = .002 pre- post intervention

• No change in the control DFAC
• ver time
• HEI score for intervention

DFAC ~3 points over time which was significant

• in whole fruits, total protein,

seafood and plant protein

• in total vegetables, dairy, fatty

acids 10 20 30 40 50 60 70 80 90 100

Control (0 ‐ 12 Mo) Intervention (0 Mo) Intervention (4‐12 Mo)

Points

49.1 56.7 60.1

U.S. adults

*

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Weight for Height Table

Army Regulation 600-9; 2013

Male weight in pounds, by age Female weight in pounds, by age

17-20 17-20 21-27 21-27 28-39 28-39 40+ 40+

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Army Weight & Body Composition Standards

Overall objective: To promote regular fitness and nutrition habits that ensure a physically capable force ready to deploy at any time1

1Friedl, J Strength and Cond Res; 2012

Age Category (y) Upper Limit BMI Relative Body Fat % Men <21 25.9 20 21‐27 26.5 22 28‐39 27.2 24 >40 27.5 26 Women <21 25.0 30 21‐27 25.3 32 28‐39 25.6 34 >40 26.0 36

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Compliance with Army Weight‐for‐Height Retention Guidelines

Health of the Force Report, U.S. Army Public Health Center, 2017.

% Classified as Overweight or Obese by BMI by Sex and Age

Overall, 17% of Soldiers were classified as obese and 52% were classified as overweight Obese Overweight

43.3 8.6 18.8 52.9

21 Health of the Force Report, U.S. Army Public Health Center, 2017.

Compliance with Army Weight‐for‐Height Retention Guidelines

% of Soldiers Who Exceeded the Authorized Weight for the Height and Age

47% of women and 50% of men do not meet the screening weight for height and age standards

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• Impact of military lifestyle on body weight

– Requirement to meet weight and fitness standards protects or prevents service members from excessive weight gain – Job‐related stress may result in negative impact on physiological and physical health (military personnel and dependents)

• Impact of overweight and obesity on military performance

– Decrements in physical performance – Increased absenteeism – Increased risk of chronic diseases – Cognitive decline – Increase health care costs – Threat to national security

Medical care for obese costs were $1,429 higher than those of normal weight

Impact of Obesity in Military Population

Ogden CL, et al 2014, Tanofsky-Kraff M, et al 2013, and, Barlas FM, et al 2013 23

Ineligibility of Military Applicants

• Approximately 9% of active duty enlisted applicants were

disqualified due to obesity (based on ICD‐9 code).1

• Approximately 16% of active duty enlisted applicants were

disqualified due to weight, body build (based on “other medical failure” codes from U.S. Military Entrance Processing Command). 1

• Existing recruitment and accessions standards are not posing

challenges to recruitment goals per each Service’s Recruit Commands.2

1Accession Medical Standards Analysis and Research Activity, 2015 Annual Report. Silver Spring, MD: Walter Reed Army Institute of

Research; 2015.

2Implications of Trends in Obesity and Overweight for the Department of Defense, Defense Health Board, Nov 22, 2013.

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Weight status of Army Enlistees

• Objectives: identify changes in weight status at Army

entry from 1989 to 2012, and the demographic characteristics associated with overweight/obesity.

• Prevalence of exceeding the screening table weights

increased with time (5.7% in 1989, 22% in 1992, high of 31% in 2006 and 2007, ~25% in 2012).

• Demographic predictors (2008‐2012):

– women less likely to exceed the guidelines compared to men – women 20‐29 or 30‐39 years more likely to exceed guidelines vs. <20 years

Hruby A, et al. Obesity; 2015.

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DoD Efforts

Research & Evaluation Holistic Health & Fitness

National Academy of Sciences, Proceedings of a Workshop in Brief; 2018 26

Why We Need Research

• DoD Health‐Related Behavior Survey (N=15,747)

Food Intake 1‐2 times/day ≥3 times/day Fruit 20% 7% Vegetables 26% 9% Whole grains 28% 11% Low‐fat dairy 28% 12% Snack food/sweets 23% 10% Fast food 14% 6% Soldiers who met Healthy People 2010 guidelines for food intake: 2.5%

Smith et al., JAND, 2013 27

Nutrition, Health, & Performance

• Food choice behaviors form the basis of

nutritional fitness

• Nutritional fitness influences body

composition, psychological status, and overall health

• Overall health is key to physical performance
• Soldiers must be ready to optimally perform

Purvis et al., AMEDD Journal, 2013.

Poor Nutrition Poor Performance

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Research Efforts

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Body Composition Program: Weight Cycling

Jayne et al., Preventive Medicine Reports, 2019.

Examples of weight cycling in Soldiers, N=7,208 men; 7,069 women

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Stressful life changes ‐ Marriage/divorce ‐ Relocation ‐ Birth/adoption of child ‐ Deployment ‐ Demotion/Promotion ‐ Develop a physical duty limitation

Stress Response

Physiological changes ‐HPA axis activity ‐Allostatic load ‐Neuro‐endocrine over activity ‐Immunosuppression

Stress: Nutrition‐Related Health Outcomes

Outcomes ‐ Blood pressure changes ‐ Hyperlipidemia dx ‐ Substantial weight gain ‐ Separation for failure to meet body comp standards RESULTS 3 mo. after marriage: women 68% higher odds of having substantial weight gain; men 23% 2 mo. after developing a physical duty limitation: women 83% higher

• dds of having a hyperlipidemia dx;

men 42%

Jayne et al., J of Primary Prevention (in review)

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Physiological Cues: Stress and Emotions

• 48% of male Soldiers report emotional eating sometimes or
• ften compared to 68% of female Soldiers (N=1,460,

p<0.001)

– BMI is significantly different depending on frequency of emotional eating behaviors (p<0.01). – Those who report emotional eating behaviors sometimes or often had BMIs that were 0.73 or 1.42 points higher, respectively.

Jayne et al., Manuscript in Preparation, 2019 32

Physiological Cues: Stress and Emotions

• Does emotional eating mediate the relationship between

perceived stress and BMI (N=1,460)?

• Perceived stress not associated with BMI unless an individual reported

emotional eating behaviors

• Higher stress scores associated with more frequent emotional eating

behaviors

• More frequent emotional eating behaviors associated with a higher BMI

Jayne et al., Manuscript in Preparation, 2019

Perceived Stress Score BMI Emotional Eating Behaviors

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Physiological Cues: Intuitive Eating

• Normal weight status in military service members was

associated with intuitive eating characteristic (N=295)

• More males ate for physical rather than emotional reasons

than female Soldiers (p = 0.014)

– Disparity between sex and intuitive eating characteristic

• Each 1‐point increase in Reliance on Internal Hunger Satiety

Score was associated with 34% lower odds of being

• verweight
• Increasing awareness of eating influences may

improve weight‐related dietary behaviors

Cole et al., Military Medicine, 2016

Eating Behaviors may be Influenced by the Army Environment

Soldiers who failed body composition standards (N=1,460) ‐ Eating mostly MREs: 2.23 times higher odds ‐ Eating at a fast rate: 2.65 times higher odds ‐ Ignored fullness cues: 1.90 times higher odds ‐ Eating most meals at a DFAC: 2.63 times lower odds Soldiers who failed physical fitness composition standards (N=1,460) ‐ Eating mostly at restaurants: 1.70 times higher odds ‐ Distracted while eating: 1.68 times higher odds ‐ Extreme hunger prior to meals: 1.55 times higher odds

34 Jayne et al., Abstract to be presented at ASN Conference, 2019 35

Nutrition Knowledge

• Army typically employs standard nutrition education strategies

– Those with a greater affiliation with a healthy eating identity may be more receptive to these strategies*

• “I am a healthy eater.”
• “I am someone who eats in a nutritious manner.”
• “I am someone who is careful about what I eat.”
• Does nutrition knowledge or affinity with a healthy eating

identity better predict “healthy” food choice behaviors? (n=575)**

• Skipping meals, eating out, and higher fruit and vegetable intake

*Blake, et al. Appetite, 2013; **Jayne et al. Military Medicine, 2018 36

Opportunities for Change

• A healthy eating identity was a better predictor of healthy food

choice behaviors

• Can we foster a healthy eating identity as part of the Soldier

identity?

– Army Strong – Soldier athlete initiative

• Basic Training is a highly formative period
• Transition from civilian to Soldier
• Drill Sergeants are highly influential
• n new Soldiers

Predictor Fruit and Veg Intake (B, p) Skipping Meals (B, p) Eating Out (B, p) Healthy Eating ID 0.29, <0.01 ‐0.31, <0.01 ‐0.14, <0.01 Nutrition Knowledge 0.07, 0.07 ‐0.12, <0.01 ‐0.08, 0.08

Jayne et al. Military Medicine, 2018

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Drill Sergeants as Key Influencers

• Drill Sergeants (DS) are instrumental in turning civilians into

Soldiers

• Qualitative study (N=30) on how DS view their role in the

nutrition behaviors of Soldiers

• Key Results:

– DS described their main duty as training new Soldiers – DS identified the ideal Soldier as lean and physically fit but did not identify training Soldiers how to eat to become the ideal Soldier as part of their duties – DS recognized that what Soldiers eat affects their physical performance and appearance – Did not see helping Soldiers establish healthy eating behaviors as their responsibility during basic combat training – Confusion about nutrition concepts was common

Jayne et al. JAND, 2018 38

Way Forward

• Changes to weight assessment frequency may be beneficial
• Tracking of stressors may proactively identify Soldiers who

need interventions

• Nutrition education programs needs to incorporate

mindfulness and building beneficial psychosocial determinants of food choice

• More specific nutrition guidance may be better
• Changes to initial training to emphasize role of nutrition in

short and long‐term physical and performance outcomes

• Need to instill healthy eating behaviors as a part of the Soldier

identity

• Changes to the eating environment need to be driven by

policy

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Conclusions/Questions

• The Army has come a long way

– Feeding approaches – Education/Health Promotion Strategies

• Still work to do

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Thank you

Adrienne Hatch, MS, RD, CSSD Adrienne.m.hatch.civ@mail.mil MAJ Julianna Jayne, PhD, RDN, CHES Julianna.m.jayne.mil@mail.mil