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Weight Management: State of the Science and

Opportunities for Military Programs
Subcommittee on Military Weight Management,
Committee on Military Nutrition Research
ISBN: 0-309-52681-7, 276 pages, 6 x 9, (2004)
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Weight Management: State of the Science and Opportunities for Military Programs
Weight Management
State of the Science and
Subcommittee on Military Weight Management

Food and Nutrition Board

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SUBCOMMITTEE ON MILITARY WEIGHT MANAGEMENT
RICHARD L. ATKINSON, JR. (chair), Obesity Institute, MedStar Research

Institute, Washington, D.C.
JOHN E. VANDERVEEN (vice-chair), San Antonio, Texas
WILLIAM H. DIETZ, Division of Nutrition and Physical Activity, Centers for
Disease Control and Prevention, Atlanta, Georgia
JOHN D. FERNSTROM, UPMC Health System Weight Management Center,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
ARTHUR FRANK, Weight Management Program, The George Washington
University, Washington, D.C.
BARBARA C. HANSEN, Obesity and Diabetes Research Center, University of
Maryland School of Medicine, Baltimore
STEVEN B. HEYMSFIELD, Human Body Composition Laboratory and
Weight Control Unit, St. Luke’s-Roosevelt Hospital, New York
ROBIN B. KANAREK, Graduate School of Arts and Sciences, Tufts Univer-
sity, Medford, Massachusetts.
BARBARA J. MOORE, Shape Up America!, Washington, D.C.
Staff
MARY I. POOS, Study Director
LESLIE J. VOGELSANG, Research Assistant (from October 2001)
HARLEEN K. SETHI, Senior Project Assistant (from February 2002)
TAZIMA A. DAVIS, Senior Project Assistant (through November 2001)

COMMITTEE ON MILITARY NUTRITION RESEARCH
JOHN E. VANDERVEEN (chair), San Antonio, Texas

BRUCE R. BISTRIAN, Department of Medicine, Harvard Medical School,
Boston, Massachusetts
JOHANNA T. DWYER, Frances Stern Nutrition Center, Tufts New England
Medical Center, Boston, Massachusetts
HELEN W. LANE, Johnson Space Center, National Aeronautics and Space
Administration, Houston, Texas
MELINDA M. MANORE, Department of Nutrition and Food Management,
Oregon State University, Corvallis
WILLIAM P. MORGAN, Sport Physiology Laboratory, University of Wis-
consin, Madison
PATRICK M. O’NEIL, Weight Management Center, Medical University of
South Carolina, Charleston
ESTHER M. STERNBERG, Neuroendocrine Immunology and Behavior
Section, National Institute of Mental Health, Bethesda, Maryland
BEVERLY J. TEPPER, Department of Food Science, Rutgers University,
New Brunswick, New Jersey
U.S. Army Grant Representative

LTC KARL E. FRIEDL, USA, Military Operational Medicine Research Pro-
gram, U.S. Army Medical Research and Materiel Command, Fort Detrick,
Frederick, Maryland
Staff
MARY I. POOS, Project Director
LESLIE J. VOGELSANG, Research Assistant
HARLEEN K. SETHI, Senior Project Assistant
vi

FOOD AND NUTRITION BOARD
CATHERINE E. WOTEKI (chair), College of Agriculture, Iowa State

University, Ames
ROBERT M. RUSSELL (vice chair), U.S. Department of Agriculture Jean
Mayer Human Nutrition Research Center on Aging, Tufts University,
Boston, Massachusetts
LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin
BENJAMIN CABALLERO, Center for Human Nutrition, Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland
SUSAN FERENC, SAF Risk, LC, Madison, Wisconsin
NANCY F. KREBS, Department of Pediatrics, University of Colorado Health
Sciences Center, Denver
SHIRIKI KUMANYIKA, Center for Clinical Epidemiology and Biostatistics,
University of Pennsylvania School of Medicine, Philadelphia
LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food
Research and Action Center, Washington, D.C.
PER PINSTRUP-ANDERSEN, Division of Nutritional Sciences, Cornell
University, Ithaca, New York
A. CATHERINE ROSS, Nutrition Department, The Pennsylvania State
University, University Park
BARBARA O. SCHNEEMAN, Department of Nutrition, University of
California at Davis
NICHOLAS J. SCHORK, Polymorphism Research Laboratory, University of
California, San Diego
JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin,
Madison
STEVE L. TAYLOR, Department of Food Science and Technology and Food
Processing Center, University of Nebraska, Lincoln
BARRY L. ZOUMAS, Department of Agricultural Economics and Rural
Sociology, The Pennsylvania State University, University Park
Staff
ALLISON A. YATES, Director
LINDA MEYERS, Deputy Director
GAIL SPEARS, Staff Editor
GERALDINE KENNEDO, Administrative Assistant
GARY WALKER, Financial Associate
vii

_____________________________
Reviewers
This report has been reviewed in draft form by individuals chosen for their
diverse perspectives and technical expertise, in accordance with procedures
approved by the NRC's Report Review Committee. The purpose of this
independent review is to provide candid and critical comments that will assist
the institution in making its published report as sound as possible and to ensure
that the report meets institutional standards for objectivity, evidence, and
responsiveness to the study charge. The review comments and draft manuscript
remain confidential to protect the integrity of the deliberative process. We wish
to thank the following individuals for their review of this report:
Catherine M. Angotti, Occupational Health, National Aeronautics and

Space Administration; George A. Brooks, Department of Integrative Biology,
University of California, Berkley; Anthony G. Comuzzie, Department of Genet-
ics, Southwest Foundation for Biomedical Research; James L. Early, Depart-
ment of Preventive Medicine, University of Kansas-Wichita; Esther F. Myers,
Scientific Affairs and Research, American Dietetic Association; Janet Rankin,
Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic In-
stitute and State University.
Although the reviewers listed above have provided many constructive

comments and suggestions, they were not asked to endorse the conclusions or
recommendations nor did they see the final draft of the report before its release.
The review of this report was overseen by Shiriki Kumanyika, Center for Clini-
cal Epidemiology and Biostatistics, University of Pennsylvania School of Medi-
cine. Appointed by the Institute of Medicine, she was responsible for making
certain that an independent examination of this report was carried out in accor-
dance with institutional procedures and that all review comments were carefully
considered. Responsibility for the final content of this report rests entirely with
the authoring subcommittee and the institution.
viii

_____________________________
Preface
This publication is the latest in a series of reports based on reviews of the

scientific literature and workshops sponsored by the Committee on Military
Nutrition Research (CMNR) of the Food and Nutrition Board (FNB), Institute of
Medicine, the National Academies. A subcommittee of CMNR, the Subcommit-
tee on Military Weight Management, was appointed to organize a workshop and
prepare a report based on information presented at a workshop, a review of the
scientific literature, and the subcommittee’s expertise and deliberations. Other
workshops or symposia conducted by CMNR have dealt with topics such as
food components to enhance performance; nutritional needs in hot, cold, and
high-altitude environments; body composition and physical performance;
nutrition and physical performance; cognitive testing methodology; fluid
replacement and heat stress; and antioxidants and oxidative stress. These
workshops form part of the response that CMNR provides to the Commander of
the U.S. Army Medical Research and Materiel Command (USAMRMC)
regarding issues brought to the committee through the Military Operational
Medicine Research Program at Fort Detrick, Maryland, and the Military Nutri-
tion Division of the U.S. Army Research Institute of Environmental Medicine at
Natick, Massachusetts.
HISTORY OF THE COMMITTEE

The CMNR was established in October 1982 following a request by the As-
sistant Surgeon General of the Army that the Board on Military Supplies of the
National Academy of Sciences set up a special committee to advise the U.S.
Department of Defense (DOD) on the need for and conduct of nutrition research
and related issues. This committee was transferred to the oversight of FNB in
1983. The committee’s primary tasks are to identify factors that may critically
influence the physical and mental performance of military personnel under all
environmental extremes; to identify knowledge gaps and recommend research
ix

x PREFACE
that would remedy these deficiencies; to recommend approaches for studying

the relationship of diet to physical and mental performance; and to review and
advise on military feeding standards.
As a standing committee of IOM, the membership of CMNR changes peri-
odically. However, the disciplines represented consistently have included human
nutrition, nutritional biochemistry, performance physiology, food science, die-
tetics, psychology, and clinical medicine. For issues that require broader exper-
tise than exists within the committee, CMNR has convened workshops, utilized
consultants, or appointed subcommittees with expertise in the desired area to
provide additional state-of-the art scientific knowledge and informed opinion to
aid in deliberations.
BACKGROUND
Following the release of the 1995 IOM report, Recommendations for
Research on the Health of Military Women, CMNR was asked to review
existing military policies governing body composition and fitness as part of the
Defense Women’s Health Research Program. In particular, the committee was
asked to determine if existing body composition and appearance standards for
women were in conflict with body composition requirements for task
performance, and whether those same standards might actually interfere with
readiness by encouraging chronic dieting, inadequate nutrient intake, or
dangerous eating practices. In March 1998, the CMNR Subcommittee on Body
Composition, Nutrition, and Health of Military Women released its report,
Assessing Readiness in Military Women: The Relationship to Body Composition,
Nutrition, and Health. This report made a number of key recommendations:
• Incorporate the use of body mass index and fitness assessment into the
current two-tiered body composition assessment procedures.
• Increase emphasis on fitness for readiness in military personnel.
• Develop and validate a single service-wide circumference equation for
the assessment of women’s body fat.
• Develop task-specific, gender-neutral strength and endurance tests and
standards for use in determining placements in military occupational specialties
requiring moderate and heavy lifting.
• Encourage military personnel to achieve and maintain healthy weights
through a continuous exercise and fitness program.
• Provide nutrition education and ongoing counseling if weight loss is a
goal.
Similar recommendations had been made in a 1992 CMNR report, Body

Composition and Physical Performance, which first suggested that a military
body composition standard should be based primarily on the ability to perform

PREFACE xi
required physical tasks and secondarily on long-term health implications, and

that all the services should develop job-related physical performance standards
for accession into military service.
THE COMMITTEE’S TASK

In July 1999, CMNR was requested to review existing data on (1) optimal
components of a weight-management program, (2) the role of age, gender, and
ethnicity in weight management, and (3) current DOD activities in weight
management; and to provide recommendations for military weight-management
programs. This request for a review of effective military and civilian weight-loss
and weight-management programs originated from the Director of Military
Operational Medicine Research at USAMRMC. Subsequently, a subgroup of
CMNR participated in a series of conference calls with USAMRMC and CMNR
staff to identify the key areas that should be reviewed and to solicit suggestions
for names of scientists who were active in the research fields of interest to serve
as workshop speakers or as members of the subcommittee.
The subcommittee was appointed in September 1999, and on October 24–
27, 1999, it convened a workshop in response to the request from the Army. The
purpose of this workshop was to gather a group of experts to:
• Share knowledge and experience in managing weight control within the

services,
• Gain relevant knowledge and experience from industry and academia,
• Develop a consensus toward a more standard DOD-wide approach to
weight management that utilizes state-of-the-art knowledge and practices,
• Examine current interventions and those under development, particu-
larly in the pharmaceutical industry, and
• Evaluate their appropriateness for military application or the need for
further research.
The subcommittee was charged to identify the most effective interventions

for weight loss and maintenance, particularly those most effective for the
nonobese overweight individuals found in the military setting. Specifically, the
subcommittee was asked to address the following questions:
1. What are the essential components of an effective weight/fat loss pro-

gram, and the most effective strategies to sustain weight loss?
2. How do age and gender influence success in weight-management pro-
grams? Should age be considered in weight/fat standards, and in weight-
management programs and interventions?
3. Which strategies would be most and least effective in a military set-
ting? Should military weight/fat loss programs involve direct participation inter-

xii PREFACE
ventions, or only monitoring and guidance? Should military programs be more

proactive in identifying and discouraging ineffective or dangerous weight-loss
practices? Is a warning or cautionary zone prior to enrollment into a weight-
control program an effective strategy? When should duty time be authorized for
participation in intervention strategies for weight/fat loss?
4. To what extent should weight-control programs/policies be standard-
ized across the services, versus tailored to the individual service, installation or
unit? What are the advantages and disadvantages of standardization? Is the pro-
vision of state-of-the-art techniques and knowledge a rationale for standardiza-
tion?
5. How can diet be effectively dealt with as a weight-management com-
ponent in the military setting? Should pharmacological treatment (anorexiants)
be considered for use in the military? In what cases? What factors bear on this
decision?
6. How should resistiveness for weight/fat control be dealt with?
7. What are the knowledge gaps in weight-management programs relative
to the military? What research is needed?
To accomplish this task, the subcommittee’s workshop brought together the

personnel responsible for both DOD-wide and service-specific weight-control
program policies; a representation of military weight-control program leaders
and innovators; and key military, academic, and industry researchers.
The subcommittee reviewed the workshop presentations and the relevant
scientific literature and developed a consensus statement on the optimal content
for a weight-control program that could be utilized across the services. In the
extensive interval since the workshop, the subcommittee has updated their
report, incorporating recent references and military data where they were
available. In November 2002, DOD released its revised Instruction 1308.3,
DOD Physical Fitness and Body Fat Program Procedures, and has made some
important changes, which the subcommittee applauds. These new guidelines are
noted throughout the report as appropriate.
ORGANIZATION OF THE REPORT

Chapter 1 of this report provides background information on the current
demographics of the U.S. population. It then describes the military’s interest in
body-weight and body-fat standards and the implications of these standards for
health, performance, fitness, and appearance. Weight standards and weight-
management programs currently provided by each of the services and issues of
concern related to these programs are described in Chapter 2. Chapter 3 briefly
reviews the factors that affect body weight, and Chapter 4 reviews the strategies
for weight management. Chapter 5 provides the subcommittee’s specific
responses to the military’s questions; Chapter 6 presents the subcommittee’s

PREFACE xiii
conclusions and recommendations and identifies research needs. The workshop

agenda and speaker abstracts are presented in Appendix A, and the biographical
sketches of the speakers and subcommittee members appear in Appendixes B
and C, respectively.
ACKNOWLEDGMENTS
It is my pleasure as chairman of the Subcommittee on Military Weight
Management to acknowledge the contributions of the FNB staff. Their
dedication in the planning and organization of the workshop and the editing of
this report made it possible for the subcommittee to respond to the Army’s
request. In particular, I wish to acknowledge the extensive efforts of Mary I.
Poos, the senior staff officer for CMNR. She worked diligently with the
subcommittee members in securing the expert panel of speakers and organizing
the program for the workshop into coherent sessions, and she contributed
substantially to the writing and final updating of the report in response to
review. I also wish to acknowledge Ms. Leslie Vogelsang, research assistant to
CMNR, for her diligence in checking references and finding missing references;
and Ms. Harleen Sethi and Ms. Tazima Davis, senior project assistants to
CMNR, and Ms. Gail Spears, staff editor to FNB, for their work in preparing the
report drafts and final manuscript.
I wish to commend the workshop speakers for their excellent contributions
to the workshop: their abstracts, participation in discussions, and their
willingness to take time from very busy schedules to prepare and deliver
outstanding presentations made it possible for the subcommittee to conduct a
review of the topic area and prepare this report. Their thoughtful responses to
questions posed by subcommittee members and workshop participants also
contributed immeasurably to the quality of the review. It would be neglectful not
to mention the many experts who attended this open meeting at their own
initiative and expense. Their questions and comments contributed in no small
measure to broadening the exchange of scientific information.
I express my deepest appreciation to the members of the subcommittee who
participated extensively during the workshop and in discussions and preparation
of the summary and recommendations in this report.
RICHARD L. ATKINSON, Chair



_____________________________
Contents
EXECUTIVE SUMMARY ..................................................................................1
1 BACKGROUND AND CONTEXT OF THE OVERWEIGHT

PROBLEM…………...............................................................................17
The Current National Situation, 17
Uniqueness of the Military Environment, 20
Previous Recommendations on Body Fat and Fitness, 25
The Current Task, 26
Summary, 28
2 MILITARY STANDARDS FOR FITNESS, WEIGHT, AND

BODY COMPOSITION ..........................................................................29
Introduction, 29
Fitness versus Fatness, 30
Weight Standards for Accession and Retention, 32
The Impact of Weight and Body-Fat Standards, 38
Meeting the Weight and Body-Fat Standards, 41
Weight-Management Programs, 43
Summary, 55
3 FACTORS THAT INFLUENCE BODY WEIGHT ................................57

Developmental Determinants, 57
Genetic Determinants, 60
Age, 63
Race/Ethnicity, 65
Physical Activity, 67
Food, 69
Physiological Factors, 74
Environmental Factors, 75
Social Factors, 76
Summary, 78
xv

xvi CONTENTS
4 WEIGHT-LOSS AND MAINTENANCE STRATEGIES……………….79

Introduction, 79
Physical Activity, 80
Behavior and Lifestyle Modification, 82
Diet, 86
Support Systems, 93
Prescription and Over-the-Counter Drugs and Supplements, 96
Future Drugs for the Treatment of Obesity, 103
Surgery, 106
The Use of Structured Maintenance Programs, 107
Public Policy Measures, 110
Summary, 111
5 RESPONSE TO THE MILITARY’S QUESTIONS..............................113

Question 1, 113
Question 2, 117
Question 3, 118
Question 4, 121
Question 5, 123
Question 6, 124
Question 7, 124
6 PROGRAMMATIC AND RESEARCH

RECOMMENDATIONS… ...................................................................125
Prevention, 125
Assessment, 130
Treatment, 133
Program Evaluation, 138
Training, 138
Research Recommendations, 139
Other Areas for Research, 140
REFERENCES…………………………………………………………..…....143
APPENDIXES
A Workshop Agenda and Abstracts, 179

B Biographical Sketches of the Workshop Speakers, 241
C Biographical Sketches of the Subcommittee on Military Weight Man-
agement, 249
D Acronyms, 255

Weight Management
State of the Science and


_____________________________
Executive Summary
The primary purpose of fitness and body composition standards in the

military has always been to select individuals best suited to the physical
demands of military service based on the assumption that proper body weight
supports good health, physical readiness, and appropriate military appearance.
Prior to the Korean Conflict, these standards were used primarily to exclude
underweight candidates. Advances in health care and improved nutrition over
the past 75 years have resulted in increases in mean height, weight, and fat-free
mass of soldiers, and in the U.S. population as a whole. However, increases in
food consumption and decreases in daily activity have raised new concerns
about the impact of overnutrition and fatness on overall health, physical fitness,
and military performance.
BACKGROUND AND CHARGE TO THE COMMITTEE

Considerable attention has been given to the alarming rise in the incidence
of overweight and obesity in the U.S. population. The most recent national data
(1999–2000 National Health and Nutrition Examination Survey) show the
prevalence of overweight and obesity (defined as a body mass index [BMI] of ≥
25 for overweight and ≥ 30 for obesity) in adults 20 years of age and older is
64.5 percent overweight and, of these, 30.5 percent are obese. Furthermore, the
prevalence of overweight in adolescents (ages 12–19 years) is 15.5 percent.
The epidemic of overweight and obesity affects the military services of the
United States in several ways. For example, it decreases the pool of individuals
eligible for recruitment into military services, and it decreases the retention of
new recruits. Almost 80 percent of recruits who exceed the military accession
weight-for-height standards at entry leave the military before they complete their
first term of enlistment. This in turn increases the cost of recruitment and
training. These issues threaten the long-term welfare and readiness of U.S.
military forces.

2 WEIGHT MANAGEMENT
To aid in developing strategies for the prevention and remediation of

overweight in military personnel, the U.S. Army Medical Research and Materiel
Command (USAMRMC), through its director of Military Operational Medicine
Research Programs, requested the Committee on Military Nutrition Research
(CMNR) to review existing data on: optimal components of a weight-manage-
ment program; the role of age, gender, and ethnicity in weight management; and
current Department of Defense (DOD) activities in weight management in order
to provide recommendations for military weight-management programs. In
response to this request, the Subcommittee on Military Weight Management was
appointed in September 1999.
for weight loss and weight maintenance, particularly those most pertinent to the
nonobese overweight individuals (BMI 25.0–29.9) found in the military setting,
to evaluate the interventions’ appropriateness for military application or the need
for further research, and to develop a consensus toward a more standard DOD-
wide approach to weight management that utilizes state-of-the-art knowledge
and practices. Specifically, the military requested guidance on the appropriate
degree of standardization of programs across the services, whether specific aids
for weight loss (e.g., drugs) should be considered, how dietary changes would
impact successful weight loss, and whether resistiveness to weight loss and
maintenance are genetically controlled to the extent that individuals with genetic
predispositions for obesity should be identified and automatically excluded.
METHODS
As part of the response to the military request, the subcommittee convened
a workshop to bring together a group of experts to share knowledge and
experience in managing weight-control programs within the services, to gain
relevant knowledge and experience from industry and academia, to examine
current interventions and those under development (particularly in the pharma-
ceutical industry) for their appropriateness for military application, and to
identify needs for further research. In addition, the subcommittee performed an
extensive review of the scientific literature for data on optimal components of a
weight-management program; the role of age, gender, and ethnicity in weight
management; and current DOD activities in this arena. From this review,
recommendations were developed on the optimal components of a weight-
management program that could be utilized across the services.
CURRENT MILITARY WEIGHT STANDARDS AND

WEIGHT-MANAGEMENT PROGRAMS
There are significant demographic differences between the military popula-
tion and the general U.S. population. The general population is almost evenly

EXECUTIVE SUMMARY 3
split with respect to gender (49.1 percent men and 50.9 percent women), while
the military population is approximately 85 percent men and 15 percent women.
There are also significant age differences in the two populations. Approximately
31.5 percent of the U.S. population is between the ages of 18 and 40 years,
while approximately 80 percent of the military population is in this age range.
The military also has a higher percentage of ethnic minorities than the general
population, especially among women.
The weight-for-height and body-fat standards of the military services were
predicated on the need for the highest level of physical performance in adverse
environments, to maintain a high level of readiness at all times, and to present a
trim military appearance (e.g., the image that the individual may convey of the
military). These standards theoretically take precedence even when individuals
demonstrate an ability to perform their assigned tasks in an exceptional manner.
Typically, the various branches of the military service have had two sets of
weight/fat standards: one set to be met by potential recruits for accession into
initial entry training and another equivalent or more stringent set to be retained
in the service once admitted. The initial body composition screen consists of a
weight-for-height assessment. Historically, maximum allowable weight-for-
height tables are used.
When only two anthropometric measurements are used to estimate body
composition, height and weight have the highest level of association with the
percentage of body fat. Height and weight can also be used to compute BMI, a
widely accepted index that correlates with percent body fat. A substantial body
of evidence shows that BMI is positively associated with both morbidity and
mortality. Each of the services screens active duty personnel at least annually or
semiannually for fitness and compliance with weight-for-height standards.
Typically, the maximum allowable weights-for-height varied across ser-
vices for individuals of the same height, age, and gender, and individual service
standards were uniformly more stringent than the DOD recommendations. The
disparity in maximum BMI between men and women was marked. For example,
prior to 2002, the maximum allowable retention weight-for-height for women in
any service corresponded to a BMI of 25.1 (Army), for men it corresponded to a
BMI of 28.2 (Air Force).
The military uses circumference measurements to estimate body composition.
Until the early 1990s, each service employed its own set of measurement
equations for estimating body composition. More recently, a single equation for
use across all the services has been mandated by DOD. In November 2002, DOD
reissued its reference document on implementation policy and procedures for
physical fitness and weight/body-fat standards. This policy mandates that the
weight-for-height tables for all the service branches will be based on BMI, and that
no service may have a standard more stringent than a BMI of 25 or more liberal
than a BMI of 27.5. In addition, all branches of the service must use a single,
validated equation based on abdominal and neck circumference and height for men;

4 WEIGHT MANAGEMENT
and one based on abdominal, neck, and hip circumference and height for women to
estimate percent body fat. Body-fat standards for men shall not be more stringent
than 18 percent and not more liberal than 26 percent. For women, the fat standards
shall not be more stringent than 26 percent and not more liberal than 36 percent.
Individuals who exceed these limits must be referred to a weight-management
program
A review of the weight-loss programs across the military services highlighted
significant deficits that could affect success. All of the programs have a strong
motivating component that is highly disciplinary in nature, and the penalties for
exceeding the body-fat limits are significant. With exception of those in the Air
Force program, the majority of participants receive only minimal counseling by a
qualified dietitian. The same appears to be true throughout the services in the area
of behavior modification. With the exception of the Air Force and some specific
sites in the other services, data collection for program evaluation is lacking.
FACTORS THAT INFLUENCE BODY WEIGHT

Maintaining a healthy body weight is an extremely complex issue. Main-
tenance of fitness and appropriate body-fat standards by military personnel is
affected by each individual’s genetics, developmental history, physiology, age,
physical activity level, diet, environment, and social background. Some of these
factors are biologically programmed (e.g., physiology, genetic makeup, age).
Other factors can be manipulated by the individual (e.g., physical activity level,
diet), while still other factors may require institutional, systemic, or environ-
mental changes (e.g., worksite and community design, availability of facilities).
Genetics
Individuals appear to show significant heterogeneity in their body weight
and body fatness responses to altered energy balance, dietary components, and
changing activity levels, although little is yet known about the specific causes of
heterogeneity.
There is a group of at least 20 Mendelian syndromes in which obesity is a
component; these genetic disorders are rare, however, and family studies do not
suggest that the genes responsible for these syndromes are involved in the
common forms of human obesity. For more than 99 percent of obese individ-
uals, the genetic basis of their obesity is unknown, and genetics may or may not
be a causal factor.
The strongest evidence for genetic weight-regulating mechanisms is the
recent elucidation of single gene defects that are associated with excessive
weight gain in animals. Of the five gene products identified to date as being
associated with weight regulation, leptin is the best characterized. Genetic
defects in leptin have been associated with extreme obesity in humans. Although

EXECUTIVE SUMMARY 5
extensive efforts have been made to identify mutations in the genes identified as
obesity-associated in rodents and in humans, only a handful of individuals have
been identified with mutations in any of the genes that have produced obesity in
rodents.
Physiology
A number of phenotypic characteristics have been associated with risk of
weight gain, notably alterations in nonvolitional components of energy expendi-
ture. Energy expenditure can be divided into three main components: resting
metabolic rate (RMR), the energy expended at rest, under thermoneutral
conditions, and in a postabsorptive state; thermic effect of feeding, the
incremental increase in energy expenditure after a meal is consumed, associated
with absorption and transport of nutrients and the synthesis, storage, and
breakdown of protein, fat, and carbohydrate; and the energy expended for
physical activity, primarily voluntary movement, but also including the
involuntary movements associated with shivering, fidgeting, and postural
control. The RMR accounts for 60 to 75 percent of total energy expended in
most adults. A number of studies have been performed to evaluate the effect of
exercise, particularly resistance training, on RMR. Results have been inconsis-
tent, and thus whether exercise training increases RMR remains controversial.
Age
Many weight-management experts agree that body weight becomes pro-
gressively more difficult to maintain with age. Some research has indicated that
body weight and associated circumferences increase with advancing age unless
food intake is significantly reduced or physical activity is substantially
increased. However, health risk associated with BMI remains unchanged in
older individuals. Thus, there appears to be little rationale for increasing the
upper BMI range consistent with good health as individuals become older.
A large number of cross-sectional studies, however, do demonstrate that
body fat increases with age. In contrast to body fat, skeletal muscle mass
declines with age beginning around the third decade, and losses of skeletal
muscle parallel decreases in bone mass. The mechanisms of body composition
changes that accompany aging are multifactorial and include physical inactivity,
diet, and hormonal alterations. This loss of lean mass and the gain in fat mass
occur even with no apparent change in body weight. Since lean mass contributes
the larger share of metabolic activity, total energy expenditure decreases pro-
portionally with loss of lean mass.

6 WEIGHT MANAGEMENT
Physical Activity
The rapid rise in the prevalence of overweight and obesity in the last 20
years likely reflects major environmental shifts in eating habits and exercise,
both of which can be controlled. Some of these shifts include changes in the
food supply, food availability, food composition, palatability, and affordability,
as well as numerous technological advances that have removed the need for
physical labor or physical movement (e.g., elevators, escalators, riding lawn
mowers, remote controls for televisions and stereos). Physical activity represents
an important component of volitional energy expenditure. Reductions in physi-
cal activity over the past several decades have likely contributed to the evolution
of positive energy balance and the weight gain characteristic of all industrialized
societies.
Exercise, especially in bouts of 30 minutes of activity or more, can promote
fat oxidation because the substrate that is preferentially oxidized by muscle
tissue switches from carbohydrate to fat. Thus, chronic extended bouts of
exercise may, in effect, substitute for expansion of the adipose tissue, allowing
the physically active individual to achieve fat balance while maintaining a lower
body-fat mass than the sedentary individual.
Food Intake
A high energy intake (i.e., energy intake in excess of energy expenditure) or
an energy intake that is not adjusted downward with age and declining physical
activity is associated with the development of overweight or obesity in suscep-
tible individuals. In addition to total energy intake, the character of the diet may
play a role in the etiology of obesity, with high-fat diets potentially promoting
increased body weight.
Social and Environmental Factors

Other factors that contribute to overweight both in the military and in civil-
ian populations include meal patterns and eating habits, familial and ethnic fac-
tors, cultural norms, socioeconomic status, smoking, alcohol consumption, use
of certain common drugs such as anti-allergens, and the use of antidepressants,
hypoglycemic agents, and certain antihypertensive agents. Members of the mili-
tary population with unusually sedentary job responsibilities and a work envi-
ronment that promotes a combination of high-pressured, hasty, and thoughtless
overeating along with inactivity are likely to be particularly at risk for weight
gain. Thus, the social and environmental context of the overweight individual
needs to be carefully evaluated.

EXECUTIVE SUMMARY 7
RECOMMENDATIONS
After careful review of the information presented at the workshop and the
scientific literature, the subcommittee makes the following specific recommen-
dations.
Prevention
• Each service should provide training on diet and health, including the
fundamentals of energy balance, the caloric content of common foods, portion
sizes, and the importance of maintaining high levels of daily activity after inten-
sive training periods (e.g., initial entry training) to prevent weight gain.
• An education program on maintaining healthy weight should also in-
clude components directed at military spouses and family.
• Programs to reinforce the concept of exercise and activity as part of the
military lifestyle should be developed, along with programs to encourage the
reduction of alcohol consumption.
• Particular emphasis should be placed on providing or upgrading physi-
cal fitness facilities and equipment that encourage exercise.
• The use of rewards for exercise achievement should be reinforced.
• The services should make the incorporation of “heart-healthy” menus a
standard for base dining facilities, with continued emphasis on training all mili-
tary cooks in low-fat cooking techniques.
• Priority consideration should be given to commercial eating establish-
ments that routinely offer reasonable portion sizes and low-fat dining options
when these establishments are competing for base contracts.
Assessment
• Assessments for weight-for-height and percent body fat should be con-
ducted quarterly rather than annually or semi-annually. More frequent assess-
ments should be evaluated to determine if they reduce disordered eating and
other risky behaviors.
• Individuals at risk of increased weight or body-fat gain should be iden-
tified at the time of accession (e.g., those entering service over the standard,
those with a family history of obesity) and their evaluations monitored so that
interventions may be instituted as soon as adverse changes are identified.
• The incidence of disordered eating behaviors needs to be documented
and addressed across all branches of the military.

8 WEIGHT MANAGEMENT
Weight-Loss Programs
• A weight-loss diet should be energy deficient by 350 to 1,000 kcal/day;
should provide a minimum daily intake of at least 800 kcal/day; should provide
a minimum of 60 g of protein/day for women and 75 g of protein/day for men;
should provide no more than 30 percent of total energy as calories from fat; and
should have a carbohydrate content of no less than 130 g/day (excessively low
carbohydrate intake can cause dehydration and impact both physical and cogni-
tive function). The daily use of a multivitamin-mineral supplement may be
included.
• A combination of aerobic and strength training exercise, along with in-
creased activities of daily living, is recommended. Energy expended in physical
activity should be at a minimum of 2,000 kcal/wk, which amounts to 200 to 300
min/wk of moderate-intensity exercise (3.5–5 hr). In keeping with other recent
recommendations, 60 min/day of moderate-intensity activity in addition to ac-
tivities of daily living is suggested.
• Training and support in behavior modification should include stimulus
control, relapse prevention, self-monitoring, cognitive restructuring, and men-
toring.
• Follow-up should include regular contact with weight-management
counselors; routine self-monitoring of diet, weight, and physical activity; and
ongoing psychological support that could be provided via the Internet or by tele-
phone.
• Training programs should be established for all personnel associated
with implementing weight-control programs. Training standards for a weight-
management military occupational specialty should include training in principles
of nutrition, portion control, physical activity/exercise, behavior modification,
psychological support, and the use of weight-loss aids. The program should also
include mandated continuing education requirements.
Research
• Internet-based programs should be developed using models already in
use by the military. Emphasis should be given to the development of a number
of options, testing their effectiveness overall, and identifying those with high
response rates. Also, the range of individual responses of military personnel
should be evaluated since there may be subpopulations that respond well to a
given intervention when overall response is not consistent.
• An evaluation of military weight-management programs is essential to
determine their effectiveness. This evaluation would require following personnel
who have completed the program for 2 to 5 years, and perhaps throughout their
military career. Recommendations provided in this report are based almost ex-

EXECUTIVE SUMMARY 9
clusively on data collected in civilian populations, and effectiveness may be

quite different in military populations.
• Many nonprescription preparations are undoubtedly being used in the
military for weight loss. Very little is known about their effects on body weight,
body composition, overall health, and physical performance. It is particularly
important to assess the use of such preparations as well as their effects on mili-
tary performance.
RESPONSE TO THE MILITARY’S QUESTIONS

What are the essential components of an effective weight/fat loss program,
and the most effective strategies for sustaining weight loss?
Years of research have demonstrated that a program for weight/fat loss can
only be effective when it is closely integrated with a program for sustaining
weight loss.
Essential Components of an Effective Weight/Fat Loss

Program
• Exercise. For overweight adults who are otherwise healthy, increased
physical activity is an essential component of a comprehensive weight-reduction
strategy.
• Behavior modification. The use of behavior and lifestyle modification
in weight management is based on a body of evidence that people become or
remain overweight as the result of modifiable habits or behaviors and that by
changing these behaviors, weight can be lost and weight loss can be maintained.
• Net dietary energy deficit. Energy expended must exceed energy
consumed on a consistent basis over an extended period of time, the length of
which depends on the degree of overweight.
• Education. Information on nutrition principles, food portion control,
and the need for energy balance is essential for individuals to develop
appropriate eating behaviors.
• Psychological support and counseling. Any weight-management
program is likely to be more successful if it is accompanied by structured
support mechanisms (e.g., from professional counselors, commanders,
coworkers, family).
• Environmental changes. Restructuring the individual’s environment to
remove factors that promote overeating and underactivity is also a significant
part of weight loss and management. The environment includes the home, the
workplace, and the community.
• Structured monitoring. The long-term success of weight management
appears to depend on a specific and deliberate follow-up program. This struc-

10 WEIGHT MANAGEMENT
tured follow-up should include monitoring body weight with regular weigh-ins
at least weekly during the weight-loss phase and monthly during the mainte-
nance phase.
Sustaining Weight Loss

An integrated program that combines the weight-loss procedures described
above with weight-maintenance strategies is essential to achieve the best long-
term benefits. The use of maintenance strategies with the strong incentive that is
provided by the military regulations on weight control should enhance the
chances for successful weight maintenance.
• Physical activity. An expenditure of at least 2,000 to 3,000 kcal/wk

from exercise is essential.
• Permanent lifestyle and behavior modifications. Balancing customary
daily energy intake with appropriate habitual levels of physical activity is also
necessary. This includes portion control, selecting foods lower in fat and
calories, and consistently sustaining higher levels of daily physical activity.
• Self-monitoring. Individuals need to record their body weight a
minimum of once weekly. They also need to periodically keep a 3-day food
diary (about every 3 months) and a physical activity diary or use an activity
monitor (e.g., a pedometer) to help maintain weight loss.
• Continuous structured support. It is also necessary to have follow-up
visits or counseling via phone or the Internet every 2 to 4 weeks for the first 3
months and every 1 to 2 months thereafter, depending on the difficulty in
maintaining a stable, healthy weight.
How do age and gender influence success in weight-management programs?

Should age be considered in weight/fat standards and in weight-management
programs and interventions?
Age
Although weight gain with age is a frequent occurrence, it is not inevitable.
Increases in weight with age can be avoided if energy intake is adjusted to
compensate for decreases in activity and the loss of lean body mass, or if
physical activity is increased (including strength or resistance exercises) to
maintain lean body mass. For the benefit of long-term health, there should not
be age-related increases in weight-for-height standards.
Research indicates that percent body fat increases with age even if weight
does not change. The current upper limits of DOD standards of 26 percent fat in
men and 36 percent fat in women, however, is well within the limits of the

EXECUTIVE SUMMARY 11
healthy percent body fat range even for those 60 to 79 years of age. While
individual services have upper limits of percent body fat that are uniformly more
stringent than the DOD maximum, increases in percent body fat with age are
appropriate.
Gender
On average, women have a higher percent body fat than men. Weight gain
and lifestyle changes during the childbearing and childrearing years, as well as
the hormonal and metabolic changes that accompany pregnancy and menopause,
are associated with higher body fat. Thus, the gender-specific fat standards are
appropriate.
Which strategies would be most and least effective in a military setting?

Should military weight/fat loss programs involve direct participation inter-
vention, or only monitoring and guidance? Should military programs be more
practices? Is a warning or cautionary zone prior to enrollment in a weight-
control program an effective strategy? When should duty time be authorized
for participation in intervention strategies for weight/fat loss?
The Most and Least Effective Strategies of a Weight/Fat

Loss Program in a Military Setting
The effective strategies for a weight/fat loss program would be the same re-
gardless of whether the setting is military or civilian. However, the implementa-
tion of some of these strategies could be facilitated in the military environment,
particularly physical fitness, exercise, and behavior modification.
The primary difficulty in the military setting would be in providing
structured follow-up due to the mobility of the military population. Other diffi-
culties include remoteness or isolation of some work locations, the paucity of
low-fat food selections in vending machines and dining facilities, the availability
and affordability of foods with low energy density (e.g., fruits and vegetables,
low-fat or nonfat milk), and high-pressure environments with short meal breaks
that may promote inappropriate dietary patterns.
Direct Participation Interventions versus Monitoring and

Guidance
Direct participation interventions have been demonstrated to improve com-
pliance, increase the success rate of weight/fat loss, and support an improved
level of weight maintenance.

Identifying and Discouraging Ineffective or Dangerous

Weight-Loss Practices
Military weight programs should collect information on weight-loss practices
of overweight individuals as a component of their medical evaluation. Military
individuals found to be using ineffective or dangerous weight-loss practices such as
extensive fasting, purging, the use of diuretics, and the use of commercially
available herbal supplements and diet pills, should be counseled on the risks of
these practices and strongly encouraged to adopt standard weight-loss practices.
One method to reduce the incidence of dangerous practices is more frequent weigh-
ins and emphasis on appropriate diet and physical activity patterns at all times as
part of a military lifestyle.
Is a Warning or Cautionary Zone Prior to Enrollment into

a Weight-Control Program an Effective Strategy?
The warning zone that is now in effect for the Air Force program (3
months) appears to be an excellent strategy. It gives individuals a chance to
manage their overweight/body-fat problem by themselves in a timely manner
without assignment to a weight control program, with its accompanying career
implications.
Authorizing Duty Time for Participation in Intervention

Programs for Weight/Fat Loss
Any medical examination and tests that are appropriate before being
assigned to a program for weight/body-fat loss, as well as counseling and
monitoring, should be accomplished during duty time. A weight-loss program
should be viewed as treatment for a medical condition and be given comparable
priority as treatment for other medical conditions.
Since current DOD policy dictates regular exercise as a part of duty time,
unit commanders should provide (or require) time for regular exercise to ensure
a high level of fitness and readiness.
To what extent should weight-control programs/policies be standardized

across the services versus tailored to the individual service, installation or
unit? What are the advantages and disadvantages of standardization? Is the
provision of state-of-the-art techniques and knowledge a rationale for stan-
dardization?

Extent of Standardization Across the Services versus

Tailored to an Individual Service
The specifics of implementation of weight-control programs and policies
may need to be tailored for each service due to the different environments in
which the programs will be carried out (e.g., aboard ships, on CONUS military
bases, or on overseas bases). However, they could be standardized across the
services to a significant extent as indicated below. A limited number of military
health centers should be identified to provide scientifically validated body
composition evaluations.
• Standard methodology. New technologies for measuring body compo-

sition should be adopted service-wide as they become available, once they are
validated for accuracy and ease of use.
• Appearance standard. A waist circumference standard of no more than
40 inches for men and 35 inches for women should be used as an objective
measure for appearance standards as these standards are known to be related to
long-term health.
• Weight-management counselors. Those responsible for weight-control
programs should be certified and their training should be standardized.
• Internet-based weight-management programs. A standardized program
across all services would be more efficient and could be easily accessed by
military personnel regardless of their duty assignment.
The advantages of standardization of weight-control programs and policies

are that all military personnel would have access to equivalent weight-manage-
ment assistance and that the incorporation of new technologies for body
composition assessment and the adoption of Internet-based services would be
facilitated. In addition, the costs of producing education materials (e.g., portion
size models, brochures) would be reduced. The disadvantage of standardization
is that it might limit innovation within the branches of the armed forces. There is
no scientific disadvantage.
Is the Provision of State-of-the-Art Techniques and

Knowledge a Rationale for Standardization?
Standardization of weight-control program components would facilitate the
incorporation of new technologies and provide a stronger base for program
evaluation, which would in turn protect DOD investments in each individual. To
date, none of the existing military weight-control programs have been
sufficiently evaluated to justify adoption DOD-wide.

How can diet be effectively dealt with as a weight-management component in

the military setting? Should pharmacological treatment (anorexiants) be
considered for use in the military? In what cases? What factors bear on this
decision?
Diet counseling needs to be administered by individuals who are fully
trained in weight-management strategies, and it should be supported by
appropriate professional personnel. For those military personnel who are on
ships or are dependent on mess halls, more healthy, low-fat food choices and
sufficient time for meal consumption are imperative. Providing choices of foods
(both snack and full-meal foods) that are less energy-dense; increasing the price
of foods high in calories, fat, and refined carbohydrates; and subsidizing the
price of fresh fruits and low-calorie snacks in vending machines and exchange
service facilities should be considered. In any case, nutrition and lifestyle
education is paramount and should be provided early in the initial entry training
period and reinforced periodically. The development of distance-based educa-
tion in nutrition and lifestyle modification may prove useful.
Pharmacological treatments should be considered for those who meet the
standard criteria for the use of such compounds (i.e., a BMI of ≥ 30 or ≥ 27 with
comorbidities such as hypertension or high cholesterol). These individuals
would have to be in military occupational specialties that do not preclude the use
of drugs that affect the central nervous system.
How should resistiveness to weight/fat control be dealt with?

Resistiveness, as defined by the military, is a condition that generally refers
to a genotype and/or a phenotype that is obesity-prone. These individuals can
lose weight, but they usually have to work harder and may need additional assis-
tance in a weight-management program and with structured follow-up.
What are the knowledge gaps in weight-management programs relative to the

military? What research is needed?
Knowledge gaps concerning weight-management programs relative to the
military are extensive. Most published research has been derived from studies on
middle-aged men and women or perimenopausal, Caucasian women in clinical
settings. These data have limited relevance to the military population where: (1)
only about 25 percent of officers and warrant officers and about 6 percent of
enlisted personnel are over the age of 40, (2) only 15 percent are women, and (3)
approximately 40 percent are minorities. Considerable research is needed in the
primary areas of prevention, treatment, and program evaluation. In addition to
the research needs highlighted in the recommendations, research should also be
conducted on the following topics.

Prevention
Early Identification of Personnel at Risk
To identify those at risk of overweight or obesity, a set of potential risk
factors for weight gain (e.g., overweight at the time of accession, family history
of obesity, initial performance on the physical training test, a gain of more than
5 percent over initial entry training weight) should be developed. The effective-
ness of educating these individuals during initial entry training or whenever they
are identified as being at risk of becoming overweight should be evaluated.
Early Education of Initial Entry Trainees and Families

Initial entry training is a time of learning for individuals new to the military.
Just as these individuals learn military tasks (e.g., how to fire a weapon), they
could also learn nutritional principles, particularly the importance of energy
balance, appropriate portion sizes, and the caloric content of frequently
consumed foods. Spouses and other family members could also be included in
instruction on nutrition, just as they are in classes on military etiquette. Large-
scale, randomized trials with alternate classes of recruits, followed over time,
would be useful in determining if such preventive efforts are effective.
Exercise (Structured and Unstructured)

All the services should adopt the strategy of promoting physical fitness as a
way of life from the first day of initial entry training. Mandating exercise during
the duty day regardless of time pressures is one strategy. Scheduling competi-
tions that require participation by the entire unit and that require unstructured
exercise to attain peak performance could be tested as a method to improve
overall fitness and activity. The usefulness of resistance or strength training and
the optimum mix of aerobic and strength training for the purpose of weight
management needs to be evaluated among military personnel.
Reduction of Environmental Factors That Promote Overweight

Research is needed that: evaluates the effectiveness of eliminating high-
calorie and high-fat snacks in vending machines, or of offering alternatives such
as fruit and low-calorie snacks and meal replacements; evaluates the effects of
different time allotments for meal consumption; and evaluates the effectiveness
of altering the environment to promote physical activity, such as the creation of
walking and bike trails on military bases.

Evaluation of Treatment Methods and Programs

Evaluation of Local Initiatives for Effectiveness
Research is needed to identify and evaluate local weight-loss programs,
both military and civilian, for effectiveness. A military-wide competition could
be established for the most innovative weight-reduction programs, with recog-
nition and meaningful rewards for the most successful.
Evaluation of Ineffective or Dangerous Weight-Loss Practices

Research from the Navy has demonstrated that unhealthy eating and purg-
ing behaviors are more prevalent among military personnel compared with the
civilian population. Information is needed on the impact of such dangerous or
ineffective weight-loss practices on physical and mental performance among
military personnel. The prevalence of bulimia, binge eating disorder, and ano-
rexia nervosa in military personnel and whether the military lifestyle and stan-
dards promotes such behavior needs to be determined.
Computerized Follow-Up of Personnel at Risk

An independent, computerized database is needed to identify individuals
with risk factors for weight gain or overweight as described above, and to
maintain routine contact with these individuals to check on their weight or
physical fitness status, to identify problems early, and to intervene as needed.
Such computerized information should be centrally maintained and used as a
source of data for longitudinal studies on the effectiveness of prevention and
treatment innovations. This data should not be available to unit commanders to
avoid the possibility of discrimination against individuals at risk.
Other Areas for Research

Information is needed on whether there are differences both in gender re-
sponses to the various components of weight-management programs (e.g., do
men and women respond differently to diet, physical activity, or behavioral
change interventions) and in race/ethnicity responses to various weight-
management strategies.

1
_________________________________________________________________________________
Background and Context of the

Overweight Problem
Considerable attention has been given to the alarming rise in the incidence
of overweight and obesity in the U.S. population, both in the scientific literature
and in the popular press. The prevalence of overweight and obesity, defined as a
body mass index (BMI = weight [kg] divided by height [m]2 ) from 25 to 29.9
and 30 or higher, respectively, was relatively stable from 1960 to 1980. How-
ever, data from the Third National Health and Nutrition Examination Survey
(NHANES III) from 1988–1994 showed an increase in the prevalence of over-
weight and obesity from 47 percent to 56 percent and a rise in the prevalence of
obesity from approximately 15 percent to 23 percent (Flegal et al., 1998; Kucz-
marski et al., 1994). More recent data indicate that these trends have continued.
THE CURRENT NATIONAL SITUATION

The latest NHANES data from 1999–2000 (Flegal et al., 2002) show that
64.5 percent of the U.S. population 20 years of age and older is now classified as
overweight or obese. The prevalence of obesity (BMI ≥ 30) has risen from 23
percent to 30.5 percent. These trends are seen across both sexes and all ethnic
groups, with the greatest increases occurring in non-Hispanic Black females.
Furthermore, since 1980, the percentage of adolescents (ages 12–19 years) who
are overweight has tripled from 5 percent to 15.5 percent (Ogden et al., 2002).
There are some disparities however; overweight and obesity are particularly
common among minority groups and those with lower family income and less
education (HHS, 2001).
The epidemic of overweight and obesity in the civilian population, which
many experts attribute to the ready availability of a vast array of foods combined
with an increasingly sedentary lifestyle, affects the military services of the
United States in two significant ways. First, it decreases the pool of individuals
eligible for recruitment into the military services, and second, it decreases
retention—almost 80 percent of recruits who exceed the accession weight-for-
17

height standards at service entry leave the military early (i.e., by year 2 of a 3–4
year term of enlistment).
Another important consideration of the impact of overweight and obesity is
their effect on chronic disease. Studies of the relationship between health and
disease have used the premise that a BMI of less than 18.5 constitutes under-
weight, and a BMI of 18.5 to 24.9 constitutes healthy weight.
NOTE: A BMI consistent with overweight (25.0–29.9) does not by itself

indicate that an individual is over-fat, nor does a BMI consistent with
underweight indicate that an individual is not over-fat. There are some instances
where an individual could be misclassified as overweight due to body
composition (e.g., individuals with a large amount of lean muscle tissue, as
might be found in the military). Additional testing must be done to determine
whether the excess weight in such individuals consists of fat.
Overweight and Health

The effects of excess body weight are widespread and raise a variety of
concerns relevant to the health and performance of members of the military. The
major comorbidities associated with obesity and the implications of these co-
morbidities for the military services are briefly reviewed below. (For an exten-
sive review of the major health effects of overweight, see Bray, 1996 and Must
et al., 1999).
Overweight and obesity have also been associated with a variety of adverse
social and economic consequences. These appear to be more significant among
women than among men. For example, one study showed that obese women
completed fewer years of school, married less frequently, and had lower
earnings than women who were not obese (Gortmaker et al., 1993). Although
these data were obtained before obesity achieved its current prevalence, they
suggest a variety of long-term effects on material and psychological well-being.
Obesity also has a variety of adverse physiological effects. The major
comorbidities associated with obesity are shown in Box 1-1. It has been
observed that the prevalence of type 2 diabetes mellitus, hyperlipidemia,
hypertension, and heart disease increased with the severity of obesity, and that
prevalence ratios were generally greater in younger than in older adults (Must et
al., 1999). Approximately 70 percent of overweight individuals have at least one
of these complications, and over 30 percent have two or more (Must et al.,
1999).
Obesity is also associated with increased mortality rates. In one study by
Allison and colleagues (1999), obesity-related mortality was estimated from data
collected in five prospective cohort studies. The estimated number of annual
deaths in the United States attributable to obesity ranged from 280,000 to

BACKGROUND AND CONTEXT 19
BOX 1-1 Consequences of Adult Obesity
Psychosocial consequences
Low self-esteem
Disordered eating behavior
Discrimination
Medical consequences
Cancer
Diabetes mellitus
Gall bladder disease
Gastro-esophogeal reflux disease
Heart disease
Hyperlipidemia
Hypertension
Osteoarthritis
Polycystic ovary disease
Pseudotumor cerebri
Sleep apnea
Urinary incontinence
Increased maternal and fetal complications during pregnancy and
postpartum
Early mortality
325,000, depending on whether the analysis controlled for smoking rates.

Approximately 80 percent of the deaths attributable to overweight occurred in
persons with a BMI ≥ 30, which is the lower limit for obesity. The estimates of
the effects of obesity on mortality rates are quite consistent with earlier
published estimates by McGinnis and Foege (1993), who suggested that
approximately 300,000 deaths per year could be attributed to poor diet and
inactivity patterns, which are the major contributors to obesity.
The comorbidities associated with obesity substantially increase health care
costs. For example, total costs associated with obesity-related type 2 diabetes
mellitus; coronary heart disease; hypertension; gall bladder diseases; breast,
endometrial, and colon cancer; and osteoarthritis in 2000 were estimated at
almost $117 billion per year (HHS, 2001). Approximately half of these costs
were medical costs directly associated with the treatment of obesity and its
comorbidities; the other half were indirect costs associated with increased
absenteeism and decreased economic productivity. In one managed care organi-
zation, obesity was clearly associated with increased outpatient visits, inpatient
days, and use of pharmacy and radiology services (Quesenberry et al., 1998).

Upper Body Adiposity

BMI does not account for all of the increased morbidity associated with
obesity; the distribution of adipose tissue also influences the risk of excess
weight. Upper body, or more specifically, visceral adipose tissue, carries a
higher morbidity risk than adipose tissue deposited in the subcutaneous compart-
ments of the buttocks, thighs, and lower extremities (NHLBI, 1998).
Individuals with upper body adiposity may be predisposed to other obesity-
related conditions such as insulin resistance, glucose intolerance, dyslipidemias,
and high blood pressure, often referred to collectively as “Syndrome X” or the
“metabolic syndrome” (Bjorntorp, 1992a, 1992b; Hjermann, 1992). Factors that
increase the deposition of visceral adipose tissue include male gender, lack of
physical activity, alcohol use, and smoking (Emery et al., 1993; Han et al.,
1998). The distribution of upper body adipose tissue may also impact appear-
ance, which is relevant to military standards.
In order to clinically evaluate adipose tissue distribution, an individual’s
waist circumference (W) is evaluated as a measure of visceral obesity, with W >
102 cm (40 in) in men and W > 88 cm (35 in) in women considered high risk for
heart disease (NHLBI, 1998). Waist circumference measurements are supple-
mentary to BMI when diagnosing overweight and obesity; waist measurements
lose their predictive value for increased risk of heart disease with a BMI ≥ 35.
UNIQUENESS OF THE MILITARY ENVIRONMENT

Among active duty military personnel, diabetes, hypertension, and ischemic
heart disease accounted for less than 1 percent of visits made to ambulatory care
clinics in 1998. These findings should not be surprising given that active duty
personnel are younger, are less likely to be obese, and are more physically fit
than the average civilian adult. However, overweight and obesity do exist in the
military, and chronic health risk is a concern, especially among older, more
senior personnel. For example, Robbins and coworkers (2002), in a retrospective
cohort study design of active duty Air Force personnel, found that approxi-
mately 20 percent of these men and women exceeded their official maximum
allowable weight-for-height. Based on a review of health records, they estimated
excess weight-attributable medical costs were $19.26 million, with an additional
$3.5 million attributable to lost productivity and 28,351 lost workdays. Although
the primary concern of the Department of Defense (DOD) has been the effects
of weight and body composition on the fitness and performance of military
personnel, recent changes in the laws regarding health care for veterans have
added the costs of obesity-related comorbidity coverage as another area of
concern.
Also of special relevance to the military are the effects of fatness and of the
lack of fitness on injury rates during initial entry training. In several small

studies, an increased BMI was associated with an increased injury rate during
initial entry training and with performance in the 1- and 2-mile runs, sit-ups, and
push-ups by men (Jones et al., 1992).
Demographics
There are a number of important demographic differences between the
military and the general population. While the general population is fairly
evenly split between genders (49.1 percent men versus 50.9 percent women)
(U.S. Census Bureau, 2003), the military is largely comprised of men (85
percent versus 15 percent women) (Personal communication, B. Maxfield,
Office of the Deputy Chief of Staff for Personnel, March 7, 2003), although this
varies somewhat with the individual services. For example, the Air Force is
comprised of 80.6 percent men and 19.4 percent women, while the Marine
Corps is comprised of 94 percent men and only 6 percent women (Personal
communication, B. Maxfield, Office of the Deputy Chief of Staff for Personnel,
March 7, 2003).
Ethnic demographics also differ somewhat between the general U.S.
population and the active-duty military population. Although the proportion of
Whites, American Indian/Alaska Natives, and Asian American/Pacific Islanders
in the military tend to reflect the general U.S. population, the percentage of
Black men is higher in the military than in the general population (17.7 percent
vs. 12.3 percent), while the percentage of Hispanic men is lower (9 percent vs.
13.4 percent) (Tables 1-1 and 1-2). There is also a notable difference in the
distribution of ethnicity by gender in the military compared with the general
population. A greater proportion of women in the military are ethnic minorities.
For example, 41.7 percent of Army women are Black and 9.7 percent are
Hispanic, while 21 percent of Marine Corps women are Black and 16.6 percent
are Hispanic (Table 1-2).
Another significant demographic that differs between the general U.S.
population and the active-duty military population is that of age. While only
31.5 percent of the U.S. population is between the ages of 18 and 40 years (U.S.
Census Bureau, 2003), this age range encompasses nearly 80 percent of the
active-duty military population.
Health and Fitness

Table 1-3 presents a comparison of the percentage of the general population
(Flegal et al., 2002; Freedman et al., 2002) versus the military service population
in four BMI categories. While the percentage of military men and women in the
BMI category of 25 to 29.9 is higher than the general population, the percentage
in the BMI category of ≥ 30 is much lower. Also, the percentage of women with
a BMI of less than 25 is higher for military women than for civilian women. The

TABLE 1-1 Percent Gender and Race/Ethnicity of the U.S. Population

Compared with the Department of Defense (DOD) Population
Gender/Race/Ethnicitya U.S. Population (%) DOD Population (%)
Men (% of total population) 49.1 85
Race/Ethnicity
White 68.7 66.4
Black 12.3 17.7
Hispanic 13.4 9.0
AA/PI 4.0 4.0
AI/AN 0.9 1.0
Women (% of total population) 50.9 15
Race/Ethnicity
White 69.1 51.6
Black 13.1 31.4
Hispanic 12.2 9.2
AA/PI 3.8 4.0
AI/AN 1.2 1.1
a
AA = Asian American, PI = Pacific Islander, AI = American Indian, AN = Alaska
Native.
SOURCE: U.S. data: 2001 U.S. population estimates, U.S. Census Bureau (2003);
DOD data: 2002 Distribution of Active Duty Forces, Personal communication, B.
Maxfield, Office of the Deputy Chief of Staff for Personnel, March 7, 2003.
high prevalence of military personnel in the 25 to 29.9 BMI category reflects the
fact that until late 2002, the military maximum weight-for-height standards were
not based on the standard BMI categories (NHLBI, 1998).
The military environment has both positive and negative aspects associated
with it in terms of maintaining physical fitness and healthy weight. On the
positive side, military personnel have ready access to health care providers. In
addition, DOD has the potential for centralized, longitudinal record-keeping on
all active duty personnel, the unusual ability to provide incentives and conse-
quences for weight change, and the potential ability to modify environmental
factors that are important for weight control. Possible negative aspects of the
military environment include a very mobile population and the potential for
inappropriate weight-loss activities fostered by the need to meet weight, fitness,
and fatness standards.
Weight and Body Composition

At present, all active-duty personnel must be weighed and assessed for
physical fitness annually or semiannually. If an individual’s weight exceeds the
maximum for his or her height according to the screening tables for his or her

TABLE 1-2 Percent Gender and Race/Ethnicity of the Military Branches

Military Branch White Black Hispanic AA/PIa AI/ANb Total
Men
Army 61.9 22.1 9.5 3.2 0.8 84.6
Navy 63.3 17.4 9.8 6.5 1.9 85.6
Marine Corps 68.2 13.9 13.1 2.6 0.9 94.0
Air Force 75.4 13.8 5.2 2.9 0.5 80.6
Women
Army 41.2 41.7 9.7 3.8 1.2 15.4
Navy 51.6 28.1 11.1 5.2 2.8 14.4
Marine Corps 55.6 21.0 16.6 3.2 1.7 6.0
Air Force 61.8 24.7 6.0 3.8 0.7 19.4
a
AA = Asian American, PI = Pacific Islander.
b
AI = American Indian, AN = Alaska Native.
SOURCE: 2002 Distribution of Active Duty Forces, Personal communication, B. Max-
field, Office of the Deputy Chief of Staff for Personnel, March 7, 2003.
service, the individual is referred for a second-tier assessment (a determination

of percent body fat), to ascertain whether the increased weight is due to fat or to
lean tissue. In addition, a commander may order an individual in his or her
command to be weighed at any time if the commander believes that the
individual presents an overweight appearance in uniform. Personnel whose
percent body fat exceeds the limit for their service and who do not qualify for a
medical waiver are referred to a weight-management program (at the discretion
of the commander), which carries professional consequences.
Administration of military weight-management programs is left to each
service individually. These programs, which are described in greater detail in
Chapter 2, generally require a single visit to a health professional followed by
regular weigh-ins until weight and/or body fat goals are reached. Individuals are
required to demonstrate continuing progress toward these goals by losing a
prescribed number of pounds per month. Failure to show continued progress in
weight loss or continued failure to comply with body-fat standards without a
medical waiver can result in separation from the service. Similar attention is not
devoted to personnel who are underweight.
Appearance
The DOD appearance standard is articulated by DOD (1995) Directive
1308.1, DOD Physical Fitness and Body Fat Programs. This policy is shared,
but described slightly differently, by each of the service branches. According to
the Directive, “maintaining desirable body composition is an integral part of

TABLE 1-3 Percent Body Mass Index (BMI) of Military Branchesa by Gender
Compared with the General U.S. Population
Army Navy
BMI Men Women Men Women
< 18.5 0.3 0.6 0.5 1.8
18.5–24.9 39.6 58.8 30.4 52.2
25.0–29.9 46.0 34.4 52.9 38.6
30.0–34.9 13.2 5.6 14.3 6.5
35.0–39.9 0.9 0.5 1.7 0.8
≥ 40 < 0.1 < 0.1 0.2 0.1
a
No data available for U.S. Marine Corps.
b
Adapted from Flegal et al. (2002); Freedman et al. (2002). BMI categories for U.S.
population data are < 25, 25.0–29.9, 30.0–39.9, ≥ 40.
SOURCE: Army data: Personal communication, G. Bathalon, U.S. Army Medical
physical fitness, general health, and military appearance” (p. 2), and the first line
of body composition evaluation is by weight-for-height and appearance. For
example, according to Army Regulation 600-9 (U.S. Army, 1987), one of the
two goals of military weight standards is for soldiers to present a physical
appearance in uniform “which is neat and trim.” The regulation goes on to
describe the standard further by emphasizing that “excessive body fat connotes a
lack of personal discipline, detracts from military appearance, and may indicate
a poor state of health, physical fitness, or stamina.” No objective criteria (rating
scales) have been associated with the appearance standard as it is enforced,
although development of objective criteria has been recommended previously
(IOM, 1992a, 1998).
Although appearance is associated slightly with percent body fat, it is
associated more significantly with abdominal circumference (Hodgdon et al.,
1990; U.S. Army, 1987; Vogel and Friedl, 1992). Army and Marine Corps
personnel must supply recent photos of themselves to their promotion boards
(this practice has been eliminated by the Air Force and Navy), but appearance
judgments can be rendered by commanding officers at any time. When these
judgments involve a suspicion of overweight (as opposed to an untidy uniform
or other details of appearance), the individual must be weighed and may be
required to have a body-fat determination and enter a weight-management
program if standards are exceeded. In essence, the Directive considers appear-
ance as important as weight-for-height standards, but it does not provide any
objective criteria for assessing appearance. Instead, the Directive defers
implementation of the policy to the individual services, which in turn defer to
the individual units to establish criteria and implement the policy. This results in
uneven application of the policy among units and across the services.

Air Force U.S. Populationb

Men Women Men Women
0.9 3.0 — —
6.7 62.2 32.8 38.1
52.7 31.4 39.8 28.5
10.5 2.8 26.0 30.6
0.7 0.4 — —
< 0.1 < 0.1 1.5 2.8
Research and Materiel Command, 2003; Navy data: Personal commu-
nication, T. Cepak, Navy Physical Readiness Program, April 25, 2003;
Air Force data: Personal communication, J. Spahn, Population Health
Support Branch, May 15, 2003.
The relative role that appearance should play in relation to weight and
body-fat programs in the military is a multifaceted issue. The military embraces
a policy on appearance for several psychosocial reasons:
• It is perceived to be an indication of fitness.

• It may affect how the general public views the military.
• The appearance of military personnel is believed by some to be a factor
in esprit de corps (Bauer et al., 1976; USMC, 1995).
• It may have some impact on how a country’s military is perceived in-
ternationally.
The issue of appearance also influences the individual’s self-esteem and accept-
ance by peers.
PREVIOUS RECOMMENDATIONS ON BODY FAT AND FITNESS

In 1992, the Committee on Military Nutrition Research (CMNR) was asked
to evaluate whether the body composition, fitness, and appearance standards of
the military were consistent with optimum job performance. Their report, Body
Composition and Physical Performance: Applications for the Military Services
(IOM, 1992a), provided five major recommendations:
1. All the services should develop job-related physical performance tests.

2. The differences between accession and retention standards need
reevaluation for all services.
3. The inequities in the body composition standards for men and women
need to be addressed.

4. Body composition standards need to be validated relative to the ethnic

diversity of the military population.
5. If the military deems appearance standards necessary (although no
relationship between military appearance and military performance could be
identified), these standards should be objective.
Following the lifting of the combat exclusion rule in 1993 (which opened to
women a large number of occupational specialties that were previously closed to
them) and the increased frequency of deployments, the percentage of female
active-duty personnel has steadily increased. Concerned that the body compo-
sition, appearance, and fitness policies might be negatively impacting the health
of female service personnel, the U.S. Army Medical Research and Materiel
Command (USAMRMC) requested that CMNR revisit these issues specifically
as they pertained to military women. In response to this request, the CMNR
Subcommittee on Body Composition, Nutrition, and Health of Military Women
published a report (IOM, 1998). This report examined the body composition and
fitness standards of the four service branches in light of recent research that
explored the relationships among body composition, fitness, performance,
nutrition status, and health. To assess the implications of meeting the body
composition and appearance standards for women, military weight-management
programs and dieting practices were examined and compared with those in the
civilian sector. The report also explored the potential health risks of chronic
dieting in light of the high performance level expected of military personnel
since underweight may be as much of a medical concern as overweight. This
review (IOM, 1998) provided several key recommendations for military women:
• BMI and fitness assessment should be incorporated into the current

two-tiered system of body composition assessment procedures.
• The maximum allowable BMI should be set at 25, based on considera-
tions of health and chronic disease risk, with a maximum body fat of 36 percent
for women if the fitness test is passed.
• A single, service-wide circumference equation should be developed and
validated for the assessment of women’s body fat.
• Military women should be strongly encouraged to achieve and maintain
healthy weights through a continuous exercise and fitness program and should
be provided nutrition education and ongoing counseling if weight loss is a goal.
THE CURRENT TASK

In July 1999, CMNR was requested to (1) review the data on optimal
components of a weight-management program, (2) review the data on the role of
age, gender, and ethnicity in weight management, (3) review current DOD
activities in weight management, and (4) provide recommendations for military

weight-management programs. This request originated from the Director of

Military Operational Medicine Research at USAMRMC. The Subcommittee on
Military Weight Management was appointed in September 1999; on October
24–27, 1999, the committee convened a workshop in response to a request from
Army representatives. The workshop brought together the personnel responsible
for both DOD-wide and service-specific weight-control program policies; a
representation of military weight-control program leaders and innovators; and
key military, academic, and industry researchers to:
• Share knowledge and experience in managing weight-control programs

within the services.
• Gain relevant knowledge and experience from industry and academia.
• Examine current interventions and those under development for weight
loss, particularly in the pharmaceutical industry.
• Evaluate the appropriateness of weight-loss interventions for military
application or the need for further research.
• Develop a consensus toward a more standard DOD-wide approach to
weight management that utilizes state-of-the-art knowledge and practices.

for weight loss and maintenance, particularly those most effective for the non-
obese overweight individuals found in the military setting. Specifically, this
subcommittee was asked to addresses the following questions:
1. What are the essential components of an effective weight/fat-loss pro-

gram, and the most effective strategies for sustaining weight loss?
2. How do age and gender influence success in weight-management pro-
grams? Should age be considered in weight/fat standards and in weight-
management programs and interventions?
3. Which strategies would be the most and least effective in a military set-
ting? Should military weight/fat loss programs involve direct participation inter-
ventions or only monitoring and guidance? Should military programs be more
practices? Is a warning or cautionary zone prior to enrollment into a weight-
control program an effective strategy? When should duty time be authorized for
participation in intervention strategies for weight/fat loss?
4. To what extent should weight-control programs/policies be standard-
ized across the services versus tailored to the individual service, installation, or
unit? What are the advantages and disadvantages of standardization? Is the pro-
vision of state-of-the-art techniques and knowledge a rationale for standardiza-
tion?
5. How can diet be effectively dealt with as a weight-management com-
ponent in the military setting? Should pharmacological treatment (anorexiants)

be considered for use in the military? In what cases? What factors bear on this
decision?
6. How should resistiveness to weight/fat control be dealt with?
7. What are the knowledge gaps in weight-management programs relative
to the military? What research is needed?
SUMMARY
The rise in prevalence of overweight and obesity in the general population
as defined by specific BMI cut-off of ≥ 25 for overweight and ≥ 30 for obesity
has been associated with a significant increase in chronic diseases and mortality.
However, among active-duty military personnel, 80 percent of whom are be-
tween 18 and 40 years of age, chronic obesity-related diseases are less of an
issue than the impact of overweight on physical fitness, performance of jobs that
require physical exertion, injury rates, and appearance.

2
_________________________________________________________________________________
Military Standards for Fitness, Weight,

and Body Composition
“The physical characteristics of the U.S. fighting soldier have long proved
to be a significant factor in the maintenance of a strong military force. Through-
out history it has been demonstrated that the stronger, more fit, mentally sound
soldier is better able to perform his or her assigned duties at optimal levels of
proficiency. This proficiency has been measured in various ways, by quality of
work, productivity, promotion success, and test scores. It may also have been
measured, at times simply by survival (Wheeler, 1965). Measurable attributes
affecting performance include physical characteristics, medical and mental ill-
ness, behaviors of risk, intelligence level (Altus, 1949), athletic ability, and en-
durance (Gould, 1979)” (Johnson, 1997).
This chapter provides a brief background on the relationship of body fat and
fitness and the current policies of each branch of the military with respect to
weight and body composition standards and weight-management programs.
INTRODUCTION
The primary purpose of fitness and body composition standards in the mili-
tary has always been to select soldiers best suited to the physical demands of
military service, based on the assumption that proper body weight supports good
health, physical readiness, and appropriate military appearance. The idea of a
strong, trim military soldier is certainly not a new concept. Weight-for-height
has been used as a key measure of a potential recruit’s fitness for military ser-
vice for almost 150 years. The first height and weight tables for the U.S. military
were created during the Civil War. Anthropometric measurements of Civil War
draft recruits were collected at the end of the war by Colonel Jedediah H. Bax-
ter, chief medical officer in the Office of the Provost Marshall General (Johnson,
1997). These data were later published in Statistics, Medical and Anthropologi-
cal (1875, as reported by Love et al., 1958). Prior to the Korean Conflict, these
standards were used primarily to exclude underweight candidates. Advances in
health care and improved nutrition over the past 75 years have resulted in in-
creases in mean height, weight, and fat-free mass of soldiers. However, the like-
29

lihood of overnutrition leading to overweight and obesity and increases in inac-

tivity have raised new concerns about the impact of fatness on health and mili-
tary performance.
FITNESS VERSUS FATNESS

Assessing Fitness versus Fatness
One of the considerations most relevant to the issue of fitness in the military
is how fitness should be assessed. As described in the recently revised Depart-
ment of Defense (DOD) Physical Fitness and Body Fat Program Procedures
(DOD, 2002), the four components of fitness assessment are: (1) aerobic capac-
ity, (2) muscular strength, (3) muscle endurance, and (4) body composition,
which is influenced by other measures of fitness. Fatness, as defined by DOD,
means a body-fat content in excess of 26 percent of total weight for men and 36
percent of total weight for women.
Fitness and fatness are frequently confused due to the methods used to ex-
press data related to fitness. For example, the definitive measure of cardiorespi-
ratory (i.e., aerobic) fitness is the determination of maximal oxygen consump-
tion (VO2max). VO2max is usually measured while the subject is exercising on a
treadmill, according to a defined protocol that gradually increases speed and
incline, until voluntary exhaustion and maximal heart rate are achieved. Maxi-
mal heart rate is usually estimated as a heart rate of 220 minus the subject’s age.
The most appropriate expression of VO2max is as ml O2/min, or as ml O2/kg fat-
free mass/min. The effects of training on cardiovascular endurance may increase
VO2max by approximately 20 percent. Unfortunately, however, in many studies
VO2max is expressed as ml O2/kg body weight. Because this expression includes
fat, which does not increase oxygen consumption in response to exercise,
VO2max expressed as ml O2/kg body weight may reflect differences in perform-
ance, but does not allow comparisons of cardiovascular fitness.
Fitness, Fatness, and Injury

Jones and colleagues (1992) studied the relationship of fitness and fatness
(percent body fat) on injury rates of recruits during entry training at Fort Jack-
son, South Carolina, in 1984 and 1988. Fitness was defined on the basis of 1- or
2-mile run times and the number of sit-ups and push-ups completed during a 2-
minute interval. All three fitness measures were highly correlated to fatness in
both men and women. In men, percent body fat, determined from four skin-fold
measures, was significantly and positively correlated with 1- and 2-mile run
times and inversely correlated with the number of sit-ups and push-ups. Fitness
was positively correlated with body mass index (BMI) as well, except no sig-
nificant relationship was found for number of push-ups. Among women, the
results of the three fitness tests were also positively correlated with percent body
fat, although the strength of the relationships was weaker. BMI was positively,

MILITARY STANDARDS 31
but weakly, correlated with 1-mile run and weakly, but inversely, correlated
with push-ups. However, in a subsequent study of female Army initial entry
trainees, Sharp and colleagues (1994) found that women who failed the percent
body fat standard performed significantly better on physical performance meas-
ures of strength. For men, injury rates were directly correlated with percent body
fat; for women, the highest rates of injury occurred in the leaner groups. Among
both men and women, faster run times were associated with increased injury
rates. In a multivariate analysis, the odds ratio for injuries to women was 2.5
times those for men. In analyses stratified by gender, both fatness and fitness
independently accounted for significant proportions of the variance in injury
rates.
Fitness, Fatness, and Mortality

Fitness may be an independent predictor of mortality. In a series of studies,
Blair and coworkers (1989) have shown that fitness, defined as maximal tread-
mill time, was inversely associated with mortality, even after control for a vari-
ety of other variables linked to early mortality, such as serum cholesterol, blood
pressure, and blood glucose. However, the highest mortality rates occurred in
the least fit individuals with the lowest BMIs. In subsequent studies, Caucasian
men who maintained or improved adequate levels of fitness had lower mortality
rates than men who were persistently unfit (Blair et al., 1995). In more detailed
studies of the relationship of obesity and fitness, low fitness appeared to increase
mortality rates among men in all weight categories and carried a risk comparable
to other cardiovascular risk factors (Wei et al., 1999). In another study (Lee et
al., 1999), men who were lean and unfit had a higher mortality rate than men
who were obese and fit. These results suggest that fatness and fitness may have
independent effects on mortality.
Caution is needed, however, in applying the data related to fitness and fat-
ness reviewed above. First, the most comprehensive studies derive from a single
patient population (Caucasian men). Therefore, the generalizability of these ob-
servations to other populations may be limited. Second, in many of the earliest
papers, VO2max was measured during submaximal exercise, but it was expressed
as ml O2/kg body weight. Because obesity was defined on the basis of BMI,
individuals with increased BMIs may have been spuriously classified as obese.
This difficulty was only partially addressed by the analyses of the effect of fit-
ness within BMI categories. A more recent study examined the relationship of
BMI, cardiorespiratory fitness, and all-cause mortality in women (Farrell et al.,
2002). After adjusting for age, smoking, and baseline health status, the authors
found that compared with normal-weight women, overweight and obesity did
not significantly increase all-cause mortality. However, women with moderate
and high cardiorespiratory fitness had significantly lower mortality risk com-
pared with those with low cardiorespiratory fitness. These highly promising

TABLE 2-1 U.S. Army Maximum Weight (lb)-for-Height Accession

Standards by Age
Height Men (y) Women (y)
(in) 17–20 21–27 28–39 40+ 17–20 21–27 28–39 40+
58 112 115 119 122
59 116 119 123 126
60 139 141 143 146 120 123 127 130
61 144 146 148 151 124 127 131 135
61 148 150 153 156 129 132 137 139
63 153 155 158 161 133 137 141 144
64 158 160 163 166 137 141 145 148
65 163 165 168 171 141 145 149 153
66 168 170 173 177 146 150 154 158
67 174 176 179 182 149 154 159 162
68 179 181 184 187 154 159 164 167
69 184 186 189 193 158 163 168 172
70 189 192 195 199 163 168 173 177
71 194 197 201 204 167 172 177 182
72 200 203 206 210 172 177 183 188
73 205 208 212 216 177 182 188 193
74 211 214 218 222 183 189 194 198
75 217 220 224 228 188 194 200 204
76 223 226 230 234 194 200 206 209
77 229 232 236 240 199 205 211 215
78 235 238 242 247 204 210 216 220
79 241 244 248 253 209 215 222 226
80 247 250 255 259 214 220 227 232
SOURCE: U.S. Army (1998).
results suggest that the military focus on the physical fitness of personnel is ap-
propriate not only for performance, but also for overall health.
WEIGHT STANDARDS FOR ACCESSION AND RETENTION

Typically, the various branches of the military have had two sets of weight
standards: one set of standards to be met by potential recruits for accession into
initial entry training, and another equivalent or more stringent set of standards in
order to be retained in the service.

TABLE 2-2 Maximum Body Mass Index (BMI) (kg/m2) for Height for
Accession
Men Women
Height Marine Air Marine Air
(in) Army Navy Corps Force Army Navy Corps Force
64 28.0 27.5 27.5 28.2 24.9 26.8 25.1 25.1
65 28.0 27.5 27.5 28.0 24.8 26.7 25.0 25.0
66 27.9 27.5 27.5 28.1 24.9 26.4 25.1 25.1
67 28.0 27.6 27.5 28.1 24.9 26.2 25.1 25.0
68 28.0 27.6 27.6 28.0 24.9 25.9 25.0 25.0
69 27.9 27.5 27.5 28.0 24.8 25.7 25.0 24.9
70 28.0 27.6 27.6 27.9 24.8 25.4 25.0 24.9
71 28.0 27.5 27.5 27.8 24.7 25.3 25.0 24.7
72 27.9 27.6 27.6 27.9 24.8 25.1 25.0 24.7
73 28.0 27.5 27.6 27.9 24.8 25.0 25.0 24.9
74 28.0 27.5 27.5 28.0 24.9 25.0 25.1 25.0
75 28.0 27.6 27.4 28.1 25.0 25.0 25.0 24.9
76 28.0 27.6 27.4 28.1 25.1 25.0 25.0 25.0
77 28.0 27.6 27.3 28.0 25.0 25.1 25.1 25.0
78 28.0 27.6 27.2 28.0 25.0 25.0 25.0 24.9
79 27.9 27.5 27.2 28.0 25.0 25.1 25.1 24.9
80 28.0 27.5 27.2 28.0 24.9 25.0 25.1 24.9
NOTE: Navy, Marine Corps, and Air Force accession standards are the same as their
retention standards. Army BMI was calculated from age group 28–39 y weight-for-
height accession standards. The new Department of Defense Instruction 1308.3 (DOD,
2002) sets BMI standards between a lower limit of 25 and an upper limit of 27.5.
SOURCE: USAF (2002); U.S. Army (1998); USMC (2002); U.S. Navy (2002).
Accession Standards
Each of the services maintains gender-specific, weight-for-height and body-
fat standards for accession (entry) into active military service in order to prevent
the entry of overfat individuals. In the Army and Navy, accession standards are
more liberal than retention standards, and the Army accession weight-for-height
standards change with increasing age (see Table 2-1). Accession standards for
all the services, based on BMI, are presented in Table 2-2. Body-fat standards
for accession and retention are presented in Table 2-3. Currently, the Navy’s
body-fat accession standard is 1 percent higher than its retention standard. The
Army accession standard is more liberal relative to the retention standard for
men than it is for women. This is based on evidence that male recruits lose
weight during initial entry training and early in their enlistment and maintain the
weight loss, while women may lose weight during initial entry training, but tend

TABLE 2-3 Maximum Body Fat (%) for Accession and Retention
Age (y)
Service Gender 17–20 21–27 28–39 40+
Army Male 20 22 24 26
Female 28 30 32 34
Navya Male 22 22 22 23
Female 33 33 33 34
Marine Corps Male 18 18 18 18
Female 26 26 26 26
Air Force Male 20 (17–29 y) 24 (30+ y)
Female 28 (17–29 y) 32 (30+ y)
NOTE: The body fat % is dependent upon age group, except for the Marine Corps,
which does not distinguish between age groups.
a
The Navy accession standard for body fat is 1% higher than retention standards. Spe-
cifically, the Navy accession standard for women is 34 percent body fat with a retention
standard of 33 percent, for men the accession standard is 23 percent body fat and the
retention standard is 22 percent.
SOURCE: GAO (1998); Singer et al. (2002).
to regain some of it (Friedl et al., 1989). Accession standards for the Air Force
and Marine Corps are the same as their retention standards.
Because an accurate measurement of height and weight is considerably eas-
ier than an accurate measurement of percent body fat, the initial body composi-
tion screen for accession consists of a weight-for-height assessment using ser-
vice-specific maximum allowable weight-for-height tables. Height and weight
can be used to compute BMI, a widely accepted surrogate index of percent body
fat (Gurrici et al., 1998; IOM, 1992a; NHLBI, 1998; Strain and Zumoff, 1992;
Wang et al., 1996). It should be noted, however, that the military standards for
maximum weight-for-height were established long before the science supporting
the use of BMI was developed.
When only two measurements are used, height and weight have the highest
level of association with the percentage of body fat. However, each service has
conducted extensive anthropometric measurements of service personnel and
used these data, together with data on body composition, to assess the best sin-
gle additional measurement for estimating body fat (Friedl, 1992; Hodgdon,
1992). Until quite recently (DOD, 2002), none of the services had adopted the
BMI per se as an alternative to maximum weight-for-height standards. However,
the Air Force has considered BMI as part of the evaluation process before as-
signing an overweight individual to a weight-control program.
The maximum allowable weights-for-height have varied across services for
individuals of the same height, age, and gender. The individual service standards
were uniformly more stringent than the DOD recommendations. For example, as

reviewed by the General Accounting Office (GAO, 1998), in 1998 the maxi-
mum allowable weight-for-height corresponded to a BMI of 25.1 for women in
the Army, whereas for women in the Marine Corps, it corresponded to a BMI of
23.8. The disparity in maximum BMI between men and women was marked:
while the maximum allowable weight-for-height for women in any service cor-
responded to a BMI of 25.1 (Army), for men it corresponded to a BMI of 28.2
(Air Force) (GAO, 1998).
However, in the recent revision of DOD Instruction 1308.3 (DOD, 2002),
the weight-for-height tables have been revised to correspond to an upper-limit
BMI of 27.5 and a lower limit BMI of 25, and it specifies that no service shall
set more stringent screening weights than those corresponding to a BMI of 25.
Thus, the Marine Corps had to raise its previous standard of 23.7 for women,
while the Air Force had to decrease its previous standard of 28.2 for men.
Prospective recruits who exceed the accession weight limit for their height
must undergo a body-fat assessment. The maximum allowable percentage of
body fat for women on entry into the service ranges from 26 percent to 34 per-
cent, depending on the service and for the Army, age. The maximum allowable
percentage of body fat for men on entry into the service ranges from 18 percent
to 26 percent depending on service and age (USAF, 2002; U.S. Army, 1987;
U.S. Navy, 2002; USMC, 2002) (see Table 2-3). Each service uses circumfer-
ence measurements to estimate body composition and, until recently, each em-
ployed its own set of measurement equations. However, as of November 2002,
DOD has mandated a single circumference equation to be used across all the
services for assessing percent body fat in men, and a different equation to be
used in women.
In 1998, the Navy adopted a maximum standard of 23 percent body fat for
men and 34 percent for women (Hodgdon, 1999). In setting these standards, the
Navy consensus panel recognized that measures of height and weight “only ap-
proximate the precise magnitude of fatness,” and that lack of a strong relation-
ship may lead to inaccurate classifications. However, height and weight were the
only measurements for which a great deal of epidemiological data were avail-
able (Hodgdon, 1999). Ideally, more sophisticated body-fat measurements
should augment the weight-for-height indices.
Setting accession standards has implications for recruiting. When the ser-
vices set restrictions on recruitment eligibility based on weight-for-height and
estimated percent body fat, they eliminate a portion of individuals who might
otherwise qualify for service. In the Third National Health and Nutrition Exami-
nation Survey (NHANES III), 59 percent of the men and 51 percent of the
women in the survey over age 20 years exceeded recent guidelines (NHLBI,
1998) that suggest that men and women are overweight when they exceed a
BMI of 25 (Flegal et al., 1998; Kuczmarski et al., 1997).
Nolte and coworkers (2002) recently examined NHANES III data to deter-
mine the percentage of the U.S. population between the ages of 17 and 20 years
that would meet the military weight-for-height standards that were in effect at

TABLE 2-4 Maximum Permissible Body Mass Index (BMI) (kg/m2) for
Given Height for Retention
Men
Height (in) DOD Army Navy Marine Corps Air Force
64 27.5 26.5 27.5 27.5 28.2
65 27.5 26.5 27.5 27.5 28.2
66 27.5 26.4 27.5 27.5 28.1
67 27.5 26.5 27.5 27.6 28.1
68 27.5 26.5 27.6 27.6 28.0
69 27.5 26.5 27.5 27.5 28.0
70 27.5 26.6 27.5 27.6 27.9
71 27.5 26.4 27.4 27.5 27.8
72 27.5 26.5 27.3 27.6 27.9
73 27.5 26.4 27.2 27.5 27.9
74 27.5 26.5 27.1 27.5 28.0
75 27.5 26.6 27.0 27.5 28.1
76 27.5 26.5 27.0 27.6 28.1
77 27.5 26.5 26.9 27.6 28.0
78 27.5 26.5 26.8 27.6 28.0
79 27.5 26.5 26.6 27.5 28.0
80 27.5 26.4 26.5 27.5 28.0
NOTE: Navy, Marine Corps, Air Force, and Department of Defense (DOD) standards
are the same as their accession standards. Army BMI was calculated from age group
28–39 y weight-for-height retention standards.
the time the study was conducted. Their analysis indicated that 13 to 18 percent
of men and 17 to 43 percent of women in this age range exceeded the military
standards. The authors concluded that these data indicated a need for the mili-
tary to reassess their standards. Perhaps a more appropriate conclusion (particu-
larly for long-term health) would be to highlight the need for weight-gain pre-
vention strategies targeted towards adolescents, particularly minority women.
Data from the 1999–2000 NHANES indicate that BMI continues to increase,
with the most recent data indicating that the prevalence of overweight and obe-
sity in all men over the age of 20 years has now increased to 67.2 percent, while
prevalence in women over the age of 20 years has risen to 61.9 percent (Flegal
et al., 2002).

Women
DOD Army Navy Marine Corps Air Force
27.5 23.6 26.8 25.1 25.1
27.5 23.5 26.7 25.0 25.0
27.5 23.6 26.4 25.1 25.1
27.5 23.4 26.2 25.1 25.0
27.5 23.5 25.9 25.0 25.0
27.5 23.4 25.7 25.0 24.9
27.5 23.4 25.4 25.0 24.9
27.5 23.3 25.3 25.0 24.7
27.5 23.4 25.1 25.0 24.7
27.5 23.4 25.0 25.0 24.9
27.5 23.5 25.0 25.1 25.0
27.5 23.5 25.0 25.1 24.9
27.5 23.7 25.0 25.0 25.0
27.5 23.6 25.1 25.1 25.0
27.5 23.6 25.0 25.0 24.9
27.5 23.6 25.1 25.1 24.9
27.5 23.6 25.0 25.1 24.9
SOURCE: DOD (2002); USAF (2002); U.S. Army (1987); USMC (2002); U.S.
Navy (2002).
Retention Standards
The retention standards are the maximum weights-for-height and percent
body fat that military personnel are allowed to avoid referral to a weight-
management program (DOD, 1995). The current BMI retention standards for
men and women for each military service are presented in Table 2-4. The maxi-
mum allowable percentage of body fat for men ranges from 18 to 26 percent
depending on service and age, while for women it ranges from 26 to 34 percent
(See Table 2-3).
Each of the services screens active duty personnel either annually or semi-
annually for fitness and compliance with weight-for-height standards. Personnel
may be screened several times a year in the course of medical examinations,
physical fitness tests, or training school examinations. Thus, personnel receive
regular feedback on how well they meet the standards of weight-for-height. The
consequences of these practices are clear. In the NHANES III study, 34 percent
of civilian men and 36 percent of civilian women over age 20 years exceeded a

BMI of 27 (NCHS, 1998). In contrast, in a 1998 worldwide survey of active

duty military personnel from all four services (n = 17,264), only 21 percent of
active duty men and 9 percent of active duty women exceeded a BMI of 27.
Additionally, 57 percent of active duty men and 25 percent of active duty
women exceeded the newer overweight standard of 25, compared with 59 per-
cent and 51 percent of civilian men and women, respectively (Bray et al., 1999;
Flegal et al., 1998).
Because the data from Bray and coworkers (1999) are self-reported rather
than actual measurements, some bias may exist. However, investigators who
collected both self-reported data and actual measurements concluded that such
biases were small. They found that correlation between self-reported data and
actual measurements was high (R > 0.82), and that self-reported data enabled
investigators to classify weight category correctly 94 percent of the time
(Jeffery, 1996; Strauss, 1999). Moreover, the data of Bray and coworkers (1999)
were taken from surveys completed anonymously and collected by personnel
who were outside the military chain of command of the respondents. Thus, these
data most likely accurately portray the scope of the problem of overweight in the
military services.
THE IMPACT OF WEIGHT AND BODY-FAT STANDARDS

One way to assess the impact of body-fat standards on the military is to
look at the cost in terms of personnel management, namely the proportion of
personnel enrolled in weight-management programs at any given time. Assign-
ment to these programs requires paperwork and other administrative costs and
may involve lost duty time. As of December 1999, 0.5 percent of male officers,
1.3 percent of female officers, 1.6 percent of male enlisted personnel, and 3.0
percent of female enlisted personnel were enrolled in the Air Force Weight
Management Program. Data on weight-management programs recidivism or
long-term success are not systematically compiled by any of the services, a
situation that is, at least in part, intentional. The services attempt to minimize the
stigma associated with participation in these programs by purging records.
The Impact on the Health Care System

Another way to assess the impact of body-fat standards on the military is to
estimate their cost to the health care system. In 1998, according to the Defense
Medical Epidemiology Database (DMED)1, active duty personnel made 9.1 mil-
lion visits2 to ambulatory care clinics. Just over 40,000 of those visits were for a
1
http://www.amsa.army.mil. The Army maintains the database, but it contains
data from all four services.
2
International Classification of Disease, 9th revision (ICD9) codes 001 through
V99.

primary diagnosis of “obesity” or “localized adiposity.”3 An additional 2,700

visits were for a primary diagnosis of “anorexia,” “bulimia,” or other “eating
disorder.”4 That is, less than one-half of 1 percent of all ambulatory visits made
by active duty personnel were recorded as being primarily for concerns about
body weight, body composition, or dysfunctional weight-loss practices. A dif-
ferent approach was reported by Robbins and colleagues (2002), who examined
anthropometrics, demographics, and health behaviors of 4,974 active duty Air
Force men and women. This analysis found that more than 20 percent exceeded
their maximum allowable weights and that this was associated with an increased
cost of $22.8 million per year for medical care and lost workdays (especially
among men). Unfortunately, the statistics on visits to military clinics for weight-
related matters do not provide a complete picture. Military personnel are likely
to enroll in commercial weight-reduction programs or to self-treat with supple-
ments or over-the-counter medications rather than call attention to their weight,
which invites possible disciplinary action or separation from the service with
loss of benefits.
Diabetes, hypertension, and ischemic heart disease accounted for less than 1
percent of the visits made to ambulatory care clinics by active duty personnel in
1998. Taken together, all visits for “endocrine, nutritional, and metabolic dis-
eases and immune disorders” and “diseases of the circulatory system” accounted
for 4.5 percent of the total visits (in contrast, musculoskeletal disease and inju-
ries/poisonings accounted for 26 percent and 16 percent of all visits, respec-
tively). Thus, since the military is made up predominately of young, healthy
individuals who exercise with some regularity, it appears that they are far more
likely to suffer musculoskeletal injuries than they are to present health problems
associated with obesity.
The Impact on Weight-Loss Behavior and Disordered Eating

Eating disorders have been widely studied among civilian women and
among select groups of men (e.g., athletes, wrestlers). Gross disturbances in
eating behavior characterize the conditions of anorexia nervosa currently seen in
1 to 2 percent of females in the general population, and bulimia nervosa, which
has a prevalence of 1 to 3 percent in this population. Both disorders have a fe-
male-to-male ratio of occurrence of 10:1. Another category of eating disorders,
known as not otherwise specified (NOS), has been reported in the literature to
occur in 3 to 35 percent of the population.
The need to maintain weight-for-height and body composition standards
does place pressure on military personnel, particularly those who may find
themselves in more sedentary occupations after completing initial entry and ad-
vanced individual training. The military policy of testing personnel annually or
3
ICD9 codes 278-0 and 278-1, respectively.
4
ICD9 codes 307-1, 307-51, and 307-51, respectively.

semi-annually can lead to undesirable and potentially unhealthy practices. For

example, Peterson and coworkers (1995) examined the incidence of bulimic
weight-loss behaviors in individuals in a military weight-management program,
a civilian weight-loss program, and military personnel not in a weight-loss pro-
gram. Military personnel in a weight-management program engaged in signifi-
cantly more bulimic behaviors than either of the other two groups. Behaviors
such as vomiting, strenuous exercise, and use of saunas or steam rooms was four
times more common in those assigned to the military weight-management pro-
gram. These results are more notable in that this group of individuals was pre-
dominantly male (65 percent).
In a series of studies of Navy personnel and of military women in all ser-
vices, McNulty used the Stanford Eating Disorders Questionnaire with 706 ac-
tive-duty Navy nurses (McNulty, 1997a), 1,425 active-duty Navy men (23.7
percent officers and 76.3 percent enlisted men, McNulty, 1997b), and 1,278
active-duty women in the Army, Navy, Marine Corps, and Air Force (McNulty,
2001).
The existence of eating disorders was found to be wide-spread in the Navy
nurses, even among normal-weight women within the standard of 30 percent
body fat. The prevalence of bulimia nervosa was 12.5 percent in this population,
more than six times the prevalence reported in the civilian literature (McNulty,
1997a). Among the top five reasons given by these women for engaging in these
practices were: being overweight, command morale, and maintaining the Navy
fitness standards.
Among Navy men, 50.1 percent of the men across all ranks were classified
as having an eating disorder (6.8 percent bulimic, 2.5 percent anorexic, and 40.8
percent NOS). While the use of diuretics, vomiting, diet pills, laxatives, and
fasting all had a 2 to 4 percent prevalence under normal conditions (binge eating
at 14 percent), these behaviors increased to a prevalence of 14 to 15 percent at
the time of weigh-ins and fitness testing (binge eating at 26 percent). The top
four reasons for engaging in these behaviors were: feeling overweight, rotating
shifts, shipboard assignments, and no time allowed for physical fitness except
during off-duty hours (McNulty, 1997b).
In another study focused on women in all branches of the service (McNulty,
2001), data were gathered from 235 Army women, 443 Navy women, 355 Air
Force women, and 245 Marine Corps women. For the combined sample of 1,278
service women, the prevalence of eating disorders was 1.1 percent for anorexia
nervosa, 8.1 percent for bulimia nervosa, and 62.8 percent NOS; 28 percent re-
porting normal eating. Marine Corps women scored significantly higher for all
disorders than women in other service branches, although they had the lowest
reported percent body fat (91.3 percent of Marine Corps women had body fat
less than 26 percent, compared with 60 percent of Army women, 69 percent of
Navy women, and 67 percent of Air Force women). Of the Marine Corps
women surveyed, 22.3 percent reported being amenorrheic, compared with 10.2
percent of Army women, 9.9 percent of Navy women, and 7.4 percent of Air

TABLE 2-5 Percent of Military Women Using Purging Behaviors to

Meet Weight/Height Standards
Behavior Army Navy Marine Corps Air Force
Diuretics 1.3 4.4 6.3 2.9
Vomiting 2.6 2.3 3.3 3.2
Fasting 18.8 18.3 38.0 20.2
Diet pills 8.6 11.2 28.6 13.4
Laxatives 2.2 2.3 12.4 3.4
Exercise (> 2×/d) 3.4 3.9 13.1 2.3
SOURCE: McNulty (2001).
Force women. The prevalence of use of various purging behaviors across the
services are shown in Table 2-5. The top five reasons given for engaging in
these types of behaviors were: competitiveness for advancement, concern for
weight, being forced into a weight-control program, being harassed by supervi-
sors for weight, and for Marine Corps women—lack of availability of low-fat
meals. Clearly, these types of behaviors, coupled with the high prevalence of
amenorrhea, could have significant long-term health implications for military
women.
The Impact on the Loss of Personnel

The impact of body-fat standards on the military also can be assessed in
terms of the separation of personnel. In 2002, almost 1.4 million men and
women served on active duty in the four military services. The data of Lindquist
and Bray (2001) suggest that 54 percent of active duty personnel are in danger
of being assigned to a weight-control program, and some of these may be at risk
of separation from the service due to overweight (based on self-reported BMIs).
As shown in Table 2-6, over 4,600 individuals were discharged from the mili-
tary for being overweight in 1999, but the numbers show a steady decline. (A
large part of the decline is due to the Navy’s decision to halt discharges for over-
weight. Navy personnel who fail to meet the standards are now allowed to serve
out their current term of enlistment, but they are not permitted to re-enlist.) In
2002, total early separations for persistent failure to meet weight and body
composition standards totaled just over 1,400 individuals. This is approximately
0.1 percent of the active duty force of 1.4 million personnel and represents a lost
investment of approximately $57 million (in 1995 dollars), based on an esti-
mated cost of recruitment and training of $40,283 per person (DOD PEC, 1997).
MEETING THE WEIGHT AND BODY-FAT STANDARDS

The past decade has brought considerable progress in developing new tech-
nologies (efforts that were funded substantially by DOD) and scientifically sound

TABLE 2-6 Number of Military Personnel Separated for Failure to Meet

Weight and Body Composition Standards
Year
Service 1999 2000 2001 2002
Army (total) 1,703 1,202 1,013 953
Men 1,448 1,004 847 776
Women 255 198 166 177
Navya (total) 2,190
Men 1,768 Not Not Not
Women 422 applicable applicable applicable
Marine Corps (total) 156b 107 94 74
Men 94 88 67
Women 13 6 7
Air Force (total) 600 537 486 392
Men 389 364 333 237
Women 211 173 153 155
Total 4,649 1,846 1,593 1,419c
NOTE: In 1999, there were a total of 1,370,963 (DOD, 1999) enlisted personnel and
officers in the services. In 2002, there were total of 1,402,120 active duty personnel.
a
Navy data is from 1997. In 1998, the Navy placed a moratorium on administrative
discharges for overweight.
b
Marine Corps data is from 1998.
c
Represents 0.1 percent of active duty forces.
SOURCE: Army data: personal communication, J. Sloan, Office of the Deputy Chief
of Staff, May 19, 2003; Navy data: personal communication, T. Cepak, Navy Physi-
cal Readiness Program, 1999; Marine Corps data: personal communication, B.
McGuire, Training Command, April 30, 2003; Air Force data: personal communica-
tion, J. Spahn, Population Health Support Branch, May 15, 2003.
methods of assessing body fat and setting appropriate weight and body-fat stan-
dards in support of the military’s body composition, fitness, and readiness goals.
DOD-wide uniformity in the use of these methodologies and standards is being
sought to promote maximum objectivity and fairness to service members across
the four services. As discussed earlier, a revised DOD Instruction has been is-
sued that presents new DOD standards for maximum weight-for-heights corre-
sponding to a minimum BMI of 25 and a maximum BMI of 27.5 (DOD, 2002).
In addition, this policy also mandates the implementation of a single circumfer-
ential equation to estimate percent body fat for men and one for women to be
used by all the services.
The weight and body-fat standards of the military services were predicated
on the need for the highest level of physical performance in adverse environ-
ments, and to a lesser degree on the image that the individual may convey of the

military. These standards theoretically take precedent even when individuals

demonstrate an ability to perform their assigned tasks in an exceptional manner.
There are a number of problems created by these standards. First, many oc-
cupational specialties of today's military services do not require demanding
physical performance and, in fact, may foster adverse changes in body composi-
tion due to their sedentary nature. Second, there is a high cost for recruiting,
training, and assimilating individuals with needed skills into some highly tech-
nical positions. Third, the pool of potential applicants is small during good eco-
nomic times. Finally, once trained by the military, many of these individuals in
critical career fields can find higher-paying jobs in the civilian community
where their body composition presents no problem.
Alternatively, the case can be made that all military personnel are poten-
tially needed for duty in situations of armed conflict and thus even individuals
that have occupational specialties that foster sedentary activity may be required
to perform other tasks that demand physical strength and endurance. There is
also the perception that individuals who have a low body-fat mass are likely to
have less illness, which is important in hostile environments. Unfortunately,
there are few data available on the relationship of body composition and per-
formance of occupational specialties that do not require significant physical ac-
tivity. There is an abundance of data on the relationship of body composition
and long-term health, but less is known about this relationship in young indi-
viduals in the short term. Compliance with the military weight and body-fat
standards may provide significant benefits to individuals after they retire from
active duty, but it may not provide significant benefit to the services in terms of
increased reliability of performance in many occupational specialties.
WEIGHT-MANAGEMENT PROGRAMS
The emphasis on methods and standards stands in sharp contrast to the lack
of effort being devoted to improving policies and programs to assist service
members who do not meet these standards, that is, programs for weight and fat
loss and sustainment of these losses. While DOD and each of the services pro-
vide general guidance on body-weight management, the specifics of most
weight/fat loss programs are unique to particular installations or units. The ser-
vices have done relatively little medical and physiological research in this area,
a deficiency that is particularly evident considering private industry’s current
effort to develop pharmacological and other novel weight-loss and maintenance
interventions. In an era of recruitment and retention difficulties, the military
could decrease the loss of trained personnel by capitalizing on these develop-
ments, improving existing programs, and attempting to provide more uniformity
to weight-management programs across the services. More importantly, DOD
needs to develop a strong focus on prevention programs, as well as on remedial
programs.

Several factors have encouraged the military services to expand and refine
their weight-control programs:
• The elimination of the draft and the conversion to an all-volunteer mili-

tary has reduced the number of new recruits.
• The impact of obesity on long-term health has been more fully defined
by epidemiological studies.
• Increases in manpower costs due to duty restriction or separations have
been found to be significant.
Where the services diverge most is in their approach to weight management

(see Table 2-7). The programs differ in a variety of ways, including:
• the amount of central control,

• the extent of medical evaluation given each individual,
• the existence of cautionary zones,
• the amount of counseling provided,
• the scope of the program (e.g., diet, exercise, behavioral modification),
• the qualifications of the staff administering the program,
• the procedures for data collection and evaluation of effectiveness, and
• the organizational setting of the program.
The Air Force has the most extensive weight-management program and
maintains the most central control. A uniform set of procedures is prescribed by
regulations that apply to all major Air Force installations. Air Force personnel
assigned to remote locations are sent to the nearest clinic for evaluation and
counseling or, in some instances, the program staff travels to the remote site.
Programs in the other services are less standardized and employ more local in-
novation. Although the Army, Navy, and Marine Corps have centrally mandated
programs, the details of the programs’ content vary from one site to another.
This is particularly true of the Army program, in which various sites have incor-
porated very different levels of counseling and the use of therapy. Some Army
and Air Force sites have instituted innovative communication techniques, such
as the use of Internet web sites. The Air Force is the only service that has
adopted what might be considered a cautionary zone in which overweight indi-
viduals are given a 3-month opportunity to achieve weight compliance without
administrative action.
No service has engaged in a preventive program applicable to all personnel,
although the requirement to maintain body weight below upper limits is part of
general indoctrination. The Air Force has reported on studies that have evaluated
the effects of diet counseling using the Dietary Guidelines and the Food Guide
Pyramid to improve responses in a 90-day fitness program (Gambera et al.,
1995) and on a pilot study that evaluated the effects on new recruits of providing

TABLE 2-7 Current Military Weight-Management Policies and Procedures
Armya Navyb Marine Corpsc Air Forced
How often/when Semiannual and at specific Semiannual Semiannual Annually at a minimum
weighed times PFA, risk factor screening Random, PCS, promo-
Height/weight measure- tion, TDY to techni-
ment includes body-fat cal training, TDY >
assessment (only for 39 days, directed by
members over maxi- commander, BOTS,
mum weight) PME
PRT: Each PFA is con-
ducted no later than 8
mo apart but no sooner
than 4 mo apart
Body-fat measure rea- Overweight (per screening Exceeds maximum Exceeds height/ Exceeds MAW, appears
son table), appears overweight-for-height weight standards to exceed body-fat
weight measurement standard, does not
present a profes-
sional military im-
age, directed by com-
mander
continued
45
46
TABLE 2-7 Continued
Sites measured Females: neck, hip, fore- Females: neck, hips, waist Females: neck, hips Females: neck, waist,
arm, wrist Males: neck, abdomen (greatest protuber- buttocks
Males: neck, abdomen ance of buttocks), Males: neck, abdomen
abdomen (at natural
waist)
Males: neck, abdomen
(at navel)
Personnel responsible Company (or similar CFL, graduated from a 1- Command PT represen- HAWC by HPM or
for body-fat assess- level) commander or wk Physical Fitness tative other medical per-
ment designee Specialist course pro- sonnel if no HAWC
vided by the Cooper In- Body fat assessed by
stitute unit commander
Weight-management Weight-reduction counsel- If a service member fails a MO evaluation Exercise/diet program

program execution ing by health care per- PFA, then it is manda- If no underlying medi- and nutrition portion
sonnel prior to or tory for the CFL to per- cal condition, as- must be authorized
shortly after soldier is sonalize their fitness signed to RPCP, nu- by MAJCOM dieti-
entered in the Weight regimen and track their trition education tian, taught by dieti-
Control Program progress until they pass program tian, diet technician,
Soldier is flagged under two consecutive PFAs or other approved
provisions of AR 600- Each member must re- person
31 ceive nutrition counsel- Fitness Program Man-
ing by a registered die- ager conducts physi-

titian and receive a cal activity/exercise
Navy Nutrition and program or other
Weight Control Self- HAWC staff member
Study Guide identified by HPM
Each member can partici-
pate in SS
Fails fitness test Remedial PT Failure to pass the body Assigned to RPCP Fitness program
composition and/or the
PRT constitutes a PFA
cycle failure
Mandatory FEP at unit
level until sailor passes
two consecutive PFAs
Fails three PFAs in a 4-y
period then denied re-
enlistment and manda-
tory punitive comments
on fitness report
continued
47
48
TABLE 2-7 Continued
Medical evaluation Health care personnel Must receive clearance MO MD
when requested by the from appropriate medi-
unit commander or cal authority to partici-
prior to separation due pate in FEP (MD, PA,
to failure to make satis- NP, IDC)
factory progress
Exemptions/deferrals Pregnancy, postpartum Pregnancy, waived from Pregnancy Pregnancy, until 6-mo
(profile) recovery PRT/BCT until 6-mo postpartum, UC may
Documented medical postpartum approve up to 18 mo
condition Well-documented medical Medical (TMD), body-
condition may be given a fat standard adjust-
medical waiver from par- ment
ticipation in body com- If over body-fat limit
position assessment, but appears fit, then
PRT, or physical condi- needs IC approval
tioning
Required weight loss 3–8 lb/mo No minimum exists Normally: (weight-loss Females; 3 lb/mo or 1%
(“progress”) CFL monitors progress of goal)/(6 mo) body fat/mo
individual on FEP Case-by-case, deter- Males: 5 lb/mo or 1%
Stays on mandatory FEP mined by MO body fat/mo
until two consecutive
PFAs have been passed

Bimonthly mock PRT and
body-fat assessments are
conducted to ensure pro-
gress
Program structure Soldier is entered into Mandatory participation in 6-mo initial assign- Pre: 3-mo exercise and
program FEP tailored to individu- ment/6-mo extension dietary period: 4
Weight-reduction counsel- als needs permissible if progress classes of WBFMP
ing (follow-up is estab- CFL utilizes MWR fitness is being made Phase I: (6 mo) body fat
lished at the discretion of instructors to assist with Second assignment 6 assessed monthly
the health care person- exercise program mo, no extension Phase II: (6 mo) obser-
nel) CFL supplies Navy Nutri- available vation; if body fat in-
Monthly weigh-ins (unit tion and Weight Control creases, returns to
level) to assess progress Manual, self paced Phase I
(body-fat measurements Nutrition counseling given
may be made at this by RD, possible partici-
time) pation in local weight-
Removal from program management program
when body-fat standard
is achieved
continued
49
50
TABLE 2-7 Continued
Program structure (con- Referral to SS, 10-wk
tinued) weight-management
program officially sanc-
tioned program by Bu-
Med
SS is only offered by
MTFs that choose to par-
ticipate; not mandatory
Completion of program When body-fat standard is Remains in FEP until two Self-maintenance of Maintenance of body-
achieved consecutive PFAs are standards/no oversight fat standards for 6
passed consecutive mo
If a member graduates
from SS, there is no re-
quirement to be back
within standards
Three-failure rule in a 4-y
period is still in effect

Administrative actions 36-mo probation Members no longer sepa- No progress during None during EDP
(grounds for separa- 6 mo without meeting rated for PRT/body initial assignment (due No PME allowed, no
tion) body-fat standards composition failures to lack of effort) or not reenlistment, no pro-
Exceeding body-fat stan- No punitive administrative meeting weight stan- motion for enlisted,
dard within 12 mo of marks until third failure dard or body-fat goal separation after four
program completion in a 4-y period during 2-d assignment unsatisfactory periods
Enlisted: May not reenlist, (not necessarily con-
advance or redesignate secutive) while in pro-
until three consecutive gram
PFAs are passed and
within standards on day
of action
Officers: May not promote
or redesignate until three
consecutive PFAs are
passed and within stan-
dards on day of action
continued
51
52
TABLE 2-7 Continued
Remedial action in Measuring outside of body See administrative ac-
basic combat training composition standards tions
constitutes a PFA cycle
failure and all above ac-
tions apply
a
AR = army regulation , PT = physical training.
b
PFA = physical fitness assessment, PRT = physical readiness test, CFL = command fitness leader, SS = shipshape, FEP = fitness enhance-
ment program, MD = medical doctor, PA = physicians assistant, NP = nurse practitioner, IDC = independent duty corpsman, BCT = basic
combat training, MWR = morale, welfare, and recreation, RD = registered dietitian, BUMED = Bureau of Medicine and Surgery, MTF =
medical treatment facilities.
c
PT = physical training, MO = medical officer, RPCP = remedial physical conditioning program.
d
PCS = permanent change of station, TDY = temporary duty away, BOTS = basic officer training school, PME = professional military edu-
cation, MAW = maximum allowable weight, HAWC = health and wellness center, HPM = health promotion manager, MAJCOM = major
command, MD = medical doctor, UC = unit commander, TMD = temporary medical deferral, IC = immediate commander, WBFMP =
weight body fat management program, EDP = exercise and dietary period.
SOURCE: USAF (2002); U.S. Army (1987); USMC (2002); U.S. Navy (2002).

“heart-healthy” dining hall menus (Fiedler et al., 1999). A recent Army study
(Arsenault and Cline, 2000) reported the positive effects of the regular consump-
tion of reduced-fat food items on total nutrient consumption and BMI in 50
women in a U.S. Army Medical Department Officer Basic Course.
Each of the services performs medical evaluations to rule out possible
medical causes of overweight before referring an individual to a weight-
management program. A medical officer evaluates the individual’s records and
physical health to ensure that participation in a weight-management program
will be safe. However, the extent of this medical evaluation is not well defined,
except by the Air Force. In some programs, specific tests are conducted for un-
derlying disease; the Air Force also assesses psychosocial factors such as readi-
ness and stress levels.
Army
The Army program, “Weigh to Stay,” is managed by physical fitness train-
ers who must complete a course on weight loss and weight-control counseling.
The Army also runs a number of hospital weight-loss and weight-management
programs that are overseen by physicians as part of preventive medicine re-
search efforts. The Hawaii-based program is highly innovative in its reliance on
behavior modification and use of the Internet to maintain support of individuals
at remote locations (James LC et al., 1997; James et al., 1999b). Monthly weigh-
ins are required, and those who fail to make satisfactory progress (loss of 3 to 8
lb/mo) for 2 consecutive months can face separation. Exemptions from the pro-
gram are granted for prolonged illness, pregnancy (up to 180 d postpartum),
hospitalization, or a medical profile waiver (U.S. Army, 1987).
Navy
According to the Physical Readiness Program (U.S. Navy, 2002) the
Navy's Command-Directed Physical Conditioning Program (CDPCP) is required
for all individuals who fail the physical fitness test or who do not meet body fat
standards. It is a 6-month program managed by a command-trained, physical-
fitness coordinator (an enlisted person who has undergone 2.5 days of training).
The program includes mandatory supervised exercise three times per week.
Each individual who exceeds body-fat standards is issued a self-study nutrition
and weight-control guide. A more rigorous, second phase program is the Bureau
of Medicine-Approved Weight Management Program, an intensive 2-week out-
patient program that requires the commanding officer’s endorsement and 6-
months prior participation in the CDPCP. Individuals with three fitness or body
fat failures are not eligible (three failures in 4 years results in administrative
action and although individuals are no longer separated from the service, they
are not permitted to reenlist and are not eligible for promotion for the duration of
their enlistment term). Successful completion of the Bureau of Medicine pro-

gram and 1 year of follow-up in which progress continues toward meeting body
fat standards result in a clear record. The Navy also conducts a 2-day course on
recipe modification for mess specialists. The Navy has some innovative, small-
scale weight-control programs to which selected individuals can be assigned.
These include a 10-week program on nutrition, behavior modification, and exer-
cise, with monthly support-group follow-up at the Norfolk Navy Environmental
Health Center; a shipboard weight-control program (Dennis et al., 1999); and a
program at San Diego Naval Medical Center that is regarded as a model for pro-
grams used at other locations (Carlson and Burman, 1984; Trent and Stevens,
1993, 1995). The challenge for the Navy has been to devise a single program
that would address the needs of personnel at diverse duty stations and that could
be taught by minimally trained personnel (Hoiberg and McNally, 1991).
Marine Corps
The Marine Corps’ physical fitness/weight-control program, “Semper Fit,”
similar to that of the Army, is managed by physical fitness trainers. Diet coun-
seling is administered by self-study or by a dietitian if the individuals are close
to an installation with an available dietetic service. Individuals who fail to meet
the body fat standards and who do not receive a medical waiver are enrolled for
an initial period of 6 months. If the individual is progressing but has not yet
reached the target weight or percent body fat at the 6-month point, he or she may
be allowed to continue for another 6 months. If after reaching the goal, the indi-
vidual fails again during the rest of his or her career, he or she is allowed an-
other 6 months to achieve compliance or face separation (USMC, 2002).
Air Force
The Air Force Weight and Body Fat Management Program (WBFMP) op-
erates from a health and wellness center (HAWC) located on each base, which is
responsible for assessment of weight, body fat, fitness, and data recording. Per-
sonnel who exceed the body-fat standards undergo clinical, laboratory, and psy-
chological assessment to determine their qualification for the WBFMP. Those
deemed unqualified are sent to an appropriate practitioner for care. The program
consists of three phases. Medically cleared personnel are admitted to a 3-month
initial program that provides counseling on diet and behavior modification by an
Air Force dietitian or other authorized medical personnel, as well as exercise
instruction provided by the HAWC staff. All individuals assigned to the pro-
gram must attend a series of four classes concerning diet, behavior modification,
and exercise. Personnel enrolled in the initial program are not penalized by ad-
ministrative actions during the 3-month enrollment, although they are restricted
from some professional activities. Personnel who meet their weight/body fat
standard after completion of the 3-month program proceed to Phase II, a 6-
month maintenance/monitoring program. Following successful completion of

Phase II, the individual’s WBFMP records are expunged. Personnel who fail to
meet their goal within the first 3 months of the initial program are enrolled in
Phase I, a more intense weight-management program in which monitoring is
conducted monthly and the individual is subject to significant administrative
restrictions relating to assignments, training, and promotions. Each Air Force
installation has the authority to select programs approved by the Major Com-
mand dietitian for use in counseling on diet and exercise (USAF, 2002), for ex-
ample, “The Sensible Weigh” or “Shape Your Future Your Weigh.”
SUMMARY
Accession and retention weight-for-height and percent body fat standards
vary across the four services, as does the comprehensiveness of weight-loss pro-
grams. A review of the weight-loss programs across the military services high-
lights some significant deficits that could affect success. All of the programs
have a strong motivating component that is highly disciplinary in nature—the
penalties for exceeding the body fat limits are significant. The majority of par-
ticipants receive only minimal counseling by a qualified dietitian (with the ex-
ception of those in the Air Force program). The same appears to be true
throughout the services for the area of behavior modification. With the excep-
tion of the Air Force (Spahn, 1999) and some specific sites in the other services,
data collection for program evaluation is lacking.


3
_________________________________________________________________________________
Factors That Influence Body Weight
There are numerous factors that can influence body weight. The individual
has no control over some of these factors, including developmental determin-
ants, genetic makeup, gender, and age. Other factors that influence body weight
over which the individual has potential control include level of physical activity,
diet, and some environmental and social factors. This chapter explores the
relationship between each of these factors and body weight.
DEVELOPMENTAL DETERMINANTS
It has been postulated that there are times during people’s lives when
exposure to certain factors may increase their risk for the onset of obesity. These
times have been termed “critical periods.” If these critical periods, along with
the influential factors, can be clearly defined, it may be possible to identify
individuals at increased risk for the development and persistence of overweight
and obesity in adulthood. The prenatal period, the period of adiposity rebound,
and adolescence have been proposed as critical periods in childhood (Dietz,
1994); pregnancy and the immediate postpartum period have been proposed as
critical periods for women in adulthood.
Prenatal Factors
Although the data are subject to a variety of interpretations, it has been
documented in both animals and humans that females who are severely food
restricted during the first one to two trimesters of pregnancy have progeny who
have a higher prevalence of obesity, diabetes, insulin resistance, and hyperten-
sion later in life. Progeny of survivors of the Dutch famine in World War II
demonstrated a higher prevalence of obesity and diabetes (Ravelli et al., 1976),
although this conclusion was questioned by later studies (Jackson et al., 1996;
Susser and Stein, 1994). Malnutrition in utero also has been reported to result in
57

increased obesity and its complications later in life (Stanner et al., 1997). Lower
birth weights also seem to be associated with increased upper body visceral
adiposity in later life with its attendant increased risk of cardiovascular disease
(Oken and Gillman, 2003; Rogers, 2003). Since individuals from a lower socio-
economic background are more likely to be exposed to malnutrition during
gestation or early childhood, the prevalence of obesity in such subgroups might
be expected to be higher.
Adiposity Rebound
Adiposity increases from birth until approximately 1 year of age, then de-
clines to a minimum at approximately 6 years of age. The term “adiposity re-
bound” refers to the increase in body mass index (BMI) and body fat that occurs
after this nadir in children between the ages of 5 and 7 years. Children experi-
encing adiposity rebound at an earlier age appear to have a three- to sixfold
greater risk of increased adult BMI than do other children (Whitaker et al.,
1998). He and Karlberg (2002) demonstrated, through the development of prob-
ability charts based on 3,650 children followed from birth to 18 years of age,
that children who experienced this rebound before 8 years of age have a higher
risk of adulthood obesity. However, Guo and coworkers (2000), using serial
BMI data from the Fels Longitudinal study demonstrated that while there was no
association between early age at adiposity rebound and adult BMI status in men,
after controlling for effects of birth weight, adult physical activity, alcohol and
cigarette use, there was approximately twice the risk for overweight with early
rebound in women.
Causes of early adiposity rebound have been variously attributed to ad-
vanced skeletal maturity (Roland-Cachera et al., 1984; Williams and Dickson,
2002), high protein intake (Roland-Cachera et al., 1995), and parental BMI
(Dorosty et al., 2000). Cameron and Demerath (2002) concluded after extensive
review of the available scientific literature that the evidence is still not clear
about whether age at adiposity rebound is a critical period for the development
of obesity, but that early adiposity rebound might well be a statistical predictor
of later obesity because of its strong relationship with early adiposity and accel-
erated maturation, both of which are established markers of later risk of obesity.
Adolescence
Although only 30 percent of adult obesity begins during childhood, 70 per-
cent of the adult obesity that begins in childhood may start during adolescence
(Dietz, 1994). Adolescent obesity is associated with a variety of adverse health
effects in adulthood, including early mortality in men and increased risks of
coronary heart disease, diabetes, and colorectal cancer (Miller, 1988; Must et al.,
1992; Wylie-Rosett, 1988). Most of these risks were only slightly attenuated by

FACTORS THAT INFLUENCE BODY WEIGHT 59
adjustment for adult obesity, which suggests that obesity during adolescence
may determine the risk of these later complications regardless of whether or not
the individuals are obese adults.
While total fatness is an important consideration when evaluating develop-
mental aspects of obesity, an additional consideration is adipose tissue distribu-
tion. Visceral adipose tissue has an independent effect on obesity-associated
comorbidities (Emery et al., 1993) that is separate from that of total body fat,
although the developmental aspects of visceral adipose tissue deposition have
not been well studied. Among children, visceral adiposity appears to be
associated with an increased risk of cardiovascular risk factors such as elevated
triglycerides and reduced high-density lipoproteins that are independent of total
body fat (Caprio et al., 1996; Gutin et al., 1994). However, the ages at which
these relationships appear remain unclear. Cross-sectional studies suggest that
visceral adipose tissue deposition is not marked before adolescence, but
increases rapidly at that time.
Adulthood
The period after adolescence has not been intensively studied, although
approximately two-thirds of adult obesity begins after adolescence. Whether
additional critical periods exist in adulthood is less certain, but pregnancy and
postpartum may constitute one such period for a subset of women (Williamson
et al., 1994). Postpartum weight retention appears to range from 0.5 to 4.8 kg for
most women (Johnston, 1991), but African-American mothers may be twice as
likely to retain 9.1 kg (20 lb) or more postpartum than Caucasian mothers
(Parker and Abrams, 1993). Boardley and colleagues (1995) found that African-
American women ate more and were less physically active postpartum than
were the Caucasian women in their sample. When the possible confounding
factors of prepregnancy weight, gestational weight gain, prenatal physical
activity, parity, and socioeconomic status were controlled, African-American
women still retained more weight in the postpartum period than did Caucasian
women. Results of several recent studies suggest that possible genetic factors
may be involved in the tendency to retain weight postpartum. One study found
that in women with normal prepregnancy BMIs, high first-trimester serum leptin
concentrations (a protein hormone encoded by the obese gene) correlated with
increased gestational weight gain and postpartum weight retention (Stein et al.,
1998). In another study, women within 12 months of the birth of their first child
who were homozygous for the 825T allele of the G-protein ß3, considered a
“thrifty” genotype, had significantly higher BMIs and postpartum weight
retention than women who did not carry the genotype (Gütersohn et al., 2000).
No effect of the genotype was observed among women who had never given
birth, suggesting a pregnancy-specific phenomenon. In addition, this relation-
ship was only observed among women who engaged in low levels of physical

activity, supporting the idea that physical activity may mitigate effects of genetic
endowment on the potential for postpartum weight retention. Whether this
particular genetic variation in this specific G protein is causally linked to the
observed differences in BMI and weight retention or is merely a marker for the
responsible mutation, as well as what the mechanism might be, are both
questions that require further investigation (Feldman and Hegele, 2000).
GENETIC DETERMINANTS
The understanding of the genetic influences on overweight and obesity in
humans has increased dramatically. Individuals show significant heterogeneity
in their body weight and body fatness responses to altered energy balance,
dietary components, and changing activity levels. It is now well-established that
overweight and obesity have a significant genetic component, with estimates of
the contribution of genetic variation to observed variation in obesity-related
phenotypes (such as BMI, fat mass, and leptin levels) ranging from 30 to 70
percent (Comuzzie et al., 1993, 1994, 1996). However, little is yet known about
the specific causes of heterogeneity (Pérusse and Bouchard, 1999). It seems
clear that energy metabolism and neural control of appetite are involved in
regulating body weight and may contribute to the etiology of obesity. Studies of
resting metabolic rate show that the variation within families is less than the
variation among families (Bogardus et al., 1986).
Several studies have evaluated the potential mechanisms by which genetic
factors may contribute to obesity. One of the mechanisms by which differences
in energy metabolism may contribute to obesity may involve defects in
uncoupling proteins (UCP). Several types of uncoupling proteins have been
identified. Fleury and colleagues (1997) first described human uncoupling
protein 2 (UCP-2) and its links to obesity and hyperinsulinemia. Bouchard
(1997) noted that markers near the UCP-2 gene in humans are linked to
differences in resting metabolic rate. Thus, genetic differences in UCP-2, and
perhaps other UCPs, may contribute to human obesity.
There is a group of at least 20 Mendelian syndromes in which obesity is a
component, including Prader-Willi, Bardet-Biedl, Borjeson, Cohen, and Wilson-
Turner (Gunay-Aygun et al., 1997; Reed et al., 1995). These genetic disorders
are rare, and family studies do not suggest that the genes responsible for these
syndromes are involved in the common forms of human obesity. For more than
99 percent of obese humans, the genetic basis of their obesity is unknown.
Animal Models of Genetic Obesity

The strongest evidence for genetic weight-regulating mechanisms is the re-
cent elucidation of single gene defects that are associated with excessive weight
gain in animals. Single gene mutations can indisputably cause obesity in both

rodent models and in humans. In rodents, such mutations have been identified in
at least five genes: the obese gene for the circulating adipose tissue-secreted
factor leptin; the db gene for the receptor of leptin; the agouti yellow mutation,
which controls hair color in mice through the production of melanin pigments
(with its human equivalent, agouti signaling protein gene); the fat mutation in
the carboxipeptidase E gene, which is a prohormone processing enzyme; and the
tub mutation, the function of which has yet to be determined. Of the five gene
products that currently have been associated with weight regulation, leptin is the
best characterized. Genetic defects in leptin are associated with extreme obesity
in both humans and laboratory animals. In addition, serum concentrations of
leptin are elevated in close proportion to body fat in obese people with no defect
in the leptin gene. Recent studies show that administration of recombinant leptin
to lean and obese individuals results in dose-dependent weight loss (Heymsfield
et al., 1999). Further research is needed to assess the potential role of leptin in
obesity treatment.
Familial Aggregation of Risk for Obesity

Using the comprehensive Danish adoption registry, Stunkard and colleagues
(1986) found that adopted children who were raised separately from their
biological parents had body weights closer to those of their biological parents
than to those of their adoptive parents. The children in this study were separated
from their parents at a very early age, generally before 3 months, so the oppor-
tunity for the biological parents to instill eating and activity habits was very
limited. Another study of adoptees showed a significant genetic influence on
obesity, but none of the environmental indicators evaluated were found to
contribute, although a number of the conditions considered have previously been
associated with obesity (Sorensen et al., 1998). Stunkard and colleagues (1986)
estimated that as much as 70 percent of the variance in the occurrence of obesity
could be attributed to genetic factors, but other authors have postulated that as
little as 20 percent of the variance is due to genetic factors. The general consen-
sus is that genetic factors account for about 30 to 50 percent of the variance in
the occurrence of obesity (Bouchard, 1997).
Twin studies provide the most impressive clinical evidence that genetic
factors play an important role in the etiology of obesity in humans. Stunkard and
colleagues (1990) studied identical and nonidentical twins who were reared
together and others who were reared apart. They found a high correlation of
body weight among identical twins, even if they were reared apart. Bouchard
and colleagues (1990) studied twins who were isolated in the Canadian wilder-
ness with no access to foods other than those provided by the investigators.
Identical twins were overfed for a period of 100 days, and their gains in body
weight and adipose tissue were evaluated. There was a closer association of both

body weight and intra-abdominal adipose tissue (visceral fat) within twin pairs
than among twin pairs.
The maximal heritability of obesity has been estimated to range from 30 to
50 percent, based on a review of family studies (Chagnon et al., 2000). Although
extensive efforts have been made to identify mutations in the genes identified as
obesity-associated in rodents and in other candidate genes for obesity in humans,
to date only a handful of individuals have been identified with mutations in any
of the genes that have produced obesity in rodents. Specifically, several humans
have been identified with mutations in the leptin gene or its receptor, but no
individuals have yet been found with mutations in the other genes identified in
rodents.
In total, single gene mutations have been identified as responsible for
obesity in 25 persons, with these mutations appearing in 7 genes (12 different
mutations) (Pérusse et al., 1999) or in 5 genes (Chagnon et al., 2000). Studies of
quantitative trait loci (QTL) in rodents have suggested at least 98 different QTLs
associated with obesity (Chagnon et al., 2000).
Currently, the major effort in the search for specific genes that contribute to
human overweight and obesity is based on the use of genome scanning. In
genome scanning, linkage analysis is conducted to identify QTLs that affect the
specific phenotype under study. The use of genome scanning has provided
evidence of QTLs that influence body weight and the number of fat cells
(Chagnon et al., 2000).
Comparison of the risks of obesity in spouses and in first-degree relatives
has suggested that genetic factors may be of greater prominence in more severe
obesity (Katzmarzyk et al., 2000). Among the members of families that contain
at least one morbidly obese person, a major gene effect was transmitted in a
codominant fashion, suggesting a gene-environment interaction (Rice et al.,
1999). Both multifactorial and major gene effects have been suggested. Efforts
are ongoing to identify the genetic and molecular basis of overweight and
obesity, and it is likely that many genes (and within these genes and their
promoters, many different mutations or variants) that are responsible for the
genetic variation of obesity in humans will be identified.
The development of obesity likely involves a combination of shared
environment and shared genetic propensities. The rapid increase in prevalence
of obesity in the United States, as well as in many other countries, across all age
groups may reflect a removal of environmental constraints (e.g., high levels of
daily activity and food availability) on the expression of obesity genotypes.
Knowledge of the genetic components of obesity is not likely to be useful to the
military in the near term, but identification of markers of potential risk of
obesity may well have implications for future screening.

45
Percent of Individuals Overweight or

40
35
30 pre-obesity
25 class I
Obese
20 class II
15 class III
10
0
20-29 30-39 40-49 50-59 60-69 70-79 > 80
Age Group
FIGURE 3-1 The prevalence (%) of overweight and obesity of men and women by age
in the U.S. population. Preobesity = body mass index (BMI) of 25–29.9, class I obesity =
BMI of 30–34.9, class II obesity = BMI of 35–39.9, and class III obesity = BMI ≥ 40.
SOURCE: Third National Health and Nutrition Examination Survey, 1988–1994, Must et
al. (1999).
AGE
Cross-sectional and longitudinal studies indicate a gradual increase in the
average BMI of Americans up to the ages of 50 to 60 years (IOM, 1995). This
trend is similar, with some variation, across males and females and across all
evaluated ethnic groups. Population studies also indicate a decline in body
weight and BMI among the elderly, usually in the seventh and eighth decades
(IOM, 1995; Kuczmarski et al., 1994; NHLBI, 1998). The same trends have
been identified in changes in total body fat and percent body fat (Chumlea et al.,
2002). Overweight and obesity thus reach maximal rates among middle-aged
adults. This pattern is shown in Figure 3-1.
The age-related body mass increase up to the fifth and sixth decades is
accompanied by additional anatomical, structural, and body compositional
changes. Stature declines from about age 30 onward, with rates in women faster
than those in men and for postmenopausal women faster than their premeno-
pausal counterparts. Declining stature accounts for a small portion of the age-
related increase in BMI (Gallagher et al., 1996).

Many weight-management experts agree that body weight becomes pro-

gressively more difficult to maintain with age, but there appears to be little
rationale for increasing the upper BMI range consistent with good health as
individuals become older. Williams (1997) indicated that body weight and
associated circumferences would increase with advancing age unless food intake
is reduced and physical activity is substantially increased.
A large number of cross-sectional studies, however, do demonstrate that
body fat increases with age, even after controlling for changes in body weight
and physical activity levels (Baumgartner et al., 1995; Flynn et al., 1989;
Forbes, 1987; Forbes and Reina, 1970; Gallagher et al., 1996, 1997; Noppa et
al., 1980; Novak, 1972; Steen et al., 1979). Gallagher and colleagues (1996)
demonstrated that the mean body-fat content in nonexercising civilian women
with a BMI of 25 increased from 30 percent for those between the ages of 17
and 20 years to 36 percent for those ages 40 years and older. The implication of
this is that lean body mass and, frequently, skeletal mass, decrease with age.
Additionally, partitioning of adipose tissue between the subcutaneous and
visceral compartments is also moderated by age (Borkan et al., 1983). Men have
more visceral adipose tissue than do women at all ages, and the rate of visceral
adipose tissue increase with age is greater in men than in women (Blaak, 2001).
In contrast to body fat, skeletal muscle mass declines with age beginning
around the third decade of life (Dutta and Hadley, 1995). This observation is
true not only for the general population, but it is also evident in military
personnel (USAF, 1975). The rates of decline may accelerate after the onset of
menopause in women (Aloia et al., 1991) and for both genders in the seventh
and eighth decades (Flynn et al., 1989). Losses of skeletal muscle parallel
changes in skeletal minerals with advancing age and are present even after
controlling for loss in body weight (Gallagher et al., 2000). The mechanisms of
body composition change with aging are multifactorial and include physical
inactivity, diet, and hormonal and cytokine alterations. The loss of lean mass
and gain in fat mass occur even with no apparent change in body weight. Since
lean mass contributes the larger share of metabolic activity, total energy
expenditure during rest or low activity will also decrease proportionally with the
loss of lean mass.
Total energy expenditure and thus, energy requirements, decrease with
advancing age (Tzankoff and Norris, 1978). Physical activity levels are lower in
older individuals, which account for a portion of the energy expenditure
reduction that comes with aging. Resting energy requirements are also lower in
the elderly, due largely to decreases in all metabolically active tissues, including
skeletal muscle, brain, and visceral organs. In laboratory animals, the heat
produced by tissues per unit of mass decreases with age (a decrease in the
specific resting energy expenditure of organs), but it remains uncertain whether
this observation also applies to humans. The practice of resistance training by
people over the age of 50 years may enhance fat-free mass, primarily skeletal

muscle, and thereby help offset the age-related decline in resting metabolic rate
(Hill and Saris, 1998; Tzankoff and Norris, 1977). In women, loss of ovarian
function accounts for a lower rate of overall heat production compared with that
observed in premenopausal women (Poehlman and Tchernof, 1998). Thus, both
older men and women have lower rates of energy expenditure and, unless
counterbalanced by increased physical activity and reduced food intake, older
individuals, in general, will gain weight over time.
RACE/ETHNICITY
Whether there are racial/ethnic differences in response to the various
components of weight management is a legitimate research question that has
been explored to only a moderate extent. Data from National Health and
Nutrition Examination Surveys (NHANES) clearly indicate that there are
racial/ethnic differences in the prevalence of overweight and obesity. Flegal and
coworkers (2002), reporting on 1999–2000 NHANES data, determined that in
men 20 years of age and older, the prevalence of overweight (BMI ≥ 25) was
67.4 percent for non-Hispanic whites, 60.7 percent for non-Hispanic blacks, and
74.7 percent for Mexican Americans. The differences were not statistically
significant, but sample sizes were relatively small. However, for women ages 20
years and older, the prevalence of overweight was 57.3 percent in non-Hispanic
whites, 77.3 percent in non-Hispanic blacks, and 71.9 percent in Mexican
Americans. The difference in prevalence between non-Hispanic white and non-
Hispanic black women was statistically significant (Flegal et al., 2002). The
causes of these differences in the prevalence of overweight have not been clearly
identified, but are likely to be a combination of physiology, culture, and
behavior.
The relationship of BMI to percent body fat is also affected by race/
ethnicity. Fernandez and colleagues (2003) recently reported the results of an
analysis of 11 cross-sectional studies involving body composition assessments
of African-American men and women, Hispanic-American men and women,
and European-American men and women. The average age ranged from 42.6 to
50.8 years, and the average BMI ranged from 25.1 (European-American
women) to 29.8 (African-American women). Total body fat was measured using
dual-energy X-ray absorptiometry. There were no differences in the estimation
of percent body fat from BMI for men across ethnic groups. However, for
women with BMIs less than 30, Hispanic-American women had a significantly
higher percent of body fat at a given BMI than did African-American or
European-American women. However, at BMIs greater than 35, European-
American women had a higher percent body fat than either of the other two
groups of women. Some earlier studies have reported greater fat free mass in
African-American women compared with Caucasian women with the same

BMI, primarily due to the greater skeletal mass in African-American women

(Gallagher et al., 1996; Ortiz et al., 1992).
A number of studies have examined possible physiological reasons for these
race/ethnic differences. Foster and colleagues (1997) explored differences in
resting energy expenditure (REE) between obese African-American women and
Caucasian-American women. They found that REE was most closely correlated
to body weight and that African-American women had lower REE than
Caucasian-American women. Melby and coworkers (2000) examined behavioral
and physiological characteristics related to obesity risk in young, sedentary,
nonobese African-American and Caucasian-American women. The two groups
were similar in age and anthropometric characteristics. Parameters examined
included REE, respiratory exchange rates (RER), insulin sensitivity, and
maximal oxygen consumption. REE was 3 to 4 percent lower in African-
American women, but the difference was not statistically significant. However,
the resting RER was significantly lower in African-American women. The
African-American women also had significantly lower insulin sensitivity values
that resulted in higher acute phase insulin response to glucose. Total daily
energy expenditure and physical activity energy expenditure were significantly
lower in the African-American women.
Tanner and coworkers (2002) recently identified a relationship between
muscle fiber type and obesity. In a study of lean and obese African-American
and Caucasian women, type I muscle fibers (slow twitch, oxidative muscle
fibers) were significantly reduced in obese women compared with the lean
women, and type IIb fibers (fast twitch, glycolytic muscle fibers) were
significantly increased. These differences between lean and obese women were
greater in African-Americans than in Caucasians. The type IIb phenotype is
insulin resistant and deficient with regard to lipid disposal. The authors
speculated that the prevalence of the type II fibers might result in partitioning
lipid toward storage in skeletal muscle or adipose tissue rather than oxidation
within the skeletal muscle, resulting in a positive fat balance.
A number of studies have also examined social and behavioral factors that
may contribute to the difference in the prevalence of overweight between
African-American and Caucasian women (Kumanyika et al., 1993; Stevens et
al., 1994). Attitudinal and behavioral factors that limit the ability of some
African-American women to lose weight or maintain weight loss have been
identified. Regardless of whether or not they were overweight, African-Ameri-
can women were half as likely as Caucasian women to consider themselves
overweight. There is a much greater cultural tolerance of overweight among
African-Americans, and they have different body image perceptions. Although
African-American women responded physiologically to a weight-reduction
program in the same manner as Caucasian women, their drop-out rate from the
program was double that of Caucasian women (Glass et al., 2002).

PHYSICAL ACTIVITY
While recent studies point to the importance of genetic factors in the
etiology of obesity (Bouchard, 1997; Chagnon et al., 2000), the rapid rise in the
prevalence of overweight and obesity in the last 20 years likely reflects major
environmental shifts in exercise habits and food availability, which can be
controlled.
Physical activity represents an important component of volitional energy
expenditure. Modern transportation and other conveniences have reduced the
need for energy expenditure in the form of physical exertion. Reductions in
physical activity over the past several decades likely contribute to the evolution
of the positive energy balance and weight-gain characteristics of all industrial-
ized societies. Lack of physical activity begins in youth, with television
watching time correlated with BMI, as well as with both prevalence and severity
of overweight (Dietz and Gortmaker, 1985; Katzmarzyk et al., 1998; Tanasescu
et al., 2000). A reduced emphasis on school physical education classes has been
accompanied by a gradual decline in childhood fitness (Luepker, 1999). Indeed,
physical inactivity is a major risk factor for development of obesity in children
and adults (Astrup, 1999; Goran, 2001). Among adults who have maintained
weight loss over time, a common factor is increased physical activity (Klem et
al., 1997).
The effects of physical activity on weight and health may be influenced by
age. Owens and coworkers (1992) evaluated the effects of physical activity on
both weight change and the risk factors for cardiovascular disease during the
perimenopausal period. Women who increased their activity levels during the 3-
year study period (as measured using the Paffenbarger Physical Activity
Questionnaire) had the smallest increases in body weight and the smallest
decrement in high-density lipoprotein cholesterol.
Flatt (1987) has pointed out that to avoid increased fat deposition, both
energy balance and macronutrient balance (especially fat balance) are necessary.
When dietary fat is elevated, there is limited capacity to reduce total body fat by
fat oxidation. Exercise, especially in bouts of 30 minutes of activity or more
(Pate et al., 1995), can promote fat oxidation because the substrate that is
preferentially oxidized switches from carbohydrate to fat. Thus, chronic
extended bouts of exercise may, in effect, substitute for expansion of the adipose
tissue, allowing the physically active individual to achieve fat balance while
maintaining a lower body-fat mass than the sedentary individual (Flatt, 1987).
Jakicic and coworkers (1995) initially demonstrated that over the short term,
four 10-minute bouts of exercise per day, four times per week is more effective
in reducing body weight than a single 30 to 40 minute period of exercise.
However, the long-term data indicated that the short-term bouts of exercise were
not as effective as the long bouts in reducing weight and maintaining weight loss
(Jakicic et al., 1999).

Most fatty-acid oxidation in the human body occurs in muscle (Calles-

Escandon and Poehlman, 1997). The intrinsic capacity of muscle to oxidize fat
can be impaired by physical inactivity and possibly by loss of estrogen in
women, but it is amenable to partial correction by exercise training (Calles-
Escandon and Poehlman, 1997). A decrease in aerobic capacity and fat-free
mass, rather than aging per se, is responsible for the decrease in fat oxidation
seen in elderly women (Calles-Escandon and Poehlman, 1997). Exercise
training increases oxidative disposal of fatty acids and improves muscle
metabolism in both young and old individuals. However, the elderly do not
increase fat utilization in response to exercise to the same extent as the young,
despite performing exercise to the same intensity and for the same duration
(Blaak, 2000; Calles-Escandon and Poehlman, 1997).
In a study of 970 healthy, female twins with a wide range of percent body
fat, both total body fat and central adiposity were associated with physical
activity (Samaras et al., 1999). Moderate-intensity sports of 1 and 2 hour
durations accounted for within-pair differences of 1.0 kg and 1.4 kg,
respectively, of total body fat. Among participants in whom one of a pair of
twins was overweight, higher levels of physical activity were still associated
with 3.96 kg lower total body fat and 0.53 kg lower central abdominal fat. In
other words, even persons with an apparent genetic predisposition to adiposity
showed an effect of physical activity on body-fat mass (Samaras et al., 1999).
Studies of energy expenditure in individuals and families show that differences
are greater between families than within families (Bogardus et al., 1986). Some
differences in energy expenditure between families are due to genetic factors
and some are due to differences in activity patterns.
Hormones affect the relationship of physical activity, body fat, and fat-free
mass. Guo and coworkers (1999) found that associations between physical
activity and fat-free mass were more pronounced in postmenopausal women
than in premenopausal women, and that hormone replacement therapy had
beneficial effects on body composition. Monozygotic twin pairs who were
concordant for smoking and hormone replacement therapy status, but discordant
for moderate-intensity activity, showed greater within-pair differences in total
body fat than those who were concordant for activity level (Samaras et al.,
1999), suggesting that the effect of physical activity is greater than that of
hormonal status.
Habitual physical activity also affects other physical characteristics. Gilliat-
Wimberly and coworkers (2001) found that an association exists between
habitual physical activity and maintenance of resting metabolic rate in middle-
aged women. Physical activity also may reduce the incidence of chronic diseases
by favorably altering blood lipid profiles, reducing body fat, and improving lean
body mass (Eliakim et al., 1997; Schwartz et al., 1991; Wei et al., 1997; Wilbur
et al., 1999).

FOOD
Intake
In conjunction with the importance of physical activity levels, energy intake
must be matched to energy expenditure. Positive energy balance results if
energy intake is greater than energy expenditure. Increased energy consumption,
decreased energy expenditure, or both can result in positive energy balance.
While the etiology of obesity is multifactoral, the common characteristic of
all obese people is excessive energy storage in the form of body fat. Whether
obese people consume more energy than do lean people has been a major source
of controversy. Studies in modern respiratory chambers using doubly-labeled
water have shown that weight-stable obese people have a higher resting
metabolic rate and total 24-hour energy expenditure than do lean people (Jequier
and Schutz, 1983; Ravussin et al., 1982; Zed and James, 1986), which
demonstrates that average energy intake must indeed be higher in the obese.
Some differences in energy expenditure, and consequently in energy intake,
among families are due to genetic factors and differences in activity patterns.
Social and cultural factors also contribute to individual food intake differences
(de Castro, 1999).
Since the energy in food is derived from the macronutrients protein, fat, and
carbohydrate (CHO), plus the optional energy source, alcohol, diets that are high
in fat tend to be low in complex CHOs such as fiber. There is still considerable
controversy over whether the role of diet composition or simply total energy
intake is important in maintaining a healthy body weight.
Composition
A high energy intake or an energy intake that is not adjusted downward
with declining physical activity or age-related decreases in lean body mass is
associated with the development of overweight or obesity in susceptible individ-
uals. In addition to total energy intake, the character of the diet may play a role
in the etiology of obesity. High-fat diets may promote increased energy intake or
may be associated with metabolic changes that promote the deposition of
adipose tissue.
Dietary Fat
Research in both animals and humans suggests that high-fat (low in
complex CHOs) diets promote obesity (Astrup et al., 2000; Bahceci et al., 1999;
Blundell and Cooling, 2000; Cheverud et al., 1999; Maffeis et al., 2001).
Because fat is more energy dense than other foods (9 kcal/g versus 4 kcal/g for
protein and CHO), eating high-fat foods results in a greater energy intake than
would eating a similar quantity of lower-fat foods. Fat modifies the taste of food

and, in some people, promotes excess intake. Fatty foods tend to be easier to
chew or may not require chewing, thus making larger quantities easier to eat in a
shorter time than foods that require more mastication. Dietary fat also has a
weaker satiation effect than CHOs, which results in the over consumption of fat
(Rolls and Hammer, 1995; Rolls et al., 1999).
Some of the difference in weight gain on a high-fat versus a low-fat diet
may be explained by differences in the metabolic processing of fat. Compared
with dietary fat, CHOs require additional energy expenditure for digestion,
assimilation, and conversion to fat. When energy intake exceeds expenditure, 23
percent of energy consumed is required to convert and store CHO as fat,
compared with only 3 percent to store fat. Two studies in laboratory animals
have demonstrated this effect of dietary fat on body weight and body
composition (Donato and Hegsted, 1985; Lin et al., 1979).
The link between dietary fat and obesity in humans is not conclusive
because of difficulties in accurately measuring or controlling the food intake and
energy expenditure of individuals and the need to rely on estimates of body
composition. Nonetheless, increasing evidence from clinical studies suggests
that dietary fat promotes weight gain in humans as well as in animals. Studies in
which people were overfed diets varying in the proportion of energy from fat
(40 to 53 percent of kcal as fat) showed that high-fat diets promoted weight gain
more efficiently than did lower-fat diets (Sims et al., 1973).
A positive correlation between the proportion of fat in the diet and the
incidence of obesity has been noted among various cultures, as well as within
ethnic groups that have migrated to the United States and adopted American
dietary patterns (Curb and Marcus, 1991; Kushi et al., 1985). While these
correlations all point to a causal role for dietary fat in obesity, they are subject to
confounding variables such as differences in energy intake and expenditure,
health status, and genetic and environmental influences. However, based on
information such as that described above, Danforth (1985) recommended
shifting to a higher-CHO and lower-fat diet to reduce the high prevalence of
obesity in affluent societies such as the United States.
Obesity is more closely correlated with the level of dietary fat than with
total energy intake (Dreon et al., 1988; Romieu et al., 1988). A low incidence of
obesity has been observed among vegetarians who typically consume low-fat,
high-CHO diets (Knuiman and West, 1982; Sacks et al., 1975). However, those
who adhere to vegetarian diets for religious rather than nutritional reasons
probably have a higher-fat diet (Dhurandhar and Kulkarni, 1993), and the
prevalence of obesity among these types of vegetarians is high compared with
that of omnivores (Dhurandhar and Kulkarni, 1992).
Some studies have failed to demonstrate an association between fat intake
and body weight in free-living populations. On the basis of food frequency
questionnaires, Macdiarmid and colleagues (1994) stratified 1,800 people by
their fat consumption (high was considered to be 45 percent or more kcal as fat

and low was considered to be 35 percent or less kcal as fat) and found no
statistically significant difference in age, BMI, or social class between the two
groups. However, the high-fat group rated their general diet and health as
poorer. The high-fat group also consumed significantly more protein and total
energy, but less CHO and fiber; consumed meat and high-fat dairy products
more frequently; and consumed fewer fruits, vegetables, and cereals.
Results of a small study suggest that the amount of energy required to
maintain body weight may be related to the proportion of fat in the diet,
regardless of an individual’s weight status (Prewitt et al., 1991). These findings
suggest that dietary fat may promote greater weight gain and body-fat accumula-
tion than expected on the basis of energy intake alone. In contrast, Leibel and
colleagues (1992) found no relationship between the ratio of dietary fat/CHO
and the total energy required to maintain body weight. CHO ranged from 15 to
85 percent of total intake, and kcal from fat ranged from 0 to 70 percent of total
intake. The disparity between findings of these two studies may be due to the
shorter duration of the second study (33 days average and ranging from 15 to 56
days compared with 140 days in the Prewitt study). Differences among the
normal-weight patients in the study of Prewitt and colleagues (1991) were not
seen consistently before 13 to 16 weeks. Also, body composition was not
assessed in the Leibel study, and results of animal studies suggest that isocaloric
diets of varying fat content may produce differences in percent of body fat
without changing body weight (Boozer et al., 1990, 1993).
The arguments for whether dietary fat promotes obesity were summarized
in two recent, competing editorials. Willett (1998a, 1998b) argues that obesity
has increased in the United States despite reductions in intake of dietary fat and
that ecological studies have found no relationship between fat intake and
obesity. In contrast, Bray and Popkin (1998) argue that individuals who gained
weight may not have decreased (or may have increased) their intake of dietary
fat. They also argue that ecological studies may not be appropriate to study the
relationship between fat intake and obesity, that body weight is a poor measure
of body fatness, and that most of the previous studies focused on outcomes other
than obesity. Although the literature is not clear, results of studies on laboratory
animals and the small number of human studies suggest that dietary fat does
promote obesity. Recently, Astrup and colleagues (2002) reviewed evidence on
the effects of low-fat diets. Four meta-analyses of weight change occurring on
low-fat diets in intervention trials with overweight subjects were reviewed.
These analyses consistently demonstrated significant weight loss in both
normal-weight and overweight subjects.
Carbohydrates
Several rationales have been postulated for the use of high-protein, low-
CHO diets: (1) intake of a high proportion of kcal as CHO has adverse physio-

logical consequences, such as increasing insulin secretion, promoting fat deposi-

tion, and increasing serum triglycerides levels; (2) low-CHO diets can lead to a
“ketogenic” state, which has been hypothesized to suppress appetite; (3) a high-
protein diet preserves lean body mass during weight loss; and (4) the ther-
mogenic effect of protein is the highest of the three macronutrients, resulting in
increased energy expenditure for a similar intake.
There is at least some scientific rationale for the above hypotheses (Skov et
al., 1999a, 1999b). A high-protein diet has been found to: stabilize blood glu-
cose during nonabsorptive periods and reduce insulin response following test
meals (Layman et al., 2003b), improve glucose oxidation (Piatti et al., 1994),
decrease lipid oxidation (Piatti et al., 1994), produce positive changes in blood
lipids (Layman et al., 2003b), and provide greater satiety than diets higher in
CHO (Layman et al., 2003a). Although more research is needed on the subject
of amino acid flux measurements and how it relates to blood glucose levels, data
from Layman and colleagues (2003b) support the idea that the ratio of dietary
protein and CHO can have a significant effect on metabolic balance and specifi-
cally on glucose homeostasis during weight loss.
The role of CHO in soft drinks in producing obesity is controversial. Some
studies suggest that an increase in the consumption of soft drinks may have
contributed to the increased prevalence of obesity (French et al., 2000; Troiano
et al., 2000), whereas others do not support this hypothesis (Gibson, 2000;
Macdiarmid et al., 1998; O’Brien et al., 1982).
Portion Size
There is little research available on the role of portion size in the increasing
prevalence of overweight in the United States. However, common sense dictates
that it is a contributing factor. For example, a single serving of meat is con-
sidered to be 3 to 4 oz based on the Dietary Guidelines and the U.S. Food Guide
Pyramid. However, in restaurants (where Americans are spending a greater
portion of their food dollars), an 8-oz portion of red meat would be considered a
“petite” serving; the standard serving would be 12 to 16 oz. Thus, an individual
consuming a 16-oz steak in a restaurant would be likely to report (if asked in a
dietary survey) consuming a single serving of red meat, when in reality 4 to 5
servings were consumed.
The intake of soft drinks has increased dramatically in the last 40 years, as
has the trend towards larger portion sizes (Hill and Peters, 1998). While a
standard serving of a soft drink in 1960 consisted of one 6-oz serving, the
standard size serving today is 12 oz, and many vendors sell 20-oz bottles almost
exclusively. Fountain drinks have also increased to the “super-jumbo” 32- to 64-
oz sizes. It is not unusual for individuals to consume some 500 to 1,000 kcal per
day from soft drinks in addition to their usual solid-food diet.

The change to larger portion sizes has been particularly apparent in fast-
food restaurants where portion size has been used as a competitive tool. Full-
service restaurants also have adopted the practice of serving larger meals.
Similar to the increase in soft drink portions sizes, fast-food restaurants now
offer “super-size” portions for a minimal increase in cost. For example, a
“jumbo super-size” order of a large hamburger, french fries, and soft drink at a
fast-food restaurant may now contain more than 1,500 kcal for a single meal
(Nielsen and Popkin, 2003; Young and Nestle, 2002, 2003). One of the
distinguishing features of dining out in Europe compared with the United States
is the difference in restaurant portion sizes, a factor that may contribute to the
lower prevalence of obesity in Europe.
A recent trend analysis of portion size was conducted by Nielsen and
Popkin (2003). Data were taken from four national food-consumption surveys
covering the period 1977 to 1996. Food consumption was estimated as energy
intake in kcal and as average portion sizes using food models to assist
respondents in identifying portion size. Results demonstrated that for foods
eaten both inside and outside the home, portions sizes have increased for salty
snacks, desserts, soft drinks, fruit drinks, french fries, hamburgers, cheese-
burgers, and Mexican food.
Meal Patterns and Eating Habits

Eating patterns that are appropriate for an active lifestyle may continue after
the individual changes to a more sedentary lifestyle. Individuals for whom this
observation has been made include athletes and a large percentage of people
with increasing age and changing occupational responsibilities. Athletes who are
in training expend large amounts of energy each day and, for many organized
sports, are encouraged to eat large quantities to maintain their weight at an
artificially high level. When activity declines, the eating pattern established
during training may not be adjusted to meet the new lower energy needs. The
same is true of military personnel. During initial entry training, advanced
individual training, and special forces training, large amounts of energy are
expended on a daily basis. By the time training is completed, individuals have
been habituated to consume large amounts of food over a very short period of
time.
In many occupations, tasks that require more physical activity are assigned
to younger workers. As these workers age and acquire more responsibility, their
work may become more sedentary, but eating patterns may not change. This
pattern of decreased occupational energy expenditure with job promotion may
be common in the military as well. Privates, airmen, and junior noncom-
missioned officers are more active than senior officers and noncommissioned
officers. Despite strong commitments to engage in daily physical fitness, which
may be unchanged or even increased in more senior individuals, the decrease in

activities of daily living and job performance can lead to a positive energy
balance unless particular care is taken to reduce energy intake.
The ubiquitousness of vending machines and fast-food outlets ensures
constant access to foods at work—usually foods with a high caloric content
largely in the form of fat or refined CHO. A major contributing factor to the
epidemic of obesity in recent years is likely the rise in the proportion of meals
eaten away from home (eating out), along with the increase in access to foods in
virtually all locations. These changes have contributed in several ways to
promoting obesity. Because more families include two-wage earners, adults
spend more time out of the home and do not have time to prepare meals as they
customarily did in the past. Meals consumed at restaurants tend to be larger and
have a higher caloric content than those consumed at home, mainly because of
higher fat content and larger portion sizes (Young and Nestle, 2003). In
addition, a high percentage of meals eaten away from home are eaten in fast-
food restaurants or consist of fast-food take-out. The presence of food in
virtually every circumstance of daily life, from fast-food outlets to vending
machines, encourages and allows individuals to consume multiple calorically
dense meals and snacks per day (Bell et al., 1998; Rolls, 2000).
PHYSIOLOGICAL FACTORS
A number of phenotypic characteristics have been associated with the risk
of weight gain, notably alterations in nonvolitional components of energy
expenditure. Energy expenditure can be divided into three main components:
• Resting metabolic rate (RMR), the rate of energy expended at rest, un-
der thermo-neutral conditions, and in a post-absorptive state.
• Thermic effect of feeding, the incremental increase in energy expendi-
ture after a meal is consumed due to the energy costs of absorption and the
transport of nutrients, as well as the synthesis and storage of protein, fat, and
CHO. Some of the thermic effect of feeding may be mediated by sympathetic
nervous system activity.
• Energy expended for physical activity, including involuntary move-
ments associated with shivering, fidgeting, and postural control.
RMR accounts for 60 to 75 percent of total energy expended in most adults.

RMR is primarily related to the maintenance of fat-free mass, reflecting such
activities as protein synthesis and breakdown, temperature and cellular
homeostasis, and cardiovascular, pulmonary, and central nervous system
function. Metabolism associated with visceral organ mass makes the largest
contribution to RMR, followed by that of skeletal muscle mass and adipose
tissue (Gallagher et al., 1998). RMR is consistently greater in men than in
women due to the greater lean tissue mass of males. A low RMR relative to

body size was found to predict weight gain (Ravussin et al., 1988) in both men
and women, although some studies have not confirmed this observation
(Weinsier et al., 2000). RMR begins to decrease with age in the middle of the
fourth decade. Gilliat-Wimberly and coworkers (2001) found that an association
exists between physical activity and maintaining RMR in middle-aged women.
The thermic effect of feeding usually accounts for 5 to 10 percent of daily
energy expenditure and varies between lean and obese individuals (Astrup,
1996). Extensive studies have been inconsistent in supporting the view that ex-
cessive weight gain is secondary to a reduced thermic effect of food (Tataranni
et al., 1995).
Recent studies support the view that small, nonvolitional physical activities
such as fidgeting may account for individual differences in energy expended
with changes in energy balance (Levine et al., 1999; Zurlo et al., 1992).
Although relatively small in caloric magnitude, these activities may account for
some of the between-individual differences observed in the regulation of body
weight.
These three phenotypic energy expenditure characteristics serve as markers
for potential weight gain over the long term. Many factors may contribute to
these individual energetic differences, and the origin of these differences is the
basis of intensive study.
ENVIRONMENTAL FACTORS
Smoking and Alcohol
Cigarette smoking increases metabolic rate and may limit food intake, and
weight gain is a common consequence of smoking cessation (Perkins, 1993;
Russ et al., 2001). The use of alcoholic beverages may also have an impact on
body weight. Energy consumed as alcohol that is in excess of need is converted
to and stored as fat. Drinking alcohol has been shown to be associated with a
greater energy intake than drinking nonalcoholic beverages, perhaps due to
increased appetite (Tremblay and St-Pierre, 1996; Tremblay et al., 1995).
A recent, large prospective study of a cohort of men ages 40 to 59 with a 5-
year follow-up found that mean BMI increased significantly from the light-to-
moderate to the very-heavy alcohol intake group. The study concluded that
heavy alcohol intake (defined as ≥ 30 g/day of alcohol) contributed directly to
weight gain and obesity, regardless of the type of alcohol consumed (Wanna-
methee and Shaper, 2003).
Pharmacological Agents That Produce Weight Gain

Numerous drugs can produce weight gain and fat gain. These include
glucocorticoids (e.g., prednisone), hypoglycemic agents (e.g., insulin, sulfonyl-

ureas), certain antihypertensive agents (e.g., prazocin), anti-allergens (e.g.,

cyproheptadine), and numerous drugs that affect the central nervous system
(e.g., thorazine, tricyclic antidepressants, valproic acid, lithium). Most of these
drugs are used for diseases that mandate separation from the military, but there
are a number of drugs that may be taken by military personnel that are not
deemed a rationale for separation.
SOCIAL FACTORS
Americans live in a culture in which food is abundant. A well-developed
and efficient food transportation and storage system assures a readily available
and affordable food supply throughout the entire year.
The relative affluence of Americans has led to an increase in consumption
of snack foods (Morgan and Goungetas, 1986) and an increase in the proportion
of foods of animal origin compared with that of foods of plant origin (Senauer,
1986). Foods of animal origin are likely to be higher in energy and fat than
comparable quantities of foods of plant origin.
The availability and abundance of food in the U.S. marketplace has
accelerated dramatically in the past 30 years. The per capita energy content of
food entering the American marketplace increased about 500 calories on a daily
basis during this time period. In addition, fat intake has also increased steadily,
although the relative intake of fat has been decreasing since the 1970s (Putnam
and Allshouse, 1999). This decrease in fat intake has been associated with an
increase in average total energy intake (Bray and Popkin, 1998). Food-supply
studies indicate that the increase in the number of calories consumed is
accompanied by a shift in macronutrient consumption that reflects an increase in
refined CHO consumption and a decrease in consumption of fruits and
vegetables (Putnam and Allshouse, 1999).
Family and Ethnicity

Eating is an intensely social activity, and many eating habits are acquired in
a familial or ethnic setting. People tend to imitate the eating habits of their
parents, so quantity and quality of foods eaten and meal patterns tends to be
established early. Traditions that arise around eating patterns in a more agrarian
or active society may favor excess consumption. Ethnic groups differ in their
perceptions about appropriate body size and what constitutes overweight
(Bhadrinath, 1990; Root, 1990).
Studies of changes in diet with immigration and acculturation show, for
example, that Japanese who migrated to California and Hawaii have tended to
abandon the traditional low-fat Japanese diet for American food patterns
(Burchfiel et al., 1995; Curb and Marcus, 1991; Goodman et al., 1992; Hara et
al., 1996; Ziegler et al., 1996). The result has been a marked increase in weight

among these immigrants. Similarly, Japanese children who remain in Japan, but
whose diet is increasingly western, are also getting heavier (Murata, 2000;
Takada et al., 1998). Thus, dietary change is strongly associated with increased
weight in both of these carefully studied population groups. The same phenome-
non is observed in studies of South Asians who have migrated to the United
Kingdom and who have modified their diet and physical activity patterns
(McKeigue et al., 1992).
Socioeconomic Status
Social class and socioeconomic status (SES) influence the prevalence of
overweight. In many countries of the world, lower SES is linked to increased
body weight (Molarius et al., 2000). In contrast, in some developing countries
and primitive societies, obesity is considered a sign of affluence or fertility
(Molarius et al., 2000). However, some researchers who contend that obesity
decreases economic status have disputed the belief that lower SES causes
obesity in the United States. For example, one study reported that women who
were overweight in late adolescence or early adult life were more likely to have
lower income, greater levels of poverty, and decreased rates of marriage than
were normal-weight women with comparable degrees of disability (Gortmaker
et al., 1993).
The Potential Role of Viruses in the Etiology of Obesity

The possibility exists that at least some cases of human obesity are due to
viral infection. Five viruses and scrapie agents cause obesity in animals (Bernard
et al., 1988, 1993; Carp et al., 1998; Carter et al., 1983a, 1983b; Dhurandhar et
al., 1990, 1992, 1997, 2000; Gosztonyi and Ludwig, 1995; Lyons et al., 1982;
Nagashima et al., 1992). One of these viruses is a human adenovirus, Ad-36,
which has been shown to produce a syndrome of increased body fat and
paradoxically decreased serum cholesterol and triglycerides in chickens and
mice (Dhurandhar et al., 2000). Preliminary data have been reported that
demonstrated similar results in monkeys (Atkinson et al., 2000). Other prelim-
inary studies suggest that humans with serum antibodies to Ad-36 have a higher
BMI and lower serum lipids than do Ad-36 antibody-negative individuals
(Atkinson et al., 1998).
Humans in Bombay, India, who had serum antibodies to SMAM-1, an avian
adenovirus, were noted to be significantly heavier and to have lower serum
lipids compared with antibody-negative individuals. Viral antigen was found in
the serum of two of the individuals with SMAM-1 antibodies (Dhurandhar et al.,
1997).
More research is needed to confirm the hypothesis generated from the
above data that some cases of human obesity might be due to a viral infection.

Since adenoviruses are common cold viruses, the possibility of the spread of
Ad-36 and perhaps other obesity-producing viruses in the military community
may be of significant concern.
SUMMARY
The brief review of factors influencing body weight presented in this chap-
ter demonstrate that maintaining a healthy body weight is an extremely complex
issue. Maintenance of fitness and appropriate body-fat standards by military
personnel is affected by each individual’s genetics, developmental history,
physiology, age, physical activity level, environment, diet, ethnicity, and social
background.

4
_________________________________________________________________________________
Weight-Loss and Maintenance

Strategies
The most important component of an effective weight-management pro-

gram must be the prevention of unwanted weight gain from excess body fat. The
military is in a unique position to address prevention from the first day of an
individual’s military career. Because the military population is selected from a
pool of individuals who meet specific criteria for body mass index (BMI) and
percent body fat, the primary goal should be to foster an environment that pro-
motes maintenance of a healthy body weight and body composition throughout
an individual’s military career. There is significant evidence that losing excess
body fat is difficult for most individuals and the risk of regaining lost weight is
high. From the first day of initial entry training, an understanding of the funda-
mental causes of excess weight gain must be communicated to each individual,
along with a strategy for maintaining a healthy body weight as a way of life.
INTRODUCTION
The principle of weight gain is simple: energy intake exceeds energy
expenditure. However, as discussed in Chapter 3, overweight and obesity are
clearly the result of a complex set of interactions among genetic, behavioral, and
environmental factors. While hundreds, if not thousands, of weight-loss strate-
gies, diets, potions, and devices have been offered to the overweight public, the
multi-factorial etiology of overweight challenges practitioners, researchers, and
the overweight themselves to identify permanent, effective strategies for weight
loss and maintenance. The percentage of individuals who lose weight and
successfully maintain the loss has been estimated to be as small as 1 to 3 percent
(Andersen et al., 1988; Wadden et al., 1989).
Evidence shows that genetics plays a role in the etiology of overweight and
obesity. However, genetics cannot account for the increase in overweight
observed in the U.S. population over the past two decades. Rather, the behav-
ioral and environmental factors that conspire to induce individuals to engage in
79

TABLE 4-1 Benefits of Physical Activity

Benefit Reference
Improved maintenance of lost weight Pavlou et al., 1989a, 1989b; Phinney, 1992;
Skender et al., 1996; Wadden, 1993;
Wing, 1992; Wing and Greeno, 1994
Preservation of lean body mass Calles-Escandon and Horton, 1992; Wad-
den, 1993
Improved cardiovascular, respiratory, Calles-Escandon and Horton, 1992
and musculoskeletal fitness
Improved psychological profile and self- ACSM, 2000
esteem
Improved mood Wadden, 1993
Improved plasma blood glucose levels, Calles-Escandon and Horton, 1992; Pate et
blood pressure, and blood lipid and al., 1995; Pavlou et al., 1989a, 1989b
lipoprotein values
Reduced risk for morbidity and mortality Blair, 1993; Dyer, 1994; Pate et al., 1995
too little physical activity and eat too much relative to their energy expenditure
must take most of the blame. It is these factors that are the target of weight-
management strategies. This chapter reviews the efficacy and safety of strategies
for weight loss, as well as the combinations of strategies that appear to be
associated with successful loss. In addition, the elements of successful weight
maintenance also will be reviewed since the difficulty in maintaining weight
loss may contribute to the overweight problem. A brief discussion of public
policy measures that may help prevent overweight and assist those who are
trying to lose weight or maintain weight loss is also included.
PHYSICAL ACTIVITY
Increased physical activity is an essential component of a comprehensive
weight-reduction strategy for overweight adults who are otherwise healthy. One
of the best predictors of success in the long-term management of overweight and
obesity is the ability to develop and sustain an exercise program (Jakicic et al.,
1995, 1999; Klem et al., 1997; McGuire et al., 1998, 1999; Schoeller et al.,
1997). The availability of exercise facilities at military bases can reinforce
exercise and fitness programs that are necessary to meet the services’ physical
readiness needs generally, and for weight management specifically. For a given
individual, the intensity, duration, frequency, and type of physical activity will
depend on existing medical conditions, degree of previous activity, physical
limitations, and individual preferences. Referral for additional professional
evaluation may be appropriate, especially for individuals with more than one of
the above extenuating factors. The benefits of physical activity (see Table 4-1)

WEIGHT-LOSS AND MAINTENANCE STRATEGIES 81
are significant and occur even in the absence of weight loss (Blair, 1993;
Kesaniemi et al., 2001). It has been shown that one of the benefits, an increase
in high-density lipoproteins, can be achieved with a threshold level of aerobic
exercise of 10 to 11 hours per month.
For previously sedentary individuals, a slow progression in physical activity
has been recommended so that 30 minutes of exercise daily is achieved after
several weeks of gradual build-up. This may also apply to some military
personnel, especially new recruits or reservists recalled to active duty who may
be entering service from previously very sedentary lifestyles. The activity goal
has been expressed as an increase in energy expenditure of 1,000 kcal/wk
(Jakicic et al., 1999; Pate et al., 1995), although this quantity may be insufficient
to prevent weight regain. For that purpose, a weekly goal of 2,000 to 3,000 kcal
of added activity may be necessary (Klem et al., 1997; Schoeller et al., 1997).
Thus, mental preparation for the amount of activity necessary to maintain weight
loss must begin while losing weight (Brownell, 1999).
For many individuals, changing activity levels is perceived as more un-
pleasant than changing dietary habits. Breaking up a 30-minute daily exercise
“prescription” into 10-minute bouts has been shown to increase compliance over
that of longer bouts (Jakicic et al., 1995, Pate et al., 1995). However, over an 18-
month period, individuals who performed short bouts of physical activity did not
experience improvements in long-term weight loss, cardiorespiratory fitness, or
physical activity participation in comparison with those who performed longer
bouts of exercise. Some evidence suggests that home exercise equipment (e.g., a
treadmill) increases the likelihood of regular exercise and is associated with
greater long-term weight loss (Jakicic et al., 1999). In addition, individual
preferences are paramount considerations in choices of activity.
When strength training or resistance exercise is combined with aerobic
activity, long-term results may be better than those with aerobics alone (Poirier
and Despres, 2001; Sothern et al., 1999). Because strength training tends to
build muscle, loss of lean body mass may be minimized and the relative loss of
body fat may be increased. An added benefit is the attenuation of the decrease in
resting metabolic rate associated with weight loss, possibly as a consequence of
preserving or enhancing lean body mass.
As valuable as exercise is, the existing research literature on overweight
individuals indicates that exercise programs alone do not produce significant
weight loss in the populations studied. It should be emphasized, however, that a
large number of such studies have been conducted with middle-aged Caucasian
women leading sedentary lifestyles. The failure of exercise alone to produce
significant weight loss may be because the neurochemical mechanisms that
regulate eating behavior cause individuals to compensate for the calories
expended in exercise by increasing food (calorie) intake. While exercise pro-
grams can result in an average weight loss of 2 to 3 kg in the short-term (Blair,
1993; Pavlou et al., 1989a; Skender et al., 1996; Wadden and Sarwer, 1999),

outcome improves significantly when physical activity is combined with dietary

intervention. For example, when physical activity was combined with a reduced-
calorie diet and lifestyle change, a weight loss of 7.2 kg was achieved after 6
months to 3 years of follow-up (Blair, 1993). Physical activity plus diet
produces better results than either diet or physical activity alone (Blair, 1993;
Dyer, 1994; Pavlou et al., 1989a, 1989b; Perri et al., 1993). In addition, weight
regain is significantly less likely when physical activity is combined with any
other weight-reduction regimen (Blair, 1993; Klem et al., 1997). Continued
follow-up after weight loss is associated with improved outcome if the activity
plan is monitored and modified as part of this follow-up (Kayman et al., 1990).
While studies have shown that military recruits were able to lose significant
amounts of weight during initial entry training through exercise alone, the
restricted time available to consume meals during training probably contributed
to this weight loss (Lee et al., 1994).
BEHAVIOR AND LIFESTYLE MODIFICATION

The use of behavior and lifestyle modification in weight management is
based on a body of evidence that people become or remain overweight as the
result of modifiable habits or behaviors (see Chapter 3), and that by changing
those behaviors, weight can be lost and the loss can be maintained. The primary
goals of behavioral strategies for weight control are to increase physical activity
and to reduce caloric intake by altering eating habits (Brownell and Kramer,
1994; Wilson, 1995). A subcategory of behavior modification, environmental
management, is discussed in the next section. Behavioral treatment, which was
introduced in the 1960s, may be provided to a single individual or to groups of
clients. Typically, individuals participate in 12 to 20 weekly sessions that last
from 1 to 2 hours each (Brownell and Kramer, 1994), with a goal of weight loss
in the range of 1 to 2 lb/wk (Brownell and Kramer, 1994). In the past, behavioral
approaches were applied as stand-alone treatments to simply modify eating
habits and reduce caloric intake. However, more recently, these treatments have
been used in combination with low-calorie diets, medical nutrition therapy,
nutrition education, exercise programs, monitoring, pharmacological agents, and
social support to promote weight loss, and as a component of maintenance
programs.
Self-Monitoring and Feedback

Self-monitoring of dietary intake and physical activity, which enables the
individual to develop a sense of accountability, is one of the cornerstones of
behavioral treatment. Patients are asked to keep a daily food diary in which they
record what and how much they have eaten, when and where the food was
consumed, and the context in which the food was consumed (e.g., what else they

were doing at the time, what they were feeling, and who else was there).
Additionally, patients may be asked to keep a record of their daily physical
activities. Self-monitoring of food intake is often associated with a relatively
immediate reduction in food intake and consequent weight loss (Blundell, 2000;
Goris et al., 2000). This reduction in food intake is believed to result from
increased awareness of food intake and/or concern about what the dietitian or
nutrition therapist will think about the patient’s eating behavior. The information
obtained from the food diaries also is used to identify personal and environ-
mental factors that contribute to overeating and to select and implement
appropriate weight-loss strategies for the individual (Wilson, 1995). The same
may be true of physical activity monitoring, although little research has been
conducted in this area. Self-monitoring also provides a way for therapists and
patients to evaluate which techniques are working and how changes in eating
behavior or activity are contributing to weight loss. Recent work has suggested
that regular self-monitoring of body weight is a useful adjunct to behavior
modification programs (Jeffery and French, 1999).
Other Behavioral Techniques
Some additional techniques included in behavioral treatment programs

include eating only regularly scheduled meals; doing nothing else while eating;
consuming meals only in one place (usually the dining room) and leaving the
table after eating; shopping only from a list; and shopping on a full stomach
(Brownell and Kramer, 1994).
Reinforcement techniques are also an integral part of the behavioral treat-
ment of overweight and obesity. For example, subjects may select a positively
reinforcing event, such as participating in a particularly enjoyable activity or
purchasing a special item when a goal is met (Brownell and Kramer, 1994).
Another important component of behavioral treatment programs may be
cognitive restructuring of erroneous or dysfunctional beliefs about weight
regulation (Wing, 1998). Techniques developed by cognitive behavior therapists
can be used to help the individual identify specific triggers for overeating, deal
with negative attitudes towards obesity in society, and realize that a minor
dietary infraction does not mean failure. Nutrition education and social support,
discussed later in this chapter, are also components of behavioral programs.
Behavioral treatments of obesity are frequently successful in the short-term.
However, the long-term effectiveness of these treatments is more controversial,
with data suggesting that many individuals return to their initial body weight
within 3 to 5 years after treatment has ended (Brownell and Kramer, 1994; Klem
et al., 1997). Techniques for improving the long-term benefits of behavioral
treatments include: (1) developing criteria to match patients to treatments, (2)
increasing initial weight loss, (3) increasing the length of treatment, (4) empha-

sizing the role of exercise, and (5) combining behavioral programs with other
treatments such as pharmacotherapy, surgery, or stringent diets (Brownell and
Kramer, 1994).
Recent studies of individuals who have achieved success at long-term
weight loss may offer other insights into ways to improve behavioral treatment
strategies. In their analysis of data from the National Weight Control Registry,
Klem and coworkers (1997) found that weight loss achieved through exercise,
sensible dieting, reduced fat consumption, and individual behavior changes
could be maintained for long periods of time. However, this population was self-
selected so it does not represent the experience of the average person in a civil-
ian population. Because they have achieved and maintained a significant amount
of weight loss (at least 30 lb for 2 or more years), there is reason to believe that
the population enrolled in the Registry may be especially disciplined. As such,
the experience of people in the Registry may provide insight into the military
population, although evidence to assert this with authority is lacking. In any
case, the majority of participants in the Registry report they have made signifi-
cant permanent changes in their behavior, including portion control, low-fat
food selection, 60 or more minutes of daily exercise, self-monitoring, and well-
honed problem-solving skills.
Eating Environments
A significant part of weight loss and management may involve restructuring
the environment that promotes overeating and underactivity. The environment
includes the home, the workplace, and the community (e.g., places of worship,
eating places, stores, movie theaters). Environmental factors include the avail-
ability of foods such as fruits, vegetables, nonfat dairy products, and other foods
of low energy density and high nutritional value. Environmental restructuring
empha-sizes frequenting dining facilities that produce appealing foods of lower
energy density and providing ample time for eating a wholesome meal rather
than grabbing a candy bar or bag of chips and a soda from a vending machine.
Busy lifestyles and hectic work schedules create eating habits that may
contribute to a less than desirable eating environment, but simple changes can
help to counter-act these habits.
Commanders of military bases should examine their facilities to identify
and eliminate conditions that encourage one or more of the eating habits that
promote overweight. Some nonmilitary employers have increased healthy eating
options at worksite dining facilities and vending machines. Although multiple
publications suggest that worksite weight-loss programs are not very effective in
reducing body weight (Cohen et al., 1987; Forster et al., 1988; Frankle et al.,
1986; Kneip et al., 1985; Loper and Barrows, 1985), this may not be the case for
the military due to the greater controls the military has over its “employees”
than do nonmilitary employers.

Eating habits that may promote overweight:
1. Eating few or no meals at home

2. Opting for high-fat, calorie-dense foods
3. Opting for high-fat snack foods from strategically placed vending ma-
chines or snack shops combined with allowing insufficient time to pre-
pare affordable, healthier alternatives.
4. Consuming meals at sit-down restaurants that feature excessive portion
sizes or “all-you-can-eat” buffets
Simple changes that can modify the eating environment:
1. Prepare meals at home and carry bag lunches

2. Learn to estimate or measure portion sizes in restaurants
3. Learn to recognize fat content of menu items and dishes on buffet tables
4. Eliminate smoking and reduce alcohol consumption
5. Substitute low-calorie for high-calorie foods
6. Modify the route to work to avoid a favorite food shop
Physical Activity Environment

Major obstacles to exercise, even in highly motivated people, include the
time it takes to complete the task and the inaccessibility of facilities or safe
places to exercise. Environmental interventions emphasize the many ways that
physical activity can be fit into a busy lifestyle and seek to make use of what-
ever opportunities are available (HHS, 1996). Environmental changes may be
needed to encourage female participation in exercise programs, such as accom-
modation of the need for more after-exercise “repair time” by women and work-
site facilities that are more “user friendly,” such as measured indoor walking
routes and lunchtime low-level aerobics classes (Wasserman et al., 2000). The
availability of safe sidewalks and parks and alternative methods of transporta-
tion to work, such as walking or bicycling, also enhance the physical activity
environment. Establishing “car-free” zones is an example of an environmental
change that could promote increased physical activity.
Nutrition Education
Management of overweight and obesity requires the active participation of
the individual. Nutrition professionals can provide individuals with a base of
information that allows them to make knowledgeable food choices.

Nutrition education is distinct from nutrition counseling, although the con-

tents overlap considerably. Nutrition counseling and dietary management tend to
focus more directly on the motivational, emotional, and psychological issues
associated with the current task of weight loss and weight management. It
addresses the how of behavioral changes in the dietary arena. Nutrition
education on the other hand, provides basic information about the scientific
foundation of nutrition that enables people to make informed decisions about
food, cooking methods, eating out, and estimating portion sizes. Nutrition
education programs also may provide information on the role of nutrition in
health promotion and disease prevention, sports nutrition, and nutrition for
pregnant and lactating women. Effective nutrition education imparts nutrition
knowledge and its use in healthy living. For example, it explains the concept of
energy balance in weight management in an accessible, practical way that has
meaning to the individual’s lifestyle, including that in the military setting.
Written materials prepared by various government agencies or by nonprofit
health organizations can be used effectively to provide nutrition education.
However, written materials are most effective when used to reinforce informal
classroom or counseling sessions and to provide specific information, such as a
table of the calorie content of foods. The format of education programs varies
considerably, and can include formal classes, informal group meetings, or tele-
conferencing. A common background among group members is helpful (but
seldom possible).
Educational formats that provide practical and relevant nutrition informa-
tion for program participants are the most successful. For example, some mili-
tary weight-management programs include field trips to post exchanges, restau-
rants (fast-food and others), movies, and other places where food is purchased or
consumed (Vorachek, 1999).
The involvement of spouses and other family members in an education pro-
gram increases the likelihood that other members of the household will make
permanent changes, which in turn enhances the likelihood that the program par-
ticipants will continue to lose weight or maintain weight loss (Hart et al., 1990;
Hertzler and Schulman, 1983; Sperry, 1985). Particular attention must be di-
rected to involvement of those in the household who are most likely to shop for
and prepare food. Unless the program participant lives alone, nutrition manage-
ment is rarely effective without the involvement of family members.
DIET
Weight-management programs may be divided into two phases: weight loss
and weight maintenance. While exercise may be the most important element of a
weight-maintenance program, it is clear that dietary restriction is the critical
component of a weight-loss program that influences the rate of weight loss.

Activity accounts for only about 15 to 30 percent of daily energy expenditure,

but food intake accounts for 100 percent of energy intake. Thus, the energy bal-
ance equation may be affected most significantly by reducing energy intake. The
number of diets that have been proposed is almost innumerable, but whatever
the name, all diets consist of reductions of some proportions of protein, carbo-
hydrate (CHO) and fat. The following sections examine a number of arrange-
ments of the proportions of these three energy-containing macronutrients.
Nutritionally Balanced, Hypocaloric Diets
A nutritionally balanced, hypocaloric diet has been the recommendation of

most dietitians who are counseling patients who wish to lose weight. This type
of diet is composed of the types of foods a patient usually eats, but in lower
quantities. There are a number of reasons such diets are appealing, but the main
reason is that the recommendation is simple—individuals need only to follow
the U.S. Department of Agriculture’s Food Guide Pyramid. The Pyramid
recommends that individuals eat a variety of foods, with the majority being
grain products (e.g., bread, pasta, cereal, rice), eat at least five servings per day
of fruits and vegetables; eat only moderate amounts of dairy and meat products;
and limit the consumption of foods that are high in fat or sugar or contain few
nutrients. In using the Pyramid, however, it is important to emphasize the
portion sizes used to establish the recommended number of servings. For
example, a majority of consumers do not realize that a portion of bread is a
single slice or that a portion of meat is only 3 oz.
A diet based on the Pyramid is easily adapted from the foods served in
group settings, including military bases, since all that is required is to eat smaller
portions. Even with smaller portions, it is not difficult to obtain adequate
quantities of the other essential nutrients. Many of the studies published in the
medical literature are based on a balanced hypocaloric diet with a reduction of
energy intake by 500 to 1,000 kcal from the patient’s usual caloric intake. The
U.S. Food and Drug Administration (FDA) recommends such diets as the
“standard treatment” for clinical trials of new weight-loss drugs, to be used by
both the active agent group and the placebo group (FDA, 1996).
Meal Replacement
Meal replacement programs are commercially available to consumers for a
reasonably low cost. The meal replacement industry suggests replacing one or
two of the three daily meals with their products, while the third meal should be
sensibly balanced. In addition, two snacks consisting of fruits, vegetables, or
diet snack bars are recommended each day. Using this plan, individuals con-
sume approximately 1,200 to 1,500 kcal/day.

A number of studies have evaluated long-term weight maintenance using

meal replacement, either self-managed (Flechtner-Mors et al., 2000; Heber et
al., 1994; Rothacker, 2000), with active dietary counseling, or with behavior
modification programs (Ashley et al., 2001; Ditschuneit and Flechtner-Mors,
2001; Ditschuneit et al., 1999) compared with traditional calorie-restricted diet
plans. The largest amount of weight loss occurred early in the studies (about the
first 3 months of the plan) (Ditschuneit et al., 1999; Heber et al., 1994). One
study found that women lost more weight between the third and sixth months of
the plan, but men lost most of their weight by the third month (Heber et al.,
1994). All of the studies resulted in maintenance of significant weight loss after
2 to 5 years of follow-up. Hill’s (2000) review of Rothacker (2000) pointed out
that the group receiving meal replacements maintained a small, yet significant,
weight loss over the 5-year program, whereas the control group gained a signifi-
cant amount of weight. Active intervention, which included dietary counseling
and behavior modification, was more effective in weight maintenance when
meal replacements were part of the diet (Ashley et al., 2001). Meal replacements
were also found to improve food patterns, including nutrient distribution, intake
of micronutrients, and maintenance of fruit and vegetable intake.
Long-term maintenance of weight loss with meal replacements improves
biomarkers of disease risk, including improvements in levels of blood glucose
(Ditschuneit and Fletchner-Mors, 2001), insulin, and triacylglycerol; improved
systolic blood pressure (Ditschuneit and Fletchner-Mors, 2001; Ditschuneit et
al., 1999); and reductions in plasma cholesterol (Heber et al., 1994).
Winick and coworkers (2002) evaluated employees in high-stress jobs (e.g.,
police, firefighters, and hospital and aviation personnel) who participated in
worksite weight-reduction and maintenance programs that used meal replace-
ments. The meal replacements were found to be effective in reducing weight and
maintaining weight loss at a 1-year follow-up. In contrast, Bendixen and co-
workers (2002) reported from Denmark that meal replacements were associated
with negative outcomes on weight loss and weight maintenance. However, this
was not an intervention study; participants were followed for 6 years by phone
interview and data were self-reported.
Unbalanced, Hypocaloric Diets

Unbalanced, hypocaloric diets restrict one or more of the calorie-containing
macronutrients (protein, fat, and CHO). The rationale given for these diets by
their advocates is that the restriction of one particular macronutrient facilitates
weight loss, while restriction of the others does not. Many of these diets are
published in books aimed at the lay public and are often not written by health
professionals and often are not based on sound scientific nutrition principles. For
some of the dietary regimens of this type, there are few or no research
publications and virtually none have been studied long term. Therefore, few

conclusions can be drawn about the safety, and even about the efficacy, of such
diets. The major types of unbalanced, hypocaloric diets are discussed below.
High-Protein, Low-Carbohydrate Diets

There has been considerable debate on the optimal ratio of macronutrient
intake for adults. This research usually compares the amount of fat and CHO;
however, there has been increasing interest in the role of protein in the diet (Hu
et al., 1999; Wolfe and Giovannetti, 1991). Studies have looked for the effects
of a higher protein diet (CHO/protein ratio ~1.0) compared with a higher CHO
diet (CHO/protein ratio ~3.0). Although the high-protein diet does not produce
significantly different weight loss compared with the high-CHO diet (Layman et
al., 2003a, 2003b; Piatti et al., 1994), the high-protein diet has been reported to
stimulate greater improvements in body composition by sparing lean body mass
(Layman et al., 2003a; Piatti et al., 1994).
High-protein, low-CHO diets were introduced to the American public
during the 1970s and 1980s by Stillman and Baker (1978) and by Atkins
(Atkins, 1988; Atkins and Linde, 1978), and more recently, by Sears and
Lawren (1998). Some of these diets are high in fat (> 35 percent of kcal), while
others have moderate levels of fat (25–35 percent of kcal). While most of these
diets have been promoted by nonscientists who have done little or no serious
scientific research, some of the regimens have been subjected to rigorous studies
(Skov et al., 1999a, 1999b). There remains, however, a lack of randomized
clinical trials of 2 or more years’ duration, which are needed to evaluate the
potent beneficial effect of weight loss (accomplished using virtually any dietary
regimen, no matter how unbalanced) on blood lipids. In addition, longer studies
are needed to separate the beneficial effects of weight loss from the long-term
effects of consuming an unbalanced diet.
Authors of books aimed at the lay public have proposed advantages of high
protein diets, including that eating a high-protein, low-CHO diet produces a
“near-euphoric” state of maximal physical and mental performance (Sears and
Lawren, 1998). These claims are unsupported by scientific data.
Although these diets are prescribed to be eaten ad libitum, total daily energy
intake tends to be reduced as a result of the monotony of the food choices, other
prescripts of the diet, and an increased satiety effect of protein. In addition, the
restriction of CHO intake leads to the loss of glycogen and marked diuresis
(Coulston and Rock, 1994; Miller and Lindeman, 1997; Pi-Sunyer, 1988). Thus,
the relatively rapid initial weight loss that occurs on these diets predominantly
reflects the loss of body water rather than stored fat. This can be a significant
concern for military personnel, where even mild dehydration can have detri-
mental effects on physical and cognitive performance. For example, small
changes in hydration status can affect a military pilot’s ability to sense changes
in equilibrium.

Results of several recent studies suggest that high-protein, low-CHO diets

may have their benefits. In addition to sparing fat-free mass (Piatti et al., 1994)
and producing greater weight and fat losses than high-CHO diets (Skov et al.,
1999b), high-protein diets have been associated with decreases in fasting
triglycerides and free fatty acids in healthy subjects and with the normalization
of fasting insulin levels in hyperinsulinemic, normoglycemic obese subjects
(Baba et al., 1999; Skov et al., 1999b). Furthermore, a 45-percent protein diet
reduced resting energy expenditure to a significantly lesser extent than did a 12-
percent protein diet (Baba et al., 1999). The length of these studies that
examined high-protein diets only lasted 1 year or less; the long-term safety of
these diets is not known.
Low-Fat Diets
Low-fat diets have been one of the most commonly used treatments for
obesity for many years (Astrup, 1999; Astrup et al., 1997; Blundell, 2000;
Castellanos and Rolls, 1997; Flatt, 1997; Kendall et al., 1991; Pritikin, 1982).
The most extreme forms of these diets, such as those proposed by Ornish (1993)
and Pritikin (1982), recommend fat intakes of no more than 10 percent of total
caloric intake. Although these stringent diets can lead to weight loss, the limited
array of food choices make them difficult to maintain for extended periods of
time by individuals who wish to follow a normal lifestyle.
More modest reductions in fat intake, which make a dietary regimen easier
to follow and more acceptable to many individuals, can also promote weight
loss (Astrup, 1999; Astrup et al., 1997, 2000; Blundell, 2000; Castellanos and
Rolls, 1997; Flatt, 1997; Kendall et al., 1991; Shah and Garg, 1996). For
example, Sheppard and colleagues (1991) reported that after 1 year, obese
women who reduced their fat intake from approximately 39 percent to 22
percent of total caloric intake lost 3.1 kg of body weight, while women who
reduced their fat intake from 38 percent to 36 percent of total calories lost only
0.4 kg.
Results of recent studies suggest that fat restriction is also valuable for
weight maintenance in those who have lost weight (Flatt 1997; Miller and
Lindeman, 1997). Dietary fat reduction can be achieved by counting and
limiting the number of grams (or calories) consumed as fat, by limiting the
intake of certain foods (for example, fattier cuts of meat), and by substituting
reduced-fat or nonfat versions of foods for their higher fat counterparts (e.g.,
skim milk for whole milk, nonfat frozen yogurt for full-fat ice cream, baked
potato chips for fried chips) (Dywer, 1995; Miller and Lindeman, 1997). Over
the past decade, pursuit of this latter strategy has been simplified by the
burgeoning availability of low-fat or fat-free products, which have been
marketed in response to evidence that decreasing fat intake can aid in weight
control.

The mechanisms for weight loss on a low-fat diet are not clear. Weight loss
may be solely the result of a reduction in total energy intake, but another
possibility is that a low-fat diet may alter metabolism (Astrup, 1999; Astrup et
al., 2000; Castellanos and Rolls, 1997; Shah and Garg, 1996). Support for the
latter possibility has come from studies showing that the short-term adherence to
a diet containing 20 or 30 percent of calories from fat increased 24-hour energy
expenditure in formerly obese women, relative to an isocaloric diet with 40
percent of calories from fat (Astrup et al., 1994).
Over the past two decades, fat consumption as a percent of total caloric
intake has declined in the United States (Anand and Basiotis, 1998), while
average body weight and the proportion of the American population suffering
from obesity have increased significantly (Mokdad et al., 1999). Several factors
may contribute to this seeming contradiction. First, all individuals appear to
selectively underestimate their intake of dietary fat and to decrease normal fat
intake when asked to record it (Goris et al., 2000; Macdiarmid et al., 1998). If
these results reflect the general tendencies of individuals completing dietary
surveys, then the amount of fat being consumed by obese and, possibly,
nonobese people, is greater than routinely reported. Second, although the pro-
portion of total calories consumed as fat has decreased over the past 20 years,
grams of fat intake per day have remained steady or increased (Anand and
Basiotis, 1998), indicating that total energy intake increased at a faster rate than
did fat intake. Coupled with these findings is the fact that since the early 1990s,
the availability of low-fat and nonfat, but calorie-rich snack foods (e.g.,
crackers, candy, cookies, cake, frozen desserts) has grown dramatically.
However, total energy intake still matters, and overconsumption of these low-fat
snacks could as easily lead to weight gain as intake of their high-fat counterparts
(Allred, 1995).
Two recent, comprehensive reviews have reported on the overall impact of
low-fat diets. Astrup and coworkers (2002) examined four meta-analyses of
weight change that occurred on intervention trials with ad libitum low-fat diets.
They found that low-fat diets consistently demonstrated significant weight loss,
both in normal-weight and overweight individuals. A dose-response relationship
was also observed in that a 10 percent reduction in dietary fat was predicted to
produce a 4- to 5-kg weight loss in an individual with a BMI of 30. Kris-
Etherton and colleagues (2002) found that a moderate-fat diet (20 to 30 percent
of energy from fat) was more likely to promote weight loss because it was easier
for patients to adhere to this type of diet than to one that was severely restricted
in fat (< 20 percent of energy).
High-Fiber Diets
Most low-fat diets are also high in dietary fiber, and some investigators
attribute the beneficial effects of low-fat diets to the high content of vegetables

and fruits that contain large amounts of dietary fiber. The rationale for using
high-fiber diets is that they may reduce energy intake and may alter metabolism
(Raben et al., 1994). The beneficial effects of dietary fiber might be accomp-
lished by the following mechanisms: (1) caloric dilution (most high-fiber foods
are low in calories and low in fat); (2) longer chewing and swallowing time
reduces total intake; (3) improved gastric and intestinal motility and emptying
and less absorption (French and Read, 1994; Leeds, 1987; McIntyre et al., 1997;
Rigaud et al., 1998; Schonfeld et al., 1997; Vincent et al., 1995); and (4) de-
creased hunger and enhanced satiety (Pasman et al., 1997a, 1997b, 1997c).
Dietary fiber is not a panacea, and the vast majority of controlled studies of the
effects of dietary fiber on weight loss show minimal or no reduction in body
weight (LSRO, 1987; Pasman et al., 1997b, 1997c).
Many individuals and companies promote the use of dietary fiber supple-
ments for weight loss and reductions in cardiovascular and cancer risks. Numer-
ous studies, usually short-term and using purified or partially purified dietary
fiber, have shown reductions in serum lipids, glucose, or insulin (Jenkins et al.,
2000). Long-term studies have usually not confirmed these findings (LSRO,
1987; Pasman et al., 1997b). Current recommendations suggest that instead of
eating dietary fiber supplements, a diet of foods high in whole fruits and
vegetables may have favorable effects on cardiovascular and cancer risk factors
(Bruce et al., 2000). Such diets are often lower in fat and higher in CHOs.
Very-Low-Calorie Diets
Very-low-calorie diets (VLCDs) were used extensively for weight loss in
the 1970s and 1980s, but have fallen into disfavor in recent years (Atkinson,
1989; Bray, 1992a; Fisler and Drenick, 1987). FDA and the National Institutes
of Health define a VLCD as a diet that provides 800 kcal/day or less. Since this
does not take into account body size, a more scientific definition is a diet that
provides 10 to 12 kcal/kg of “desirable” body weight/day (Atkinson, 1989). The
VLCDs used most frequently consist of powdered formulas or limited-calorie
servings of foods that contain a high-quality protein source, CHO, a small
percentage of calories as fat, and the daily recommendations of vitamins and
minerals (Kanders and Blackburn, 1994; Wadden, 1995). The servings are eaten
three to five times per day. The primary goal of VLCDs is to produce relatively
rapid weight loss without substantial loss in lean body mass. To achieve this
goal, VLCDs usually provide 1.2 to 1.5 g of protein/kg of desirable body weight
in the formula or as fish, lean meat, or fowl. Fisler and Drenick (1987) reviewed
the literature and concluded that about 70 g/day of protein is needed to ensure
that nitrogen balance is achieved within a short period of time on a VLCD.
VLCDs are not appropriate for all overweight individuals, and they are
usually limited to patients with a BMI of greater than 25 (some guidelines
suggest a BMI of 27 or even 30) who have medical complications associated

TABLE 4-2 One through Five-Year Maintenance of Initial Weight Loss of

Individuals (%) Placed on Either Very-Low-Calorie Diets or Hypocaloric-
Balanced Diets
Diet 1 year 2 years 3 years 4 years 5 years
Very-low-calorie diet 16.1 9.7 7.8 7 6.2
Hypocaloric-balanced diet 7.2 4.2 3.5 2.8 2
SOURCE: Adapted from Anderson et al. (2001).
with being overweight and have already tried more conservative treatment
programs. Additionally, because of the potential detrimental side effects of these
diets (e.g., gallstone formation, nutritional deficiencies, cardiac arrhythmias),
medical and nutritional monitoring is important while individuals are on the diet.
On a short-term basis, VLCDs are relatively effective, with weight losses of
approximately 15 to 30 kg over 12 to 20 weeks being reported in a number of
studies (Anderson et al., 1992, 1999; Apfelbaum et al., 1987; Atkinson, 1989;
Fisler and Drenick, 1987; Kanders and Blackburn, 1994). However, the long-
term effectiveness of these diets is somewhat limited. Approximately 40 to 50
percent of patients drop out of the program before achieving their weight-loss
goals. In addition, relatively few people who lose large amounts of weight using
VLCDs are able to sustain the weight loss when they resume normal eating. In
two studies, only 30 percent of patients who reached their goal were able to
maintain their weight loss for at least 18 months. Within 1 year, the majority of
patients regained approximately two-thirds of the lost weight (Apfelbaum et al.,
1987; Kanders and Blackburn, 1994). In a more recent study with longer follow-
up, the average regain over the first 3 years of follow-up was 73 percent. How-
ever, weight tended to stabilize over the fourth year. At 5 years, the dieters had
maintained an average of 23 percent of their initial weight loss. At 7 years, 25
percent of the dieters were maintaining a weight loss of 10 percent of their initial
body weight (Anderson et al., 1999, 2001).
It appears that VLCDs are more effective for long-term weight loss than
hypocaloric-balanced diets. In a meta-analysis of 29 studies, Anderson and col-
leagues (2001) examined the long-term weight-loss maintenance of individuals
put on a VLCD diet with behavioral modification as compared with individuals
put on a hypocaloric-balanced diet. They found that VLCD participants lost sig-
nificantly more weight initially and maintained significantly more weight loss
than participants on the hypocaloric-balanced diet (see Table 4-2).
SUPPORT SYSTEMS
Almost any kind of assistance provided to participants in a weight-manage-
ment program can be characterized as support services. These can include emo-
tional support, dietary support, and support services for physical activity. The

support services used most often are structured in a standard way. Other services
are developed to meet the specific needs of a site, program, or the individual
involved. With few exceptions, almost any weight-management program is
likely to be more successful if it is accompanied by support services (Heshka et
al., 2000). However, not all services will be productively applicable to all pa-
tients, and not all can be made available in all settings. Furthermore, some
weight-loss program participants will be reluctant to use any support services.
Counseling and Psychotherapy Services

Psychological and emotional factors play a significant role in weight man-
agement. Counseling services are those that consider psychological issues asso-
ciated with inappropriate eating and that are structured to inform the patient
about the nature of these issues, their implications, and the possibilities available
for their ongoing management. This intervention is less elaborate, intense, and
sustaining than psychotherapy services. For example, it should be useful to help
patients understand the existence and nature of a sabotaging household or the
phenomenon of stress-related eating without undertaking continuing psycho-
therapy. A counselor or therapist can provide this service either in individual or
group sessions. These counselors should, however, be sufficiently familiar with
the issues that arise with weight-management programs, such as binge eating
and purging. Short-term, individual case management can be helpful, as can
group sessions because patients can hear the perspective of other individuals
with similar weight-management concerns while addressing their individual
concerns (Hughes et al., 1999; Perri et al., 2001; Wadden and Sarwer, 1999).
Psychotherapy services, both individual and group, can also be useful.
However, the costs of this type of service limits its applicability to many pa-
tients. Nevertheless, the value for individual patients can be substantial, and the
option should not be dismissed simply because of cost. Concerns about child-
hood abuse, emotional linkages to sustaining obesity (fat-dependent personal-
ity), and the management of coexisting mental health problems are the kinds of
issues that might be addressed with this type of support service. The individual
therapist can structure the format of the therapy but, as with counseling services,
the therapist should be familiar with weight-management issues.
Patient-Led Groups
Nonprofessional patient-led groups and counseling, such as those available
with organized programs like Take Off Pounds Sensibly and Overeaters Anony-
mous, can be useful adjuncts to weight-loss efforts. These programs have the
advantages of low cost, continuing support and encouragement, and a semi-
structured approach to the issues that arise among weight-management patients.
Their disadvantage is that, since the counseling is nonprofessional in nature, the

programs are only as good as the people who are involved. These peer-support
programs are more likely to be productive when they are used as a supplement
to a program with professional therapists and counselors. In Overeaters Anony-
mous, a variant of these groups is a sponsor-system program that pairs individu-
als who can help one another.
Commercial Groups
Certain commercial programs like Weight Watchers and Jenny Craig can
also be helpful. Since commercial groups have their own agenda, caution must
be exercised to avoid contradictions between the advice of professional counsel-
ors and that of the supportive commercial program. Since the counselors in com-
mercial programs are not likely to be professionals, the quality of counseling
offered by these programs varies with the training of the counselors.
Other Community Resources

Many communities offer supplemental weight-management services. Edu-
cational services, particularly in nutrition, may be provided through community
adult education using teaching materials from nonprofit organizations such as
the American Heart Association, the American Diabetes Association, and gov-
ernment agencies (FDA, National Institutes of Health, and U.S. Department of
Agriculture). Many community hospitals have staff dietitians who are available
for out-patient individual counseling (Pavlou et al., 1989a). However, the mili-
tary’s TRICARE health services contracts would need to be modified to include
dietitian services from community hospitals or other community services since
these contracts do not currently include medical nutrition therapy (and therefore
dietitian counseling).
Family Support
The family unit can be a source of significant assistance to an individual in
a weight-management program. For example, program dropout rates tend to be
lower when a participant’s spouse is involved in the program (Jeffery et al.,
1984). With simple guidance and direction, the involvement of the spouse as a
form of reinforcement (rather than as a source of discipline and monitoring) can
become a resource to assist in supporting the participant. However, individual
family members (or the family as a group) can become an obstacle when they
express reluctance to make changes in food and eating patterns within the
household. Issues of family conflict become more complex when the partici-
pants are children or adolescents or when spouses are reluctant to relinquish
status quo positions of control.

Internet Services
A variety of Internet- and web-related services are available to individuals
who are trying to manage their weight (Davison, 1997; Gray and Raab, 1999;
Riva et al., 2000). As with any other Internet service, the quality of these sites
varies substantially (Miles et al., 2000). An important role for weight-manage-
ment professionals is to review such sites so they can recommend those that are
the most useful. The use of e-mail counseling services by military personnel
who travel frequently or who are stationed in remote locations has been tested at
one facility; initial results are promising (James et al., 1999a). The use of web-
based modalities by qualified counselors or facilitators located at large military
installations would extend the accessibility of such services to personnel located
at small bases or stationed in remote locations.
Physical Activity Support Services

Support is also required for military personnel who need to enhance their
levels of physical fitness and physical activity. All branches of the services have
remedial physical fitness training programs for personnel who fail their fitness
test, but support is also needed for those who need to lose weight and for all
personnel to aid in maintaining proper weight. Support services should include
personnel, facilities, and equipment, and should provide practical advice on how
to begin and progress through physical training routines (including proper use of
training equipment and how to prevent musculoskeletal injuries), as well as
advice on when and how to eat in conjunction with physical activity demands.
PRESCRIPTION AND OVER-THE-COUNTER DRUGS

AND SUPPLEMENTS
Success in the promotion of weight loss can sometimes be achieved with
the use of drugs. Almost all prescription drugs in current use cause weight loss
by suppressing appetite or enhancing satiety. One drug, however, promotes
weight loss by inhibiting fat digestion. To sustain weight loss, these drugs must
be taken on a continuing basis; when their use is discontinued, some or all of the
lost weight is typically regained. Therefore, when drugs are effective, it is ex-
pected that their use will continue indefinitely. For maximum benefit and safety,
the use of weight-loss drugs should occur only in the context of a comprehen-
sive weight-loss program. In general, these drugs can induce a 5- to 10-percent
mean drop in body weight within 6 months of treatment initiation, but the effect
can be larger or smaller depending on the individual. As with any drug, the oc-
currence of side effects may exclude their use in certain occupational contexts.
Current convention recommends the use of weight-loss drugs in otherwise
healthy individuals who have a BMI ≥ 30, or in individuals with a BMI between

27 and 30 with an existing comorbid condition (e.g., hypertension, diabetes,

heart disease). Recognition that weight-related diseases, such as diabetes and
hypertension, occur in individuals with BMI levels below 25, and that weight
loss improves these conditions in these individuals, suggests that indications for
weight-loss drugs need to be individualized to the specific patient.
A number of hormonal and metabolic differences distinguish obese people
from lean people (Leibel et al., 1995; Pi-Sunyer, 1993), suggesting that genetic
factors play a role in weight. Weight loss alters metabolism in obese individuals,
limiting energy expenditure and reducing protein synthesis. This alteration sug-
gests that the body may attempt to maintain an elevated body weight.
The facts that genetics might play a role in hormonal and metabolic
differences between people and that weight loss alters metabolism imply that
obesity is not a simple psychological problem or a failure of self-discipline.
Instead, it is a chronic metabolic disease similar to other chronic diseases and it
involves alterations of the body’s biochemistry. Like most other chronic dis-
eases that require ongoing pharmacotherapy to prevent the recurrence of
symptoms, obesity management and relapse prevention may someday be accom-
plished through this form of treatment. The following sections provide a brief
review of the mechanisms of action, efficacy, and safety of prescription agents
that have been approved for weight loss and the various over-the-counter
substances that are promoted for weight loss.
Mechanisms of Action of Obesity Drugs

Obesity drugs act by a variety of mechanisms (see Box 4-1), but all must
either reduce energy intake and/or increase energy output (Arch, 1981; Aronne,
1998; Astrup et al., 1998; Bray et al., 1996; Bross and Hoffer, 1995; Cole et al.,
1998; Hanotin et al., 1998a, 1998b; Heal et al., 1998; Hollander et al., 1998;
Jonderko and Kucio, 1989; Kogon et al., 1994; McNeely and Benfield, 1998;
Rolls et al., 1998; Scalfi et al., 1993; Sjostrom et al., 1998; Tonstad et al., 1994;
Troiano et al., 1990; van Gaal et al., 1998). Energy intake may be curbed by
reducing hunger or appetite or by enhancing satiety.
Some obesity drugs may reduce the preference for dietary fat or refined
CHOs (Blundell et al., 1995; Bray, 1992b; Foltin et al., 1995; Leibowitz, 1995;
Wurtman et al., 1987). For example, the drug orlistat reduces the absorption of
fat, which results in energy loss in the feces; other drugs not approved for
obesity treatment reduce CHO absorption (Heal et al., 1998; McNeely and
Benfield, 1998; Sjostrom et al., 1998; van Gaal et al., 1998). These drugs may
produce sufficiently adverse effects, such as oily stools or increased flatus, so
that patients reduce consumption of high-fat foods in favor of less energy-dense
foods (McNeely and Benfield, 1998; Sjostrom et al., 1998; van Gaal et al.,
1998).

BOX 4-1 Summary of Potential Mechanisms of Action

of Obesity Drugs
1. Reductions in food intake

a. Reduction in hunger and/or appetite
b. Enhanced satiety
c. Reduction of fat and/or carbohydrate preference
d. Reduction of nutrient absorption
2. Increases in energy expenditure
a. Increased physical activity
i. Tremor
ii. Spontaneous physical activity (fidgeting)
iii. Increased willingness to exercise
b. Increased metabolic rate
i. Increased resting metabolic rate
ii. Increased thermogenesis with food intake, cold, activity
c. Altered nutrient partitioning: increased fat oxidation
Obesity drugs also may increase activity levels or stimulate metabolic rate.
Drugs such as fenfluramine or sibutramine were reported to increase energy
expenditure in some studies (Arch, 1981; Astrup et al., 1998; Bross and Hoffer,
1995; Heal et al., 1998; Scalfi et al., 1993; Troiano et al., 1990), but not in
others (Schutz et al., 1992; Seagle et al., 1998). Fluoxetine, although not
approved for obesity treatment, has been shown to increase resting metabolic
rate (Bross and Hoffer, 1995). Ephedrine and caffeine, which act on adenosine
receptors, may increase metabolic rate, reduce body-fat storage, and increase
lean mass (Liu et al., 1995; Stock, 1996; Toubro et al., 1993). With one
exception (orlistat), all currently available prescription obesity drugs act on
either the adrenergic or serotonergic systems in the central nervous system to
regulate energy intake or expenditure (Bray, 1992b). These adrenergic and
serotonergic agonists increase secretion of norepinephrine, serotonin, and/or
dopamine, or inhibit neuronal reuptake. Table 4-3 summarizes the mechanism of
action of pharmacological agents used for treating obesity, which are discussed
in detail below.
Efficacy and Safety of Currently Available Prescription Obesity Drugs

Adrenergic and Serotonergic Agents
Efficacy. Phentermine, an adrenergic agent, is the most commonly used
prescription drug for obesity and has one of the lowest costs of all prescription
agents. Weight loss is comparable with that of other single agents (Silverstone,

1992). Diethylpropion, phendimetrazine, and benzphetamine are other adrener-

gic agents that stimulate central norepinephrine secretion and produce weight
loss similar to that of phentermine (Griffiths et al., 1979; Silverstone, 1992). The
categorization of phendimetrazine and benzphetamine as Drug Enforcement
Agency Schedule III drugs may have limited their use, although little evidence
exists to suggest that they have a higher abuse potential than does phentermine.
Diethylpropion was reported to have a higher reinforcement potential in
nonhuman primates than that of the other Schedule III and IV adrenergic drugs
(Griffiths et al., 1979).
No currently available agents for treating obesity are exclusively seroto-
nergic. Fluoxetine and sertraline are selective serotonin reuptake inhibitors that
produce weight loss (Bross and Hoffer, 1995; Goldstein et al., 1993, 1995; Ricca
et al., 1997; Wadden et al., 1995), but they do not have FDA approval for use in
obesity treatment. Fluoxetine produced good weight loss after 6 months, but 1-
year results were not different from those of placebo treatment (Goldstein et al.,
1993). Sertraline also produced short-term weight loss (Ricca et al., 1997;
Wadden et al., 1995).
Sibutramine inhibits reuptake of both norepinephrine and serotonin in
central nervous system neurons. At doses of 15 mg/day, the drug produced a 1-
year weight loss of 6 to 10 percent (Astrup et al., 1998; Bray et al., 1996;
Hanotin et al., 1998b; Seagle et al., 1998). Blood pressure rose slightly in
normotensive subjects, but fell in hypertensive subjects (Heal et al., 1998).
Decreases in fasting blood glucose, insulin, waist circumference, waist-hip ratio,
and computerized tomography-estimated abdominal fat were greater with
sibutramine than with placebo (Heal et al., 1998). The greater weight losses
observed in the sibutramine group compared with the placebo group may be
responsible for the greater improvements in other parameters.
Safety. Common complaints with the use of centrally active adrenergic and
serotonergic obesity drugs include dry mouth, fatigue, hair loss, constipation,
sweating, sleep disturbances, and sexual dysfunction (Atkinson et al., 1997;
Bray, 1998). Sibutramine can increase blood pressure and pulse rate in
occasional patients and may cause dizziness and increased food intake (Cole et
al., 1998; Hanotin et al., 1998a, 1998b). Mazindol may cause penile discharge
(van Puijenbroek and Meyboom, 1998).
Drugs Affecting Absorption: Lipase and Amylase Inhibitors

Efficacy. Orlistat binds to lipase in the gastrointestinal tract and inhibits
absorption of about one-third of dietary fat (Hollander et al., 1998; James WP et
al., 1997; McNeely and Benfield, 1998; Sjostrom et al., 1998; Tonstad et al.,
1994; van Gaal et al., 1998; Zhi et al., 1994). Thus, consumption of over 100 g
of fat/day should result in about 30 g or more of fat reaching the colon. Average

TABLE 4-3 Prescription Pharmacological Agents for Weight-Loss Treatment

and Mechanisms of Action
Drug Class Drug
Adrenergic (DEAa II) Amphetamineb,d
Methamphetamineb,d
Adrenergic (DEAa III) Benzphetamine
Phedimetrazine
Adrenergic (DEAa IV) Diethylpropionb
Mazindolc
Phentermine
Adrenergic over-the-counter Phenylpropanolaminec
Serotonergic d,1-fenfluraminec
d-norfenfluraminec
SSRI anti-depressantsd
Combined adrenergic and serotonergic (DEAa IV) Sibutramine
Drugs affecting absorption Orlistat

Acarbosed
a
DEA = Drug Enforcement Agency
b
High abuse potential – measured by the ratio of anorexiant dose to reinforcing dose.
weight loss on orlistat is about 8 to 11 percent of initial body weight at 1 year

(James WP et al., 1997; Sjostrom et al., 1998).
Compared with the effects of a placebo, orlistat treatment resulted in greater
improvements in total cholesterol, low-density lipoprotein (LDL) cholesterol,
LDL/high-density lipoprotein ratio, and concentrations of glucose and insulin
(Hollander et al., 1998; James WP et al., 1997; McNeely and Benfield, 1998;
Sjostrom et al., 1998; Tonstad et al., 1994; van Gaal et al., 1998). Although
weight loss may be responsible for some of the observed improvements, orlistat
lowered LDL independently of its effect on weight loss.
Acarbose is an alpha glucosidase inhibitor that inhibits or delays absorption
of complex CHOs (Wolever et al., 1997). This drug is approved by FDA for the
treatment of diabetes mellitus, but not for weight loss. Although it produces
modest weight loss in animals, it has minimal or no effect on humans.
Safety. Adverse side effects of orlistat include abdominal cramping,
increased flatus formation, diarrhea, oily spotting, and fecal incontinence
(Hollander et al., 1998; James WP et al., 1997; McNeely and Benfield, 1998;
Sjostrom et al., 1998; Tonstad et al., 1994; van Gaal et al., 1998; Zhi et al.,
1994). These adverse effects may serve as a behavior modification tool to
reduce the level of fat in the diet and presumably to reduce energy intake.
Orlistat has been shown to produce small reductions in serum levels of fat-

Mechanism of Action Efficacy/Safety

DEAa II drugs rarely used for obesity treat-
ment due to high abuse potential
Stimulates norepinephrine release Weight loss varies but significant compared
Stimulates norepinephrine release with placebo; insomnia and dry mouth
Stimulates norepinephrine release Weight loss varies but significant compared
Blocks norepinephrine reuptake with placebo; insomnia and dry mouth
Stimulates norepinephrine release
α1 Agonist Significant weight loss compared with placebo
but less than class III and IV adrenergics
Acts to block serotonin reuptake Significant weight loss compared with pla-
Acts to enhance serotonin release cebo; plateau at 6 months; dry mouth and
Acts to block serotonin reuptake insomnia; pulmonary hypertension
Stimulates norepinephrine and sero- Significant weight loss compared with pla-
tonin release or blocks uptake cebo; dry mouth and insomnia; raises blood
pressure in some individuals
Inhibits lipase activity Significant weight loss compared with pla-
cebo; abdominal cramps and diarrhea
c
Removed from market by manufacturers.
d
Not approved by the Food and Drug Administration for weight-loss treatment
SOURCE: Bray (1998); James et al. (1997).
soluble vitamins. The manufacturer recommends that a vitamin supplement

containing vitamins A, D, E, and K be prescribed for patients taking orlistat.
Drugs Approved for Other Conditions

A variety of drugs currently on the market for other conditions, but not
approved by FDA for obesity treatment, have been evaluated for their ability to
induce weight loss. Metformin (Lee and Morley, 1998), cimetidine (Rasmussen
et al., 1993; Stoa-Birketvedt, 1993), diazoxide (Alemzadeh et al., 1998),
bromocriptine (Cincotta and Meier, 1996), nicotine (Grant et al., 1997; Jensen et
al., 1995; Nides et al., 1994), bupropion (Croft et al., 2000; Gadde et al., 1999),
and topiramate (Rosenfeld et al., 1997) have produced modest weight loss.
Additional studies are needed to support these findings.
Drugs Used in Combination

Efficacy. Although chronic diseases often require treatment with more than
one drug, few studies have evaluated combination therapy for obesity. Private
practitioners have used various combinations in an off-label fashion. The

available data suggest that combination therapy is somewhat more effective than
therapy with single agents. Combinations such as phentermine and fenfluramine
or ephedrine and caffeine produce weight losses of about 15 percent or more of
initial body weight compared with about 10 percent or less with single drug use.
However, due to reported side-effects of cardiac valve lesions and pulmonary
hypertension, fenfluramine and dexfenfluramine are no longer available.
Results of tests using combinations of phentermine with selective serotonin
reuptake inhibitors (mainly fluoxetine or sertraline) have been reported in ab-
stracts or preliminary reports (Dhurandhar and Atkinson, 1996; Griffen and An-
chors, 1998). These combinations produced weight losses somewhat less than
that of the combination treatment of ephedrine-caffeine, but greater than that of
treatment with single agents (Dhurandhar and Atkinson, 1996).
Safety. Anchors (1997) used the combination of phentermine and fluoxetine
in a large series of patients and suggested that this combination is safe and effec-
tive. Griffen and Anchors (1998) reported that the combination of phentermine-
fluoxetine was not associated with the cardiac valve lesions that were reported
for fenfluramine and dexfenfluramine.
Alternative Medicines, Herbs, and Diet Supplements

In 1994, Congress passed the Dietary Supplement Health and Education
Act, which exempted dietary supplements (including those promoted for weight
loss) from the requirement to demonstrate safety and efficacy. As a result, the
variety of over-the-counter preparations touted to promote weight loss has ex-
ploded. Dietary supplements include compounds such as herbal preparations
(often of unknown composition), chemicals (e.g., hydroxycitrate, chromium),
vitamin preparations, and protein powder preparations. With the exception of
herbal preparations of ephedrine and caffeine, none of these compounds have
produced more than a minimal weight loss and most are ineffective or have been
insufficiently studied to determine their efficacy. Furthermore, while little is
known about the safety of many of these compounds, there are a growing num-
ber of adverse event reports for several of them. Table 4-4 summarizes the cur-
rent safety and efficacy profile of a number of alternative compounds promoted
for the purpose of weight loss.
The combination of ephedrine and caffeine to treat obesity has been re-
ported to produce weight losses of 15 percent or more of initial body weight
(Daly et al., 1993; Toubro et al., 1993). Both drugs are the active ingredients in a
number of herbal weight-loss preparations. Weight loss is maximal at about 4 to
6 months on this combination, but body-fat levels may continue to decrease
through 9 to 12 months, with increases in lean body mass (Toubro et al., 1993).
This observation suggests that the combination may be a beta-3 adrenergic ago-
nist (Liu et al., 1995; Toubro et al., 1993).

Reports of cardiovascular and cerebrovascular events following use of

ephedrine and caffeine to treat obesity have reached sufficient frequency that
FDA and the Federal Trade Commission have begun to investigate the safety of
this combination and have issued warnings to consumers. In addition, FDA has
proposed new regulations for the labeling of products containing ephedrine,
which would require warning statements for potential adverse health effects.
Use of ephedrine alone or in combination with caffeine has been associated with
a wide range of cardiovascular, cerebrovascular, neurological, psychological,
gastrointestinal, and other symptoms in adverse events reports (Haller and Be-
nowitz, 2000; Shekelle et al., 2003). Some prospective studies do not support the
concept that there are major adverse events with ephedrine and caffeine (Boozer
et al., 2001, 2002; Greenway, 2001; Kalman et al., 2002), but these studies were
conducted using healthy individuals selected using careful exclusion criteria.
FUTURE DRUGS FOR THE TREATMENT OF OBESITY

Body weight, body fat, energy metabolism, and fat oxidation are regulated
by numerous hormones, peptides, neurotransmitters, and other substances in the
body. Drug companies are devoting a large amount of resources to find new
agents to treat obesity. Potential candidates include cholecystokinin, cortioco-
tropin-releasing hormone, glucagon-like peptide 1, growth hormone and other
growth factors, enterostatin, neurotensin, vasopressin, anorectin, ciliary neuro-
trophic factor, and bombesin, all of which potentially either inhibit food intake
or reduce body weight in humans or animals (Bray, 1992b, 1998; Ettinger et al.,
2003; Okada et al., 1991; Rudman et al., 1990; Smith and Gibbs, 1984).
Neuropeptide Y and galanin are central nervous system neurotransmitters that
stimulate food intake (Bray, 1998; Leibowitz, 1995), so antagonists to these
substances might be expected to reduce food intake. Beta-3 adrenergic receptor
agonists reduce body fat and increase lean body mass in animals (Stock, 1996;
Yen, 1995), but human analogs have not been identified that are effective and
safe in humans. Several types of uncoupling proteins have been identified as
being involved with the regulation of energy metabolism and body fat (Bao et
al., 1998; Bouchard et al., 1998; Chagnon et al., 2000; Pérusse et al., 1999), but
no agents based on these proteins have yet been produced to treat obesity.
As discussed in Chapter 3, seven single gene defects have been reported to
produce obesity in humans (Pérusse et al., 1999). The leptin gene is defective in
ob/ob mice, and leptin administration has been shown to be highly effective in
reducing body weight in these mice (Campfield et al., 1995; Halaas et al., 1995;
Pelleymounter et al., 1995). A very small number of humans with this gene de-
fect have been identified, and at least one responded to leptin (Clement et al.,
1998; Pérusse et al., 1999). Leptin levels are high in most obese individuals
(Considine et al., 1996; Phillips, 1998), and preliminary trials of administration
of leptin to these individuals show modest effects. Defects in the genes for

TABLE 4-4 Alternative Medicines, Herbs, and Supplements Used for Weight
Loss
Name/Compound Description
Bladderwrack Fucus vesiculosus
Chitosan Polymer of glucosamine derived from chitin
Chromium Cr—an essential element
CLA Conjugated linoleic acid
DHEA Dehydroepiandrosterone
Ephedrine fat-burning stack Ephedrine with caffeine and aspirin, ma huang
with guarana and willow bark
Garcinia cambogia Contains hydroxycitrate (HCA)
Germander Teucrium chamaedrys

HMB β-Hydroxy-β-methylbutryrate
Olestra (Lawson et al., 1997) Mixture of hexa-, hepta-, and octa-esters of
sucrose formed from long-chain fatty acids
isolated from edible oils
Plantago Plantain leaf or psyllium seed
Pyruvate A 3-carbon compound

Sunflower Helianthus annuus
St. John’s Wort Hypericum perforatum
SOURCE: Allison et al. (2001).
protein convertase subtilisin/kexin type 1, PPAR-gamma, and pro-opiomelano-

cortin and in the genes for the receptors for leptin, thyroid hormone, and
melanocortin-4R (Bouchard et al., 1998; Chagnon et al., 2000; Pérusse et al.,
1999) have been identified in humans. It may be possible in the future to
develop gene therapy or products that correct these defects in order to treat
obesity.
Summary
Although obesity drugs have been available for more than 50 years, the
concept of long-term treatment of obesity with drugs has been seriously
advanced only in the last 10 years. The evidence that obesity, as opposed to
overweight, is a pathophysiological process of multiple etiologies and not
simply a problem of self-discipline is gradually being recognized—obesity is

Safety Efficacy for Weight/Fat Loss

No, increases risk of hyperthyroidism Insufficient data
Insufficient data No (Pittler et al., 1999; Wuolijoki et al.,
1999)
Yes, when used in recommended Likely ineffective (Hallmark et al., 1996;
doses Lukaski et al., 1996; Trent and Thieding-
Cencel, 1995)
Yes, preliminary report Yes, preliminary report (Blankson et al.,
2000)
No Yes, but studies are limited
Adverse effects have been reported Yes, appropriate dose and in combination
(Haller and Benowitz, 2000; with caffeine (Astrup et al., 1992a, 1992b;
HHS/FDA, 1997; Shekelle et al., Boozer et al., 2001)
2003)
Insufficient data Insufficient data, possibly ineffective at dose
of 1,500 mg/d in obese adults (Heymsfield
et al., 1998)
No Insufficient data
Yes, short-term Yes
Yes Insufficient data
Unknown, may cause gastrointestinal Insufficient data

distress and affect absorption of
medications
Insufficient data No
Yes Insufficient data
Insufficient data Insufficient data
similar to other chronic diseases associated with alterations in the biochemistry

of the body. Most other chronic diseases are treated with drugs, and it is likely
that the primary treatment for obesity in the future will be the long-term
administration of drugs. Unfortunately, current drug treatment of obesity
produces only moderately better success than does diet, exercise, and behavioral
modification over the intermediate term. Newer drugs need to be developed, and
combinations of current drugs need to be tested for short- and long-term
effectiveness and safety. As drugs are proven to be safe and effective, their use
in less severe obesity and overweight may be justified.
The appropriateness of using weight-loss drugs in the military population
requires careful consideration. On average, a 5 to 10 percent weight loss can
improve comorbid conditions associated with obesity, but it is not known if this
degree of weight reduction by itself would improve fitness or if it could be
expected to improve performance in all military contexts. The side effects that

are sometimes encountered might also restrict the use of weight-loss drugs in
some military contexts. On the other hand, the military is losing or is in danger
of losing otherwise qualified individuals who cannot “make weight.” Such
people might be able to keep their weight within regulation if they are allowed
to take weight-loss drugs for the remainder of their term in the military. The
frequency of known side effects of current weight-loss drugs is sufficiently low
that the potential for adverse events would not seem to be a reason to avoid the
use of these drugs by military personnel.
The use of available dietary supplements and herbal preparations to control
body weight is generally not recommended because of a lack of demonstrated
efficacy of such preparations, the absence of control on their purity, and evi-
dence that at least some of these agents have significant side effects and safety
problems. The occurrence of potential adverse effects (e.g., dehydration, mood
alterations) would be of particular concern for military personnel.
SURGERY
Although it would be expected that very few active duty military personnel
would qualify for consideration for obesity surgery, a review of weight-
management programs would not be complete without a discussion of this
option.
For massively obese individuals (those with a BMI above 35 or 40), the
modest weight losses from behavioral treatments and/or drugs do not alter their
obese status. For these individuals, obesity surgery may produce massive, long-
term weight loss. Recent studies have shown dramatic improvements in the
morbidity and mortality of those who are massively obese, and surgery is being
recommended with increasing frequency for these individuals (Hubbard and
Hall, 1991). Table 4-5 presents the rationale and results of all forms of obesity
surgery.
Individuals who are candidates for obesity surgery are those who (1) exhibit
any of the complications of obesity such as diabetes, hypertension, dyslipidemia,
sleep disorders, pulmonary dysfunction, or increased intracranial pressure and
have a BMI above 35, or (2) have a BMI above 40.
Gastric bypass is currently the most commonly used procedure for obesity
surgery. Following this procedure, patients lose about 62 to 70 percent of excess
weight and maintain this loss for more than 5 years (Kral, 1998; MacDonald et
al., 1997; Pories et al., 1992, 1995; Sugerman et al., 1989). Biliopancreatic
bypass, another type of obesity surgery, and its variations produce weight losses
comparable or superior to gastric bypass (Kral, 1998). In addition to massive
weight loss, individuals who undergo obesity surgery experience improvements
in health status relative to hypertension, dyslipidemia, sleep apnea, pulmonary
function (oxygen saturation and oxyhemoglobin levels and decreased carbon
dioxide saturation) (Sugerman, 1987; Sugerman et al., 1986, 1988), obesity-

hypoventilation syndrome, and pseudotumor cerebri, urinary incontinence, and

pulmonary dysfunction possibly due to increased intra-abdominal pressure
(Sugerman et al., 1995, 1999).
Obesity surgery is, however, considered the treatment of last resort because
of the short- and long-term complications associated with the surgery. Pe-
rioperative mortality is small but significant (about 0.3 to 2 percent) and appears
to vary inversely with the experience of the surgeon (Kral, 1998). Other poten-
tial side effects include vomiting, diarrhea, electrolyte abnormalities, liver fail-
ure, renal stones, pseudo-obstruction syndrome, arthritis syndrome, and bacterial
overgrowth syndromes.
THE USE OF STRUCTURED MAINTENANCE PROGRAMS

When to Use a Maintenance Program
The long-term success of weight management appears to depend on the in-
dividual participating in a specific and deliberate follow-up program. Programs
to aid personnel in weight maintenance or prevention of weight gain are appro-
priate when:
• An individual has successfully achieved his or her weight-loss goal and

now seeks to maintain the new weight,
• An individual who is gaining weight has taken a weight-loss readiness
assessment and has determined that he or she is not ready for weight loss at this
time, or
• An overweight individual is temporarily excluded from a weight-
reduction program until a medical, physical, or psychological problem stabilizes.
Components of a Maintenance Program

A comprehensive weight-maintenance strategy has five fundamental com-
ponents:
1. It helps the patient select a weight range within which he or she can
realistically stay and, if possible, minimize health risks.
2. It provides an opportunity for continued monitoring of weight, food in-
take, and physical activity.
3. It helps the patient understand and implement the principle of balancing
the energy consumed from food with routine physical activity.
4. It helps the patient establish and maintain lifestyle change strategies for
a sufficiently long period of time to make the new behaviors into permanent
habits (a minimum of 6 months has been suggested [Wing, 1998]).
5. It considers the long-term use of drugs.

TABLE 4-5 Surgical Procedures Used for Treatment of Obesity in Humans

Procedure Proposed Mechanism
Intestinal resection (Kral, 1989) Small intestine malabsorption
Intestinal bypass (Kral, 1998) Small intestine malabsorption

Jujuno-ileal bypass (Hallberg et al.,
1975; Kral, 1998; Payne and
DeWind, 1969)
End-to-end, end-to-side (Bray et al.,
1977)
Biblio-pancreatic bypass (Kral, 1998; Small intestine malabsorption
Scopinaro et al., 1979, 1998)
Stomach to ileum (Kral, 1998) Small intestine malabsorption
Gastric stapling (MacLean et al., 1993) Partial gastric outlet obstruction, limited
food intake
Gastric bypass (Benotti et al., 1989; Reduced food intake secondary to very
Linner, 1982; Yale, 1989) small stomach size and restricted flow
rate into small intestine, reduced
intestinal absorption
Vertical banded gastroplasty (Benotti et Reduced food intake secondary to very

al., 1989; Linner, 1982; Mason, 1982; small stomach size and restricted flow
Yale, 1989) rate into small intestine, reduced
Gastric wrapping (Kral, 1998) Reduced food intake secondary to very
small stomach size and restricted flow
rate into small intestine, reduced
Jaw wiring Prevents solid food consumption
Subdiaphragmatic truncal vagotomy ± Loss of motor function leads to stomach
pyloroplasty (Holle and Bauer, 1978) distension which causes a feeling of
fullness that may signal the central
nervous system
Liposuction (Kral, 1998) Removal of subcutaneous fat
a
Humoral or neural effects of exposure of ileum to nutrients may lead to increased
effects.
Helping Patients Learn How to Balance Energy

Individuals who have achieved a weight-loss goal generally fall into one of
two groups: those who see no point in participating in a maintenance program
since they believe they know how to keep the weight off and those who remain
open to change and improving their skills in weight management.
The critical role of the health care provider is to motivate the former group
to learn the skills necessary for weight management. The skills necessary to:

Results Notes
80% Decrease in energy intake in
immediate postoperative period
Gradual weight increase over 2 years
High failure rate
Considered more effective than vertical

banded gastroplasty and gastric
wrapping, causes dumping, laparoscopic
(leads to decrease in perioperative
complications)a
Rarely used due to large number of
complications
100% Failure
Average weight loss ≈ 20 kg Procedure abandoned
Effects minimal Cosmetic use only
• Maintain regular exercise for at least 60 min/day or an expenditure of

2,000 to 3,000 kcal/wk (8,368 kJ) (Klem et al., 1997; Schoeller et al., 1997).
• Decrease the amount of energy-dense foods eaten (especially those that
are low in nutrients).
• Practice healthy eating by including fruits, vegetables, and whole grains
in the diet.
• Understand portion control.
• Access the services of nutrition counselors or other forms of guidance.

Helping Patients Establish Permanent Lifestyle Change Strategies

As mentioned above, individuals who have lost weight need to make per-
manent lifestyle changes in order to maintain their loss. To assist patients in
making these changes, successful maintenance programs will include education
on and assistance with the following factors (Foreyt and Goodrick, 1993, 1994;
Kayman et al., 1990):
• Self-monitoring. Regular weighing and recording of daily food intake

and physical activity for the first month or two of the maintenance period and
during periods of increased exposure to food (e.g., during the holidays). If
weight gain occurs, reinstitution of this practice may help bring weight back into
control. Frequent follow-up contact with counselors is also crucial (Perri et al.,
1993). Effective follow-up consists of a schedule of regular weekly to monthly
contacts by mail, phone, or in person. Support groups may substitute for some of
this follow-up with a health care provider, but should not replace it.
• Physical activity. Daily physical activity is key to successful weight
maintenance; it is the factor cited as the most important in maintaining weight
loss by the majority of individuals in the National Weight Loss Registry (Klem
et al., 1997). An average of 80 min/day of moderate activity or 35 min/day of
vigorous activity is needed to maintain weight (Schoeller et al., 1997).
• Problem solving. Learning to identify and anticipate problems that
threaten to undermine success is necessary. Problem solving skills allow the
individual to craft strategies that will resolve problems as they emerge.
• Stress management. Exercise, relaxation, and social support can help
reduce stress. Techniques to reduce stress can be critical for some individuals
who overeat in response to stress.
• Relapse prevention. Relapse, temporary loss of control, and return to
old behaviors is common. The key to relapse prevention is learning to anticipate
high-risk situations and to devise plans to reduce the damages. Patients need to
learn to forgive themselves for a lapse and view it as a “learning experience.”
Reestablishing control is crucial.
• Social influence/support. Sabotage by family or friends is seen often
and may be stressful for the individual who is trying to maintain weight. The
skills to recognize intentional or unintentional sabotage may be learned. In ex-
treme cases, a choice may need to be made between the weight-maintenance
program or the relationship. Identifying a fresh circle of supporters or starting a
support group may be useful.
PUBLIC POLICY MEASURES

To the extent that the epidemic of obesity can be attributed to changes in
our living and working environments (the increased availability of calorie-dense

foods and decreased opportunity to expend energy), public policy efforts may
help prevent overweight and may assist those who are trying to lose weight or
maintain weight loss (Koplan and Dietz, 1999). Some measures that have been
suggested and/or tried include the following:
• Increasing choices and decreasing prices of low-calorie (and low-fat)

foods (e.g., fruits and vegetables) offered at worksite eating places and in vend-
ing machines (French et al., 1997; Hoerr and Louden, 1993)
• Instituting workplace and community programs that include regular
monitoring, nutrition and health promotion, overweight prevention education,
and exercise classes or groups
• Renovating community spaces to provide more and safer spaces for
physical activity
• Modifying work environments or schedules to encourage greater physi-
cal activity on and off the job
• Mandating regular physical activity during the workday (IOM, 1998).
SUMMARY
Apart from the obvious need to increase energy expenditure relative to
intake, none of the strategies that have been proposed to promote weight loss or
maintenance of weight loss are universally recognized as having any utility in
weight management. The efficacy of individual interventions is poor, and
evidence regarding the efficacy of combinations of strategies is sparse, with
results varying from one study to another and with the individual. Recent studies
that have focused on identifying and studying individuals who have been
successful at weight management have identified some common techniques.
These include self-monitoring, contact with and support from others, regular
physical activity, development of problem-solving skills (to deal with difficult
environments and situations), and relapse-prevention/limitation skills. However,
an additional factor identified among successful weight managers, and one not
generally included in discussing weight-management techniques, is individual
readiness, that is, strong personal motivation to succeed in weight management.


5
_________________________________________________________________________________
Response to the Military’s Questions
Based on a thorough review of the scientific literature, the material pre-

sented at the workshop, and current military data and discussions with workshop
speakers and others, the subcommittee provides the following responses to the
questions posed by the military. It should be noted, however, that prevention of
weight and fat gain throughout an individual’s military career would be
preferable to even the most comprehensive weight-loss program.
QUESTION 1
What are the essential components of an effective weight/fat loss program,
and the most effective strategies for sustaining weight loss?
Years of research have demonstrated that a program for weight/fat loss can
only be effective when it is closely integrated with a program for sustaining
weight loss. The rate of failure to maintain weight loss for those individuals who
have successfully completed weight-loss programs has been disappointingly
high. Successful cases clearly demonstrate that permanent major lifestyle
changes must be adopted during the weight-loss phase of the program in order to
prevent regain of the weight lost. Even in the most successful programs, the ma-
jority of patients regain some of their lost weight over time. The greatest likeli-
hood of success requires an integrated program, both during and after the
weight-loss phase, in which assessment, increased energy expenditure
through exercise and other daily activities, energy intake reduction, nutri-
tion education, lifestyle change, environmental change, and psychological
support are all components.
Essential Components of an Effective Weight/Fat Loss Program

The first component of an effective weight/fat loss program is an appropri-
ate assessment. In most cases, body weight and height measurements should be
113

taken and the individual’s body mass index (BMI) calculated from this data. If
the BMI is within the acceptable range as defined by the Department of Defense
(DOD), no further measurement is necessary. However, if the height and weight
measurements indicate that the individual exceeds the service’s standards or that
the calculated BMI exceeds the newly adopted DOD maximum of 27.5, then
additional anthropometric measures should be taken to assess body-fat content.
DOD has extensively validated the circumference equations used to estimate
percent body fat, and a single equation for men and one for women has now
been mandated across all service branches (DOD, 2002). Care should be taken
to assure that the standard procedures for measuring body circumferences are
followed. Proper training and adequate criteria for assessing technician skill in
conducting accurate circumference measurements should be standardized across
DOD. Considering the seriousness of the consequences of overweight for mili-
tary personnel, validation of technician skill and availability of the data demon-
strating the reliability and repeatability of a technician’s circumference measures
is warranted. Once there are clear indications that an individual’s body-fat mass
exceeds desired standards, a medical evaluation should be conducted to deter-
mine if a medical condition exists that might be the underlying cause of body-fat
accumulation. In the absence of any apparent medical condition, the individual
can enter a weight-reduction program.
The essential components of a weight/fat loss program include:
• Exercise. For overweight adults who are otherwise healthy, increased

physical activity is an essential component of a comprehensive weight-reduction
strategy. There is compelling evidence that habitual physical activity is associ-
ated not only with weight/fat loss, but also with desirable health outcomes
(Angotti and Levine, 1994; IOM, 2002; Kesaniemi et al., 2001), and there is
evidence from industrial research that workers are more productive and lose
fewer days due to health problems when provisions are made for regular exer-
cise. Retrospective analyses of weight regain as a function of energy expended
in physical activity indicated a threshold for weight maintenance of 11.23 kcal
(47 kJ)/kg of body weight/day. This corresponds to an average of 80 min/day of
moderate activity or 35 min/day of vigorous activity added to a sedentary life-
style (Schoeller et al., 1997). As indicated, this would be considered the thresh-
old level and would likely need to be higher (either longer time periods or
greater intensity) to effect weight loss. There is good evidence that peak rates of
lipid oxidation are achieved at exercise intensities of approximately 45 percent
of VO2max (Bergman and Brooks, 1999; Brooks, 1998; Wolfe, 1998).
• Behavioral modification. The use of behavior and lifestyle modification
in weight management is based on a body of evidence that people become or
remain overweight as a result of modifiable habits or behaviors and that by
changing these behaviors, weight can be lost and weight loss can be maintained.
The modifications that need to be made are: increased activity, decreased energy

RESPONSE TO THE MILITARY’S QUESTIONS 115
intake, and improved diet quality. In addition, the individual needs to learn to
effectively deal with stress and identify situations that may trigger excessive
intake or inactivity.
• Net dietary energy deficit. Energy expended must exceed energy
consumed on a consistent basis over an extended period of time, the length of
which depends on the degree of overweight. While balanced macronutrient diets
are usually recommended, the composition of the diet may vary to suit
individual preferences and health concerns that may need to be addressed. There
is no scientific consensus on the ideal dietary composition, but extremes of
individual macronutrients should be avoided. For military personnel who stand
to lose their livelihood if they cannot reduce their weight, options such as high-
protein diets should not be precluded. Recent data suggest that these types of
diets may better preserve lean body mass, lower insulin levels, and enhance
energy expenditure (protein has the highest thermal effect of feeding).
A potential downside to high-protein diets, particularly if they are quite low
in carbohydrate, is that there may be changes in levels of potassium and other
cations. Evidence suggests that the initial weight that is lost on high-protein
diets is mostly fluid and thus, dehydration is a risk, particularly for military
pilots.
• Education. Information on nutrition principles, food-portion control,
and the need for energy balance is essential for individuals to develop appropri-
ate eating behaviors.
• Psychological Support. Any weight-management program is likely to
be more successful if it is accompanied by structured support mechanisms (e.g.,
from professional counselors, commanders, coworkers, and family).
• Environmental changes. The services should take measures to change
the environments that foster underactivity and overconsumption of energy. Ex-
amples of environmental changes include putting low-fat, healthy snacks in
vending machines; increasing the variety of low-fat, low-calorie entrees in base
dining facilities; selecting commercial food establishments for base contracts
that provide a variety of low-fat, healthy menu items; and encouraging the con-
sumption of low-fat, low-calorie snacks during working hours. Environmental
changes that promote greater activity are also essential (e.g., using stairs rather
than elevators and escalators). The environment includes the home, the work-
place, and the community.
• Structured monitoring. The long-term success of weight-loss programs
appears to depend on a specific and deliberate follow-up program. This struc-
tured follow-up should include monitoring body weight with weigh-ins at least
weekly during weight loss and monthly during maintenance, monitoring food
intake, and monitoring physical activity. Keeping a diary or record that includes
this information, along with notations on feelings and challenges, can also be
useful. The frequency of monitoring is usually weekly until new habits and be-

haviors are well established. After that, less frequent monitoring is needed
unless the individual encounters difficulties and needs to get back on track.
Sustaining Weight Loss

Most studies in which patients are not provided weight-maintenance assis-
tance following achievement of weight-loss goals show that complete weight
regain will occur in a majority of the patients within 5 years (Stalonas et al.,
1984; Wadden et al., 1989). A recent review of studies on the effectiveness of
weight-maintenance strategies show that programs that incorporate continued
professional guidance, skills training for coping with challenges, enhanced so-
cial support, enhanced aerobic exercise, and techniques for sustaining behavior
change lower the rate of relapse (Perri et al., 1993). Although such strategies do
not ensure success, the outcome is much more favorable. Considering that these
studies were conducted with patients in the general population where relapse is
undesirable, but often not punitive, makes the results even more compelling for
the military where failure to maintain weight loss can have serious consequences
for career progression.
A successful program for sustaining weight loss should include the follow-
ing components:
• Physical activity is an essential component for long-term, sustained

weight loss. Studies suggest that expenditure of at least 2,000 kcal (8,368 kJ) to
3,000 kcal (12,558 kJ) per week from exercise is necessary to prevent regain of
lost weight (Klem et al., 1997; Schoeller et al., 1997). This is in addition to the
normal daily activities of sedentary individuals.
• Permanent lifestyle and behavioral modifications are important for
maintaining energy balance. The individual needs practice in problem solving
and coping skills that are essential to balance daily energy intake and habitual
levels of physical activity. This includes portion control, selecting foods lower
in fat and calories, and consistently sustaining higher levels of daily physical
activity. Sustained professional guidance, support, and feedback are essential for
the maintenance of these skills.
• Self-monitoring is important to success in weight maintenance. Indi-
viduals who have been overweight need to weigh themselves at least once a
week and record their weight. They should also be encouraged to periodically
(about every 3 months) keep a 3-day diary of the type and amounts of foods
consumed and the type and amounts of physical activity performed. The diary
information can provide counselors with important clues on problem areas and
highlight necessary changes in the diet and activity level needed to support
weight maintenance.
• Continuous structured support is necessary for weight maintenance. At
a minimum, an individual embarking on a weight-maintenance program, in addi-

tion to self-monitoring, should have follow-up visits or counseling via phone or

the Internet every 2 to 4 weeks for the first 3 months, depending on the difficulty
in maintaining a stable healthy weight, and every 1 to 2 months thereafter.
QUESTION 2
How do age and gender influence success in weight-management programs?
Should age be considered in weight/fat standards and in weight-management
programs and interventions?
Age
Research indicates that percent body fat increases with age even if weight
has not changed. The current upper limits of DOD standards of 26 percent fat in
men and 36 percent fat in women, however, are well within the limits of the
healthy percent body-fat range even for men and women as old as 60 to 79 years
of age. However, since the individual services all have body-fat limits more
stringent than the DOD upper limits, increases with age up to the DOD limit
appear to be appropriate.
Weight loss is more difficult with age due to decreases in physical activity,
strength, and endurance without concomitant decreases in energy intake, cou-
pled with decreases in lean body mass and increases (either absolute or relative)
in percent body fat. Energy requirements may be reduced due to decreased lean
body mass; therefore, energy intake must be carefully controlled. If the goal of
the military is to maintain health, there should not be age-related BMI increases.
However, increases in the allowable percent fat with increasing age are reason-
able, but should not exceed the maximum of 36 percent in women and 26 per-
cent in men. If the goal is performance, BMI and fat increases may not affect
performance in some military occupations. (This is an area that needs further
research.) In such occupational specialties, it may be reasonable to rely on per-
formance-based physical training tests. If the goal is military appearance, there
is little data to suggest that appearance standards are closely related to perform-
ance, health, fitness, or nutrition (IOM, 1998). However, from both an appear-
ance and a health perspective, abdominal circumference should be used as an
objective measure. Upper body adiposity as measured by abdominal circumfer-
ence has been shown to be a separate risk factor for mortality and coronary heart
disease. Current National Institutes of Health guidelines for maximum abdomi-
nal girths are 102 cm (approximately 40 in) for men and 89 cm (approximately
35 in) for women.

Gender
Women, because of their smaller body size, specific adipose tissue stores,
and lower lean body mass, automatically have a higher percent body fat than
men at the same BMI. In addition, excessive weight gain during pregnancy, as
well as hormonal and metabolic changes after pregnancy and menopause, may
be associated with higher body fat. This may make weight loss more difficult for
women. Preventive measures would include counseling to keep pregnancy
weight gain within the recommended range (IOM, 1990, 1992b).
QUESTION 3
Which strategies would be most and least effective in a military setting?
Should military weight/fat loss programs involve direct participation interven-
tions or only monitoring and guidance? Should military programs be more
practices? Is a warning or cautionary zone prior to enrollment in a weight-
control program an effective strategy? When should duty time be authorized
for participation in intervention strategies for weight/fat loss?
Most and Least Effective Strategies

The effective strategies for a weight/fat loss program would be the same
regardless of whether the setting is military or civilian. However, the implemen-
tation of some of these strategies could be facilitated in the military environ-
ment, particularly physical fitness, exercise, and behavior modification. The
safest program designed for weight loss and maintenance is an increase of
energy expenditure through exercise and daily activity coupled with control or
reduction of energy intake, behavior modification, and lifestyle changes. A key
factor in the control of energy intake is behavior modification—individuals who
have an overweight problem have a pattern of food consumption and/or energy
expenditure that contributes to positive energy balance.
The primary difficulty in the military setting would be in providing
structured follow-up due to the mobility of the military population. When diet
and exercise are insufficient, the addition of certain prescription drugs may be
useful as an adjunct, but the use of drugs should be carefully monitored and
controlled. A person whose overweight is severe enough to warrant drugs (BMI
≥ 30) is likely to require the drugs on a long-term basis. Such individuals may
have genetic or other etiologies of obesity that make it difficult to adhere to
lifestyle modification programs. In such cases, drug therapy may alter the
biochemistry of the body sufficiently to allow them to adhere to a diet and
exercise program that will bring them into compliance with weight regulations.

Direct Participation Interventions versus Monitoring and

Guidance
Direct participation interventions have been demonstrated to improve com-
pliance, increase the success rate of weight/fat loss, and support an improved
level of weight maintenance. It is important that overweight individuals be
counseled for individualized diet modification and exercise and be continually
monitored. Do-it-yourself pamphlets may be useful to some people, but many
individuals need one-on-one or group contact with competent counselors to
address both diet and exercise. Weight loss and weight-loss maintenance pro-
grams have high rates of failure. The goal is to develop permanent behavior
modification.
Long-term follow-up is clearly needed for individuals to maintain their
weight loss. Innovative strategies, perhaps with centralized dietitians or other
counselors who can follow military personnel via the Internet, might be devel-
oped. Since recidivism in overweight people is high, the military might consider
mandating routine follow-up for anyone who has at any time exceeded the
weight standards. While drastic, a focus on constant follow-up and feedback
may prevent weight regain or identify a problem very early in its course, thus
making it easier to rectify.
There is a correlation between frequency of monitoring and success in
weight loss and maintenance of weight loss. A comprehensive program that
individualizes the degree of direct participation intervention will increase the
success rate of weight/fat loss and support an improved level of weight main-
tenance. If only monitoring and guidance are provided, individuals may seek
help from unqualified nonmilitary weight-loss sources or pursue other unhealthy
weight-loss approaches to meet their monitoring goals. Individuals’ use of
prescription drugs or nonprescription supplements unknown to their military
health-care providers could have negative health consequences.
Identifying and Discouraging Ineffective or Dangerous

Weight-Loss Practices
The military setting is unique in providing a strong disciplinary incentive to
achieve and maintain a healthy body weight and body-fat content. Few employ-
ment environments have standards for weight and percent body fat and the
authority to enforce them by affecting promotion and retention. In fact, the
incentive is so strong that individuals in the military have been observed to
practice high-risk crash dieting in order to pass weigh-ins.
It is appropriate for military weight programs to collect information and
evaluate weight-loss practices of overweight (as well as normal-weight) individuals
as a component of their medical evaluation. Research reports (McNulty, 1997a,
1997b, 2001; Peterson et al., 1995) demonstrate that unhealthy eating and purging

behaviors are much more prevalent among military personnel compared with
civilian populations. One method to reduce the incidence of dangerous practices is
more frequent weigh-ins and an emphasis on appropriate diet and physical activity
patterns at all times as part of a military lifestyle. Not only is this strategy in the
individual's best interest, but also the military is responsible for the health and
welfare of all uniformed personnel and must bear the cost of care for individuals
who may be injured by unsafe weight-loss practices.
Is A Warning or Cautionary Zone Prior to Enrollment in a

Weight-Control Program an Effective Strategy?
The use of a warning or cautionary zone in a military weight-control pro-
gram, the Air Force has a 3-month warning period now in effect, appears to be
an excellent strategy. A significant number of individuals are capable of
correcting a marginal overweight condition with appropriate support. The
restrictions associated with being assigned to a military weight/fat-loss program
are very punitive to the individual and costly to the military service. Those who
are able to solve their overweight/fat problems by themselves (or with minimal
help) in a timely manner should be given the chance to accomplish this goal
without being assigned to the military weight/fat-loss program with its attendant
consequences. In addition, a strong, preventive weight-control effort should be
added to military public health programs (beginning with initial entry training)
to encourage young military personnel to monitor their body weight and seek
help early if they find they are gaining weight.
Authorizing Duty Time for Participation in Intervention

Strategies for Weight/Fat Loss
Certain tasks associated with the weight/fat loss program should be
accomp-lished during duty time. They include any medical examination and
tests that are appropriate before being assigned to the program, as well as
counseling and monitoring. A weight-loss program should be viewed as
treatment for a medical condition and, as such, be given the same priority as
treatment for other medical conditions. Given the benefits of exercise for long-
term obesity prevention, long-term health outcomes, and possibly for enhanced
mental performance, the military might consider mandatory exercise at fixed
times each day or other schemes to ensure that the vast majority of military
personnel exercise several times per week.
Current DOD policy dictates regular exercise as a part of the duty day. This
policy should be mandatory rather than at the unit commander’s discretion. Unit
commanders should provide (or require) regular exercise to ensure a high level
of fitness and readiness. Allowing duty time for participation in associated ac-
tivities of weight-management programs, such as exercise classes, support group

sessions, and classes that teach appropriate dietary selection and new food
preparation techniques, should be at the discretion of the unit commander. Such
activities could be viewed as part of a healthy life style and the individual should
be expected to do these tasks on their own time in the same manner as individu-
als who maintain a healthy weight.
QUESTION 4
To what extent should weight-control programs/policies be standardized
across the services versus tailored to the individual service, installation, or
unit? What are the advantages and disadvantages of standardization? Is the
provision of state-of-the-art- techniques and knowledge a rationale for stan-
dardization?
Lower rates of recruitment, increased attrition of those who enter over-
weight, and reduced retention of skilled, highly trained older personnel threaten
the long-term welfare and readiness of U.S. military forces. Therefore, the sub-
committee provides the following responses regarding the standardization of
weight-control policies.
Extent of Standardization Across the Services versus

Tailored to an Individual Service
The specifics of implementation of weight-control policies and programs
may need to be tailored for each service due to the different environments in
which the programs will be carried out (e.g., aboard ships, on CONUS military
bases, on overseas bases). However, they could be standardized across the ser-
vices to a significant extent as indicated below. A limited number of military
centers should be identified to provide scientifically-validated body composition
evaluations (IOM, 1992a).
Body Composition Standards

The current DOD target for body fat, with a maximum body fat of 36 per-
cent for women and 26 percent for men, seems appropriate based on considera-
tions of health and chronic disease risk. This percentage of body fat should be
acceptable if the fitness test is passed (IOM, 1998). Cut-off points for the maxi-
mum weight-for-height standards should reflect BMI categories that are consis-
tent with the guidelines released by the National Heart, Lung and Blood Institute
(NHLBI, 1998). A BMI < 18.5 constitutes underweight, a BMI of 18.5 to 24.9
constitutes healthy weight, a BMI of 25.0 to 29.9 constitutes overweight, and a
BMI > 30.0 constitutes obesity. A BMI consistent with overweight does not
by itself indicate that an individual is overfat. Additional testing must be done

to determine whether the excess weight in such individuals consists of fat or of

lean mass. This is especially relevant because research has linked BMI to injury
rates in initial entry training (Jones et al., 1992). In several small studies, an in-
creased BMI was associated with reduced performance in 1- and 2-mile runs,
sit-ups, and push-ups by men, and also was associated with an increased injury
rate during initial entry training.
Body Composition Measurements

New technologies for measuring body composition should be adopted ser-
vice-wide as they become available, once they are validated for accuracy and
ease of use.
Appearance Standard
The DOD appearance standard is articulated in DOD Directive 1308.1,
DOD Physical Fitness and Body Fat Program (DOD, 1995). This document
states that “. . . maintaining desirable body composition is an integral part of
physical fitness, general health, and military appearance” (p. 2). Further, Army
Regulation 600-9 (U.S. Army, 1987) states that soldiers should present a physi-
cal appearance in uniform “that is trim and smart” and that enlarged waistlines
detract from a good military appearance. The need to develop objective criteria
has been highlighted previously (IOM, 1992a, 1998). The subcommittee com-
mends the military for its recent adoption of waist circumference as a criteria for
proper appearance (DOD, 2002), although research is needed to clarify whether
the present appearance policy unfairly penalizes certain individuals (e.g., those
of Hispanic heritage, female gender, older age) (Ellis et al., 1997; Thomas et al.,
1997). The only objective health-based standard the subcommittee can offer that
relates to appearance is that waist circumference should not exceed 40 inches in
men and 35 inches in women.
Weight-Management Counselors
Those responsible for weight-control programs should be certified and their
training should be standardized. The number of certified weight-management
counselors should be increased in each of the military branches. These counsel-
ors should be experienced in weight management issues that are specific to gen-
der, ethnic background, and age.
Internet-Based Weight-Management Programs

Web-based weight-management programs should be developed that are
portable and consistent DOD-wide so that counseling, records, and support tech-

niques move with military personnel when they are assigned to a permanent
change of station.
What Are the Advantages and Disadvantages of

Standardization?
The advantages of standardization are that all military personnel would
have access to equivalent weight-management assistance and that the incorpora-
tion of new technologies for body composition assessment and the adoption of
Internet-based services would be facilitated. In addition, the costs of producing
education materials (e.g., portion size models, brochures) would be reduced.
The disadvantage of standardization is that it might limit autonomy within
the branches of the armed forces. There is no scientific disadvantage.
Is the Provision of State-of-the-Art Techniques and

Knowledge a Rationale for Standardization?
Standardization of weight-control program components would facilitate the
incorporation of new technologies and provide a stronger base for program eval-
uation, which would in turn protect DOD investments in each soldier. Although
programs would need to be tailored to some degree for the various military
settings, all programs need to be multidisciplinary and comprehensive (e.g., all
should incorporate the elements of successful programs as discussed earlier).
QUESTION 5
How can diet be effectively dealt with as a weight-management component in
the military setting? Should pharmacological treatment (anorexiants) be
considered for use in the military? In what cases? What factors bear on this
decision?
Diet counseling needs to be administered by individuals fully trained in
weight-management concepts and supported by appropriate professional person-
nel. For those military personnel who are on ships or are dependent on mess
halls, more healthy, low-fat food choices and sufficient time for meal consump-
tion are imperative. In any case, nutrition and lifestyle education are paramount
and should be provided early in the initial entry training period and reinforced
periodically. The development of distance-based education in nutrition and
lifestyle modification may prove useful.
Pharmacological treatments should be considered for those who meet the
standard criteria for the use of such compounds (i.e., BMI ≥ 30 or BMI ≥ 27
with comorbidities and who are in military operational specialties that do not
preclude the use of central nervous system-active drugs. Current prescription

weight-loss drugs appear to have minimal side effects; long-term use during an
individual’s military career may need to be considered.
QUESTION 6
How should resistiveness to weight/fat control be dealt with?
In the context of the military use of the term, resistiveness is a condition
that generally refers to a genotype and/or a phenotype that is obesity-prone. An
individual may have physiological factors that favor obesity (e.g., family history
of obesity), thus making weight loss much more difficult. These individuals can
lose weight, but usually have to work harder and may need additional assistance
in the program and in the structured follow-up. Such individuals have a higher
risk of being unresponsive to lifestyle modification; drug therapy may be the
most efficient and effective long-term option for their treatment.
QUESTION 7
What are the knowledge gaps in weight-management programs relative to the
military? What research is needed?
Chapter 6 has been partly dedicated to research needs from a health and
weight-loss effectiveness perspective. This report does not address the funda-
mental issues of the relationship of body weight/fat standards to performance,
nor does it consider the impact of military service policies on manpower needs.
Additional research on the impact of modest overweight/overfat on performance
in various military occupational specialties is recommended to address these
issues.

6
_________________________________________________________________________________
Programmatic and Research

Recommendations
Knowledge gaps concerning weight-management programs relative to the

military are extensive. Much published research has been derived from studies
on middle-class, middle-aged or perimenopausal, Caucasian women in clinical
settings. This data may have little relevance to the military population where: (1)
only about 25 percent of officers and warrant officers and about 6 percent of
enlisted personnel are over the age of 40, (2) only 15 percent are women, and (3)
approximately 40 percent are minorities. Considerable research is needed in the
primary areas of prevention, treatment, and program evaluation. Research
recommendations are focused on those areas that are of specific concern to the
military community.
This chapter provides recommendations on the structure and content of
military weight-management programs and highlights research needed under
each of these areas. In addition, recommendations are provided for other poten-
tial areas of relevant research.
PREVENTION
National health survey data from the U.S. general population clearly
demonstrate that a significant percentage of individuals are overweight or obese.
This is true for both adolescents and adults. The existence of the Department of
Defense’s (DOD) weight-for-height and body-fat standards currently means that
an estimated 13 to 18 percent of young men between the ages of 17 and 20 and
17 to 43 percent of young women in this age group would fail to meet military
standards for accession (Nolte et al., 2002). While this situation will certainly
have a negative impact on DOD’s ability to meet recruitment goals, the fact that
accession standards exist also offers an extremely unique opportunity to develop
and study interventions to prevent weight gain.
Since the majority of military recruits will have met the DOD weight-for-
height and body-composition standards at the time of entry into the service, the
125

need for combat readiness (Robbins et al., 2001), optimal health, and economics
(Robbins et al., 2002) dictate that the prevention of weight gain should be a
major focus of military health programs and research.
Research is needed on interventions at the individual, group, worksite, and
community levels to prevent overweight and obesity. Most of the studies that
have evaluated prevention efforts in communities, in the workplace, or in
schools have shown modest or no effect on body weight (Atkinson and Nitzke,
2001; Taylor et al., 1991). However, intervention studies in targeted individuals
have been more positive (Angotti and Levine, 1994; Angotti et al., 2000; Latner
et al., 2000; Perri et al., 2001). There is a general consensus that preventing the
onset of obesity with appropriate interventions is likely to produce a better
success rate than attempting to treat overweight or obesity after it develops;
however, solid clinical research has not yet verified this assumption. Evidence
from a large body of literature indicates that once an individual becomes
overweight, loss of the excess weight is difficult to accomplish and the fre-
quency of regain is high.
Early Education of Initial Entry Trainees

Almost uniquely in American society, the military has the ability to mold
belief systems and behaviors of large groups of young people. This is apparent
in the ability of the military to take people in their late teens and early twenties
and instill in them character issues of discipline, honor, integrity, and hard work.
If the military made a commitment to nutrition education and physical activity
as part of the “military lifestyle,” generations of young people would have a
high possibility of adopting good nutrition and exercise habits as a part of
expected behavior. The military currently expects and demands a commitment
to physical fitness that far surpasses that which is customary in the civilian
population, and recruits change behavior dramatically in regard to physical
fitness. Initial entry training is a time of learning for individuals entering the
military. Just as these individuals learn military tasks (e.g., how to fire a
weapon), they could also learn nutritional principles and to adopt physically
active lifestyles. It is recommended that classes be included in initial entry
training that deal with appropriate nutrition behavior, eating patterns (such as
consumption of ample quantities of fruits, vegetables, and whole grains and
limiting portions of saturated fat), portion sizes, and the basic human biology of
nutrition and energy balance. An early training effort can provide large benefits,
including decreased loss of time from the job, reduced administration cost of
weight-control programs, and improved morale.
Military mess halls have a long history of closer adherence to recommended
dietary allowances than is usual in the civilian population. Educating recruits on
why this is appropriate and expected may produce life-long eating habits that are
healthier than that of the civilian population. The effectiveness of such a pro-

PROGRAMMATIC AND RESEARCH RECOMMENDATIONS 127
gram, including its specific components, should be evaluated. Controlled studies

of pilot programs could be conducted at selected bases to determine if behavior
changes are observed in response to the nutrition and healthy lifestyle education
and to identify the most appropriate methods of nutritional training. Large-scale,
randomized trials with alternate classes of recruits, followed over time, could be
highly useful in evaluating the efficacy of the preventive efforts and whether
they prove to be helpful in preventing overweight and obesity later in military
service. Positive results would encourage expansion of the program to the entire
military.
Particular attention should be paid to the concept that, as daily physical
activity declines with time in the service due to more administratively oriented
duties, energy intake needs to decline in order to maintain energy balance, even
if the level of fitness training remains unchanged.
Education of Families
Spouses and families of new military inductees should be included in
instruction on nutrition and healthy lifestyle habits, just as they are in classes on
military etiquette. Classes should also be set up for military spouses to learn
appropriate nutrition, cooking skills, shopping skills, and the importance of a
high level of exercise and activities of daily living. Evaluation of the effective-
ness of these programs should be carried out as described above (for the initial
entry trainees).
Exercise/Activity
As indicated in Chapters 3 and 4, there is much evidence to indicate that
activity is an important factor in preventing excess adipose tissue gain. Activity
may be divided into two categories: structured exercise and unstructured
exercise (or activities of daily living). Both of these provide opportunities for
research that could be of benefit to the military.
Structured Exercise
Current DOD policy dictates regular exercise as part of duty time, but this
policy is routinely ignored due to time pressures. Enforcement of these policies
by DOD or, for example, by holding commanders accountable for their units’
achieving a minimum average level of performance on the physical fitness test,
would engage commanders in the quest for routine exercise and attainment of
physical fitness.
The use of exercise as entertainment, as competition, and as games can play
an important role, especially among men. It is particularly valuable in military
facilities in which personnel are often organized into units around which compe-

tition can be developed. Scheduling competitions that involve unit fitness could
be tested as a method to improve overall fitness and activity. The competitions
should require participation by the entire unit and could include activities such
as comparisons of the unit-wide average performance on annual physical fitness
tests. Competition among companies or battalions would necessitate that all
individuals take part and would require nonmandated exercise to attain peak
performance.
Activities of Daily Living

Structured exercise requires time and may impinge on the performance of
other military duties. It usually is confined to a very limited period each day or
to several times per week. Increasing the activities of daily living to increase
unstructured exercise has been proposed as a way to help prevent overweight
and obesity. This could be studied in the military environment in a number of
ways, such as:
• Comparisons of environmental changes that might promote increased

activity. Changes to the design of military facilities that encourage increased
activity (a model that has been recommended but not tested in civilian life)
include prohibiting the use of cars in the center of bases (or cities), thus
increasing the likelihood of walking or biking, and designing (or renovating)
buildings so that stairs are readily available and that elevators or escalators are
not the first option for movement between a few floors. Such changes could only
be introduced gradually, but would provide an opportunity for evaluating the
effect on the prevalence of overweight or the average performance on physical
fitness tests. The military setting provides a unique environment in which to
examine the potential role of such features.
• DOD-wide competitions for model activity programs. A DOD-wide
competition, held periodically, could stimulate innovative individuals to develop
programs locally that could be tested and, if found to be effective, then applied
on a broader scale. Awards for the most innovative, effective program locally,
by region, by service, and throughout all services would bring attention to the
possibilities, stimulate creative solutions, and take advantage of the huge range
of talents of military personnel.
Diet and Nutrition

Recent research by the Air Force (Fiedler et al., 1999) showed that provid-
ing “heart-healthy” menus in base dining facilities was not only possible, but
also that these menus improved body mass index (BMI) for women recruits with
no detrimental effects on physical conditioning or visits to the doctor. Another
study by the Army found that women consuming more than 14 reduced-energy

foods per week had a lower BMI, exercised more, and had significantly higher
intakes of dietary fiber, folate, calcium, and iron. (Arsenault and Cline, 2000).
Environmental Factors
Current theories to explain the epidemic of obesity point to an increased
availability of foods, particularly energy-dense foods. Vending machines are a
ubiquitous presence in both military and civilian life. The majority of foods in
these machines are snack items containing high amounts of fat, calories, or both.
Careful studies could be undertaken to determine the roll of vending
machines in promoting obesity or overweight. For example, studies could be
conducted that compare the presence or absence of vending machines with the
hypothesis that severely limiting their availability might reduce impulse eating.
Also, offering alternatives such as fruit, low-calorie snacks, meal replacement
bars and drinks, should be evaluated. It is possible that the availability of
vending machines is important for morale on military bases, but the effect of
removing these machines on the prevalence of overweight and on military
morale are appropriate questions for well-designed studies. In addition, studies
could be conducted to determine if increasing the price of high-energy and high-
fat foods and reducing (or subsidizing) the price of fresh fruit and other low-
calorie snacks encourages healthier eating behavior.
RECOMMENDATIONS ON PREVENTION
• Each service should provide its members training on diet and health, in-
cluding the fundamentals of energy balance, the caloric content of common
foods, portion sizes, and the importance of maintaining high levels of daily
activity even after intensive training periods (e.g., initial entry training) to
prevent weight gain.
• An education program on maintaining healthy weight should include com-
ponents directed at the entire military family.
• Programs to reinforce the concept of exercise and activity as part of the
military lifestyle should be developed, along with ones to encourage the re-
duction of alcohol consumption, which contributes to excess energy intake.
• Particular emphasis should be placed on providing or upgrading physical
fitness facilities and equipment that encourage exercise. Creating bicycle
paths and sidewalks, making community-owned bicycles available to per-
sonnel, discouraging the use of automobiles, and organizing competitions
should be given high priority.

• The use of rewards for exercise achievement should be reinforced. More

tangible and immediate benefits in recognition, awards, and personnel and
performance ratings should be developed within military facilities.
• The military services should make the incorporation of “heart healthy”
menus a standard for base dining facilities, with continued emphasis on
training all military cooks in low-fat cooking techniques. In addition, low-
calorie and low-fat food items should be offered in vending machines and
at base exchange facilities. Lowering the costs of these items could be an
incentive to increase their consumption.
• Priority consideration should be given to commercial eating establishments
that routinely offer reasonable portion sizes and low-fat dining options
when these establishments are competing for base contracts.
ASSESSMENT
The reissued instruction, DOD Physical Fitness and Body Fat Program
Procedures, states that “service members shall maintain physical readiness
through appropriate nutrition, health, and fitness habits,” and that “aerobic
capacity, muscular strength, muscle endurance and desirable body-fat compo-
sition” form the basis for the military’s relevant programs (DOD, 2002). This
policy also mandates that all service members, regardless of age, will be
formally evaluated and tested for the record at least once annually unless under
medical waiver. If the prevention of weight gain is an appropriate goal (as it
should be), annual or semi-annual evaluations are clearly inadequate to aid in
achievement of this goal. Individuals have ample opportunity to increase their
weight and body composition to levels above standards over a 6- to 12-month
period. They will have a much better chance of returning to standards if their
problems are identified early. Thus, more frequent evaluations, while potentially
costly, may be less costly than remedial programs. In addition, more frequent
evaluations may decrease the number of disordered eating behaviors that have
been documented to occur in military personnel within 3 months of their annual
assessments (McNulty, 1997a, 1997b, 2001; Peterson et al., 1995). Ideally,
evaluations (at least weigh-ins and body-fat assessments, if not physical fitness)
should be performed quarterly.
Early Identification of Personnel at Risk

Many obesity experts believe that preventing obesity or treating it at the
initial stages of overweight is more effective than individuals’ attempting to lose

significant amounts of weight. Inviting individuals at risk (e.g., those who have
gained weight or body fat since their last assessment but are still within stan-
dards) and those who have only recently become overweight to enroll in weight-
management programs may reduce the prevalence of personnel who later
become significantly overweight. This deserves careful study. The Air Force has
recently modified its weight-management program to include a 3-month
cautionary zone prior to enrollment in the program itself (with its administrative
consequences). Research is recommended on the impact of this program change
on weight-management efforts before instituting such a change in the other
services.
Identifying potential risk factors for weight gain (e.g., overweight at time of
accession, family history of obesity, poor initial performance on physical fitness
test, a weight gain of more than 5 percent over initial entry training weight) may
help identify individuals who are at risk. Educating these individuals during
initial entry training, or whenever risk factors are identified, about their risk of
becoming overweight might allow self-directed preventive measures. An
evaluation of the usefulness of these efforts should be undertaken as there is a
potential for negative consequences: individuals identified as potentially at risk
may be singled out for attention or suffer discrimination by their commanders.
The military appearance policy raises several concerns. Individuals differ
anatomically and some accumulate adipose tissue in the abdomen (upper-body
adiposity), while others tend to have a more even distribution of fat over several
regions of the body. However, from an appearance perspective, an individual
with abdominal fat may attract negative attention, while an individual with an
even distribution of fat may not. Age, gender, and ethnic background (e.g.,
Hispanic, African-American) may exacerbate the disproportionate accumulation
of abdominal adipose tissue, but the available data are insufficient to support
these associations (IOM, 1998). Implementation of the appearance policy may
unfairly penalize some individuals due to their demographics. In addition, an
individual who has been accused of violating the appearance standard but is later
found to be within the height and weight standards may suffer some loss of self-
esteem. Also, the use of the appearance standard by unit commanders has
frequently been criticized as being flawed because it is not uniformly applied to
all personnel.
DOD is to be commended for the recent changes in procedure instructions
relative to body fat that mandate the use of a single abdominal circumference-
based equation for men and one for women to be used by all the services (DOD,
2002). The emphasis on abdominal circumference is appropriate as it is the site
of human body-fat deposition most strongly associated with health risks and it
corresponds most closely with military goals on appropriate appearance.

Underweight and Eating Disorders

One of the negative aspects of military enforcement of weight-for-height
and body-fat standards is the possibility that such efforts may provoke the onset
of eating disorders (e.g., bulimia, binge eating, anorexia nervosa). Questions that
need research attention include:
1. What is the prevalence of bulimia, binge eating, and anorexia nervosa

in military personnel? Some research has been conducted in this area, primarily
by the Navy (McNulty, 1997a, 1997b, 2001). One study of Air Force weight-
management program participants has been conducted (Peterson et al., 1995),
but this information needs to be collected in both men and women across all the
services.
2. Does the military lifestyle promote disordered eating behavior in
military personnel?
3. Does the diagnosis of an eating disorder preclude retention in the
military?
4. What are the effects of disordered eating on performance?
Performance
It is recognized that implementation of the new DOD policy requires that
specific physical fitness standards for occupation specialties be established, and
that once these standards are identified, physical fitness training and testing
would be linked to occupational requirements. This should benefit personnel
needs as performance can not always be linked to compliance with standards.
For example, Sharp and colleagues (1994) found that in female Army recruits in
initial entry training, women who exceeded the weight-for-height standards or
the percent body-fat standards before initial entry training performed as well as
or better than women who initially passed the standards. Thus, the standards at
that time tended to eliminate stronger women. Implementation of the new DOD
weight-for-height standards should alleviate this problem, but it merits investi-
gation.
RECOMMENDATIONS ON ASSESSMENT
• Assessments for weight-for-height (BMI) and percent body fat should be

conducted quarterly rather than annually or semi-annually to facilitate
identifying personnel at risk of exceeding standards and to allow for early
intervention. More frequent assessments should be evaluated to determine if
they reduce disordered eating and other risky behaviors.

• Individuals at risk of increased weight gain or body fat (e.g., those entering
the service over the standard or those with a family history of obesity)
should be identified at the time of accession and their evaluations monitored
so that interventions may be instituted as soon as adverse changes are
identified.
• The incidence of disordered eating behaviors needs to be documented and
addressed across all branches of the military.
TREATMENT
Military personnel who are identified as exceeding body composition stan-
dards are mandated to enter a military weight-management program for treatment.
A good weight-management program must include two phases: weight loss and
weight maintenance. Details of each are provided below. There are however, two
overarching recommendations for military weight-management programs: (1) the
critical components of the programs should be uniform across the services so that
all personnel who are referred to such programs obtain equal assistance, and (2)
the personnel administering these programs should have training in weight-
management principles with respect to diet, physical activity, and counseling on
behavior modification.
The particular problems of establishing these services for military personnel
are immediately obvious. Treatment programs are based on the concept of long-
term care. Military personnel are rarely stationed at one facility long enough to
be able to take advantage of continuing services, even if they are available. The
problem is compounded still further by the instability of the staff. Even if staff
were available for a continuing care program, there would be no expectation that
these personnel would be continuously assigned at one facility. These environ-
mental factors make it more urgent that each service strive to have a uniform
program that will allow the individual to continue to progress in weight control
regardless of assigned duty station. Furthermore, where possible, the programs
of all the services should be coordinated to the maximum extent to assist
individuals who receive medical care from another service and to facilitate
fairness across the services.
It may be possible to reorganize aspects of care to permit patients to
maintain contact with individual service providers through e-mail, regardless of
the location of patient or provider. This will only be useful, however, if com-
puters are generally available to all service personnel and if resources are locally
available for the patient to be able to follow-up on recommendations developed
through this system.

Essential Components of Military Weight-Loss Programs

The key components of military weight-loss programs are diet, physical ac-
tivity, behavior modification, and structured follow-up. Recommendations on
each of these components are discussed in detail below.
Diet
General criteria for a diet that provides reasonable and steady weight loss
are based on the principle of a hypocaloric-balanced diet. However, there is re-
cent evidence that in obese individuals, use of very-low-calorie diets, coupled
with behavior modification, may be more successful in initial weight loss and
maintenance of weight loss than the hypocaloric-balanced diet.
Although there is still considerable controversy over the ideal macronutrient
distribution of a hypocaloric-balanced diet, recent evidence suggests that there
may be some benefits to diets with a higher ratio of protein to carbohydrate in
terms of stabilization of blood glucose, maintenance of lean body mass during
weight loss, and better satiety. In a recent comprehensive review, Astrup and
coworkers (2002) examined four meta-analyses of weight change occurring on
intervention trials with ad libitum low-fat diets and found that these diets
consistently demonstrated significant weight loss both in normal-weight and
overweight individuals. On the other hand, Kris-Etherton and colleagues (2002)
found that a moderate-fat diet (20 to 30 percent of energy from fat) was more
likely to promote weight loss because it was easier for patients to adhere to this
type of diet than to one that was severely restricted in fat (< 20 percent of
energy). Thus, the macronutrient distribution of a recommended diet could be
tailored somewhat to individual preferences.
The most important dietary considerations are that:
• The diet must be deficient in energy, as determined by comparing its

energy value with an estimate of the individual’s energy expenditure. Energy
intake should be sufficient, and the level of other essential nutrients adequate, to
allow individuals to pursue their regularly scheduled activities and to maintain
appropriate levels of fitness.
• The diet program should promote a new set of eating habits that can
help to maintain weight loss over time and should emphasize changes in what,
how much, and how often one eats.
• The diet should include at least five servings of fruits and vegetables a
day and should be able to be readily incorporated into an individual’s life style.
It must be one that can be followed for a sufficient period of time to achieve
desired weight loss.

• The diet should contain sufficient volume to promote feelings of

satiety. It should also be palatable and familiar, with the foods reflecting the
food preferences of the individual, if possible.
• The foods in the diet must be readily available and affordable.
Additionally, given that personnel may be living in barracks or at home, married
or single, in the United States or abroad, the diet must be easily adaptable to a
variety of situations, including mess halls and other group feeding environments,
restaurants, and home.
An appropriate weight-loss diet would be one that incorporates the points

above and is energy deficient by 350 to 1,000 kcal/day (with intakes no lower
than 800 kcal/day). For women, protein intake should be no less than 60 g/day,
and for men, no less than 75 g/day. Fat content should be no greater than 30
percent of total calories and carbohydrate intake no less than 130 g/day. A daily
multivitamin and mineral supplement may be useful.
Low-Carbohydrate Diets. Use of low-carbohydrate diets by military
personnel should be discouraged. These diets have been associated with a
number of potential side effects such as physiological dehydration, nausea,
hyperuricemia, ketosis, and fatigue incidental to the depletion of glycogen
stores, which could comprise performance (Phinney et al., 1980). Furthermore,
the recently released Dietary Reference Intakes for macronutrients (IOM, 2002)
concluded that the adult requirement for carbohydrate to supply adequate
glucose for proper brain function is 100 g/day, with a recommended daily intake
of 130 g/day. Thus, it is recommended that under no circumstances should
weight-loss diets recommended for military personnel contain less than 130
g/day of carbohydrate.
Dietary Supplements. Little or no information is available to guide medical

providers on possible interactions between weight-loss drugs and medications,
herbals, or supplements taken for other purposes. Because military personnel
must be combat-ready and side effects and interactions of supplements are
largely unknown, personnel should be advised against the use of weight-loss
supplements.
Physical Activity
A weight-reduction strategy based solely upon an increase in physical
activity (in the absence of calorie restriction) is likely to yield only a modest
weight loss of no more than 5 to 6 lb (Blair, 1993; Wadden and Sarwer, 1999).
Weight-loss outcomes are optimized when physical activity is combined with
dietary intervention (Dyer, 1994; Pavlou et al., 1989a, 1989b; Perri et al., 1993;
Wing and Greeno, 1994). Finally, physically active dieters are far more likely to

be successful in maintaining lost weight as compared with dieters who do not

embrace physical activity (Kayman et al., 1990; Klem et al., 1997). It should be
kept in mind that persons who include bouts of structured physical activity in
their weight-reduction regimen may inadvertently reduce their activities of daily
living.
It is difficult to develop specific physical activity recommendations for
weight loss that may be appropriate for military programs. The amount of
activity needed in conjunction with decreased energy intake will depend on
whether the individual is genetically and phenotypically obesity-prone or
obesity-resistant, and how much weight or body fat needs to be lost to bring
them into compliance with military standards. There are few data available for
physical activity requirements for predominantly young (< 50 y), male, over-
weight (as opposed to obese) individuals. Recent recommendations for normal-
weight individuals are 60 min/day of moderately intense physical activity to
maintain healthy weight (IOM, 2002). Data also indicate that the threshold of
energy expenditure as physical activity needed to minimize weight regain in
previously obese women is 47 kJ/kg body weight/day, which equates to an
average of 80 min/day of moderate activity or 35 min/day of vigorous activity
added to a sedentary lifestyle (Schoeller et al., 1997).
In a thorough review of the literature, Jakicic and colleagues (2001)
developed a consensus statement for the American College of Sports Medicine
that recommends an initial physical activity goal for overweight and obese
individuals as a minimum of 150 min/wk of moderately intense exercise. To
enhance weight loss and maintenance of this loss, exercise should be gradually
increased to 200 to 300 min/wk (3.3–5 hr). Similar results may also be achieved
through the expenditure of > 2,000 kcal/week through activities of daily living
(Dunn et al., 1999). The physical activity component of a weight-loss program
should include both structured and unstructured exercise (e.g., aerobics, strength
training, increased activities of daily living).
Behavior Modification
The behavior modification component of a weight-loss program should in-
clude instructions on stimulus control, cognitive restructuring, relapse preven-
tion, and self-monitoring, and it should provide mentoring.
The primary goals of behavioral strategies for weight control are to
increase physical activity and to reduce energy intake by altering eating habits
(Brownell and Kramer, 1994; Wilson, 1995). Self-monitoring of dietary intake
and physical activity, which enables the individual to develop a sense of
accountability, is one of the cornerstones of behavioral treatment (Jeffery and
French, 1999). Patients are asked to keep a daily food/activity diary in which
they record what and how much they have eaten, when and where the food was
consumed, the context in which the food was consumed (e.g., what else they

were doing at the time, what they were feeling, who else was there), and the
types and amount of physical activity. The information obtained from the diary
can also be used to identify personal and environmental factors that contribute to
overeating and sedentary behavior, which helps in selecting and implementing
appropriate weight-loss strategies for the individual (Wilson, 1995). Self-
monitoring also provides a way for therapists and patients to evaluate which
techniques are working and how changes in eating behavior and activity are
contributing to weight loss.
The Use of Structured Follow-Up/Maintenance

Once individuals have achieved their weight-loss goals, systematic contact
and follow-up from the weight-loss program staff is crucial to maintain the
weight loss. This structured follow-up should include monitoring of body weight
and weigh-ins weekly during the weight-loss phase and at least monthly during
the weight-maintenance phase. Contact with program staff via phone or the
Internet every 1 to 2 months, depending on the individual's difficulty in main-
taining a stable weight, would facilitate continuity of care.
RECOMMENDATIONS ON THE SPECIFIC CONTENT OF WEIGHT-

LOSS PROGRAMS
• Diet. A weight-loss diet should be energy deficient by 350 to 1,000

kcal/day, with a minimum intake of 800 kcal/day. It should provide a mini-
mum of 60 g of protein/day for women and 75 g of protein/day for men. Fat
should provide no more than 30 percent of total energy and carbohydrate
content should be no less than 130 g/day. In addition, the daily use of a mul-
tivitamin-mineral supplement may help to ensure adequate micronutrient in-
take.
• Exercise. A combination of aerobic and strength training exercise, along
with increased activities of daily living, is recommended. Energy expended
in physical activity should be at least 200 to 300 min/wk of moderate inten-
sity exercise (3.5–5 hr), or greater than 2,000 kcal/wk.
• Behavior Modification. Training and support in behavior modification
should include stimulus control, relapse prevention, self-monitoring, cogni-
tive restructuring, and mentoring.
• Structured Follow-up. Follow-up should include regular contact with
weight management counselors, routine self-monitoring, and ongoing sup-
port that could be provided via the Internet.

PROGRAM EVALUATION
An important aspect of implementation of any weight-management program
is an evaluation of the program results. The effectiveness of a weight-manage-
ment program is determined by the success of the participants in losing the nec-
essary amount of weight and being able to maintain that weight loss. This re-
quires long-term tracking of these individuals. While this may be inherently
more difficult in the military setting because of frequency of relocation and
terms of enlistment, a minimum period of tracking would be 2 years. Because of
the high rate of weight regain documented in many civilian settings, 5 and even
10 years of follow-up data would be optimal for program evaluation.
TRAINING
If one assumes a shortage of personnel trained to assist in weight manage-

ment, it may be advantageous for the military services to establish weight-
control training programs for professionals as a military occupational specialty.
The development of a specialty skill in administering weight-management
programs may be useful for personnel otherwise trained as nurses, dietitians,
physician assistants, nurse practitioners, counselors, and psychologists and
would aid in developing uniform quality of weight-loss programs across the
services. Special efforts will be needed to develop these programs in an effective
way and to recruit personnel with sufficient interest in, and understanding of, the
problems in losing and maintaining weight loss, so that they can be effective in
the delivery of services.
RECOMMENDATIONS ON A WEIGHT-MANAGEMENT MILITARY

OCCUPATIONAL SPECIALTY
• Weight-control training programs should be established to train a multidis-
ciplinary team of personnel associated with implementing weight-loss and
weight-maintenance programs.
• Training standards for a weight-management military occupational specialty
should include training in the principles of:
– Nutrition
– Physical activity/exercise
– Behavior modification
– Weight-loss aids (e.g., counseling, mentoring, psychological support).
• The program should include mandated continuing education requirements.

RESEARCH RECOMMENDATIONS
The modest success of weight-management endeavors in the civilian world
sends a signal that losing weight and maintaining weight loss will not be easy
and research on weight management in the military is sorely needed. Further
suggestions for military research on overweight are presented in the following
sections.
Use of the Internet
Internet-based programs could be developed using models already being

used by the military (James et al., 1999a) in which participation may be
completed during off-duty time. Emphasis should be given to the development
of a number of options, testing their effectiveness overall, and identifying those
with high response rates. Also, the range of individual responses of military
personnel should be evaluated since there may be subpopulations that respond
well to a given intervention even though overall response is not consistent.
The concept of web-based programs may be very fruitful. Also, with a few
resources put into development, a program could be created that followed
military personnel regardless of where they were stationed. Classes could be
conducted on line and even live (with current technology, two-way video can be
inexpensive). Individuals could do this on their own time at home. Since
members of the military risk losing their job if they exceed standards, it may not
be too much to expect them to spend some off-duty time working at a weight-
loss or weight-management program. The military could develop its own pro-
gram with its own personnel or it could contract to one or more of the
outstanding civilian obesity-treatment programs (Brownell, 1999; Foreyt and
Goodrick, 1994; Jakicic et al., 1995; McGuire et al., 1999; Wadden et al., 1989).
These computerized weight-loss interventions optimize staff time (Wylie-Rosett
et al., 2001) and could be used as a model for weight-reduction education in the
military.
Evaluation of Existing Military Initiatives and Programs for

Effectiveness
Evaluation of military weight-management programs is essential to deter-

mine their effectiveness. Recommendations provided in this report are based
almost exclusively on data collected in civilian populations; effectiveness may
be quite different in military populations. This type of evaluation research will
require the identification and long-term monitoring of personnel who have
completed military programs.

Computerized Follow-Up of Personnel at Risk

It is necessary to create an independent computerized database that can be
used to identify individuals with risk factors for weight gain or overweight as
described above, to maintain routine contact with these individuals to check on
their weight and physical fitness status, and to identify problems early and inter-
vene as needed. Such computerized information should be centrally maintained
and used as a source of data for longitudinal studies on the effectiveness of
prevention and treatment innovations. This data should not be available to unit
commanders to avoid the possibility of discrimination against individuals at risk.
Evaluation of Pharmacological Treatments

Pharmacological treatments compatible with military performance need to
be identified. Some military operational specialties preclude the use of central
nervous system-active agents, but other types of Food And Drug Administra-
tion-approved drugs could be considered. For all other operational specialties,
obesity drugs could be used on a long-term basis. Studies of individual weight-
loss drugs and combinations of drugs to determine their effects on mental and
physical performance of military duties, as well as on their success in reducing
body weight, need to be carried out. Most current drugs have been evaluated as
single agents, so research on the effects of drug combinations should receive
special attention.
Evaluation of the Use of Dietary Supplements and Herbal

Remedies
Many nonprescription preparations are being used for weight loss by the
civilian population and are undoubtedly being used in the military population.
Very little is known about their effects on body weight, body composition,
overall health, and physical performance. It may be particularly important to
assess their effects on military performance. Of particular importance is
evaluation of the prevalence of the use of ephedrine/caffeine preparations and
their effects. Although DOD has followed Food and Drug Administration
warnings and removed this compound from post exchanges and base
establishments, personnel may still obtain ephedrine/caffeine preparations from
civilian establishments.
OTHER AREAS FOR RESEARCH

The military environment affords an excellent opportunity to conduct
important research needed to fill gaps in knowledge about weight control and
treatment for overweight. It is recognized that some of this research may not

have a direct or apparent need in military operations and, therefore, may have
lower priority in military research funding. However, in keeping with the current
policy that encourages increased leveraging of resources for research in the
federal government, the areas described below should be considered.
Body Weight and Aging

Little is known about developmental aspects of fat deposition or the effects
of early attempts at weight control on later propensity for obesity. Because most
personnel enter the military during late adolescence or young adulthood, and
because the military has the capability to follow its personnel longitudinally, the
military is in a unique position to follow a large population of young adults from
the time of accession into retirement to examine the following questions:
• How do the mechanisms of fat deposition change with aging?

• Do individuals who remain in strenuous (heavy lifting or very physical-
ly active) occupations throughout their careers increase their proportion of body
fat at a lower rate as they age than do those in low-activity occupations?
• Do they preserve lean body mass as they age?
• Do they remain healthier as they age?
• Do they cost the military less money as they age?
• Is bone mass/bone density better preserved as they age?
Gender
Information is needed on whether there are differences in gender responses
to the various components of weight-management programs (e.g., do men and
women respond differently to diet, physical activity, and behavioral change
interventions). In addition, gestational weight gain is a major risk factor for
overweight in women of childbearing age. Little is known about the factors
responsible for postpartum weight retention or the effects of pregnancy and
breastfeeding on military performance. Research is needed to answer the
following questions:
• Does a program of regular physical activity throughout pregnancy

(and/or beginning early in the postpartum period) reduce postpartum weight
retention?
• Does weight loss at the rate that is required to return to within body
composition standards in the recommended time frame (180 days) (IOM, 1998)
permit adequate breastfeeding?
• Does competency in estimating portion sizes lead to less maternal
weight gain and more rapid return to prepregnancy body weight and body
composition?

• Is improved fitness when one becomes pregnant and throughout

pregnancy associated with better outcomes (assessed by infant birth weight as
well as by lower perinatal mortality and morbidity)?
• Does breastfeeding (which needs to be measured carefully and defined
in terms of frequency and duration of feedings) lead to a more rapid return to
prepregnancy body weight and body composition?
Genetic Screening
Currently, there are about 250 genes and gene markers that have been
identified as associated with human obesity (Rankinen et al., 2002). As science
progresses, common patterns of genes or gene markers may be identified that
correlate with the development of obesity. While it would be an extremely
sensitive area of research, the military could address the question of whether
genetic screening for obesity-prone individuals is appropriate for its mission.
Role of Infectious Disease in Obesity

A provocative hypothesis that has been proposed as an explanation for at
least some of the increase in the prevalence of obesity is that one or more viral
infections may produce obesity. Several animal viruses produce obesity in
animals, and both animal and human viruses have been associated with obesity
in humans (Dhurandhar et al., 1997, 2000.).
Although the current committee was not constituted to evaluate this
particular issue, it was presented at the committee’s workshop and thus is
mentioned here as an area where numerous research questions exist on the role
of viruses in the etiology of obesity. Both basic and clinical studies are needed
to identify whether human adenoviruses that have been demonstrated to produce
obesity in animals are associated with obesity in humans.

_________________________________________________________________________________
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A
_________________________________________________________________________________
Workshop Agenda and Abstracts
Military Weight-Management Program Workshop

State of the Art and Future Initiatives

Food and Nutrition Board
Institute of Medicine
The National Academies
October 25–26, 1999
Monday October 25, 1999
9:00 Welcome on Behalf of the Food and Nutrition Board

Dr. Allison A. Yates, Director, Food and Nutrition Board
9:05 Welcome on Behalf of the Subcommittee on Military Weight Manage-

ment
Dr. Richard Atkinson, Chair, Subcommittee
9:15 Opening Comments on Behalf of the Military

LTC Karl E. Friedl, U.S. Army Medical Research and Materiel Com-
mand, Fort Detrick, Frederick, MD
9:30 Important Historical Military Data: Obesity and Mortality

Dr. William Page, Medical Follow-Up Agency, The National Acad-
emies
179

Part I: Weight Management in the Military Today (Moderator: Richard

Atkinson)
9:45 Panel: Current Military Policies and Approaches to Body-Weight Man-

agement
LCDR Sue Hite, Health and Physical Fitness Branch, USN
LTC Francine LeDoux, Health Promotion Policy Officer, USA
LTC Leon Pappa, Training Program Branch, USMC
COL Esther Myers/LTC Regina Watson, Health Promotion, USAF
Discussion
11:00 Break
11:15 Challenges to Military Weight Standards and Maladaptive Practices of

Service Members to Meet These Weight Standards
MAJ Stephen Bowles, M.D., U.S. Army Soldier Support Institute, Ft.
Jackson, SC
12:30 Lunch
Part II: Current Military Weight-Loss/Management Programs (Moderator:

John Vanderveen)
1:30 Panel: Effective Military Programs

Air Force Weight-Management Program – LTC Joanne Spahn, Elmen-
dorf AFB, Alaska
The Air Force LEAN Program – CAPT Trisha Vorachek, McConnell
AFB
Impact of a Shipboard Weight-Control Program - Dr. Karen E. Dennis,
Veterans Affairs Medical Center, University of MD School of
Medicine
Nutrition and Diet Aboard Submarines – LT Deborah White, Naval
Submarine Medical Research Lab, Groton, CT
The Army’s LEAN Program: Current Update – LTC Larry James, Wal-
ter Reed Army Medical Center
Army Weight-Management Instruction to Master Fitness Trainers – Dr.
Lou Tomasi, LT Kerryn Davidson, Army Physical Fitness School,
Ft. Benning, GA
Discussion
3:45 Break

APPENDIX A 181
Part III. Factors Affecting Weight Management (Moderator: John Fern-

strom)
4:00 Behavior
Dr. Patrick O’Neil, Medical University of South Carolina
Dr. Gary Foster, University of Pennsylvania
Discussion
5:30 Adjourn
Tuesday, October 26, 1999
Part III. Factors Affecting Weight Management (cont.) (Moderator: Wil-

liam Dietz)
9:00 Genetic Influences on Obesity

Dr. Anthony Comuzzi, Southwestern Foundation for Biomedical Re-
search
Effects of Age, Gender, and Ethnicity on Ideal Weight
Dr. June Stevens, University of North Carolina – Chapel Hill
Discussion
10:30 Break
Pharmacological Aids (Moderator: Steven Heymsfield)
11:00 The Pharmacology of Weight Loss and Its Potential Application in the
Military Setting
MAJ H. Glenn Ramos, M.D., Fort Gordon, GA
Use of Pharmacologic Aids in Weight Management
Dr. Frank Greenway, Pennington Biomedical Research Center
Discussion
12:00 Lunch
Physiology – Physical Activity (Moderator: Barbara Hansen)
1:00 Effects of Exercise, Diet, and Weight Loss on Lipid Metabolism

Dr. Marcia Stefanick, Stanford University
Reproductive Health Issues in Fitness and Weight-Control Programs
Dr. Anne Loucks, Ohio University

2:00 Obesity: An Infectious Disease?

Dr. Nikhil Dhurandhar, Wayne State University
Discussion
Part IV: Factors Affecting Long-Term Maintenance of Weight Loss (Mod-

erator: Arthur Frank)
2:45 Dr. George Blackburn, Harvard Medical School

Dr. John Jakicic, Miriam Hospital and Brown University
Discussion
3:45 Break
Part V: Effective Strategies for the Military Setting (Moderator: Gail

Butterfield)
4:00 Panel Discussion

Military Speakers:
CAPT Trisha Vorachek (USAF)
LT Deborah White (USN)
Dr. H. Glenn Ramos (USA)
LT Kerryn Davidson (USA)
Civilian Speakers:
Dr. Frank Greenway
Dr. John Jakicic
Dr. Patrick O’Neil
5:00 Summary of the Workshop

Dr. Richard Atkinson, Subcommittee Chair
Dr. John Vanderveen, Vice-Chair
5:30 Adjourn

APPENDIX A 183
WORKSHOP ABSTRACTS
THE ARMY WEIGHT CONTROL PROGRAM (AR 600-9)

LTC Francince M. LeDoux, Health Promotion Policy Officer
The primary objective of the Army Weight Control Program (AWCP) is to

ensure that all personnel are able to meet the physical demands of their duties
under combat conditions and to present a trim military appearance at all times.
Proper weight control assists Army personnel in establishing and maintaining
discipline, operational readiness, optimal physical readiness, and effectiveness.
The regulation establishes appropriate body-fat standards and provides proce-
dures by which personnel are counseled to assist them in meeting the prescribed
standards.
Historical Perspective
Prior to 1981, height/weight tables and a physician’s assessment were used
to determine body-fat standards. In 1981 DOD implemented the Physical Fitness
and Weight Control Program (DOD Directive 1308.1). This program stated that
various tests were acceptable for use in determining body fat. Between 1983 and
1986, the Army used the “pinch test” to determine body fat. Beginning in 1987,
the DOD revised Directive 1308.1 stating that the skinfold measurement test
would no longer be used, and that only the “Tape” measurement method should
be used to measure body fat. The Army Weight Control Program (U.S. Army,
1986) was published in 1986. In 1994, Interim Change 101 specified that all
soldiers were to be issued Handbook/Issue 15. In 1995, DOD Directive 1308.1
was revised, changing the body-fat standards and establishing fat standards for
pregnant soldiers (DOD, 1995).
Rationale
The AWCP is based on body composition (body fat vs. total body mass).
Physical fitness is key to body composition. Fit soldiers are better able to carry
their load. They have less body fat and more muscle mass. In contrast, overfat
soldiers are: less able to perform physical tasks, are at greater risk of developing
injury, and have lower Army Physical Fitness Test scores. Excessive body fat
also detracts from soldierly appearance.
Key Requirements
Soldiers are weighed every 6 months. If a soldier is overweight (exceeds the
weight-for-height standard) he or she will be measured for percent body fat us-

ing the “tape test” circumference method. The measurement sites for males are:
abdomen, neck with a range of 20–26 percent body fat (maximum); and for fe-
males: neck, forearm, wrist, and hip with a range of 20–36 percent body fat
(maximum). If a soldier is overfat he or she is enrolled in the AWCP.
AWCP Enrollment
Soldiers enrolled in the AWCP will have a permanent record on file. Each
soldier enrolled is required to attend nutritional counseling and is weighed on a
monthly basis. A soldier may only be removed from the program when body-fat
standards have been achieved. The height/weight table standards will not be
used. The standard requires a loss of 3–8 lb per month. If a soldier fails to make
satisfactory progress in two consecutive months, he or she can be discharged per
AR 635-200, Chapter 18, Personnel Separations (U.S. Army, 2000).
Medical Limitations and Pregnant Soldiers

Medical limitations include pregnancy, hospitalization, prolonged medical
treatment, and positive profiles according to Mandatory Medical Review
Boards.
Once a female soldier is diagnosed as pregnant, she is exempt from the
standards of AR 600-9 during pregnancy and for 6 months postpartum. The sol-
dier will remain in the program if she was enrolled previously. After 6 months
postpartum, she will continue on the AWCP with physician clearance. Postpar-
tum soldiers may request to be weighed anytime before 6 months. This standard
implements DOD Directive 1308.1, July 20, 1995.
References
DOD (U.S. Department of Defense). 1995. DOD Physical Fitness and Body Fat
Program Procedures. Department of Defense Directive 1308.1. July 20.
Washington, DC: U.S. Government Printing Office.
September 1. Washington, DC: U.S. Government Printing Office.
U.S. Army (U.S. Department of the Army). 2000. Enlisted Personnel. Army
Regulation 635-200. November 1. Washington, DC: U.S. Government
Printing Office.

APPENDIX A 185
CHALLENGES TO MILITARY WEIGHT STANDARDS

AND MALADAPTIVE PRACTICES OF SERVICE
MEMBERS TO MEET THESE WEIGHT STANDARDS
MAJ Stephen V. Bowles, PhD, United States Army Soldier Support Institute,
Director, USAREC Command Psychological Operations, Fort Jackson, South
Carolina
At the time this abstract was written, no information on service members

who exceed weight standards or have been discharged from the service in 1999
could be obtained from DOD or individual services. It has been reported that as
many as 40 percent of the soldiers discharged from the Army was due to service
members being overweight (James et al., 1997). The military faces several
challenges to include: overweight accessions into the military, lifestyle practices
of overweight service members, and command awareness of lifestyle change
programs.
Challenges to Military Weight Standards

With current recruitment shortfalls, the number of overweight recruits
(meeting accession standards but not the services retention standard for weight)
may be increasing due to a smaller applicant pool. This can translate into a
considerable number of overweight personnel entering yearly that meet
accession standards but do not meet military retention standards at that time.
This may place extra strain on the system to get personnel physically fit, while
preparing new service members for the complexities of the military. In addition,
this also places increased stress on young service members who are in many
cases away from home for the first time in their first job.
With this in mind, educating recruiters on healthy lifestyle changes for new
recruits may be beneficial. This may help reduce the time spent on new
overweight service members and retain more personnel. Recruiters can be
provided with lifestyle change training in recruiting school and provide recruits
with approaches to healthy lifestyle change. Similarly, military academies and
ROTC programs can provide training to new officers throughout their school
years. Students must be trained in maintaining healthy lifestyles in accordance
with military weight guidelines. These are important preventative measures in
stressful academic environments, which may preclude students from engaging in
maladaptive eating behaviors.
Eating on the run is sometimes dictated by our mission. When training new
service members today we have attempted to offer adequate time to eat in
dinning facilities. This is different from the past where older, overweight service
members have identified early dining experiences as eating as much as they can
in as little time as possible. This set the pattern of their eating over the course of

their military careers. When providing new personnel training and education on
healthy lifestyle behaviors, we must incorporate these changes into our training
structures as best we can. As a tradition, service members have complained
about the food provided to them in the mess hall or galley. However, great
improvements have been made in the quality of foods. More effort needs to be
initiated in educating cooks (James et al., 1999) to provide more variety in the
low-fat main dishes served for lunch and dinner. Furthermore, there should be
uniformity across dining facilities in the education of customers on calorie and
fat gram amounts per food served.
Maladaptive Practices of Service Members

While there are differences in each of the services’ military weight/body-fat
standards, the goal of each service member twice a year is to meet the weight
standard and pass the physical fitness test. The family is well aware of the
borderline or overweight service member’s plight at these times of the year.
There is often tension in the home emanating from the service member’s desire
and actions to stay off the weight program. This may involve physical fitness
training five times or more a week. Additionally, a service member will attempt
to lose weight by using over-the-counter medication. They may go to the local
health food store and purchase different herbal supplements or attend a local
weight-reduction clinic and get on prescription medication. They will sit in the
sauna, or they may obtain laxatives through the local drug store or their medical
facility if they are on the hospital staff. If they are looking for the more popular
diets, they can choose from protein, blood, cabbage, grapefruit or what ever the
most recent diet is. Of the 108 applicant records examined for the Eisenhower
LIFE Program, 34 percent reported starving or fasting, 33 percent reported using
laxatives or over-the-counter medication, and 4 percent reported purging at
some time in their career.
Meeting Military Weight Standards: Lifestyle Change

Programs
Across the services there is a need to become more familiar with various
programs available in local areas and encourage the use of these programs. Units
that have used local lifestyle change (weight) programs are able to save financial
resources for their organizations and save units time if their armed service
program is several hours or states away from where they are located.
As a group, the medical field must educate the commanders in their area on
services available to assist service members in weight reduction. Commanders,
after seeing the results of their service members in lifestyle change programs,
will be a steady referral source to programs. The Eisenhower LIFE Program (a
week-long day-treatment program and 1 year follow-up) disseminated an 11

APPENDIX A 187
question survey asking commanders and supervisors for their feedback on the
program. The results of 9 of the questions from the survey are found in Figure 1.
Ninety percent of the respondents were from the Army, while the remainder of
the respondents were from the Air Force, Navy, and Marines.
The results of the survey indicate that 22 out of 24 commanders/
supervisors responding, were satisfied with the program. Most respondents
agreed that the program saved their unit time (81 percent), prevented the service
member from separation from the military (91 percent), taught the service
member new information for weight management (96 percent), and provided a
comprehensive multidisciplinary program for weight reduction (91 percent). In
addition, 96 percent believed a specialized physical training program is helpful
for weight reduction, while 86 percent supported a specialized LIFE physical
training program. While 95 percent believed weekly support groups are helpful,
only 73 percent supported service members attending weekly support groups.
Though some commanders/supervisors prefer to operate their own physical
training and follow-up support (perhaps due to unit esprit de corps or due to
shortage of work personnel), these results suggest that overall, commanders
support this lifestyle change program.
Support Weekly meetings
Believe in weekly support groups
Support Specialized LIFE PT
Sepcialized Pt Program
Satisfaction
Provided Comp. Multi-disciplinary

program
Taught New Info
Prevented Separation
Saving Unit Time
0 10 20 30 40 50 60 70 80 90 100
Percentage
FIGURE 1 Command Satisfaction Survey.

These findings suggest that commands are open to assistance from weight-
reduction programs to maintain readiness levels in their organizations. Similar
education and training can be provided across the services to assist service
members in meeting their organizations’ weight standards. The training pro-
vided to service members and in support of service members can be provided
through healthy lifestyle change programs.
References
James LC, Folen RA, Garland FN, Edwards C, Noce M, Gohdes D, Williams D,
Bowles S, Kellar MA, Supplee E. 1997. The Tripler Army Medical Center
LEAN program: A healthy lifestyle model for the treatment of obesity. Mil
Med 162:328–332.
James LC, Folen RA, Page H, Noce M, Brown J, Britton C. 1999. The Tripler
LEAN program: A two-year follow-up report. Mil Med 164:389–395.
THE SENSIBLE WEIGH LIFESTYLE CHANGE

PROGRAM: AN AIR FORCE WEIGHT-
MANAGEMENT PROGRAM
Joanne M. Spahn, Lt Col, USAF, BSC, MS, RD
The health risks associated with overweight and obesity are well established
(NHLBI, 1998; Van Itallie, 1985) and the incidence of overweight continues to
rise (Kuczmarski et al., 1994). In the military, sustained overweight can end an
otherwise successful career. An increased operations tempo, decreased physical
activity, and easy availability of calorie-dense foods may frustrate earnest
weight-management efforts. Until the 1990s, the typical Air Force treatment
program for overweight entailed a single group class where military members
were given instruction on a low calorie diet, typically 1,200–1,800 calories,
information on behavior modification, and counseled to exercise three to five
times a week for 30 minutes. In the late 1980s and early 1990s, numerous
published or home-grown multisession programs were established at a variety of
sites. These programs for the most part emphasized increased physical activity,
modest calorie restriction, skill development in selecting and preparing healthy
foods, and behavior modification techniques. At most sites, these programs
could accommodate few participants. There was fear among active duty person-
nel that weight loss would be too slow to meet weight-loss requirements.
In the early 1990s, the National Institutes of Health held a Technology
Assessment Conference on Methods for Voluntary Weight Loss and Control. In
1995, Weighing the Options: Criteria for Evaluating Weight-Management
Programs was published (IOM, 1995). These materials were utilized to guide
development of The Sensible Weigh Program initiated in 1997. Practical

APPENDIX A 189
managerial constraints and Weight Management Program (WMP) guidelines

factored into program development. Specifically, this included the need for
military members to loss 3 to 5 lb the first month identified as overweight to
avoid disciplinary action and the need for Wing and Army Commander support
of treatment incorporating increased use of duty time. Deployment of The
Sensible Weigh to a large number of bases with varying levels of manpower
support has also shaped program implementation across the Air Force.
The Sensible Weigh is a lifestyle change program aimed at optimizing
weight and fitness of military members and their families. It is a science-based
protocol designed to prevent weight gain, facilitate weight loss, and the
maintenance of weight loss. It was developed to support the Air Force WMP and
as an avenue for commanders and health care providers to intervene with
concerned individuals early, before negative consequences occur. This multi-
disciplinary program offers participants a variety of strategies from which to
choose to improve their nutrition, fitness, and health. Program materials are
available on the web at the following site: http://afmam.satx.disa.mil.
Clients enrolling in The Sensible Weigh can either self-refer, be sent by
their squadron, or be referred by a medical provider. The protocol begins with a
thorough assessment of anthropometric, biochemical parameters, comorbidities,
medications, family history, weight and dieting history, exercise habits, diet
readiness, and evaluation of the Physical Activity Readiness Questionnaire.
Nursing personnel review the assessment form with clients and use standardized
guidelines to refer clients to medical providers when the need arises. Assessment
data is used to tailor the program to meet client needs, discuss the benefits of
weight management in terms other than pounds lost, and to facilitate measure-
ment of program efficacy.
Program length varies from 4 to 12 weeks. The first four core classes are
taken by all participants in The Sensible Weigh and provide a foundation of
information and skills. The first class orients clients to the concept of lifestyle
change, the diverse benefits of weight management, addresses relapse preven-
tion and diet readiness, and encourages increased physical activity. Clients are
instructed on how to complete a food and exercise diary and are required to
monitor their eating habits for the coming week. This is an important class for
establishing rapport, venting anger, and building a trusting relationship. This
was a difficult class to implement because of the immediate penalties incurred if
members did not lose the prescribed weight in the first 30 days. Members and
supervisors were concerned that the member did not “get the diet.”
During the second class, each client receives a calorie and fat budget
following Step I diet recommendations. Clients are offered a variety of strategies
from which to choose to modify their diet. Strategies include calorie counting,
fat gram counting, following food guide pyramid guidelines, and following a
calorie controlled meal plan. Pros and cons of each method are discussed and
clients select the strategy they feel best meets their needs. The food and exercise

diary is used to track progress. Instructors, called coaches, review food diaries at
each visit and provide individualized coaching on strategies to improve the
healthfulness of the client’s diet and fitness regimen and provide encourage-
ment. It takes a few weeks for many clients to become proficient in maintaining
a food diary.
Class three is taught by an exercise physiologist who covers the basic
components of a personal fitness program targeted at reducing body fat.
American Academy of Sports Medicine fitness guidelines are used. A strong
emphasis on fitness is crucial in this young, moderately overweight and healthy
population (IOM, 1995). Members are encouraged to have a personalized fitness
prescription designed for them by the exercise physiologist. The forth class
covers the basics of behavior modification and the concept of behavior chains.
During the final core class, clients sign-up for their next four electives. Client
goals and Diet Readiness Test results are utilized in deciding which electives
might be most beneficial.
Electives are taught by a variety of people from diverse disciplines and may
include skill development classes on dining out, supermarket tours and cooking
demonstrations, stress management and classes covering relapse prevention,
cognitive-behavioral therapy, and a variety of fitness topics. Support groups are
offered weekly and participants are encouraged to attend one elective or one
support group per week. This modular approach facilitates tailoring the program
to the diverse needs of a population and allows for more flexible use of limited
manpower resources. Electives are typically scheduled two times per month.
Outcome statistics have been maintained on The Sensible Weigh. Between
February 1997 and June 1998, 656 clients enrolled in The Sensible Weigh. Of
this group, 24 percent were active duty, 38 percent were family members of
active duty personnel, 8.9 percent were retirees, and 28 percent were spouses of
retired personnel. Thirty-three percent were self-referrals and 49 percent were
referred by the Family Practice Clinic. At the 3-month follow-up, 163 (25
percent) returned and the average weight loss was 11.2 pounds. At the 6-month
follow-up, 50 (10 percent) of clients returned for follow-up with an average
weight loss of 15.7 pounds. Between October 1998 and February 1999, 94
active duty personnel were enrolled in The Sensible Weigh. Fifty-two (55
percent) returned for 3-month follow-up (21 Air Force, 21 Army personnel), and
an average of 11.5 pounds was lost.
The Sensible Weigh represents incremental improvement in weight-
management treatment in the Air Force. The program has been exported to
many Air Force bases worldwide and a 1-week training program has been
developed to train The Sensible Weigh coaches. Recent changes in Air Force
WMP guidance have made implementation of The Sensible Weigh easier,
particularly the requirement for a 90-day fitness and dietary program and the
official implementation of a warning or cautionary zone prior to enrollment into
the program. The withholding of promotions during this cautionary phase

APPENDIX A 191
however, is still considered a significant program penalty. The new 90-day

period, provided for a fitness and exercise program, allows members more time
to address readiness to change issues. Few members referred due to the Weight
and Body Fat Management Program come voluntarily and many would fall into
Prochaska’s precontemplation and contemplation stages of change (DiPietro,
1995). Most programs currently offered are tailored for clients in the preparation
and action stage.
Posting The Sensible Weigh materials on the Air Force Medical Applica-
tions Model web site has facilitated implementation of the program at multiple
sites and allows for a certain degree of standardization of weight-management
treatment at numerous sites. Standardized treatment programs have many
benefits, including the potential to improve staff training, improve continuity of
care in a highly mobile population, facilitate increased collaboration, testing of
hypotheses which could lead to program improvement, and allows for efficient
program updates. Use of one standardized program however, is not sufficient to
meet the needs of the entire population.
Availability of a variety of standardized programs using a variety of educa-
tional modalities would provide increased flexibility for service members,
particularly those frequently deployed or on field duty. Research should describe
characteristics of personnel on the weight-management program, barriers,
enabling factors, stage of change information, current diet and fitness habits,
typical lapse situations, strategies currently used for weight loss, sources of
weight-management information, and preferred modes of education. This would
be helpful in the development of programs tailored to the unique needs of
military personnel and their families. Community programs, which address both
prevention and treatment of overweight in military communities, are essential.
The Sensible Weigh provides treatment on the individual level, but community
programs that address environmental support for health and fitness are crucial.
References
DiPietro L. 1995. Physical activity, body weight, and adiposity: An epidemiol-
ogical perspective. Exerc Sport Sci Rev 23:275–303.
IOM (Institute of Medicine). Weighing the Options: Criteria for Evaluating
Weight-Management Programs. Washington, DC: National Academy Press.
Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL. 1994. Increasing preva-
lence of overweight among U.S. adults: The National Health and Nutrition
Examination Surveys, 1960 to 1991. J Am Med Assoc 272:205–211.
adults—The evidence report. In: Pi-Sunyer XP, Rosenhouse-Romeo H, eds.
Obes Res 6:51S–209S.

Van Itallie TB. 1985. Health implications of overweight and obesity in the
United States. Ann Internal Med 103:983– 988.
THE AIR FORCE LEAN PROGRAM

CAPT Trisha Vorachek, McConnell AFB
Prior to the July 1999 policy changes in the Air Force (AF) weight
management program (WMP), most AF members identified as overfat received
only a 2-hour nutrition class, taught by a registered dietitian or nutrition certified
dietitian or medical technician, before officially entering the WMP. The overfat
AF members were also monitored for successful weight loss progress. Once
placed in the WMP, members were required monthly to lose either 3 pounds if
female or 5 pounds if male or percent body fat until the body-fat standard was
reached. If members did not make satisfactory progress, punitive action was
taken, and after four failures, members were discharged from the AF. With only
an insufficient 2-hour nutrition class to assist members in successfully
attempting to reach their body-fat percentage goal, WMP discharges and
frustrations of members and commanders were high. Therefore, in response to
commanders’ requests to develop a more positively focused WMP, the Lifestyle,
Exercise, Attitude and Nutrition (LEAN) weight-loss program was developed
and implemented at McConnell Air Force Base (AFB) in October 1995.
After reviewing the current research on weight-loss programs, the LEAN
program was developed by a multidisciplinary team that included a physician,
registered dietitian, psychologist, mental health technician, fitness specialist and
the base health promotion manager. The newly created LEAN program was a
mandatory, multidisciplinary 4-week program for all active duty (AD) members
identified for the WMP after 15 Oct 1995. The LEAN program met weekly for 2
½ to 3 ½ hours and, during each session, nutrition, behavior change and exercise
were taught by a registered dietitian, psychologist, and exercise physiologist,
respectively. Each member was required to attend all four sessions prior to
officially being placed in the WMP. While in the LEAN program, members
were not allowed to go on temporary duty or leave, except for emergency
situations. Squadron commanders or first sergeants were notified of all missed
appointments, and the member was automatically scheduled for the missed class
in the next month’s LEAN program. A new LEAN program started each month,
and 1 week prior to the start of a new program, any remaining open slots were
opened to AD volunteers, dependents, and retirees. After completing the LEAN
program, members were required to attend a monthly group follow-up session
until they met their body-fat standard.
The nutrition component of the LEAN program included guidelines on
healthy weight loss, principles of the Food Guide Pyramid, food label reading,
calorie and fat gram counting, self monitoring, dangers of fad dieting, low-fat

APPENDIX A 193
cooking techniques, and healthy dining out. The behavior change portion of the
LEAN program consisted of assessing stage of readiness, stimulus control,
breaking associations, generating social support, realistic goal setting, stress
management, and relapse prevention. Finally, the exercise component included
recommendations and hands-on training regarding proper exercise warm-up and
cool-down, stretching, aerobic conditioning, and strength training. The monthly
group follow-up sessions expanded on the already discussed LEAN program
topics, and monthly rotated between each discipline.
Only 9 months after the initial implementation of LEAN program, the
program experienced great success. There was a 50 percent decrease in the
percent of AD population on the WMP and over a 60 percent decrease in the
monthly failure rate in the WMP. The LEAN program was also cited as one of
the top three best things about McConnell AFB at the Senior Enlisted Advisor’s
Enlisted Call. Without a doubt, the greatest strengths of the LEAN program
were the multidisciplinary approach and the length of the program. It was the
first AF program to provide members with increased education, skills and
support in all the disciplines necessary for successful weight loss prior to
official placement in the WMP. The success of the LEAN program was a key
factor in the current AF policy of members receiving 3 months of weight-loss
counseling prior to starting the WMP.
Although I strongly agree that the military individual WMP needs improve-
ment, I would also highly encourage the committee to consider making recom-
mendations for environmental approaches to improving the military’s WMP.
Broad policy changes in regards to nutrition and exercise can have a much
greater impact on the military’s population as a whole then even the best
individual focused weight-loss programs. For example, we know from current
research that availability, taste, and price are three of the greatest factors
affecting food selection today (Colby et al., 1987; French et al., 1999; Glanz et
al., 1998; National Restaurant Association, 1984; National Restaurant Associa-
tion and Gallop Organization, 1986). Therefore, example policies could be: all
base eating establishments must have at least 30 percent of their menu as low-fat
selections; or all low-fat foods in vending machines and cafeterias must cost 30
percent less than the high-fat food choices; or all food service personnel receive
at least 1 week of low-fat cooking training during their technical school; or for at
least 1 week every quarter, the food service workers on base receive additional
training on low-fat cooking from a certified executive chef and culinary trainer.
I commend the committee for addressing the need for changes to the counseling
portion of the WMP, and I challenge the committee to take the next step and
recommend policy changes that modify the military’s environment to decrease
barriers and enable the population as a whole to become more fit and healthy.

References
Colby JJ, Elder JP, Peterson Q, Knisley PK, Carleton RA. 1987. Promoting the
selection of health food through menu item description in a family-style res-
taurants. Am J Prev Med 3:171–177.
French SA, Story K, Hannan P, Breitlow KK, Jeffery RW, Baxter JS, Snyder W.
1999. Cognitive and demographic correlates of low-fat vending snack
choices among adolescents and adults. J Am Diet Assoc 99:471–475.
Glanz K, Basil K, Malibach E, Goldberg J, Snyder D. 1998. Why Americans eat
what they do: Taste, nutrition, cost, convenience, and weight control con-
cerns as influences on food consumption. J Am Diet Assoc 98:1118–1126.
National Restaurant Association. 1984. Consumer Restaurant Behavior: A View
based on Occasion Segmentation. Washington, DC: NRA.
National Restaurant Association and Gallup Organization. 1986. Changes in
Consumer Eating Habits. Washington, DC: NRA.
Additional Recommended Resources

Battle EK, Brownell KD. 1996. Confronting a rising tide of eating disorders and
obesity: Treatment vs prevention and policy. Addict Behav 21:755–765.
French SA, Jeffrey RW, Story K Hannan P, Snyder MP. 1997. A pricing strat-
egy to promote low-fat snack choices through vending machines. Am J Pub-
lic Health 97:849–851.
French SA, Story K Jeffery RW, Snyder P, Eisenberg K, Sidebottom A, Murray
D. 1997. Pricing strategy to promote fruit and vegetable purchase in high
school cafeterias. J Am Diet Assoc 97:1008–1010.
Jeffrey RW. 1998. Prevention of obesity. In: Bray GA, Bouchard C, James
WPT, eds. Handbook of Obesity. New York: Marcel Dekker. Pp. 819–829.
Jeffery RW, French SA, Raether C, Baxter JE. 1994. An environmental inter-
vention to increase fruit and salad purchases in a cafeteria. Prev Med
23:788–792.
THE IMPACT OF A SHIPBOARD WEIGHT-CONTROL

PROGRAM
Karen E. Dennis, PhD, RN, FAAN, and CAPT, NC, USNR1,2,3, Karen W. Pane,
MPA, RN, and LT, NC, USNR3, Douglas D. Bradham, DrPH1,2, Brett R. South,
BS1,2, Heather J. Saunders, MBA1,2, Mark D. Heuser, MD, MS1,2, Bing Bing Qi,
MS2
1
University of Maryland, Baltimore, School of Medicine;
2
Geriatric Research Education and Clinical Center at the Maryland VA Health
Care System, Baltimore;
3
US Navy-Reserve

APPENDIX A 195
Background
Superimposed on obesity’s risk factors for cardiovascular disease (CVD),
Navy personnel who fail to meet Physical Readiness Test (PRT) and body-
weight standards are subject to potentially serious administrative sanctions such
as ineligibility for promotion or potential termination of their military careers.
With impact beyond the well being of the individual service member, these
administrative actions may signify the Navy’s forfeiture of its investment in the
development of personnel’s unique knowledge, skills, and services. Although
obesity has been projected to cost the Navy considerable dollars in inpatient bed
days (Hoiberg and McNally, 1991), to our knowledge, health care expenses due
to this particular condition and its associated sequelae among Navy personnel
have never been quantified. Yet this is only a portion of the total economic
impact of obesity (Colditz, 1992).
To assist its obese service members in attaining weight and fitness
standards, the Navy implemented a multiple-tiered obesity treatment program.
However, this remedial approach is not standardized and it typically fails to
bring the majority of participants within weight standards (Trent and Stevens,
1993). In addition, over 80 percent of program time is devoted to physical
activity even though 63 percent of enrollees are obese (Trent and Stevens, 1993)
who need state-of-the-art, multi-faceted weight-loss programs (Goodrick and
Foreyt, 1991; Wadden and Bell, 1990).
Aims
This study assessed whether a multi-faceted approach to weight loss and
physical readiness could be implemented onboard ship, evaluated factors at sea
that could affect the program’s implementation, and determined its relative
effectiveness in helping obese service members meet weight and physical fitness
standards. Uniquely, this study also documented the economic impact (cost-
effectiveness and cost-savings) of the shipboard weight-control program relative
to the current Command Level program.
Methods, Intervention Component

Thirty-nine men (31 ± 6 years old, mean ± sd) assigned to the USS ENTER-
PRISE (CVN 65) during a 6-month Mediterranean deployment who had failed
their previous PRT due to excessive body weight (108 ± 11 kg overweight) were
randomly assigned to: (1) an experimental treatment of weekly sessions on diet,
behavior modification, psychosocial issues, plus the current Command Level
program of exercise, or (2) a usual care control treatment comprised of the
existing Command Level program of exercise alone.

The goal of the experimental treatment was to educate participants in

effective, realistic, and acceptable ways to adopt lifestyle, lifetime behaviors
conducive to healthy nutrition, long-term weight control, and physical activity.
The format was small group lecture/discussion conducted by a Navy dietitian.
Groups of 10–12 individuals met in hour-long, weekly sessions for 16 weeks of
the 6-month deployment to fit within the constraints of deployment time,
departure from and return-to-port activities, as well as data collection onboard.
The diet followed NCEP Step I (Heart Healthy) guidelines for dietary
composition, with portions controlled to decrease energy intake by 500 calories
per day to promote weight loss of 0.5–1 kg per week. The dietitian used a
standardized instructor manual, and each participant received a notebook of
course material generated and used in numerous studies in the Geriatric
Research Education and Clinical Center at the VA Maryland Health Care
System, Baltimore (Dengel et al., 1995; Dennis and Goldberg, 1996; Dennis et
al., 2001; Landkammer et al., 1992; Nicklas et al., 1997a, 1997b). Behavior
modification consisted of teaching participants well-documented behavioral
modification techniques, such as dealing with external stimuli associated with
eating occasions, and managing holidays and special events, including shore
liberty. Combining a greater knowledge of food choices with an understanding
of behavioral techniques enabled participants to select foods from a wider
variety of alternatives, fully consider the consequences of each one, and
structure the environment for success. Self-monitoring was introduced as a new
lifestyle behavior that is central to achieving the desired weight-loss outcomes.
Interpersonal processes were designed to build camaraderie and group support
as participants were guided to creatively problem solve and adopt a series of
small, achievable steps that had a cumulative impact on body weight.
The exercise program for the experimental group was the mandated
program already being conducted for Command Level remediation (i.e., “Navy
usual care”), which consisted of 1 hour of exercise 4 days per week. Established
exercises included curl-ups, push-ups, walking, jogging, and other aerobic
exercises conducive to successful completion of the PRT. PRT in the Navy
involves sit-reach, curl-ups, push-ups, and a 1.5 mile run. Although standards
are age- and gender-based, the “average” 31-year-old male participating in this
study would need to touch his toes with legs out-stretched, perform 32 curl-ups
and 23 push-ups, and run 1.5 miles in 15 minutes/30 seconds to pass the PRT.
Exercise was not experimentally controlled because the intent of the study was
to evaluate the addition of a standardized dietary behavioral modification
component to the Navy’s existing program.
Like the experimental group, men in the “usual care” control group (i.e.,
existing Command Level remediation program) knew that weight loss was
requisite to continue their Navy careers beyond an 18-month grace period.
While these men were provided nutrition fact sheets and brochures if requested,
they did not receive group or individual counseling. The control group received

APPENDIX A 197
“usual care” by participating, as required, in the current Command Level I

program of exercise described above for the treatment group.
Methods and Results

Intervention Component
Prior to treatment there were no significant differences in body composition
parameters (weight, BMI, percent body fat, waist and hip girths, waist/hip ratio)
between men in the treatment and control groups. However, outcomes for the
treatment group were significantly better than the controls, with 8.6 ± 5.0 vs 5.0
± 4.1 kg weight loss, 8 percent versus 5 percent reduction in original body
weight, and body-fat loss of 7 percent versus 5 percent. Moreover, 10 men in the
treatment group vs only 2 in the control group lost at least 10 kg of their initial
body weight. Prior to treatment, most CVD risk factors reflected values that
were within NCEP guidelines. The exception was high-density lipoprotein
cholesterol, which averaged 35 ± 8 mg/dl for the total group, and was low
enough to place these men at increased CVD risk. With weight loss and
exercise, triglycerides declined significantly greater in the treatment group than
the controls (145 to 109 mg/dl vs 146 to 145 mg/dl, p < .05)
At baseline, despite random assignment, men in the treatment group
reported significantly greater binge eating symptoms, less use of eating
behaviors conducive to weight loss, and more difficulty controlling overeating at
times of negative affect than men in the control group. At the end of the
program, however, treated men had significant improvements in all of these
elements, as well as a significant improvement in the difficulty they experienced
controlling overeating in certain social circumstances. Beginning worse than the
control group, men in the treatment group finished the study with similar or
better eating behaviors than their counterparts. These outcomes hold even when
controlling for significant differences pretreatment.
Problematic environmental factors were the limited variety of heart healthy
foods in the galley, short meal breaks and long mess hall lines that led to eating
snacks from vending machines, and frequent port calls. Although greater weight
loss than would be expected of a Command Level remedial group diluted the
treatment effect, the treated men still fared significantly better (Dennis et al.,
1999).
Intervention Cost-Effectiveness
To examine the cost-effectiveness of the standardized shipboard weight-
control program (SBWC) vs the Navy’s current exercise-only Physical Readi-
ness Test (PRT) remediation, costs were examined from the Navy (long-term)
and Command (short-term) perspectives. The Navy’s costs, both direct (i.e.,

intervention and personnel replacement) and indirect (i.e., participant’s obesity-

related health care savings), formulated the cost-effectiveness analysis. The
frequency and probability of medical events in the Navy active duty population,
valued at Medicare cost rates, generated total inpatient and outpatient obesity-
related expected per person health care costs to calculate cost-saving from the
effects of the innovative shipboard weight control and the current Command-
Level interventions.
The SBWC was more expensive to deliver than the PRT-exercise only
remediation. The per-person expense for the SBWC was $1,269, which
consisted of $509 for the conduct of the intervention plus $722 in the
participants’ indirect costs. The Command-Level, PRT exercise-only cost per-
person was $760, with $38 for the intervention and the same $722 of indirect
costs. Additionally, $65,561 is required to replace the average service member
when dismissed for PRT non-compliance. However, these PRT-intervention and
replacement costs apply only to personnel in PRT remediation or those who are
discharged, so the probability of these events is accounted for in the final
calculation of expected per person costs of: $143 for the PRT exercise-only and
$195 for the SBWC remediations, at the Command Level. The “effect” measure
is the percent of weight loss, which is the most meaningful clinical outcome
achieved by the two interventions under scrutiny. The SBWC and PRT groups
on average achieved weight reductions of 7.8 percent and 4.6 percent,
respectively, indicating that the SBWC is more effective.
The simple or “average” cost-effectiveness ratios indicate that the SBWC is
cheaper to deliver, considering the gains achieved, under either the Command or
Navy perspective. Exercise-alone remediation annually costs the Command (per
person) $31 per percent weight loss achieved, while the SBWC costs $25. In the
Navy’s perspective, PRT-exercise-only obtains a ratio of $19 per percent
weight-loss achieved while SBWC obtains a value of $13. These ratios indicate
the SBWC is “dominant” across perspectives with consistently lower average
annual per person costs per effect unit achieved.
Because the SBWC is an enhancement of the PRT-exercise remediation, the
cost effectiveness analysis (CEA) also can examine the preferred cost-effective-
ness of program efficiency, the incremental cost-effectiveness. That incremental
CEA comparison examines whether the additional costs achieve an additional
effect, which makes the SBWC incrementally more cost-effective. The SBWC
program is estimated to annually save approximately $1 per percentage weight
loss per person over the PRT-exercise-only remediation from both the
Command and Navy perspectives. Thus, the estimated annual impact would be a
savings of $675,198 with an investment of $24,363 twice annually, assuming the
probabilities of PRT failures and discharges are maintained. These findings were
sustained under sensitivity analysis that tests the influence of the assumptions
and inclusiveness of the CEAs.

APPENDIX A 199
This study documents the average cost-effectiveness of the Navy’s current

Command Level PRT exercise-only program and the improved cost-effective-
ness when that intervention is standardized and augmented with nutrition and
behavioral modification interventions (SBWC), even while onboard the Navy’s
sea-going vessels. These findings are based on conservative assumptions and
valuation techniques at each stage of the analysis underlying the comparisons.
The consistent dominance of the SBWC over the PRT-exercise-only remedia-
tion across both Command and Navy perspectives further confirms the findings
that SBWC should be implemented Navy-wide (Bradham et al., in press).
Obesity-Related Hospitalization Costs

The objective to estimate the cost to the U.S. Navy for obesity-related
hospital admissions was examined by: (1) the inpatient utilization associated
with obesity; (2) the rank order, probability, and total facility costs of obesity-
related Diagnosis Related Groups (DRG); and (3) the expected inpatient
expenses. The analysis was structured by age groups (18–24, 25–34, 35–44, and
45–64 years old) that are commonly used in the Navy’s central health care data
system. Stratification by age also permitted documentation of increased
cardiovascular disease incidence over life span. Detailed hospital event data
were extracted from the Retrospective Case Mix Analysis System (RCMAS).
The RCMAS database provides several descriptors of the admission and
associated treatment including up to 20 diagnostic classifications (ICD9 codes),
the DRG for the admission, the length of the hospital stay, and procedures
(ICD9 codes) delivered during the admission. Having a CVD diagnosis ICD9
code in the primary or lower-order diagnosis fields for a 1995 or 1996 admission
identified patients who were entered into this analysis. The candidate CVD
diagnoses were determined from both empirical evidence and expert judgment.
Among patents admitted with an ICD9 of CVD as one of the diagnoses,
advancing age was associated with more admissions for chest pain and
circulatory disorders. Coronary bypass began to appear in the top five obesity-
related DRGs in the 45–64 year old age group. The number of CVD admissions
in that oldest age group drops markedly, which is consistent with military
retirement and the number of personnel of that age who remain on active duty.
Expected facility costs per obesity-related admission for active duty Navy
personnel increased by age group from $3,328 for 18–24 year olds to $5,746 for
45–64 year olds. Annual avoidable inpatient for the Navy was estimated to be
$5,842,627 for the top ten obesity-related DRGs (Bradham et al., 2001).
Clinical Significance
Results of the standardized shipboard weight-control program support the
ability to conduct multifaceted weight-control programs on deployed naval

vessels and are important to the Navy because of their potential to positively
impact Navy policy on obesity treatment. Through extension and replication, the
effect of this program conducted on other types of operational platforms and at
shore-based facilities may result in a feasible and effective approach to
improving the health and well-being of the Navy’s service members. Pilot data
from a refinement of this shipboard weight-control program that uses indigenous
shipboard personnel rather than a Navy dietitian to conduct the intervention are
very promising.
Obesity extracts a large economic cost from the Navy in terms of health
care services (inpatient and outpatient) and premature discharges for failure to
maintain body composition and physical readiness standards. These costs are
high in aggregate, and no less significant at the individual level. Importantly,
these costs are avoidable if innovative and cost-effective remedial treatments are
implemented. Improvements to the Navy’s physical readiness remedial program
and other health promotion interventions that might reduce weight, cardio-
vascular risks, obesity-related health care, and personnel discharges should be
examined rigorously before adoption. Those that are efficacious and cost-
effective should be implemented to reduce the public’s economic burden.
References
Bradham DD, South BR, Saunders HJ, Heuser MD, Pane KW, Dennis KE. In
press. The cost effectiveness of a shipboard weight control program.
Bradham DD, South BR, Saunders HJ, Heuser MD, Pane KW, Dennis KE.
2001. Obesity-related hospitalization costs to the U.S. Navy, 1993 to 1998.
Mil Med 166:1–10.
Colditz GA. 1992. Economic costs of severe obesity. Am J Clin Nutr 55:503S–
507S.
Dengel JL, Katzel LI, Goldberg AP. 1995. Effect of an American Heart Associa-
tion diet, with or without weight loss, on lipids in obese middle-aged and
older men. Am J Clin Nutr 62:715–721.
Dennis KE, Goldberg AP. 1996. Weight control self-efficacy types and positive
transitions affect weight loss in obese women. Addict Behav 21:103–116.
Dennis KE, Pane KW, Adams BK, Qi BB. 1999. The impact of a shipboard
weight control program. Obes Res 7:60–67.
Dennis KE, Tomoyasu N, Goldberg AP, McCrone SH, Bunyard L, Qi BB. 2001.
Self-efficacy targeted treatments for weight loss in postmenopausal women.
Sch Inq Nurs Pract 15:259–276.
Goodrick GK, Foreyt JP. 1991. Why treatments for obesity don’t last. J Am Diet
Assoc 91:1243–1247.
Hoiberg A, McNally MS. 1991. Profiling overweight patients in the U.S. Navy:
Health conditions and costs. Mil Med 156:76–82.

APPENDIX A 201
Landkammer J, Katzel L, Engelhardt S, Simpson K, Goldberg A. 1992. Cardio-

vascular risk factors modification after dietary therapy of obese older men.
32:71A.
Nicklas BJ, Katzel LI, Bunyard LB, Dennis KE, Goldberg AP. 1997a. Effects of
an American Heart Association diet and weight loss on lipoprotein lipids in
obese, postmenopausal women. Am J Clin Nutr 66:853–859.
Nicklas BJ, Katzel LI, Ryan AS, Dennis KE, Goldberg AP. 1997b. Gender dif-
ferences in the response of plasma leptin concentrations to weight loss in
obese older individuals. Obes Res 5:62–68.
Trent LK, Stevens LT. 1993. Survey of the Navy’s three-tiered obesity treatment
program. NEI Med 158:614–618.
Trent LK, Stevens LT. 1995. Evaluation of the Navy's obesity treatment pro-
gram. Mil Med 160:326–330.
Wadden TA, Bell ST. 1990. Obesity. In: Bellack AS, Hersen M, Kazdin AE,
eds. International Handbook of Behavior Modification and Therapy. New
York: Plenum. Pp. 449–473.
THE TRIPLER L2E3AN PROGRAM: A CURRENT

UPDATE
Larry C. James, PhD, ABPP, Jay Earles, PsyD LTC MS USA CPT(P) MS USA,
Raymond A. Folen, PhD, ABPP
As obesity has effected the civilian population over the last two decades, so
have the rates of obesity increased in the U.S. military. In 1994, many service
members were administratively discharged for their inability to maintain weight
standards. Moreover, as the armed services downsizes, loss of trained and
skilled personnel due to weight problems has taken on increased importance. As
a result of the problems associated with obesity and other behavioral disorders
and lifestyle diseases (such as obesity, essential hypertension, type II diabetes,
and hyperlipidemia), Tripler Army Medical Center developed a healthy lifestyle
program to treat any of these diseases. Coined the L2E3AN PROGRAM
(emphasizing healthy Lifestyles, health for Life, Exercise, Emotions, Expecta-
tions that are reasonable, Attitudes and Nutrition), its major emphasis is on short
bout, low intensity exercise consuming three well-balanced meals each day
rather than fad diets or painful exercise. Additionally, the programs six
psychologists teach patients how to cope with the wide array of emotions
associated with food and eating. The presentation will discuss the conceptualiza-
tion behind the program’s development as well as major components and ideas
for program implementation, and highlight practical problems. An emphasis will
be placed on key aspects of the program curriculum that are most efficacious
and helpful in assisting military patients in managing their weight. Demo-
graphics of weight loss by age, gender, race, military ranks, and occupation will

be provided. The results suggest that at 18 months post-treatment, patients

maintained 8 to 10 percent weight loss. Of particular interest was the fact that
minority men did equally well as nonminority men in the program. Although
these programs are very promising, the researchers had difficulty testing out
quantifiable reasons for the success of the minority men, a pattern inconsistent
with studies on minorities (U.S. African-American women on the other hand,
had great difficulty achieving even modest weight loss). This finding has been
demonstrated in some previous studies. A practical problem for potential
program participants is that this program requires 12 months of follow-up. It
involves 3 weeks of day treatment and 12 months of weekly follow-up. Thus,
patients unable to follow the year-long follow-up regimen are not admitted to
the program. The exclusion criteria eliminates many active duty navy patients
from participation. To offset this problem, the researchers developed and
pioneered behavioral health telemedicine treatment. An inter-active webpage
was developed and coupled with the use of low-cost video teleconferencing.
Currently, all service members who can attend the day treatment phase of the
program can participate in the program. The researchers have compared the
finding between patients (n = 30) who participate in follow-up via the interactive
web page and those who attend weekly follow-up sessions. The weight-loss
slopes are nearly identical for both groups. To date, the L2E3AN Program and its
innovative telemedicine web page offers promise for the treatment of obesity
and it related diseases. The authors of this study will continue to develop similar
programs at other military medical facilities and hope to find innovative ways to
treat obesity.
ARMY WEIGHT-MANAGEMENT INSTRUCTION TO

MASTER FITNESS TRAINERS (MFTS),
Lou Tomasi, EdD and 1LT Kerryn Davidson, RD, US Army Physical Fitness
School, Ft. Benning, GA
Introduction
The United States Army Physical Fitness School (APFS) is located in Ft.
Benning, GA, Home of the US Army Infantry Training Center. The APFS is
responsible for writing operational physical fitness doctrine, conducting physical
fitness research, and providing physical training support to the Army. Writing
the fitness doctrine includes composing, staffing, reviewing and publishing Field
Manual 21-20, Physical Fitness Training (U.S. Army, 1992) and the on-going
responsibility of updating changes and authoring articles for Army publications.
The APFS also conducts operational research. For example, APFS
personnel designed the protocol and administered the research procedures to set
the 1995 Army Physical Fitness Test (APFT) Standards Update Study, 1997

APPENDIX A 203
APFT Validation Study, 1998 Entrance and Exit Requirements for the Army
Basic Combat Training (BCT) Fitness Training Units, 1999 Impact of the New
APFT Standards on Attrited Soldiers from BCT, and 1999 Upper Body Strength
Needed to Complete Army Airborne Training.
Providing training support to the Army includes conducting many mid-
length and short physical training courses. The most visible course is the Master
Fitness Trainer (MFT) course, a 101-hour course that begins with some basic
anatomy, muscle and exercise physiology, strength, flexibility, and cardio-
respiratory training techniques. Additionally, other topics include nutrition, unit
and individual exercise prescriptions, and teaching the MFTs the Army Weight
Control Program.
MFT Instruction
The agenda of this presentation is to provide the audience with an overview
of the Army Weight Control Program instruction provided to the MFTs, and the
role of the MFT in the Army Weight Control Program. This instruction is
segmented in two parts: Army Regulation (AR) 600-9 (4 hours) (U.S. Army,
1986), and nutrition (4 hours). The purpose of the regulation is to establish
policy and procedure for the implementation of the Army Weight Control
Program. The objectives include: meeting the physical demands of their duties
under combat conditions and presenting a trim military appearance at all times.
The commanders’ responsibilities include the following: program implementa-
tion, personnel monitoring, exercise programs, and providing education
programs to the soldiers enrolled in the Army Weight Control Program.
The MFTs have an integral role in the Army Weight Control Program. They
conduct weight-ins when the APFT is administered (i.e., biannually). Soldiers
are placed in the Army Weight Control Program when they exceed the set
weight for their height as determined by the AR 600-9 Screening Table Weight
(U.S. Army, 1986). The MFT’s role is to assess the identified soldiers, write an
exercise prescription, assist with the maintenance of personal weight and body
composition goals, assist the commander in the development of proactive fitness
programs, and provide dietary and nutritional guidance. Soldiers are monitored
monthly, weigh-ins are conducted by the commander or designee, body fat is
evaluated regularly. Satisfactory progress is 3–8 lb per month weight loss.
Identified soldiers are removed from the program by the commanders and
supervisors when body-fat standards are met, and the AR 600-9 Screening Table
Weight is not used for removal. When there is unsatisfactory progress, the
soldiers are screened for a medical condition. When there is a medical condition,
hospital personnel provide medical treatment. When there is no medical
condition, Army administrative personnel bar the soldier from reenlistment,
other favorable actions, and administrative separation procedures begin.

Soldiers are monitored for 36 months upon removal from the program. If a
soldier again exceeds body fat within 12 months of removal date, the soldier is
separated. If soldier again exceeds the body-fat standards after the twelfth
month, but within 36 months, the soldier is allowed 90 days to meet the
standard.
The Army Weight Control Program uses separate circumference measure-
ment sites for females and males. The males’ measurement sites are at the
abdomen at the level of the navel and around the neck, just below the larynx.
The females’ measurement sites are: at the hip where the point of the gluts
protrude the most, forearm at the largest point, neck just below the larynx, and
the wrist between the bones of the wrist and the forearm.
During MFT instruction, APFS instructors teach the MFT students Lean
Body Mass and Target Weight Formulae, that is, Lean Body Mass = Present
Body Weight X (1 – % present body fat) and Target Weight = Lean Body Mass
÷ (1 – % target body fat). The concept of energy balance is presented. For
example these formulae are taught to the MFT students:
Energy Input = Energy Output = Stable Body Weight;

Energy Input > Energy Output = Increase Body Weight;
Energy Input < Energy Output = Decrease Body Weight.
During MFT instruction, APFS instructors teach the MFT students energy
balance manipulation for effective weight loss. These include:
• Reduce caloric intake below daily energy requirements;

• Maintain caloric intake and increase caloric output through exercise;
• Ideally, reduce caloric intake below daily energy requirements and in-
crease caloric output through exercise.
To determine weight-maintenance formula, the activity factors of sedentary:

12–14 calories per lb (desk job, little/no exercise), active: 15 calories per lb
(regular exercise program) and highly active: 16–18 calories per lb (physically
demanding work and/or high level of physical training) are used. MFT instruc-
tion presents safe minimum calorie intakes of no less than 1,500 kcal for males
and no less than 1,200 kcal for females. Nutrition in the MFT course is directly
linked to weight management through the dietary guidelines; nutrients, class,
characteristics, function; interpreting food labels, conducting a dietary recall;
and calculating of per cent calories from carbohydrate, protein, and fat.
Mandatory requirements for nutrition education prior to or shortly after
enrollment in Army Weight Control Program includes instruction by a registered
dietitian in which soldiers learn proper diet for weight control. Follow-up with
the RD is encouraged; however, it is not required under the provisions of AR
600-9 (U.S. Army, 1986).

APPENDIX A 205
Summary
In summary, the overview of Army weight-management instruction to
Master Fitness Trainers includes: program implementation, personnel monito-
ring, exercise programs, and education programs.
References
September 1. Washington, DC: U.S. Government Printing Office.
U.S. Army. 1992. Physical Fitness Training. Field Manual 21-20. September
30. Washington, DC: U.S. Government Printing Office.
THE GENETICS OF OBESITY

Anthony G. Comuzzie
The understanding of the genetic influences on obesity in humans has

recently increased at a tremendous rate. It is now well established that obesity
has a significant genetic component. In humans approximately 50 to 70 percent
of the within-population variation in a variety of obesity-related phenotypes
appears to be due to within-population genetic variation. Several single gene
defects leading to massive obesity have been found in animal models, but very
few humans appear to be obese due to mutations in single obesity genes. As a
result, investigators are actively searching for oligogenic influences on human
adiposity.
One of the greatest challenges in biomedical research today is the elucida-
tion of the underlying genetic architecture of complex phenotypes such as
obesity. In contrast to simple Mendelian disorders, in which there is generally a
one-to-one relationship between genotype at a single locus and the presence or
absence of the disorder, obesity rises as a result of numerous behavioral,
environmental, and genetic factors (i.e., obesity is multifactoral in origin).
Twin, adoption, and family status have long established that an individual’s
risk of obesity is increases when he/she has relatives who are obese. In fact, it
has been shown repeatedly that a substantial portion (≈ 40 to 70 percent) of the
variation in obesity related phenotypes, such as body mass index (BMI), sum of
skinfolds thickness, fat mass, and leptin levels, is heritable (Comuzzie et al.,
1993, 1994, 1996). Finally, numerous segregation analyses (studies evaluating
the evidence and mode or transmission for a major gene based on observed
patterns of phenotypic inheritance among related individuals) have provided
evidence that among the genes influencing the expression of these obesity-
related phenotypes, there are at least a few with relatively large measurable
contributions. For example ≈ 40 percent of the variation in fat mass has been

attributed to the effects of such a major gene (Comuzzie et al., 1995; Rice et al.,
1993). These segregation analyses reveal that there are genes with major effects
on the amount and distribution of body fat, and that these genes appear to exert
their affects across various ethnic populations. In addition, segregation analysis
of longitudinal changes in percent body fat over a 5-year period has yielded
evidence for a major gene effect (Comuzzie et al., 1999).
Most recently the emphasis has shifted from the question of whether human
obesity has a genetic component to the question of which specific genes are
responsible. Currently the major effect in the search for specific genes
contributing to human obesity is based on the use of genome scanning. In a
genome scan, linkage analysis is conducted using a series of anonymous
polymorphisms, spaced at a relatively constant interval over the entire genome
(for example ≅ 350–370 markers with an average spacing of 10cM), to identify
quantitative trait loci (QTLs) affecting the phenotype under study. In contrast to
the typical candidate gene approach, with genome scanning there are no a priori
assumptions about the potential importance of specific genes or chromosomal
regions. Instead, the results of the scan are used to identify candidate
chromosomal regions, or in some cases, positional candidate genes, which then
become the focus of more intensive follow-up analyses. A positional candidate
gene differs from a traditional candidate gene in that it is only considered as a
candidate after the establishment of its proximity to a QTL identified via linkage
in a genome scan. Thus, the genomic scan approach offers the potential of
identifying previously unknown, or unsuspected, genes influencing the
phenotype of interest.
In the case of our work in the San Antonio Family Heart Study, ten
extended families of Mexican Americans (representing 459 individuals
comprising 5,667 relative pairs ranging from parent-offspring to double second
cousins) were evaluated for several obesity related phenotypes in a 20 cM
genomic span (Comuzzie et al., 1997). Significant linkages were detected for
QTLs on chromosome 2 (≈ 74 cM from the tip of the short arm) and
chromosome 8 (≈ 65 cM from the tip of the short arm) and leptin levels (LOD
scores = 4.3 and 2.2, respectively). A significant linkage was also detected
between fat mass (FM) and the chromosome 2 QTL (LOD score = 1.9).
Multipoint analysis of the leptin linkages increased the LOD score to 4.95 for
the QTL on chromosome 2 and 2.2 for the chromosome 8 QTL (Comuzzie et al.,
1997). In the case of the chromosome 2 linkages, this QTL is estimated to
account for 47 percent of the variation in serum leptin levels and 32 percent of
the variation in fat mass. Recent follow-up work in this region of chromosome 2
has now boosted the LOD score for the leptin linkage to 7.5 (Hixon et al., 1999).
The areas of linkage on chromosome 2 and chromosome 8 contain strong
positional candidate genes for obesity. For example, the region on chromosome
2 encompasses POMC, which codes for the prohormone pro-opiomelanocortin,
which is post-transcriptionally processed to produce a number of hormones in

APPENDIX A 207
the hypothalamic-pituitary axis such as melanocyte-stimulating hormones and

adrenocorticotrophic hormone, which have long been suspected of being
involved in obesity. POMC was originally identified as a candidate gene based
on its location, and its gene product has now been implicated in appetite
regulation (Boston et al., 1997; Schwartz et al., 1997; Seeley et al., 1996, 1997).
We have now identified two polymorphisms in POMC that are associated with
variation in leptin levels in this population of Mexican Americans (Hixon et al.,
1999). The region of linkage on chromosome 8 encompasses ADRB3, for the β-
3Adrenergic receptor, which represents a previously identified candidate based
on its physiological activity with respect to the regulation of energy expenditure.
Although the cumulative evidence of linkage between the well-known
tryptophan to arginine mutation (trp64Arg) in ADRB3 and BMI is weak, the
argument that ADRB3 is a human obesity gene has been strengthened by the
follow-up analyses in this same sample of Mexican Americans (Mitchell et al.,
1998). These analyses have revealed an association between ADRB3 variants
and BMI, FM, and waist circumference after first continuing on the stronger
QTL signal on chromosome 2.
In addition to our work in humans, our preliminary genome scanning efforts
in primates (i.e., baboons) have also begun to reveal additional QTLs with
significant effects on obesity-related phenotypes. At present, we have detected
suggestive evidence of linkage for QTLs influencing body weight (LOD = 2.12)
and fat cell number (LOD = 2.15). In both cases, the confidence intervals
surrounding these two QTLs contain two strong positional candidates. The QTL
for body weight is located near NPY and QTL for fat cell number is near IGF-1.
While there are undoubtedly single genes that produce massive phenotypic
effects on obesity-related phenotypes in isolated individuals or families, the
identification of at least a few loci with common alleles with measurable effects
on the general population has significant implications for public health. Work to
date suggests the existence of roughly a dozen genes with measurable effects of
the expression of obesity-related phenotypes at the population level. As a result,
there is now not only strong evidence for a genetic component in the variation of
body weight across individuals, but we are beginning to identify specific genes
with measurable effects.
References
Boston BA, Blaydon KM, Varnerin J, Cone RD. 1997. Independent and additive
effects of central POMC and leptin pathways on murine obesity. Science
278:1641–1644.
Comuzzie AG, Blangero J, Mahaney MC, Mitchell BD, Stern MP, MAcCluer
JW. 1993. The quantitative genetics of sexual dimorphism in body fat
measurements. Am J Hum Biol 5:725–734.

Comuzzie AG, Blangero J, Mahaney MC, Mitchell BD, Stern MP, MacCluer
JW. 1994. Genetic and environmental correlations among skinfold meas-
ures. Int J Obes Relat Metab Disord 18:413–418.
Comuzzie AG, Blangero J, Mahaney MC, Mitchell BD, Hixson JE, Samollow
PB, Stern MP, MacCluer JW. 1995. Major gene with sex-specific effects in-
fluences fat mass in Mexican Americans. Genet Epidemiol 12:475–488.
Comuzzie AG, Blangero J, Mahaney MC, Haffner SM, Mitchell BD, Stern MP,
MacCluer JW. 1996. Genetic and environmental correlations among hor-
mone levels and measures of body fat accumulation and topography. J Clin
Endocrinol Metabol 81:597–600.
Comuzzie AG, Hixson JE, Almasy L, Mitchell BD, Mahaney MC, Dyer TD,
Stern MP, MacCluer JW, Blangero J. 1997. A major quantitative trait locus
determining serum leptin levels and fat mass is located on human chromo-
some 2. Nat Genet 15:273–276.
Comuzzie AG, Mitchell BD, Blangero J, MacCluer JW, Stern MP. 1999. Evi-
dence for genetic influences on the change in percent body fat over time in
Mexican Americans. Genet Epidemiol 17:221–222.
Hixon JE, Almasy L, Cole S, Birnbaum S, Mitchell BD, Mahaney MC, Stern
MP, MacCluer JW, Blangero J, Comuzzie AG. 1999. Normal variation in
leptin levels in associated with polymorphisms in the proopiomelanocortin
gene, POMC. J Clin Endocrinol Metab 84:3187–3191.
Mitchell BD, Blangero J, Comuzzie AG, Almasy LA, Shuldiner AR, Silver K,
Stern MP, MacCluer JW, Hixson JE. 1998. A paired sibling analysis of the
beta-3 adrenergic receptor and obesity in Mexican Americans. J Clin Invest
101:584–587.
Rice T, Borecki IB, Bouchard C, Rao DC. 1993. Segregation analysis of fat
mass and other body composition measures derived from underwater
weighing. Am J Human Genet 52:967–973.
Schwartz MW, Seeley RJ, Woods SC, Weigle DS, Campfield LA, Burn P,
Baskin DG. 1997. Leptin increases hypothalamic pro-opiomelanocortin
mRNA expression in the rostral arcuate nucleus. Diabetes 46:2119–2123.
Seeley RJ, van Dijk G, Campfield LA, Smith FJ, Burn P, Nelligan JA, Bell SM,
Baskin DG, Woods SC, Schwartz MW. 1996. Intraentricular leptin reduces
food intake and body weight of lean rats but not obese Zucker rats. Horm
Metab Res 28:664–668.
Seeley RJ, Yagaloff KA, Fisher SL, Burn P, Thiele TE, van Dijk G, Baskin DG,
Schwartz MW. 1997. Melanocortin receptors in leptin effects. Nature
390:349.

APPENDIX A 209
THE PHARMACOTHERAPY OF WEIGHT LOSS AND

ITS POTENTIAL APPLICATION IN THE MILITARY
SETTING
MAJ H. Glenn Ramos, Fort Gordon, GA
General Information
Only a small percentage of obese patients are able to achieve their weight
goals and an even smaller percentage are able to maintain such weights over
time. The majority of those who lose weight return to their initial obese state or
gain more (Turner et al., 1995).
This is particularly well illustrated by Kramer (Kramer et al., 1999) who, in
a 5-year study, demonstrated that only 5.3 percent of women and 0.9 percent of
men were able to maintain all the weight that they had lost. Forty percent in
general gained weight at least to baseline levels or above at some point during
the follow-up.
The “bright” side of Kramer’s study was that there were measurable
residual benefits from behavioral weight-management programs 4–5 years
beyond termination of initial treatment—18.5 percent maintained at least half of
their losses throughout follow-up, and 34 percent kept off at least 25 percent.
The view that short-term interventions will cure a chronic condition has
hampered the development of methods for controlling weight. The major
challenge facing obese patients and health care providers is to improve the
ability to sustain, rather than to achieve, weight loss.
The definition of success that is applied in evaluating weight-loss programs
should be broadened and made more realistic based on the research to date that
small weight losses can reduce the risks of developing chronic diseases.
Specifically, the goal of obesity treatment should be refocused from weight loss
alone to weight management, achieving the best weight possible in the context
of overall health. In contrast to weight loss, the primary purpose of weight
management is to achieve and maintain good health. This concept includes
weight loss but is not limited to it (IOM, 1995).
In this light, pharmacotherapy for obesity must be seriously considered in
the acute, and chronic, management of this disease.
Anorectics and Weight Loss/Weight Maintenance

The following are the three currently available classes of anorectics:
1. Catecholamine-like agents
2. Serotonin re-uptake inhibitors
3. Lipase inhibitors

The following two additional classes are undergoing research:
1. Leptin
2. Metabolic enhancers
The catecholarnine-like agents include phentermine (Fastin/Adipex),

diethylproprion (Tenuate), and the phenopropanalamines (Accutrim and
Dexatrim). These are the oldest agents available and are very effective.
Sympathomimetic amines have actions that include symptoms similar to the
fight or flight syndrome, to include central nervous system stimulation and
anorexia. This is also the source of most of the medication’s side-effects that
include insomnia, palpitations, tachycardia, dry mouth, dizziness, euphoria and
headache, elevation of blood pressure, and tachycardia,.
The average weight loss is around 10 kg at 6 months. Studies of greater than
6 months are lacking with the exception of the combination Phen-Fen, which
was studied out to 3.5 years, and will be discussed later.
The rate of weight loss associated with the use of phentermine tends to be
greatest in the first weeks of therapy, and decrease with succeeding weeks, to an
eventual plateau around the sixth month of treatment.
Use of these agents is contraindicated in advanced atherosclerotic coronary
artery disease, moderate to severe hypertension, hyperthyroidism, glaucoma,
agitated states, pregnancy, and in eating disorders.
• Fecal urgency 10.0–29.0 percent

• Fecal incontinence 5.0–11.8 percent
Both high fiber meals and low-fat diets have reduced the frequency of
intestinal complaints by producing fewer liquid or oily stools.
In some the fat-soluble vitamins (A, D, E, K, and beta-carotene) are reduced
and need to be supplemented (2 hours before or after use of Xenical).
Since orlistat undergoes minimal systemic absorption, the primary drug
interaction concern has been its influence on the absorption of coadministered
drugs. Orlistat has been found to increase the half-life of farosernide and the
time to peak concentration of sustained-release nifedipine (adalat/procardia XL),
although these increases were not considered to be clinically significant. The
concomitant administration of pravastatin and orlistat increased pravastatin’s
bioavailability and lipid-lowering effect modestly. The combination has also
been shown to increase the risk of rhabdomyolosis. Because of the decreased
absorption of vitamin K, Coumadin use must be monitored closely during
coadministration with Xenical.
Orlistat is contraindicated in patients with chronic malabsorption syndrome,
or cholestasis, and in patients with known hypersensitivity to Xenical.

APPENDIX A 211
Leptin is a natural human protein produced by fat that has few or no

apparent significant adverse side effects. Currently this medication is experi-
mental, and given subcutaneously, with its most common adverse effect being
moderate skin reaction (redness, itching, swelling) at the injection site.
It appears to act as a chemical messenger from fat cells to the brain to
indicate the level of fat in the body. By complex endocrine controls that may
include decreasing levels of a hormone called neuropeptide Y, the Leptin tells
the brain to decrease fat intake and increase energy use. Theoretically, the lateral
hypothalmus of an individual taking Leptin would not realize that the body is
losing weight, and compensatory mechanisms would not be put into effect.
In animals it not only reduces food intake, but also increases basal
metabolic rate with selective promotion of fat metabolism.
In contrast to the Leptin-deficient lab mice upon which this was initially
tested, most obese mammals have elevated plasma concentrations of Leptin and
insulin, and appear to be resistant to leptin-induced anorexia. This resistance is
similar to a type II diabetic resistance to insulin. Thus, Leptin’s effect in humans
has not been as dramatic as in animals. It is modestly effective, causing an
average weight loss of 16 lb over 6 months.
Thyroid hormone is one prototype of a thermogenic drug. It produces a log-
dose increase in metabolic expenditure. Pharmacologic doses of thyroid hor-
mone, however, are associated with increased breakdown of protein, increased
calcium loss from bone, and an increased risk of cardiovascular dysfunction.
Interest in triiodothyronine (T3) as a treatment for obesity has been revived
by the observation that T3 falls in very low-calorie diets (as well as in anorexics
and bulemics), and the administration of T3 can prevent the decline in metabolic
rate that occurs. However, the reduction in T3 when dieting may be a compensa-
tory effort by the body to conserve visceral proteins since it has been found that
up to 75 percent of the extra weight lost on T3 replacement can be accounted for
by the loss of fat-free mass.
Brown fat stimulants show much promise in the future, but are only in the
beginning phases of animal research. Currently there are no agents on the
market that have been proven to increase the metabolism of dieting patients
(despite all the “health food” claims to the opposite).
Barriers to Drug Treatment

The view that obese people need “only to close their mouths” has caused us
to demand a higher standard for medications used in treating obesity than we do
for treatments of any other chronic condition. In many conditions we accept that
the condition will relapse following the cessation of therapy. Even in the
absence of cure, patients and physicians still view ocular hypotensive agents,
anti-hypertensive agents, cholesterol-lowering medications, antidepressants, and
H2-blockers as valuable. However, the failure of a medication to “cure” obesity

is found to be unacceptable. The anorexiants are labeled as failures when the

patient regains weight after treatment has ended.
References
IOM (Institute of Medicine). 1995. Weighing the Options; Criteria for Evaluat-
ing Weight Management Programs. Washington, DC: National Academy
Press. Pp. 122.
Kramer FM, Jeffery RW, Forster JL, Snell MK. 1989. Long-term follow-up of
behavioral treatment for obesity: Patterns of weight regain among men and
women. Int J Obes 13:123–136.
Turner LW, Wang MQ, Wasterfield RC. 1995. Preventing relapse in weight
control: A discussion of cognitive and behavioral strategies. Psychol Rep
77:651–656.
Additional References
Griffiths RR, Brady JV, Bradford LD. 1979. Predicting the abuse liability of
drugs with animal drug self-administration procedures: Psychomotor stimu-
lants and hallucinogens. Adv Behav Pharmacol 2:163–208.
James WP, Avenell A, Broom J, Whitehead J. 1997. A one-year trial to assess
the value of orlistat in the management of obesity. Int J Obes 21:S24–S30.
Lean ME. 1997. Sibutramine—A review of clinical efficacy. Int J Obes Relat
Metab Disord 21:S30–S36.
Marston AR, Criss J. 1984. Maintenance of successful weight loss: Incidence
and prediction. Int J Obes 8:435–439.
Perri MG, McAllister DA, Gange JJ, Jordan RC, McAdoo G, Nezu AM. 1988.
Effects of four maintenance programs on the long-term management of
obesity. J Consult Clin Psychol 56:529–534.
Perri MG, Nezu AM, Patti ET, McCann KL. 1989. Effect of length of treatment
on weight loss. J Consult Clin Psychol 57:450–452.
Perri MG, McAdoo WG, Spevak PA, Newlin DB. 1984. Effect of a multicom-
ponent maintenance program on long-term weight loss. J Consult Clin Psy-
chol 52:480–481.
Reddy P, Chow SS. 1998. Focus on orlistat: A nonsystemic inhibitor of gastro-
intestinal lipase for weight reduction in the management of obesity. Formu-
lary 33:943–959.
Safer DJ. 1991. Diet, behavior modification, and exercise: A review of obesity
treatments from a long-term perspective. South Med J 84:1470–1474.
Van Gaal LF, Broom JI, Enzi G, Toplak H. 1998. Efficacy and tolerability of
orlistat in the treatment of obesity: A 6-month dose ranging study. Eur J
Clin Pharmacol 54:125–132.

APPENDIX A 213
Weintraub M, Sundaresan RP, Madan M, Schuster B, Balder A, Lasagna L, Cox

C. 1992. Long-term weight control study I (weeks 0 to 34). The enhance-
ment of behavior modification, caloric restriction, and exercise by fenflu-
ramine plus phentermine versus placebo. Clin Pharmaco Ther 51:586–594.
Weintraub M, Sundaresan RP, Schuster B, Ginsberg G, Madan M, Balder A,
Stein EC, Byrne L. 1992. Long-term weight control study II (weeks 34 to
104). An open-labeled study of continuous fenfluramine plus phentermine
versus targeted intermittent medication as adjuncts to behavior modifica-
tion, caloric restriction, and exercise. Clin Pharmaco Ther 51:595–601.
Weintraub M, Sundaresan RP, Schuster B, Moscucci M, Stein EC. 1992. Long-
term weight control study III (weeks 104 to 156). An open-labeled study of
dose adjustment of fenfluramine and phentermine. Clin Pharmaco Ther
51:602–607.
Weintraub M, Sundaresan RP, Schuster B, Averbuch M, Stein EC, Cox C,
Byrne L. 1992. Long-term weight control study IV (weeks 156 to 190). The
second double-blind phase. Clin Pharmaco Ther 51:608–614.
Weintraub M, Sundaresan RP, Schuster B, Stein EC, Byrne L. 1992. Long-term
weight control study V (weeks 190 to 210). Follow-up of participants after
cessation of medication. Clin Pharmaco Ther 51:615–618.
Weintraub M, Sundaresan RP, Cox C. 1992. Long-term weight control study VI.
Individual participant response patterns. Clin Pharmaco Ther 51:619–633.
Weintraub M, Sundaresan RP, Schuster B. 1992. Long-term weight control
study VII (weeks 0 to 210). Serum lipid changes. Clin Pharmaco Ther
51:634–641.
USE OF PHARMACOLOGICAL AIDS IN WEIGHT

MANAGEMENT
Frank Greenway, MD
Obesity is now recognized as a chronic disease. Although the NIH Con-

sensus Conference declared such as early as 1985 (Anonymous, 1985), it was
not until the identification of the leptin gene (Halaas et al., 1995) and the other
single-gene mutations causing rodent obesity that the chronic disease model of
obesity gained wider acceptance. Like hypertension and other chronic medical
conditions, obesity will, in all likelihood, require chronic pharmacological
treatment in a stepped-care approached when diet and lifestyle modification
alone are inadequate.
Treatment of any medical condition involves weighing risks of the disease
against the risks and benefits of treatment. Evidence-based national guidelines
have evaluated these risks and benefits. They suggest that medications be a
consideration in obesity treatment programs for individuals with a BMI greater
than 30 kg/m2 or greater than 27 kg/m2 when complicated by diabetes or other

medical conditions likely to improve with weight loss (NHLBI, 1998). Although
individuals less than 30 years of age have a lower mortality risk from obesity
than individuals over 50, this difference is not clinically significant until the
BMI exceeds kg/m2 (Calle et al., 1999).
Although obesity is now recognized in the medical community as a chronic
disease, the public is much more concerned about the cosmetic aspects of being
obese. The average American woman has a BMI of 24 kg/m2, while the average
fashion model, the ideal to which many women aspire, has a BMI of 16 kg/m2.
The upper limits of military standards for weight correspond to a BMI of 22–25
kg/m2 for women and 23–28 kg/m2 for men. The stated reasons for these
standards are to maintain a trim military appearance.
It could be argued that, like national guidelines for obesity treatment,
military weight standards should be based upon medical risks rather than
cosmetic considerations. Since one-third of the American population has a BMI
greater than 27 kg/m2, the military may be losing the services of many healthy
and talented people who would like to serve in their nation’s military service.
The military service draws its ranks disproportionately from minority groups.
Minority groups bear a disproportionate obesity burden making the potential
loss of talent to the military even greater (NHLBI, 1998).
The basis of any weight-loss program is diet and lifestyle change. When
these modalities by themselves are not sufficient, and the BMI is 27–30 kg/m2
depending on the presence or absence of comorbid diseases, medications for
obesity can be justified. Therefore, except in the case of unequal application of
military standards, individuals with this degree of obesity will be discharged
from the military service. Thus, the indications for obesity medications in the
military are vanishingly small.
There are two medications approved for the long-term treatment of obesity.
Sibutramine is a norepinephrine and serotonin reuptake inhibitor that inhibits
food intake centrally, and orlistat is an inhibitor of pancreatic lipase that
functions within the intestinal lumen. Both drugs give a 7–10 percent weight
loss over 6 months that is maintained at 1 year (Bray et al., 1999; Sjostrom et al.,
1998). Orlistat gives a drop of cholesterol in excess of that predicted from the
weight loss it induces, but sibutramine does not give the blood pressure drop
expected from weight loss. In other respects, cardiovascular risk factors are
reduced in proportion to weight loss.
If serotonin reuptake inhibitors are excluded from the military formulary,
sibutramine may not qualify for use in the military. Although generally well
tolerated, orlistat can give gastrointestinal symptoms such as abdominal cramps,
soft stools, and fecal urgency. If these symptoms were to occur in a military
field exercise, training disruptions could result. Due to the loss of fat-soluble
vitamins in the stool, a vitamin supplement is recommended with orlistat. The
only other prescription medications indicated for weight loss are scheduled by
the DEA, since all of them have at least some potential for abuse. In addition,

APPENDIX A 215
they have only been approved and tested for use over periods up to 12 weeks.
Therefore, the approved prescription medications for weight loss have little
utility in the military service.
The criteria for using nonprescription drugs in the treatment of obesity have
received much less attention from groups forming guidelines for obesity
treatment. Phenylpropanolamine is sold without a prescription for the treatment
of obesity. Ephedrine with a methylxanthine is sold without a prescription for
the treatment of asthma, but is approved and sold for the treatment of obesity in
Denmark. At least in the 1970s, phenylpropanolamine was on the military
formulary as a decongestant and ephedrine with theophylline was on the military
formulary for asthma. These two pharmacological approaches deserve further
comment.
Phenylpropanolamine is approved for the short-term treatment of obesity
(less than 12 weeks). Phenylpropolamine is a central alpha-1 adrenergic
stimulator that has no addictive potential and gives weight loss equivalent to
prescription anorectic drugs during the first 4 weeks of treatment. The longest
study with this medication lasted 20 weeks and was small, but the phenylpro-
panolamine group lost 6.5 percent of their body weight (Schteingart, 1992).
Phenylpropanolamine has a remarkable record of safety. It gives a small
increase in blood pressure that is statistically, but not clinically, significant. The
dose approved to treat obesity is 75 mg/d. Phenylpropanolamine is approved for
use without a prescription in cough and cold preparations in twice that dose.
Short-term treatment of a long-term disease is not logical, but it is unlikely that
approval of phenylpropanolamine for the long-term treatment of obesity will be
pursued unless financed by the government, since the drug is no longer covered
by patent. The wholesale price of 1 month of treatment with phenylpropano-
lamine is less than $0.50 per month.
Caffeine and theophylline are both methylxanthines. Two mg of caffeine
has the potency of 1 mg of theophylline, but they are otherwise equivalent.
Ephedrine 24 mg combined with 125 mg of theophylline is sold without a
prescription for the treatment of asthma in the dose of one or two tablets three
times a day. This combination was the first-line treatment for asthma in both
adults and children in the 1970s. Caffeine 200 mg with ephedrine 20 mg given
three times a day is an approved obesity medication in Denmark. In a trial
conducted in Denmark, the combination gave a 16 percent weight loss over 6
months that was maintained with continued treatment at 1 year (Toubro et al.,
1993). Caffeine and ephedrine is also inexpensive. A month of treatment at
wholesale prices runs less than $2.50, but not being covered by patent, is
unlikely to be approved for the long-term treatment of obesity without
government subsidy.
Not only are the risks and benefits of using even nonprescription
medications to treat obesity in a population of healthy individuals with a BMI
less than 28 kg/m2 unclear, but dietary treatments may have greater long-term

efficacy than the available obesity medications. A recent study lasting 3 months
demonstrated that a 1,200-calorie balanced diet was many times more effective
in causing weight loss when it included calorie-controlled portions substituted
for two meals and two snacks per day compared to the standard 1,200-calorie
diet utilizing an exchange system (Ditschuneit et al., 1999). Individuals
replacing one meal and one snack with calorie controlled portions following this
3-month weight-loss program lost 9 percent of their body weight at 1 year and
11 percent at 2 years.
Studies with sibutramie, orlistat, and phenylpropanolarnine give a 6–10
percent weight loss at 1 year. The military appears to be in an ideal position to
exploit this new information. Meals Ready to Eat (MREs), the military field
rations perfected through military nutrition research, could easily be modified
for a weight-loss program using a 1,200-calorie diet and calorie controlled
portions.
Epidemiological studies such as the Framingham study show a higher
mortality in those individuals losing weight. Since the risk factors for cardio-
vascular disease improve with weight loss, this finding has remained a paradox.
Recently, Allison et al. reanalyzed the Framingham and Tecumseh studies and
demonstrated that mortality increases by 29 percent for every standard deviation
(4.6–6.7 kg) of weight loss but decreases 15 percent for every standard deviation
of fat loss (4.8–10 mm of skin-fold thickness) (Allison et al., 1999). This
suggests that losing lean tissue during weight loss carries a mortality risk.
Therefore, the ideal weight-loss medication should cause fat loss and spare lean
tissue.
When people gain weight, 75 percent of the weight gain is fat and 25
percent is lean tissue. Weight is lost with diet or appetite suppressing
medications in these same proportions of fat and lean tissue. Exercise and
caffeine with ephedrine, both of which increase catacholamine turnover, induce
a selective loss of body fat. Not only does a selective fat loss have the potential
to impact in a positive way upon mortality risk, but preservation of lean tissue is
likely to reduce injury and contribute positively to the fighting strength in a
military setting.
In conclusion:
• The military may be paying a price in lost talent for its stringent weight
requirements aimed at maintaining a trim military appearance.
• Given that military personnel have a BMI less than 28 kg/M2, there is
little place for the pharmacological treatment of obesity in the military.
• Caffeine and ephedrine give preferential fat loss and might deserve fur-
ther consideration as a military obesity treatment if military weight standards are
liberalized.
• Calorie-controlled portions combined into a 1,200-calorie balanced
diet may give better sustained weight loss than presently available obesity medi-

APPENDIX A 217
cations, and these calorie-controlled portions could be created for the military
through modification of existing field rations (MREs).
References
Allison DB, Zannolli R, Faith MS, Heo M, Pietrobelli A, Vanltallie TB, Pi-
Sunyer FX, Heymsfield SB. 1999. Weight loss increases and fat loss de-
creases all-cause mortality rate: Results from two independent cohort stud-
ies. Int J Obes 23:603–611.
Anonymous. 1985. Health implications of obesity. National Institutes of Health
Consensus Developed Conference Statement. Ann Int Med 103:1073–1077.
Bray GA, Blackburn GL, Ferguson JM, Greenway FL, Jain AK, Mendel CM,
Mendels J, Ryan DH, Schwartz SL, Scheinbaum ML, Seaton TB. 1999.
Sibutramine produces dose-related weight loss. Obes Res 7:189–198.
Calle EE, Thim MJ, Petrelli JM, Rodriguez C, Heath CW. 1999. Body-mass
index and mortality in a prospective cohort of U.S. adults. N Engl J Med
241:1097–1105.
Ditschuneit HH, Flechtner-Mors M, Johnson TD, Adler G. 1999. Metabolic and
weight loss effects of a long-term dietary intervention in obese patients. Am
J Clin Nutr 69:198–204.
Halaas JL, Gajiwala KS, Maffei M, Cohen SL, Chait BT, Rabinowitz D, Lallone
RL, Burley SK, Friedman JM. 1995. Weight-reducing effects of the plasma
protein encoded by the obese gene. Science 269:543–546.
NHLBI (National Heart, Lung and Blood Institute). 1998. Clinical Guidelines of
the Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults - The Evidence Report. Obes Res 6:51S–209S.
Sjostrom L, Rissanan A, Andersen T, Boldrin M, Golay A, Koppeschaar HP,
Krempf M. 1998. Randomised placebo-controlled trial of orlistat for weight
loss and prevention of weight regain in obese patients. Lancet 352:167–172.
Schteingart DE. 1992. Effectiveness of phenylpropanolamine in the manage-
ment of moderate obesity. Int J Obes Relat Metab Disord 16:487–493.
Toubro S, Astrup AV, Breum L, Quaade F. 1993. Safety and efficacy of long-
term treatment with ephedrine, caffeine, and an ephedrine/caffeine mixture.
Int J Obes Relat Metab Disord 17:S69–S72.
EFFECTS OF EXERCISE, DIET, AND WEIGHT LOSS

ON LIPID METABOLISM IN WOMEN
Marcia L. Stefanick, PhD, Associate Professor of Medicine, and of Obstetrics
and Gynecology, Stanford University
Consensus has been reached within the past 5 years that sedentary status
and overweight are each independent risk factors for coronary heart disease

(CHD) in adults, despite their strong associations with other established CHD
risk factors, including low levels of high-density lipoprotein (HDL) cholesterol,
elevated triglycerides, hypertension, and diabetes (HHS, 1996; NHLBI, 1998).
Many observational and prospective cohort studies have shown that physical
inactivity (Blair et al., 1989; HHS, 1996; Kushi et al., 1997; Manson et al.,
1999) and excess body weight (Manson et al., 1990; NHLBI, 1998) are each
associated with a two- to threefold increased risk of CHD in women compared
with active and/or normal-weight women. In addition to low HDL cholesterol, it
is generally accepted that elevated low-density lipoprotein (LDL) cholesterol is
a major CHD risk factor in women, and that a diet high in fat, especially
saturated fat, raises LDL-cholesterol levels; furthermore, adoption of a low-fat
diet is recommended as the initial step in managing an adverse lipoprotein
profile before resorting to a pharmacological approach (NHLBI, 1993). The role
of exercise, diet, and weight loss on lipid metabolism is, therefore, of major
interest for women.
Recent national surveys report that over a third of U.S. women aged ≥ 45
years participate in no leisure-time physical activity and less than 20 percent
participate in regular, sustained physical activity at the recommended level (≥ 5
days per week for ≥ 30 minutes) (HHS, 1996); while nearly two-thirds of
women aged ≥ 50 years are overweight (BMI ≥ 25.0 kg/m2), half of whom are
obese (BMI ≥ 30.0 kg/m2) (NHLBI, 1998). It has been suggested that adoption
of the recommended level of physical activity could reduce the risk of coronary
events by 30–40 percent in women (Manson et al., 1999) and that as much as 70
percent of the coronary disease observed in obese women and 40 percent of that
among women overall is attributable to overweight and is therefore preventable
(Manson et al., 1990). A combined intervention of caloric reduction (emphasiz-
ing reduction of dietary fat, especially saturated fat, simple carbohydrates, and
alcohol), physical activity, and behavior therapy, provide the most successful
therapy for weight loss, (with a goal of losing 10 percent of body weight over a
period of about 6 months), and weight maintenance (NHLBI, 1998).
Although trials of exercise, diet, or weight loss for prevention of CHD
morbidity or mortality have not been completed, to date, the effects of diet and
exercise by initially sedentary or overweight women on specific CHD risk
factors, such as HDL and LDL cholesterol, have been reported in several
randomized, controlled clinical trials (Duncan et al., 1991; King et al., 1991,
1995; McCarron et al., 1997; Stefanick, 1999; Stefanick et al., 1998; Svendsen
et al., 1993; Wood et al., 1991). While several such studies have reported an
HDL-lowering effect of a low-fat diet in women, when LDL cholesterol is
lowered, or no significant lipoprotein improvements of diet alone, for women
with initially unfavorable lipoproteins, the addition of exercise to the low-fat
diet has been shown to result in significantly greater lipoprotein improvements
in both pre- and postmenopausal women, even in the absence of greater weight
loss with the addition of exercise to the diet (Stefanick, 1999; Stefanick et al.,

APPENDIX A 219
1998; Wood et al., 1991). There is little evidence, however, that aerobic or
resistance exercise alone can improve obesity-related lipoprotein problems;
therefore, diet, and if appropriate, weight loss, should be a focus of intervention
as well (Stefanick, 1999). In general, these trials suggest that a lifestyle
approach (diet, exercise, and weight loss) can substantially reduce CHD risk in
women by reducing body weight and improving HDL and LDL cholesterol,
triglycerides, blood pressure, and blood glucose.
Physical activity need not be of high intensity to reduce CHD risk
substantially (HHS, 1996; Manson et al., 1999) and lower-intensity activity may
result in better adherence over the long term (King et al., 1995). For weight loss,
women randomized to three 10 minute bouts appeared to do better than those
randomized to one 30 minute bout (Stefanick, 1999). Finally, for both
improvement in cardiovascular fitness (King et al., 1991) and in weight loss
(Perri et al., 1997), home-based programs seem to be more effective than group-
based programs for women, although this will certainly depend on the
individual. Whether lifestyle in combination with hormone replacement therapy
(HRT) is superior in improving lipoproteins in postmenopausal women
compared with HRT alone is unknown, but is being explored in the Women’s
Healthy Lifestyle Project (Simkin-Silverman et al., 1998).
References
Blair SN, Kohl HW III, Paffenbarger RS Jr, Clark DG, Cooper KN, Gibbons
LW. 1989. Physical fitness and all-cause mortality: A prospective study of
healthy men and women. J Am Med Assoc 262:2395–2401.
Duncan JJ, Gordan NF, Scott CB. 1991. Women walking for health and fitness:
How much is enough? J Am Med Assoc 266:3295–3299.
and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Depart-
ment of Health and Human Services, Centers for Disease Control and Pre-
vention, National Center for Chronic Disease Prevention and Health Promo-
tion.
Jakicic JM, Wing RR, Butler BA, Roberson RI. 1995. Prescribing exercise in
diorespiratory fitness, and weight loss in overweight women. Int J Obes Re-
King AC, Haskell WL, Taylor CB, Kraemer HC, DeBusk RF. 1991. Group-
versus home-based exercise training in healthy older men and women: A
community-based clinical trial. J Am Med Assoc 266:1535–1542.
King AC, Haskell WL, Young DR, Oka R, Stefanick ML. 1995. Long-term ef-
fects of varying intensities and formats of physical activity on participation
rates, fitness, and lipoproteins in men and women aged 50 to 65 years. Cir-
culation 91:2596–2604.

Kushi LH, Fee RM, Folsom AT, Mink PI, Anderson Ke, Sellers TA. 1997.
Physical activity and mortality in postmenopausal women. J Am Med Assoc
277:1287–1292.
Manson JE, Colditz GA, Stampfer MJ, Willett WC, Rosner B, Nonson RR,
Speizer FE, Hennekens CH. 1990. A prospective study of obesity and risk
of coronary heart disease in women. N Engl J Med 322:882–889.
Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampger MJ, Willett WC,
Speizer FE, Hennekens CH. 1999. A prospective study of walking as com-
pared with vigorous exercise in the prevention of coronary heart disease in
women. N Engl J Med 341:650–658.
McCarron DA, Oparil S, Chait A, Haynes RB, Kris-Etherton P, Stern JS, Res-
nick LM, Clark S, Morris CD, Hatton DC, Metz JA, McMahon M, Hol-
comb S, Snyder GW, Pi-Sunyer FX. 1997. Nutritional management of car-
diovascular risk factors: A randomized clinical trial. Arch Intern Med
157:169–177.
NHLBI (National Heart, Lung and Blood Institute). 1993. Second Report of the
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cho-
lesterol in Adults (Adult treatment panel II). NIH Publication no. 93-3095.
Bethesda, MD: U.S. Department of Health and Human Services, National
Institutes of Health.
NHLBI. 1998. Clinical guidelines on the identification, evaluation, and treat-
ment of overweight and obesity in adults: The evidence report. Obesity Res
6:51S–209S.
Perri MG, Marin AD, Leermakers EA, Sears SF, Notelovitz M. 1997. Effects of
group-versus home-based exercise in the treatment of obesity. J Consult
Clin Psychol 65:278–285.
Simkin-Silverman LR, Wing RR, Boraz MA, Meilahn EN, Kuller LH. 1998.
Maintenance of cardiovascular risk factor changes among middle aged
women in a lifestyle intervention trial. Womens Health 4:255–272.
Stefanick ML. 1999. Physical activity for preventing and treating obesity-related
dyslipoproteinemias. Med Sci Sports Exerc 31:S609–S618.
Stefanick ML, Mackey SM, Sheehan M, Ellsworth N, Haskell WL, Wood PD.
1998. Effects of diet and exercise in men and postmenopausal women with
low levels of HDL-cholesterol and high levels of LDL-cholesterol. N Engl J
Med 339:12–20.
Svendsen OL, Hassager C, Christiansen C. 1993. Effect of an energy-restrictive
diet with or without exercise on lean tissue, resting metabolic rate, cardio-
vascular risk factors, and bone in overweight postmenopausal women. Am J
Med 95:131–140.
Wood PD, Stefanick ML, Williams PT, Haskell WL. 1991. The effects on
plasma in plasma lipoproteins of a prudent weight-reducing diet, with or
without exercise in overweight men and women. N Engl J Med 325:461–
468.

APPENDIX A 221
REPRODUCTIVE HEALTH ISSUES IN FITNESS AND

WEIGHT- CONTROL PROGRAMS
Anne B. Loucks, Department of Biological Sciences Ohio University, Athens
Many women who restrict their diets or who exercise for fitness or weight-
control experience a loss of menstrual cycles. In such amenorrheic women, the
normal monthly rhythms of estrogen and progesterone are absent, indicating a
complete suppression of ovarian follicular development, ovulation, and luteal
function (Loucks et al., 1989). In addition to infertility, these estrogen-deficient
women suffer an irreversible skeletal demineralization (Keen and Drinkwater,
1997) leading to osteoporosis and fractures (Loyd et al., 1986; Myburgh et al.,
1990; Wilson and Wolman, 1994). Among athletic women, spinal bone mineral
density is negatively proportional to the number of menstrual cycles missed
(Drinkwater et al., 1990).
The proximal cause of these menstrual disorders is the slowing and
disorganization of the pulsatile secretion of luteinizing hormone (LH) by the
pituitary gland (Loucks et al., 1989), which reflects the disorganized secretion of
gonadotropin-releasing hormone (GnRH) by the hypothalamus in the brain
(Veldhuis et al., 1985). The influence of behavioral and environmental factors
on the regulation of GnRH has been controversial and the subject of much
research in recent years.
Early reports of amenorrhea in physically active women were attributed to
low body fatness (Frisch, 1984), but many observational studies have accumu-
lated evidence to disprove this hypothesis (Manning and Bronson, 1991; Sinning
and Little, 1987). Nevertheless, this hypothesis was rejuvenated with the
discovery that the adipose tissue hormone leptin is suppressed in amenorrheic
women and that neurons with leptin receptors in the arcuate nucleus influence
GnRH secretion via pro-opiomelanocortin and neuropeptide Y pathways
(Cunningham et al., 1999). More recently, however, the secretion of leptin by
adipose tissue has been found to be acutely and profoundly responsive to energy
availability (Kolaczynski et al., 1996; Weigle et al., 1997), and even more
specifically to carbohydrate availability (Boden et al., 1996; Grinspoon et al.,
1997).
Most current research into the mechanism of menstrual disorders in
exercising women is focused on two competing hypotheses. The energy
availability hypothesis holds that the reproductive system is disrupted by an as
yet undetermined mechanism when physically active women fail to consume
enough dietary energy each day to match their daily energy expenditure (Wade
and Schneider, 1992). A recent variant of this hypothesis holds that reproductive
function depends specifically on glucose availability, since the brain relies on
glucose for energy (Foster and Nagatani, 1999; Wade et al., 1996). The
competing stress hypothesis holds that exercise activates the hypothalamic-

pituitary adrenal (HPA) axis and that the hormones secreted by this axis disrupt
the reproductive system.
Because the HPA axis has a glucoregulatory role, we designed experiments
to measure the independent effects of energy availability and exercise stress on
regularly menstruating, habitually sedentary women. Until these experiments, all
investigations into the influence of exercise on reproductive function since those
of Selye in the 1930s (1939) had confounded the “stress” of exercise with its
impact on energy availability.
So far, these experiments appear to have taught us three lessons. First, LH
pulsatility depends on energy availability, defined as dietary energy intake
minus exercise energy expenditure, and not on either exercise stress or on
energy intake or energy expenditure alone. In our experiments, exercise had no
effect on LH pulsatility beyond the impact of its energy cost on energy
availability (Loucks et al., 1998). By increasing dietary energy intake in
compensation for exercise energy expenditure, we prevented the apparent
disruptive effects of exercise stress on LH pulsatility.
Second, in women the disruptive effects of low energy availability appear to
occur at a threshold of energy availability between 20 and 30 kcal/kglean body
mass (LBM)/day. (In the women studied, 30 kcal/kgLBM/day corresponds to
approximately 1,350 kcal/day.) For energy availability above 30
kcal/kgLBM/day, alterations in metabolic hormones maintain approximately
normal levels of plasma glucose and ketones. Below 30 kcal/kgLBM/day,
however, even larger alterations of metabolic hormones are unable to maintain
normal plasma levels of these substrates, and effects on LH pulsatility begin.
Below 20 kcal/kgLBM/day, the responses of certain metabolic hormones, such
as insulin-like growth factor I/insulin-like growth factor-binding protein-1 and
leptin, appear to have reached their limit while the responses of other metabolic
hormones, such as cortisol and T3, become exaggerated. Nevertheless, these
exaggerated responses are unable to prevent further alterations in the metabolic
substrates and LH pulsatility. Thus, alterations in LH pulsatility appear to be
more closely associated with metabolic substrates than with metabolic
hormones.
The third lesson currently emerging from these experiments is that the
effects of low energy availability on LH pulsatility appear to be smaller in men
than in women. Extensive observational field studies have indicated that in
mammals reproductive function continues in males under conditions in which it
is completely blocked in females (Aguilar et al., 1984; Widdowson et al., 1964).
In our experiments at 10 kcal/kgLBM/day, effects of low energy availability on
LH pulsatility appear to be blunted in men compared with women, so that we
expect to find no effects in men at 20 kcaI/kgLBM/day. That is, we expect to
find that the threshold at which low energy availability disrupts LH pulsatility is
lower in men than in women. At 10 kcal/kgLBM/day, the only metabolic
parameters distinguishing men and women are leptin and absolute carbohydrate

APPENDIX A 223
availability (i.e., dietary carbohydrate intake minus carbohydrate oxidation

during exercise).
In summary, fitness and weight-control programs can damage reproductive
and skeletal health. In exercising women, reproductive health appears to depend
on energy availability. Damage to reproductive and skeletal health might be
avoided in fitness and weight-loss programs by maintaining energy availability
above 30 kcal/kgLBM/day through dietary reform alone without moderating the
exercise regimen. These speculations need to be tested, though, through longer-
term experiments measuring effects on ovarian function. Finally, women appear
to require higher levels of energy availability than men to maintain reproductive
health.
References
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body weight, growth rate, chronological age, and puberty in male and fe-
male rats. Rev Esp Fisiol 40:82–86.
Boden G, Chen X, Mozzoli M, Ryan I. 1996. Effect of fasting on serum leptin in
normal human subjects. J Clin Endocrinol Metab 81:3419–3423.
Cunningham MJ, Clifton DK, Steiner RA. 1999. Leptin’s actions on the repro-
ductive axis: Perspectives and mechanisms. Biol Reprod 60:216–222.
Drinkwater BL, Nilson K, Chesnut CH III. 1990. Menstrual history as a deter-
minant of current bone density in young athletes. J Am Med Assoc 263:545–
548.
Foster DL, Nagatani S. 1999. Physiological perspectives on leptin as a regulator
of reproduction: Role in timing puberty. Biol Reprod 60:205–215.
Frisch RE. 1984. Body fat, puberty, and fertility. Biol Rev 59:161–188.
Grinspoon SK, Askari H, Landt L, Nathan DM, Schoenfeld DA, Hayden DL,
Laposata M, Hubbard J, Klibanski A. 1997. Effects of fasting and glucose
infusion on basal and overnight leptin concentrations in normal-weight
women. Am J Clin Nutr 66:1352–1366.
Keen AD, Drinkwater BL. 1997. Irreversible bone loss in former amenorrheic
athletes. Osteoporosis Int 1:311–315.
Kolaczynski JW, Considine RV, Ohannesian J, Marco C, Opentanova I, Nyce
MR, Myint M, Caro JF. 1996. Responses of leptin to short-term fasting and
refeeding in humans: A link with ketogenesis but not ketones themselves.
Diabetes 45:1511–1515.
Lloyd T, Triantafyllou SJ, Baker ER, Houts PS, Whiteside JA, Kalenak A,
Stumpf PG. 1986. Women athletes with menstrual irregularity have in-
creased musculoskelatal injuries. Med Sci Sports Exerc 18:374–379.
Loucks AB, Mortola JF, Girton L, Yen SSC. 1989. Alterations in the hypotha-
lamicpituitary-ovarian and the hypothalamic-pituitary-adrenal axes in ath-
letic women. J Clin Endocrinol Metab 68:402–411.

Loucks AB, Verdun M, Heath EM. 1998. Low energy availability, not stress of
exercise, alters LH pulsatility in exercising women. J App Physiol 84:37–
46.
Manning JM, Bronson FH. 1991. Suppression of puberty in rats by exercise:
Effects on hormone levels and reversal with GnRH infusion. Am J Physiol
260:R717–R723.
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density is an etiologic factor for stress fractures in athletes. Ann Intern Med
113:754–759.
Selye H. 1939. The effect of adaptation to various damaging agents on the fe-
male sex organs in the rat. Endocrinol 25:615–624.
Sinning WE, Little KD. 1987. Body composition and menstrual function in ath-
letes. Sports Med 4:34–45.
Veldhuis JD, Evans WS, Demers LM, Thorner MO, Wakat D, Rogol AD. 1985.
Altered neuroendocrine regulation of gonadotropin secretion in women dis-
tance runners. Clin Endocrinol Metab 61:557–563.
Wade GN, Schneider JE. 1992. Metabolic fuels and reproduction in female
mammals. Neurosci Biobehav Rev 16:235–272.
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Am J Physiol 270:E1–E19.
Weigle DS, Duell PB, Connor WE, Steiner RA, Soules MR, Kuijper JL. 1997.
Effect of fasting, refeeding, and dietary fat restriction on plasma leptin lev-
els. J Clin Endocrinol Metab 82:561–565.
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OBESITY: AN INFECTIOUS DISEASE?

Nikhil V. Dhurandhar, PhD
Introduction
Obesity has been called the number one public health problem in America
(Bray, 1979). Although obesity is recognized as a disease of multiple etiologies,
a virus infection as an etiological factor has been ignored until now. Five
different viruses have been shown to cause obesity in animal models (Carter et
al., 1990; Dhurandhar and Atkinson, 1996; Dhurandhar et al., 1990, 1992, 1997;
Gostonyi and Ludwig, 1995; Lyons et al., 1982). Of these, we have identified
two viruses, SMAM-1, an avian adenovirus, and AD-36, a human adenovirus,
that produce obesity in animals. The concept that adenoviruses cause obesity

APPENDIX A 225
and that the virus may be linked to human obesity was developed by Dr.
Dhurandhar while working with SMAM-1 virus in Bombay, India, and was
pursued further by Dr. Dhurandhar when he started work at the University of
Wisconsin-Madison. The work led to the discovery of the obesity-promoting
potential of another adenovirus, AD-36, which produced obesity in animals
along with a paradoxical decrease in serum cholesterol and triglycerides levels
(Dhurandhar and Atkinson, 1996). Our data described below demonstrate that a
human virus produces obesity in animal models, and that a unique syndrome
consisting of paradoxically low serum cholesterol and triglycerides levels, is
present in about 30 percent of obese humans screened who have antibodies to
this human virus. Antibodies to AD-36 were present in only 5 percent of the
non-obese subjects screened to date, suggesting that infection with this
syndrome carries a high probability of association (causation has not yet been
proven in humans) with obesity. The possible link between a virus and obesity
in humans warrants serious investigation of the obesity-promoting effect of this
virus.
Adenoviruses: Background Information

Adenoviruses are naked DNA viruses with icosahedral symmetry and a
diameter of 65–80 nm. The American Type Culture Collection maintains 50
types of human adenoviruses. In humans, adenoviruses are frequently associated
with acute upper respiratory tract infections and may cause enteritis and
conjunctivitis. Adenoviruses can easily be isolated from nasal swabs or from
feces. Adenovirus infections are transmitted via respiratory, fomite, droplet,
venereal, and fecal-oral routes. AD-36 was first isolated in 1978 in Germany in
the feces of a 6-year-old girl with diabetes and enteritis (Wigand et al., 1980).
Review of Experiments
Experiments with SMAM-1
We demonstrated that chickens experimentally infected with SMAM-1, an
avian adenovirus isolated in Bombay, India, produced excessive fat accumula-
tion in the visceral depots and a paradoxical reduction of serum levels of choles-
terol and triglycerides (Dhurandahr et al., 1990, 1992). The findings were repli-
cated. Of 52 obese humans tested by agar gel-precipitation test, 10 had
antibodies to SMAM-1 (Dhurandhar et al., 1997). These 10 individuals had a
higher body weight and lower serum cholesterol and triglycerides compared
with antibody-negative individuals (Dhurandhar et al., 1997).

Experiments with AD-36: Animal Studies

Chicken Experiments: Specific pathogen-free white leghorn chickens were
used for three separate experiments that are summarized below. Chickens were
housed under biosafety level 2 containment and were inoculated with AD-36
virus (infected group) or the tissue culture media (uninfected controls) at 3
weeks of age. Chickens were inoculated intra-nasally in experiments 1 and 2 and
i.p. in experiment 3. Chickens in experiments 1, 2, and 3 were killed 3, 5, and 16
weeks post inoculation, respectively. Food intake was not different for any of
the groups within any experiment. Chickens inoculated with AD-36 in experi-
ments 1 and 2 had significantly greater visceral and total body fat and signifi-
cantly lower serum cholesterol and triglycerides compared to the controls. For
example, compared to the control, the AD-36 group in experiment 2 had 128
percent greater visceral fat (p < .0005) and 46 percent greater total body fat (p <
.0005). These data show that AD-36 infection reliably and reproducibly induces
adiposity in chickens, which is associated with a reduction in serum cholesterol
and triglycerides.
The AD-36-infected group in experiment 3 had significantly greater visceral
fat and the histopathological study of the brain including hypothalamic area did
not show any difference in the infected versus the control groups. Unlike some
other obesity promoting viruses, AD-36-induced obesity does not appear to be
due to the hypothalamic damage. Virus was isolated from the oral and the rectal
swabs taken from the infected chickens 1-week post inoculation, but not from
the controls. Also, using capillary electrophoresis assay, AD-36
deoxyribonucleic acid (DNA) was detected in the DNA isolated from the
adipose tissue and the blood of some of the infected chickens screened but not
from the DNA obtained from their skeletal muscles. AD-36 DNA could not be
detected in any of the control chickens screened. Absence of hypothalamic
lesions and the presence of the viral DNA in the adipose tissue suggest a
peripheral and not a central mechanism for the development of obesity
syndrome.
Mice Experiment: The obesity promoting effect of AD-36 was tested in
mice as a mammal model. Institue for Cancer Research out bred Swiss albino
female mice (4 weeks old) were inoculated i.p. with AD-36 (AD-36 group), or
tissue culture media (control group) and the animals were killed 22 weeks post
inoculation. Food intake was not different for the two groups. Compared with
the control, the AD-36 group had 9 percent greater body weight (p < .05), 67
percent greater visceral fat (p < .02) and 30 percent greater total body fat (p <
.02). Sixty percent of the mice infected with AD-36 had total percent body-fat
weights above the 85th percentile of the control group (p < .02). Serum choles-
terol and triglycerides in the AD-36 group were significantly lower than control
by 38 percent and 31 percent, respectively. This is the first report of obesity in-
duced by a human virus in a mammal.

APPENDIX A 227
Monkey Experiment: This experiment was carried out to screen rhesus

monkey serum for the presence of AD-36 antibodies and to ascertain any asso-
ciation of such antibodies to obesity and cholesterol levels. Frozen serum sam-
ples from 15 adult male rhesus monkeys were obtained from the Wisconsin Re-
gional Primate Research Center. For each monkey, the samples were drawn
every 6 months for a period of 90 months and a corresponding body weight was
available for each sample drawn. Monkeys were between 8 and 14 years of age
when the first sample available for this study was drawn (baseline sample) and
were on an ad libitum diet. Antibodies to AD-36 in the experiment were deter-
mined with serum neutralization assay.
During the 90-month period, all 15 monkeys showed AD-36 antibodies at
some point in time. Out of 15 monkeys, 7 monkeys were seropositive at the
baseline and, therefore, not included in the analysis. These 7 monkeys were
excluded from the analysis because a comparison for body weight and
cholesterol between before and after the appearance of AD-36 antibodies was
not possible. The remaining 8 monkeys were seronegative for AD-36 antibodies
at baseline and became seropositive after variable periods. Body weight and
serum cholesterol at 6 monthly intervals were analyzed for these 8 monkeys.
Body weight and cholesterol of the 8 monkeys before turning antibody positive
were compared with those after the first appearance of AD-36 antibodies.
Analysis was restricted to the 90-month period for which the serum samples
were obtained.
Prior to the first appearance of AD-36 antibody, body weight of the
monkeys had plateaued for at least 18 months but increased by 10 percent in just
6 months after the first appearance of AD-36 antibody. The body weight was 15
percent greater after 12 months and 18 months after the first appearance of AD-
36 antibody, compared with the body weight 6 months prior to the first
appearance of AD-36 antibody (p < .03). Serum cholesterol levels increased
slightly in the 18 months before the appearance of AD-36 antibodies. However,
cholesterol levels decreased by 28 percent in 6 months after the first appearance
of AD-36 antibody (p < 0.03) and remained lower for at least 18 months after
the first appearance of AD-36 antibody. Thus, the increase in body weight and
the reduction in cholesterol levels coincided with the first appearance of AD-36
antibody in the serum. Significant changes were observed despite the small
number of monkeys. This is an indirect evidence of a possible effect of AD-36
infection on body weight and cholesterol levels. Only infecting monkeys with
AD-36 can conclusively show direct effect of AD-36 on body weight and
cholesterol levels.
Human Studies
Human serum samples obtained from obese (body mass index > 27 kg/M2,
N = 418) and nonobese volunteers (N = 93) from three different sites (Wiscon-

sin, Florida, and New York) were screened for the presence of AD-36 antibodies
using serum neutralization test. At each of the three sites, prevalence of AD-36
antibodies was significantly greater for the obese compared with the nonobese
subjects. Prevalence of AD-36 antibodies in three sites pooled together was 5
percent for the nonobese and 30 percent for the obese subjects. At each of the
sites, the antibody-positive obese had significantly lower serum cholesterol
compared with the antibody negative obese subjects from the respective site (p <
.002).
Conclusion
Our data show that a human adenovirus causes adiposity in animals and is
strongly associated with obesity in humans. Due to ethical reasons, humans
cannot be experimentally inoculated with the virus and we have to depend on
indirect evidence of the obesity-promoting effect of AD-36 in humans.
Understanding the mechanism involved in promoting adiposity and reduction in
serum lipid levels caused by the virus is critical. Long-term goal of this research
is to develop a vaccine to prevent AD-36-induced adiposity.
References
Bray GA. 1979. Obesity in America. NIH Publication 79-359. Washington,
D.C.: National Institutes of Health.
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drome in chickens characterized by stunting and obesity. Infect Immun
39:410–422.
Dhurandhar NV, Atkinson RL. 1996. Development of obesity in chickens after
infection with a human adenovirus. Obesity Res 4:24S.
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Association of adenovirus infection with human obesity. Obesity Res
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sis. Curr Top Microbiol Immunol 190:39–73.
Lyons MJ, Faust IM, Hemmes RB, Buskirk DR, Hirsch J, Zabriskie JB. 1982. A
virally induced obesity syndrome in mice. Science 216:82–85.
Wigand R, Gelderblom H, Wadell G. 1980. New human adenovirus (candidate
adenovirus 36), a novel member of subgroup D. Arch Virol 64:225–233.

APPENDIX A 229
FACTORS AFFECTING LONG-TERM WEIGHT

LOSS/WEIGHT REGAIN
George Blackburn, MD, PhD
Introduction
Obesity has been described by the World Health Organization as an
“escalating epidemic” and “one of the greatest neglected public health problems
of our time with an impact on health which may well prove to be as great as
smoking (Rippe et al., 1998).” An estimated 97 million adults in the United
States are overweight or obese, a condition that substantially raises their risk of
morbidity from hypertension, dyslipidemia, type 2 diabetes, coronary heart
disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, and cancer
(NHLBI, 1998). The obesity epidemic is costing our country billions. The cost
attributable to obesity amounted to $99.2 billion in 1995, of this total, $51.6
billion were direct medical costs associated with diseases attributable to obesity
(NHLBI, 1998). Overweight and obesity prevalence has been rising at a steady
pace between 1960–1994. This increase has occurred across all ages, genders
and racial/ethnic groups. A recent survey reported that 59.4 percent of men and
50.7 percent of women in the United States are overweight or obese (NHLBI,
1998). Estimates show that at any one time, approximately 25 percent of men
and 45 percent of women are trying to lose weight (Williamson et al., 1992). Of
the participants who enter a behavioral weight-loss program, it is estimated that
they will lose approximately 10 percent of their body weight over the course of
20–24 weeks (Shick et al., 1998). Unfortunately, it has also been shown that
these participants also regain an average of 33 percent of their weight loss and
typically return to their baseline weight within 5 years (Shick et al., 1998).
Brief Review of Factors Affecting Long-Term Weight

Loss/Weight Regain
Why is America gaining weight? Consider the change in our environment
over the past century. There are a greater variety of foods available. Simply
consider the potato chip choices alone. There are currently a plethora of brands,
varieties, and flavors available to the consumer everyday and often 24 hours a
day. Compare this with the turn of the century where it was common to walk to
the market and purchase a 25-pound bag of potatoes to use in cooking. Food has
also become more palatable. Improved manufacturing and technology have
improved colors and flavors to make food appear and taste richer and more
satisfying than ever before. Food has also become increasingly convenient to
obtain. Gone are the days of being forced to borrow from the neighbors because
the supermarkets are closed. Many supermarkets and convenience store are open
24 hours a day, ready to sell consumers the foods that contribute to weight gain.

The fast-food market has increasingly become a staple of American food culture
over the years. Effective marketing strategies coupled with broader, inexpensive
choices have made this industry a prime culprit in the American obesity
epidemic. Unfortunately, with the increase in variety, palatability, convenience,
and availability of food, there has also been a decline in the amount of exercise
performed by the average American. Sedentary desk jobs, computers, fewer safe
places for exercise, and more elevators and drive-through restaurants are only a
few of the contributors to this escalating problem.
With the changing environment and the discouraging rates of weight regain,
it is imperative that we take a closer look at long-term weight maintenance and
the various methods successful maintainers utilize to prevent weight gain. To get
a better perspective in this area, it is appropriate to review a portion of the long-
term data provided by the National Weight Control Registry (NWCR). The
NWCR is a registry of individuals who have been followed in a prospective
manner having been successful at maintaining significant weight losses. Partici-
pants in the NWCR have lost, on average, more than 65 pounds and maintained
their weight losses for 5.7 years (McGuire et al., 1999b). Long-term studies of
weight loss in individuals participating in the NWCR indicate that those who
regain weight typically show a demonstrated decline in self-monitoring. This
includes techniques such as frequent self-weighing as well as keeping food and
exercise diaries. These individuals showed a marked decrease in physical activ-
ity of more than 800 calories per week, coupled with increases in the percentage
of calories taken in from fat. The study also showed the re-gainers to have a
higher lifetime level of intentional weight cycling (McGuire et al., 1999b).
Those who regained weight were more likely to have sought assistance for
weight loss rather than utilizing self-directed weight loss methods, and were
more likely to have used a liquid formula diets for their initial weight loss. In
comparison, it has been shown that 72 percent of successful weight losers lost
weight on their own, 20 percent used commercial weight-loss programs, and 5
percent utilized a university-based program (McGuire et al., 1998). Those who
gained weight also were shown to have been heavier at their maximum weight,
initially lost a greater percentage of their maximum weight (> 30 percent) and
had maintained their weight loss for fewer years than maintainers (McGuire et
al., 1999b).
What predicts successful weight maintenance? Research has shown the five
most common links appear to be (1) physical activity, (2) self-monitoring, (3)
problem solving, (4) continued contact, and (5) stress management (Foreyt,
1999).
Physical Activity
Longitudinal studies with 2–10 years of follow-up results have observed
that physical activity is related to less weight gain over time (NHLBI, 1998). It

APPENDIX A 231
is a well-known fact that physical activity is a good predictor of weight mainte-

nance (Foreyt, 1999). A review of successful weight maintainers reveals that
they engaged in more strenuous activities such as running, weight lifting and
aerobics than regainers, and participated in more activities that made them sweat
(McGuire et al., 1999a). Specifically, 52 percent of maintainers reported engag-
ing in three or more episodes that made them sweat in a typical 7-day week
compared with 32–36 percent of the regainers and controls (McGuire et al.,
1999a). Although, it is important to note it has been demonstrated that both
gainers and maintainers reported decreases in total calories expended thorough
physical activity. However, maintainers reported a decrease of only 500 calories
per week where gainers reported a decrease of almost 1,000 calories per week at
1-year follow-up (McGuire et al., 1999b).
Self-Monitoring
Self-monitoring is the cornerstone of behavioral treatment (Foreyt, 1999).
One of the common findings observed in individuals who are successful at long-
term weight loss is that maintainers report extensive use of behavioral strategies
for reduction in dietary fat intake, self weighing, and physical activity (McGuire
et al., 1999a). Taking a closer look at self weighing as a form of self-monitoring,
it has been shown that 55 percent of maintainers reported weighing themselves
at least once each week, where only 35 percent of the regainers reported weigh-
ing themselves frequently (McGuire et al., 1999a). Other forms of self-
monitoring, such as keeping a food or exercise record, functions to assist the
patient in assessing overall intake of various foods in relation to the amount of
exercise performed. Despite the fact that caloric intake may be underestimated,
the records sensitize patients to the eating and exercise portion of their lifestyle
(Blackburn and Kanders, 1994).
Problem Solving
Generally, it has been shown that those individuals who confront life’s
stressors with a positive problem-solving attitude are more likely to have greater
success in any endeavor (Foreyt, 1999). All aspects of effective obesity treat-
ment involve improved problem solving and confrontational skills. A survey of
weight maintainers showed that 95 percent of them utilized problem solving or
confrontational technique. In comparison, only 10 percent of those who relapsed
used problem solving skills and instead, tended to use escape-avoidance ways of
coping with stress, such as eating, smoking, or taking tranquilizers (Blackburn
and Kanders, 1994). These findings support the theory that once an individual
makes a behavioral change, relapse occurs in the face of insufficient coping
skills (Blackburn and Kanders, 1994).

Continued Contact
Frequent patient-provider contact is associated with the best maintenance of
weight loss (Anderson and Wadden, 1999). This contact does not have to be
given solely by the physician, but by a registered dietitian, nurse, or office staff.
Contact can be made to patients, via phone, fax, or email. These continued visits
have been shown to enhance motivation, troubleshooting, and teach patients a
new set of skills. Overall, the longer patients remain in behavioral treatment the
longer they are expected to maintain their weight loss (Anderson and Wadden,
1999).
Stress Management
Literature has shown that stress has a facilitating effect on the eating behav-
ior of individuals most likely to be patients in a weight-loss program (Blackburn
and Kanders, 1994). This excessive stress appears to predict early drop out from
organized weight-loss programs (Foreyt, 1999). It is essential to help patients
identify a strategy when confronted with stressful events to allow them to gain
quick composure in order to use other behavioral techniques (Blackburn and
Kanders, 1994). Working with patients to help address and alleviate the stress-
eating relationship in weight-loss treatment and maintenance is of key impor-
tance (Foreyt, 1999). Four basic stress management procedures used in weight
maintenance include self-monitoring, environmental control, relaxation training,
and contingent relaxation (Blackburn and Kanders, 1994).
Conclusion
Regardless of the weight-loss option selected, patients should strive to
develop the skills that have been reported by successful weight-loss maintainers.
These techniques include exercising regularly, monitoring weight frequently,
eating a low-fat diet, recording food intake, and developing effective problem
solving skills (Anderson and Wadden, 1999). In addition, believing in yourself
(Fletcher, 1994) and not relying on willpower can help your patients achieve
success in their weight-maintenance endeavors.
References
Anderson DA, Wadden TA. 1999. Treating the obese patient. Suggestions for
primary care practice. Arch Family Med 8:156–167.
Blackburn GL, Kanders BS. 1994. Obesity: Pathophysiology, Psychology and
Treatment. New York: Chapman and Hall.
Fletcher AM. 1994. Thin for Life. 10 Keys to Success from People Who have
Lost Weight and Kept it Off. Shelburne, VT: Chapters Publishing.

APPENDIX A 233
Foreyt JP. 1999 (July). Strategies for Maintenance and Relapse Prevention. Ab-
stract and slides presented at the Harvard Obesity Conference.
McGuire MT, Wing RR, Klem ML, Hill JO. 1999a. Behavioral strategies of
individuals who have maintained long-term weight losses. Obes Res 7:334–
341.
McGuire MT, Wing RR, Klem ML, Lang W, Hill JO. 1999b.What predicts
weight regain in a group of successful weight losers? J Consult Clin Psy-
chol 67:177–185.
McGuire MT, Wing RR, Klem ML, Seagle HM, Hill JO. 1998. Long-term
maintenance of weight loss: Do people who lose weight through various
weight loss methods use different behaviors to maintain their weight? Int J
Obes 22:572–577.
adults: The evidence report. Obes Res 6:51S–209S.
Rippe JM, Crossley S, Ringer R. 1998. Obesity as a chronic disease: Modern
medical and lifestyle management. J Am Diet Assoc 98:S9–S15.
Shick SM, Wing RR, Klem ML, McGuire MT, Hill JO, Seagle H. 1998. Persons
successful at long term weight loss and maintenance continue to consume a
low energy, low fat diet. J Am Diet Assoc 98:408–413.
Williamson DF, Derdula MK, Serdula MK, Anda RF, Levy A, Byers T. 1992.
Weight loss attempts in adults: Goal, duration and rate of weight loss. Am J
Public Health 82:1251–1257.
FACTORS AFFECTING LONG-TERM MAINTENANCE OF WEIGHT

LOSS AND WEIGHT REGAIN
John M. Jakicic, PhD, Assistant Professor, Brown University School of Medi-
cine, Miriam Hospital Weight Control and Diabetes Research Center
Obesity is a significant health problem in the United States, and it is

estimated that in excess of 50 percent of adults are considered overweight (BMI
> 25 kg/m2). Despite documented short-term success in weight-loss programs, it
has been shown that typically, one-third of weight lost will be regained within
1–3 years, with total regain occurring within 3–5 years. Therefore, it is
important to examine the most effective implementation of strategies that have
been shown to maximize long-term weight loss and prevent weight regain.
Despite the belief that most individuals are unsuccessful at long-term
weight loss, the National Weight Control Registry (NWCR) has identified a
large number of individuals that have successfully maintained at least a 30-lb
weight loss for a minimum of 1 year (Klem et al., 1997). Close examination of
this data set shows that there are individuals that have maintained a weight loss
of approximately 60 lb and have maintained this for 5.6 ± 6.8 years. Therefore,

results from this study should be examined closely to determine if there are
unique strategies that can be used to enhance long-term weight loss in over-
weight adults.
Exercise
An interesting finding in the NWCR is that individuals continue to
participate in strategies to maintain both healthful eating and exercise behaviors.
However, a unique finding in these data is that these individuals are maintaining
extremely high levels of exercise, with leisure-time activity being 2,000 to 2,500
kcal/week for both men and women (Klem et al., 1997). This value is much
greater than the current public health recommendation for physical activity to
improve health (HHS, 1996; Pate et al., 1998). However, this level is similar to
the amount of activity shown by Schoeller and colleagues (1997) to minimize
weight regain in overweight women, and this amount of activity was verified
using doubly labeled water. Jakicic and colleagues (1999) have shown that when
combined with dietary modification, weight regain in the 12 months following
was minimized when exercise exceeded 150 minutes per week. However, of
interest is that there was no weight regain in women exercising greater than 200
minutes per week throughout the entire 18 months of treatment. Thus, overall,
these results appear to verify the conclusion of Pronk and Wing (1994) based on
a review of the literature, that physical activity is one of the best predictors of
long-term weight maintenance.
Despite the evidence presented above, debate remains regarding the optimal
intensity of the activity that will enhance long-term weight loss and minimize
weight regain. In a 20-week study of overweight women, Duncan and
colleagues (1991) showed that total energy expenditure rather than exercise
intensity is the key factor for regulating body weight. However, data from the
NWCR suggests that individuals successful at long-term weight loss participate
in a high level of vigorous intensity activity (Klem et al., 1997). Despite these
findings, the results of this study are cross-sectional and have not been
confirmed by a randomized clinical trial. Currently, Jakicic and colleagues are
conducting a randomized clinical trial to examine the dose-response of exercise
(intensity and energy expenditure) on weight loss across a 24-month period of
time.
Despite the debate over the optimal amount of activity that is necessary to
maximize long-term weight loss, little debate exists as to the importance of
physical activity for overweight adults. Data from the Center for Aerobics
Research at the Cooper Institute have shown that physical fitness can have a
significant impact on mortality rates independent of body weight. Lee and
colleagues (1998) have shown that there is a significant reduction in mortality
rates in overweight adults that also have higher levels of physical fitness, and
this mortality rate is similar to leaner unfit adults. These results suggest that

APPENDIX A 235
interventions that improve physical fitness in overweight adults can have

significant health benefits independent of changes in body weight. Therefore, it
is important to develop and implement strategies to increase exercise participa-
tion in overweight adults.
Recently, Dunn and colleagues (1999) have shown that a home-based
lifestyle activity intervention can be as effective over 18–24 months as a
structured clinic-based exercise intervention. In addition, in studies of over-
weight women, Jakicic and colleagues (1995, 1999) have shown that multiple
short bouts of exercise can be effective in previously sedentary individuals.
Therefore these strategies should be considered when implementing inter-
ventions to address body-weight regulation within the military.
Changes in the Micro and Macro Environments

It has been suggested that we live in a “toxic environment” relative to
factors that affect body weight. There are a number of factors, such as
accessibility of high fat/calorie foods and labor saving devices that affect our
eating and exercise behaviors. However, it has been shown that the environment
can be manipulated to have a positive impact on eating and exercise behaviors.
For example, French and colleagues (1997) showed that lowering prices in
vending machines for low-fat snacks increased the amount of low-fat snacks that
were purchased. In addition, Andersen and colleagues (1998) have reported that
posting signs to encourage the use of stairs in a shopping mall can have a
positive impact on activity patterns.
It may also be important to increase access to healthier foods and provide
opportunities for physical activity, and this can be done to both the macro and
micro environments. For example, Sallis and colleagues (1990) showed that
individuals living in close proximity to exercise facilities were more active than
those living further away from these facilities. Jakicic and colleagues (1997)
showed that there was a significant correlation between physical activity and
having home-exercise equipment. More recently, Jakicic and colleagues (1999)
reported that providing overweight adults with home treadmills increased
exercise participation. Therefore, these findings suggests that modifications to
the environment may have a positive impact on health behaviors related to body-
weight regulation.
Long-Term Changes in Dietary Intake

Despite the fact that exercise appears to be one of the best predictors of
long-term weight loss, the impact of eating behaviors on this process should not
be overlooked. It has been shown in short-term studies that exercise alone has
little impact on body weight when compared with diet or the combination of diet
plus exercise (Wing et al., 1998). Moreover, the effectiveness of exercise in

long-term weight loss may be partially explained by its link to healthful eating
behaviors. For example, Klem and colleagues (1997) reported that individuals
successful at long-term weight loss maintained healthful eating behaviors along
with high levels of exercise. Unpublished data from a study conducted in our
laboratory has shown that individuals that have maintained high levels of
exercise also report maintaining more healthful eating behaviors than those not
maintaining their exercise over a period of 18 months. Thus, these results appear
to suggest that both dietary and exercise behaviors should be targeted to enhance
long-term weight loss and to prevent weight regain.
Continued Contact
It has been suggested that obesity is a chronic disease and should be treated
with a chronic disease intervention. Perri and colleagues (1987) have shown that
maintaining contact with a weight-loss program long-term enhances weight loss.
However, from a clinical perspective, it becomes difficult to keep individuals in
treatment programs for long periods of time. Thus, the typical model of
providing group sessions during the maintenance phase of treatment may not be
appealing to individuals participating in these programs. Therefore, maintaining
contact through other means may prove to be more effective in long-term
intervention programs. Some of the strategies that have been shown to be
successful are telephone contacts and mailings. In addition, interventions using
social support strategies and computers are currently ongoing. Therefore, these
intervention strategies may be appealing to the military when attempting to
deliver interventions to soldiers that may be deployed throughout the world.
Targeting High Risk Periods for Weight Gain

There is some evidence that there are specific periods when individuals may
be at risk for weight gain, and this may be an important factor for the military to
consider. One period of time is during early adulthood, and weight gain is
typically accompanied by a trend for decreases in physical activity. For
example, unpublished data from our laboratory has shown that college-aged men
and women participating in regular exercise gained less weight during their
college years than those not regularly participating in exercise.
Weight gain may also occur in individuals that are already moderately
overweight. We have shown that moderately overweight adult men left
untreated will gain a significant amount of weight over a period of 16 weeks,
whereas participation in a program to modify exercise behaviors and minimize
fat intake appears to have a beneficial effect on body weight in these individuals
(Leermakers et al., 1998). Therefore, it may be important for the military to
identify individuals that are moderately overweight and encourage changes in
exercise and eating behaviors to prevent further weight gain.

APPENDIX A 237
The postpartum period may be an extremely important time for women with
regard to body-weight regulation, and interventions targeting this period may be
extremely important. For example, in a study of women following pregnancy,
women left untreated lost 4.9 kg with 11.5 percent returning to prepregnancy
weight, whereas those participating in a correspondence-based treatment pro-
gram lost 7.8 kg and 33 percent returned to prepregnancy weight (Leermakers et
al., 1998). Therefore, it may be important for the military to consider offering
postpartum interventions to minimize the retention of body weight in women
during this period.
Application to Weight-Regulation Initiatives in the Military

There may be some debate in the various branches of the military regarding
acceptable body-weight values and methods of measuring these parameters.
However, regardless of the absolute value that is determined to be acceptable, it
should be recognized that there are soldiers in the military that are at risk for
weight gain. Therefore, the military should consider implementing strategies
that may minimize weight gain in these individuals, and these could include
changes in the environment and providing access to programs related to eating
and exercise behaviors.
In addition, the military should consider implementing interventions early
on (i.e., basic training) that will permit soldiers to transfer their activity and
eating behavior outside of a controlled environment setting. For example, when
an individual enters the military, it is commonly believed that they are in an
environment in which they have little control over their eating and exercise
behaviors, and these factors are controlled by the military. However, soon after
that period of time, soldiers have more freedom of choice, and this is a period
when they could potentially relapse into typical behavioral patterns. Thus,
providing opportunities for soldiers to maintain their newly developed exercise
and eating behaviors may minimize body weight-regulation concerns in this
population. Moreover, one factor that should be considered is the history of the
soldier prior to entering the military. It is likely in some cases that an individual
lost weight just prior to entering the military in order to conform to the military
standards and to be accepted into the military. However, the period following
this initial weight loss is a high-risk time for weight regain. Identifying
individuals that meet these criteria, and targeting interventions at this group of
individuals may prove to be beneficial in preventing relapse while in the
military.

References
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inexpensive signs encourage the use of stairs? Results from a community
intervention. Ann Intern Med 129:363–369.
Duncan JJ, Gordon NF, Scott CB. 1991. Women walking for health and fitness:
How much is enough? J Am Med Assoc 266:3295–3299.
Dunn AL, Marcus BH, Kampert JB, Garcia ME, Kohl III HW, Blair SN. 1999.
Comparison of lifestyle and structured interventions to increase physical ac-
tivity and cardiorespiratory fitness. J Am Med Assoc 281:327–334.
French SA, Jeffery RW, Story M, Hannan P, Snyder MP. 1997. A pricing strat-
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the presence of exercise equipment and participation in physical activity.
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and use of home exercise equipment on adherence, weight loss, and fitness
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study of individuals successful at long-term maintenance of substantial
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Lee CD, Jackson AS, Blair SN. 1998. U.S. weight guidelines: Is it also impor-
tant to consider cardiorespiratory fitness? Int J Obes Relat Metab Disord
22:S2–S7.
Leermakers EA, Anglin K, Wing RR. 1998. Reducing postpartum weight reten-
tion through a correspondence intervention. Int J Obes Relat Metab Disord
22:1103–1109.
Leermakers EA, Jakicic JM, Viteri J, Wing RR. 1998. Clinic-based vs. home-
based interventions for preventing weight gain in men. Obes Res 6:346–
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APPENDIX A 239
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B
_________________________________________________________________________________
Biographical Sketches of the

Workshop Speakers
GEORGE L. BLACKBURN serves as an associate professor of surgery and

nutrition, associate director of the Division of Nutrition, and is the first
incumbent of the S. Daniel Abraham Chair in Nutrition Medicine at Harvard
Medical School. He is the director of the Nutrition Support Service, chief of the
Nutritional/Metabolism Laboratory, director of the Center for the Study of
Nutrition and Medicine, and program director for Surgical Treatment of Severe
Obesity, all of which are affiliated with the Beth Israel Deaconess Medical
Center in Boston, Massachusetts. He received his M.D. from the University of
Kansas and completed his internship and residency at Boston City Hospital,
Harvard Medical School. He obtained his Ph.D. in nutritional biochemistry from
Massachusetts Institute of Technology. Dr. Blackburn has trained over 100
fellows in applied and clinical nutrition and has over 390 publications on various
aspects of nutrition, medicine, and metabolism. He is on the editorial board of
and reviewer for several journals and received the Grace Goldsmith Award from
the American College of Nutrition and the Joseph Goldberger award in clinical
nutrition from the American Medical Association. He is president of the North
American Association for the Study of Obesity and immediate past president of
the American Board of Nutrition. He also serves as the chair of the Scientific
Advisory Committee of the C. Everett Koop Foundation Shape Up America
Campaign. He remains on the Board of Advisors for the American Society of
Parenteral and Enteral Nutrition of which he served as president, he was also
president of the American Society for Clinical Nutrition, and is a member of
numerous other medical societies. Dr. Blackburn is a principal investigator or
coprincipal investigator on several National Institutes of Health-funded grants.
MAJ STEPHN V. BOWLES was the U.S. Army Recruiting Command Direc-
tor of Command Psychological Operations and was located at the U.S. Army
Soldier Support Institute in Columbia, South Carolina. He also serves as an as-
sistant clinical professor in psychiatry and health behavior at the Medical Col-
241

lege of Georgia in Augusta. Dr. Bowles has previously held positions as director
of the LIFE Wellness Program, chief of Behavioral Medicine and chief of Or-
ganizational Health Psychology at Eisenhower Army Southeast Regional Medi-
cal Center in Augusta. He held a staff position at Tripler Army Medical Center
and was the director of the Aeromedical Psychology Course and chief of Human
Factors at the U.S. Army School of Aviation Medicine. He has an M.S.W. from
Washington University in St. Louis and a Ph.D. in clinical psychology from the
California School of Professional Psychology at Berkeley. He completed his
internship at William Beaumont Army Medical Center in El Paso, Texas and his
health psychology fellowship at Tripler Army Medical Center in Honolulu, Ha-
waii. His current research interests are in ASD and PTSD, aviation psychology,
fitness/weight reduction, pregnancy loss, and recruiting and selection.
ANTHONY G. COMUZZIE is an associate scientist for the Southwest Foun-

dation for Biomedical Research in San Antonio, Texas. The focus of his re-
search is the genetic and environmental components of obesity. Dr. Comuzzie
received his B.S. in biology and M.A. in biological anthropology from Texas
A&M University in College Station. He received his Ph.D. in population genet-
ics from The University of Kansas in Lawrence.
NIKHIL V. DHURANDHAR is currently an assistant professor and William

Hardy Chair of Obesity Research in the Department of Nutrition and Food Sci-
ence, Wayne State University, Detroit. Before moving to Wayne State, Dr.
Dhurandhar was an assistant scientist and associate director of the Beers-
Murphy Clinical Nutrition Center in the Clinical Nutrition Section of the De-
partment of Medicine, University of Wisconsin School of Medicine. He received
his M.S. in nutrition from North Dakota State University and his Ph.D. from the
University of Bombay, India. Dr. Dhurandhar was also a medical practitioner in
India, where he treated about 8,000 cases of obesity over an 8-year period. His
research interests focus on the use of pharmacological aids in the treatment of
obesity and, more recently, on virus-induced obesity.
GARY D. FOSTER is an assistant professor of psychology and clinical director

of the Weight and Eating Disorders Program at the University of Pennsylvania
School of Medicine. He received his B.S. from Duquesne University, his M.S.
from the University of Pennsylvania, and his Ph.D. in clinical psychology from
Temple University. He has published over 50 scientific studies, reviews, and
book chapters on the causes and treatments of obesity. He also has considerable
experience in the clinical aspects of obesity management, having treated obese
patients in individual and group settings over the last 15 years.
FRANK GREENWAY is medical director and a professor at the Pennington

Biomedical Research Center, a research campus of Louisiana State University.

APPENDIX B 243
He graduated from Stanford University and obtained an M.D. from the Univer-
sity of California at Los Angeles. He did his internship and residency in internal
medicine and fellowship in endocrinology and metabolism at Harbor-UCLA
Medical Center. Dr. Greenway practiced internal medicine, endocrinology and
metabolism in Marina del Rey, California, from 1975 to 1995. During those
years, he taught on the clinical faculty of UCLA and did obesity research, pri-
marily through clinical trials of pharmacological agents. He moved to the Pen-
nington Biomedical Research Center in 1995, where he has continued to do
clinical research on the pharmacological treatment of obesity and its related dis-
eases: diabetes, hypertension, and hyperlipidemia.
JOHN M. JAKICIC is currently an assistant professor at Brown University

School of Medicine, with primary responsibilities in the Weight Control and
Diabetes Research Center. Prior to his current position, Dr. Jakicic was an assis-
tant professor at the University of Kansas and the University of Pittsburgh.
While at the University of Pittsburgh, Dr. Jakicic was the scientific administra-
tor of the Obesity/Nutrition Research Center. He received his Ph.D. from the
University of Pittsburgh. Dr. Jakicic’s primary research area is behavioral ap-
proaches for enhancing long-term weight loss. Currently, Dr. Jakicic is the prin-
cipal investigator for three grants from the National Institutes of Health that fo-
cus on long-term weight loss and exercise adoption in overweight adults. He has
published extensively in this area.
ANNE LOUCKS received her Ph.D. in physiology from the University of Cali-
fornia at Santa Barbara. She did post-doctoral training and research in reproduc-
tive endocrinology at the University of California at San Diego School of Medi-
cine. She is currently a professor and interim chair in the Department of
Biological Sciences at Ohio University. Dr. Loucks’ research in San Diego fo-
cused on characterizing the neuroendocrine profile of cyclic and amenorrheic
athletes. At Ohio University, she has conducted short-term, prospective experi-
ments to distinguish the independent effects of energy availability and exercise
stress on LH pulsatility and metabolic substrates and hormones. Her current
research is funded by the U.S. Army’s Defense Women’s Health Research Pro-
gram. Dr. Loucks is a coauthor of the position stand of the American College of
Sports Medicine on the Female Athlete Triad and a frequent participator in na-
tional and international meetings on the menstrual cycle.
PATRICK MAHLEN O’NEIL is a professor of psychiatry and behavioral

sciences at the Medical University of South Carolina, where he is director of the
Weight Management Center. He received his B.S. in economics from Louisiana
State University and his M.S. and Ph.D. in clinical psychology from the Univer-
sity of Georgia. Dr. O’Neil has been professionally involved in obesity since
1977 in numerous clinical, teaching, research, and public education roles. He

directs a long-standing, multidisciplinary weight-management center that offers

services for people of all degrees overweight. His teaching activities include
supervision of psychology interns on clinical rotations in the Center, lectures to
medical and other student groups, and invited continuing education lectures to
physician and other practitioner audiences. He is or has been principal investiga-
tor for a number of externally funded clinical trials of weight-loss agents and is
the author of more than 100 professional publications, chapters, and presenta-
tions, primarily concerning psychological, behavioral, and other clinical aspects
of obesity and its management. From 1987 to 1996, he authored Weighing the
Choices, a weekly column on weight control in the Charleston, SC, Sunday Post
and Courier. Dr. O’Neil has served on the Education Committee of the North
American Association for the Study of Obesity (NAASO) since 1994 and is a
member of the NAASO Ad Hoc Committee for Development of the Practical
Guidelines. He is also immediate past president of the South Carolina Academy
of Professional Psychologists, former member and chair of the South Carolina
Board of Examiners in Psychology, and former chair of the Obesity and Eating
Disorders Special Interest Group of the Association for the Advancement of
Behavior Therapy.
LT COL LEON PAPPA was head, Training Programs Branch, Training and
Education Division, Marine Corps Combat Development Command, Quantico,
Virginia. An infantry officer commissioned in December 1979, he has held nu-
merous operational assignments, both in CONUS and overseas. He reported to
his current assignment in August 1995 from HQ Marine Forces Europe, Stutt-
gart, Germany. As head of training programs, he has oversight of a myriad of
training-related programs, ranging from aviation training pipeline, recruit train-
ing, special operations, U.S. Navy field medical and religious programs, close
combat, combat water survival training, physical fitness/weight control, and the
Marine Corps ROTC program. Key assignments for Lt Col Pappa have included
tours in the United Kingdom, Germany, recruit depot, Parris Island, Officer
Candidate School, and operational tours with the 2nd battalion 8th Marines and
3rd battalion 3rd Marines, deploying to the Mediterranean, Lebanon, Okinawa,
Thailand, and Southwest Asia.
LT COL JOANNE M. SPAHN was the Health Promotion Flight Commander at

Elmendorf AFB, Alaska. She attended the College of St. Elizabeth in Morristown,
New Jersey, where she received a B.S. in foods and nutrition. She was selected for the
Air Force Dietetic Internship Program in 1982 and started her Air Force career at
Malcolm Grow Medical Center, Andrews Air Force Base, Maryland. She served as
chief of Medical Food Service at Tinker AFB, Oklahoma, from July 1983 to February
1986. During this time she also completed Squadron Officer’s School and earned a
M.S. in consumer studies from Oklahoma State University. In 1986 she transferred to
Davis Monthan AFB, Arizona, as chief, Nutritional Medicine Service. In 1991 she

APPENDIX B 245
started on an Air Force Institute of Technology assignment at the University of Ari-

zona where she received a M.S. in human nutrition and was transferred back to An-
drews AFB as chief, Clinical Dietetics, 89th Medical Group. In 1994, she became
director of the USAF Dietetic Internship program and served in that capacity until
July 1996. Lt Col Spahn completed Air Command and Staff College in 1996 and
served as Nutritional Medicine Flight Commander at the 3rd Medical Group, Elmen-
dorf AFB, Alaska, from 1996 to 1999. She has served as consultant dietitian, Pacific
Air Forces, since 1996.
MARCIA STEFANICK received her B.S. in biology from the University of

Pennsylvania in 1974 and her Ph.D. in physiology from Stanford University in
1982, focusing on reproductive physiology and neuroendocrinology. Subse-
quently, she did fellowship training in cardiovascular disease prevention at the
Stanford Center for Research in Disease Prevention. In 1997, Dr. Stefanick was
appointed an associate professor of medicine (with a courtesy appointment in
gynecology and obstetrics) at Stanford University School of Medicine. Dr. Ste-
fanick’s research interests focus on the role of diet, exercise, and weight control
in chronic disease prevention for both men and women, and in hormone re-
placement interventions for overall health issues of postmenopausal women. Dr.
Stefanick is principal investigator of the Women’s Health Initiative, which has a
diet study focused on prevention of both breast and colon cancer and heart dis-
ease, a hormone study focused on cardiovascular disease prevention, and a cal-
cium trial directed toward osteoporosis and prevention of hip and other bone
fractures. Dr. Stefanick is also principal investigator of the Women’s Healthy
Eating and Living Trial, a diet study of women previously diagnosed with breast
cancer. In addition, she is the research director of the Lipoprotein and Biochem-
istry Laboratory of the Stanford Center for Research in Disease Prevention.
JUNE STEVENS is an associate professor in the Departments of Nutrition and Epi-

demiology at the University of North Carolina-Chapel Hill. A graduate of the human
nutrition program at Cornell University, her research career had its beginning in
bench top studies of adipocytes from genetically obese rats. Her dissertation research
was a clinical study of the effect of dietary fiber on food intake, gastrointestinal tran-
sit, and vitamin absorption in women. She pursued post-doctoral training in epidemi-
ology and has since focused her career on population-based studies of obesity. Her
current research examines the causes, consequences, and prevention of obesity with a
focus on obesity-prone minority populations. She is principal investigator of the coor-
dinating center for the Pathways study, a multicenter trial designed to develop and test
a school-based intervention to prevent obesity in American Indian children. She also
investigates the effects of obesity and fat patterning on chronic disease and mortality
in African Americans. She has received attention from the popular press for her stud-
ies on the impact of age on the relationship between body weight and mortality. Dr.
Stevens is an expert in epidemiological studies of obesity.

LOUIS F. TOMASI is a research physiologist for the U. S. Army Physical Fit-

ness School (APFS). His primary responsibilities include independent research,
writing army physical fitness doctrine, and teaching human performance and
health-related classes for the master fitness trainer and exercise leader courses.
Other fitness related projects associated with Dr. Tomasi are the civilian fitness
program, physical training for pregnant soldiers, physical training for the retired
officer association, and various local fitness agencies including the YMCA,
American Heart Association, United States Swimming Association, regional
swim teams, and many other fitness-related programs. His last project involved
designing, administering, and analyzing the current army physical fitness test
update study. Recently, he completed the fitness training unit exit and entrance
requirement study for initial entry training. Dr. Tomasi’s current project in-
volves reviewing the hand position on the sit-up event on the APFT and devel-
oping standards for the alternate aerobic event. He is the liaison between the
APFS and the American College of Sports Medicine and DSCPER process ac-
tion team for fitness and health. In March 1992, Dr. Tomasi earned the Fort
Benjamin Harrison Instructor of the Year and was nominated for TRADOC in-
structor of the year. Prior to his tenure at USAPFS, Dr. Tomasi served 13 years
at the U. S. Military Academy, West Point, as an associate professor and head
athletic trainer in the department of physical education. There, he was involved
in community projects throughout the Hudson Valley. His earned degrees in-
clude a B.S. in physical education and biology from the University of Vermont;
an M.S. from East Stroudsburg University, Pennsylvania, and a Ph.D. in educa-
tion in biomechanics and physiology from New York University. Dr. Tomasi is
a member of the American College of Sports Medicine, the National Athletic
Trainers’ Association, and other professional organizations.
CAPT TRISHA VORACHEK was a graduate student in the University of Minne-

sota School of Public Health. She will receive her degree this December and move to
Maxwell AFB, Montgomery, Alabama, to be the Base Health Promotion Manager.
Her previous assignment was at McConnel AFB, Wichita, Kansas, where she was
one of four Air Force dietitians to conduct the Air Force Surgeon General’s Super-
Clinic Dietitian Study. The purpose of the study was to demonstrate the cost-
effectiveness and need for dietitians in smaller Air Force communities, where tradi-
tionally, dietitians were not assigned. The study at McConnell AFB was highly suc-
cessful, and currently a dietitian continues to be assigned there. McConnell AFB is
where the Lifestyles, Exercise, Attitudes, and Nutrition (LEAN) program was devel-
oped.
LT DEBORAH WHITE was a research physiologist for the U.S. Navy, work-
ing in the Department of Operational Medicine, Naval Submarine Medical Re-
search Laboratory, Groton, Connecticut. She received a B.S. from California

APPENDIX B 247
Polytechnic State University at San Luis Obispo (1988), California, and a Ph.D.
in cardiovascular physiology from Colorado State University at Ft. Collins
(1994). Her publications include papers on cardiovascular responses to central
hypovolemia and lower body negative pressure, with emphasis on the effects of
gender and fitness level on these responses. Before entering the Navy, LT White
worked for a manufacturing company in the United Kingdom, working on the
design, development, and testing of safety and survival equipment for fighter
pilots and other military applications. Currently, she works as a program coordi-
nator, overseeing the design, development, and testing of safety and survival
equipment for submariners. LT White successfully completed Basic Enlisted
Submarine School in October 1997 and is an active member of the Naval Sub-
marine League and the Aerospace Medical Association.


C
_________________________________________________________________________________
Biographical Sketches of the

Subcommittee on Military Weight
Management
RICHARD ATKINSON (Chair) is director of the Obesity Institute of the

MedStar Research Institute in Washington, D.C. Formerly, he was professor of
medicine and nutritional sciences and director of the Beers-Murphy Clinical
Nutrition Center at the University of Wisconsin-Madison. Previously he was a
professor of internal medicine and chief, Division of Clinical Nutrition at the
Eastern Virginia Medical School, and chief of staff for research and develop-
ment, and chief, Medical Research Service at the VA Medical Center in Hamp-
ton, Virginia. Dr. Atkinson also served in the military as division surgeon for the
101st Airborne Division, and chief of the Department of Medicine at the U.S.
Army Hospital, Fort Campbell, Kentucky following a 2-year tour as endocrine
fellow at the Walter Reed Army Hospital. Dr. Atkinson’s research has focused
on a variety of interventions (surgical, behavioral, and pharmacological) for the
treatment and prevention of obesity. He is a former member of the Committee
on Military Nutrition Research.
JOHN E. VANDERVEEN (Vice-Chair) is a former director of the Food and

Drug Administration’s (FDA) Office of Plant and Dairy Foods and Beverages in
Washington, D.C. His previous position at FDA was director of the Division of
Nutrition at the Center for Food Safety and Applied Nutrition. He also served in
various capacities at the U.S. Air Force (USAF) School of Aerospace Medicine
at Brooks Air Force Base, Texas. He has received accolades for service from
FDA and USAF. Dr. Vanderveen is a member of the American Society for
Clinical Nutrition, American Institute of Nutrition, Aerospace Medical Associa-
tion, American Dairy Science Association, Institute of Food Technologists, and
American Chemical Society. In the past, he was the treasurer of the American
Society of Clinical Nutrition and a member of the Institute of Food Technology,
National Academy of Sciences Advisory Committee. Dr. Vanderveen holds a
B.S. in agriculture from Rutgers University in New Jersey and a Ph.D. in chem-
istry from the University of New Hampshire.
249

WILLIAM DIETZ is the director of the Division of Nutrition and Physical

Activity in the National Center for Chronic Disease Prevention and Health Pro-
motion at the Centers for Disease Control and Prevention (CDC). Prior to his
appointment at CDC, he was a professor of pediatrics at the Tufts University
School of Medicine and director of clinical nutrition at the Floating Hospital of
New England Medical Center Hospitals. He received his B.A. from Wesleyan
University in 1966 and his M.D. from the University of Pennsylvania in 1970.
Following an internship at Children’s Hospital of Philadelphia, he spent 3 years
in the Middle America Research Unit of the National Institute of Allergy and
Infectious Diseases in Panama studying insect-borne viruses. After the comple-
tion of his residency at Upstate Medical Center, he received a Ph.D. in nutri-
tional biochemistry from Massachusetts Institute of Technology (MIT). Dr.
Dietz was a principal research scientist at the MIT/Harvard Division of Health
Science and Technology, associate director of the Clinical Research Center at
MIT, and director of the Boston Obesity/Nutrition Research Center. He served
on the counsel of the American Society for Clinical Nutrition and is a past presi-
dent of the North American Association for the Study of Obesity. In 1995, he
received the John Stalker Award from the American School Food Service Asso-
ciation for his efforts to improve school lunches. Dr. Dietz served on the 1995
Dietary Guidelines Advisory Committee and is a past member of the National
Institute of Diabetes and Digestive and Kidney Diseases Task Force on Obesity
and president-elect of the American Society for Clinical Nutrition. In 1998, Dr.
Dietz was elected to the Institute of Medicine of the National Academies. In
2000, he received the William G. Anderson Award from the American Alliance
for Health, Physical Education, Recreation, and Dance. In 2002, he received the
Holroyd-Sherry award for his outstanding contributions to the field of children,
adolescents, and the media.
JOHN D. FERNSTROM is a professor of psychiatry, pharmacology, and

neuroscience at the University of Pittsburgh School of Medicine and research
director of the UPMC Health System Weight Management Center. He received
his B.S. in biology and his Ph.D. in nutritional biochemistry from the
Massachusetts Institute of Technology (MIT). He was a postdoctoral fellow in
neuroendocrinology at the Roche Institute for Molecular Biology in Nutley,
New Jersey. Before coming to the University of Pittsburgh, Dr. Fernstrom was
an assistant and then associate professor in the Department of Nutrition and
Food Science at MIT. He served on numerous governmental advisory
committees and is a member of several professional societies, including the
American Society for Nutritional Sciences, the American Society for Clinical
Nutrition, The North American Society for the Study of Obesity, the American
Physiological Society, the American Society for Pharmacology and
Experimental Therapeutics, the American Society for Neurochemistry, the
Society for Neuroscience, and the Endocrine Society. Among other awards, Dr.

APPENDIX C 251
Fernstrom received the Mead-Johnson Award of the American Society for

Nutritional Sciences, a Research Scientist Award from the National Institute of
Mental Health, a Wellcome Visiting Professorship in the Basic Medical
Sciences, and an Alfred P. Sloan Fellowship in Neurochemistry. His current
research interests include the influence of the diet and drugs (particularly
appetite suppressants) on neurotransmitters in the central and peripheral nervous
systems.
ARTHUR FRANK, an internist, is the medical director of the George

Washington University Weight Management Program in Washington, D.C. He
received his B.S. in chemistry from the Massachusetts Institute of Technology,
his M.S. in biochemistry from the University of Pennsylvania, and his M.D.
from New York University. His residency was completed at the Stanford
Medical Center. He was a U.S. Public Health Service post-doctoral fellow in
endocrinology and metabolism at Stanford and a post-doctoral fellow at the
National Heart Institute. Subsequently, he directed the food and nutrition
programs at the Office of Economic Opportunity and served as an adviser to the
Assistant Secretary for Health at the Department of Health and Human Services.
He has been responsible for the provision and management of medical care of
overweight and obese patients since 1977. He has been the principle investigator
in a number of clinical research trials involving the pharmacotherapy of obesity.
His research interests also involve the development of systems for the
organization and evaluation of weight-management services (he was on the
National Academies committee that wrote the book Weighing the Options) and
the evaluation and measurement of the maintenance of weight loss. Dr. Frank
has been the chairman of the Clinical Committee of the North American
Association for the Study of Obesity (NAASO). In this position he was
responsible for facilitating NAASO’s increasing involvement in the scientific
aspects of clinical activities. He has been a member of the Board of Directors
and treasurer of the American Obesity Association since its inception and has
actively participated in litigation related to the protection of the rights of obese
patients who were subjected to discrimination.
BARBARA C. HANSEN is the director of the Obesity and Diabetes Research

Center at the University of Maryland School of Medicine and a professor of
physiology. She received her B.S. and M.S. from the University of California,
Los Angeles. She completed a Ph.D. in physiology and psychology at the Uni-
versity of Washington, Seattle. Dr. Hansen is a past president of the North
American Association for the Study of Obesity and served as the first president
of the International Association for the Study of Obesity for four years. She was
president of the American Society for Clinical Nutrition from 1995 to 1996. She
is a member of the Institute of Medicine and has served on its program commit-
tee and in other consulting roles. Dr. Hansen has also served as a member of

several organizations, including the Advisory Committee to the Director of the

National Institutes of Health, the U.S.-Japan Nutrition and Metabolism Panel,
and the Armed Forces Epidemiological Board of the Department of Defense.
She has published extensively in biomedical journals and lectures widely in the
field of obesity and diabetes. Dr. Hansen is an associate editor of the Journal of
Obesity Research and coeditor of Diabetes/Metabolism Research and Reviews
and has served as associate editor/editorial board roles for Diabetes Care, Inter-
national Journal of Obesity, International Journal of Primatology, and Journal
of Parental and Enteral Nutrition. Dr. Hansen’s laboratory is involved in the
study and evaluation of new compounds for the treatment of diabetes, obesity,
and dyslipidemia.
STEVEN B. HEYMSFIELD is a professor of medicine at Columbia Univer-

sity, College of Physicians and Surgeons in New York. He also serves as deputy
director of the New York Obesity Research Center and is director of the Human
Body Composition Laboratory. Dr. Heymsfield is immediate past president of
the American Society of Parenteral and Enteral Nutrition and is an active mem-
ber of the American Society of Clinical Nutrition and the North American Soci-
ety for the Study of Obesity. He was recently made an honorary member of the
American Dietetic Association. He received his B.A. in chemistry from Hunter
College of the City University of New York and his M.D. from Mt. Sinai School
of Medicine. Dr. Heymsfield has done extensive research and has clinical ex-
perience in the areas of body composition, weight cycling, nutrition, and obe-
sity, especially as they relate to women.
ROBIN B. KANAREK is dean of the Graduate School of Arts and Sciences

and professor of psychology and nutrition at Tufts University in Medford,
Massachusetts. Her prior experience includes research fellow, Division of
Endocrinology, University of California, Los Angeles School of Medicine and
research fellow in nutrition at Harvard University. In addition to reviewing for
several journals, including Science, Brain Research Bulletin, Journal of
Nutrition, American Journal of Clinical Nutrition, and Annals of Internal
Medicine, she is a member of the editorial boards of Physiology and Behavior
and the Tufts Diet and Nutrition Newsletter and is a past editor-in-chief of
Nutrition and Behavior. Dr. Kanarek has served on ad hoc review committees
for the National Science Foundation, National Institutes of Health, and U.S.
Department of Agriculture nutrition research, as well as the Member Program
Committee of the Eastern Psychological Association. She is a fellow of the
American College of Nutrition, and her other professional memberships include
the American Society for Nutritional Sciences, New York Academy of Sciences,
Society for the Study of Ingestive Behavior, and Society for Neurosciences. Dr.
Kanarek received a B.A. in biology from Antioch College in Yellow Springs,

APPENDIX C 253
Ohio, and an M.S. and a Ph.D. in psychology from Rutgers University in New
Brunswick, New Jersey.
BARBARA J. MOORE is president and chief executive officer of Shape Up

America!, a national initiative to promote healthy weight and increased physical
activity in the United States. Committed to providing achievable science-based
messages, Shape Up America! was founded by C. Everett Koop in 1994. Dr.
Moore joined in June 1995 and serves as key liaison with the scientific, profes-
sional, and corporate communities. Dr. Moore earned a B.S. from Skidmore
College and an M.S. and Ph.D. in nutrition from Columbia University. She has
several years of postdoctoral training at the University of California at Davis.
Dr. Moore was appointed a Henry Rutgers Fellow at Rutgers University, where
she held a tenure track position in the Department of Nutritional Sciences. After
leaving academia, Dr. Moore served as general manager of program develop-
ment and primary technical policy advisor for Weight Watchers International.
Dr. Moore joined the Executive Office of the President in 1993 as acting assis-
tant for social and behavioral science in the Office of Science and Technology
Policy. She was involved in the process of policy formation and budgetary sup-
port of fundamental scientific research policy. Prior to joining Shape Up Amer-
ica!, Dr. Moore worked at the National Institutes of Health, Division of Nutri-
tion Research Coordination, where she was responsible for providing guidance
on nutrition policy and dietary guidance materials promulgated by the federal
government. In this position, Dr. Moore focused on the development of the 1994
Progress Report to the Assistant Secretary of Health on the nutrition objectives
of Healthy People 2000. She maintains active membership in the American So-
ciety for Nutritional Sciences, American Society for Clinical Nutrition, North
American Association for the Study of Obesity, Society for the Study of Inges-
tive Behavior, and Sigma Xi.
MARY I. POOS (FNB Staff, Study Director) is project director for the Commit-
tee on Military Nutrition Research. She joined the Food and Nutrition Board
(FNB) of the Institute of Medicine in November 1997. She has been a project
director for the National Academies since 1990. Prior to officially joining the
FNB staff, she served as a project director for the National Research Council’s
Board on Agriculture for more than seven years, two of which were spent on
loan to FNB. Her work with FNB includes senior staff officer for the IOM re-
port The Program of Research for Military Nursing and study director for the
reports A Review of the Department of Defense’s Program for Breast Cancer
Research and Vitamin C Fortification of Food Aid Commodities. Currently, she
also serves as study director to the Subcommittee on Interpretation and Uses of
Dietary Reference Intakes. While working with the Board on Agriculture, Dr.
Poos was responsible for the Committee on Animal Nutrition and directed the
production of seven reports in the Nutrient Requirements of Domestic Animals

series, including a letter report to the commissioner of the Food and Drug Ad-
ministration concerning the importance of selenium in animal nutrition. Prior to
joining the National Academies, she was consultant/owner of Nutrition Consult-
ing Services of Greenfield, Massachusetts; assistant professor in the Department
of Veterinary and Animal Sciences at the University of Massachusetts, Amherst;
and adjunct assistant professor in the Department of Animal Sciences, Univer-
sity of Vermont. She received her B.S. in biology from Virginia Polytechnic
Institute and State University and a Ph.D. in animal sciences (nutrition/bio-
chemistry) from the University of Kentucky. She completed a postdoctoral fel-
lowship in the Department of Animal Sciences Area of Excellence Program at
the University of Nebraska.

D
_________________________________________________________________________________
Acronyms
AA Asian American
AD Active duty
AFB Air Force base
AI American Indian
AN Alaska Native
APFS Army physical fitness school
APFS Army physical fitness test
AR Army regulation
AWCP Army weight control program
BCT Basic combat training

BF Body fat
BMI Body mass index
BOTS Basic Officer Training School
BUMED Bureau of Medicine and Surgery
CDPCP Command-directed physical conditioning program

CEA Cost effectiveness analysis
CFL Command fitness leader
CHD Coronary heart disease
CHO Carbohydrate
CLA Conjugated linoleic acid
CMNR Committee on Military Nutrition Research
CNS Central nervous system
CONUS Continential United States
CVD Cardiovascular disease
DEA U.S. Drug Enforcement Agency

DHEA Dehydroepiandrosterone
255

DMED Defense medical epidemiology database

DOD U.S. Department of Defense
DNA Deoxyribonucleic acid
DRG Diagnosis related group
FDA U.S. Food and Drug Administration

FEP Fitness Enhancement Program
FFM Fat-free mass
FNB Food and Nutrition Board
GnRH Gonadotropin-releasing hormone

GW Gastric wrapping
HAWC Health and Wellness Center

HCA Hydroxycitrate
HDL High-density lipoprotein
HMB Beta-hydroxy-beta-methylbutyrate
HPA Hypothalamic-pituitary adrenal
HPM Health promotion manager
HRT Hormone replacement therapy
IC Immediate Commander
IDC Independent Duty Corpsman
LBM Lean body mass

LDL Low-density lipoprotein
LH Luteinizing hormone
LEAN Lifestyle, exercise, attitude, and nutrition
MAJCOM Major Command

MAW Maximum allowable weight
MD Medical doctor
MFT Master fitness trainer
MO Medical officer
MOS Military operational specialities
MRE Meals ready to eat
MTF Medical treatment facilities
MWR Morale, welfare, and recreation
NE Norepinephrine
NHANES National Health and Nutrition Examination Survey
NIH National Institutes of Health

APPENDIX D 257
NOS Not otherwise specified

NP Nurse practioner
NWCR National weight control registry
OA Overeaters anonyomous
OTC Over-the-counter
PA Physicians assistant
PCS Permanent change of station
PFA Physical Fitness Assessment
PI Pacific Islander
PME Professional military education
PRT Physical Readiness Test
PT Physical training
QTL Quantitative trait loci
RCMAS Retrospective case mix analysis system

RD Registered dietitian
REE Resting energy expenditure
RER Respiratory exchange rate
RMR Resting metabolic rate
RPCP Remedial Physical Conditioning Program
SBWC Shipboard weight-control program

SES Socioeconomic status
SS Shipshape
SSRI Selective serotonin reuptake inhibitors
T3 triiodothyronine
TDY Temporary duty away
TMD Temporary medical deferral
UC Unit commander
UCP Uncoupling protein
USAMRMC U.S. Army Medical Research and Materiel Command
USDA U.S. Department of Agriculture
VBG Vertical banded gastroplasty

VLCD Very-low-calorie diets
VO2max Maximal oxygen consumption
W Waist circumference

WBFMP Weight and Body Fat Management Program

WMP Weight management program

Weight Loss Military Us

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http://www.nap.edu/catalog/10783.

Weight Management: State of the Science and

This book plus thousands more are available at http://www.nap.edu.

Subcommittee on Military Weight Management

Copyright © National Academy of Sciences. All rights reserved.

International Standard Book Number 0-309-08996-4 (Pbk)

Copyright 2003 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

Copyright © National Academy of Sciences. All rights reserved.

Copyright © National Academy of Sciences. All rights reserved.

The National Academy of Sciences is a private, nonprofit, self-perpetuat-

The National Academy of Engineering was established in 1964, under the

The Institute of Medicine was established in 1970 by the National Acad-

The National Research Council was organized by the National Academy of

Copyright © National Academy of Sciences. All rights reserved.

SUBCOMMITTEE ON MILITARY WEIGHT MANAGEMENT

RICHARD L. ATKINSON, JR. (chair), Obesity Institute, MedStar Research

Copyright © National Academy of Sciences. All rights reserved.

COMMITTEE ON MILITARY NUTRITION RESEARCH

JOHN E. VANDERVEEN (chair), San Antonio, Texas

U.S. Army Grant Representative

Copyright © National Academy of Sciences. All rights reserved.

FOOD AND NUTRITION BOARD

CATHERINE E. WOTEKI (chair), College of Agriculture, Iowa State

Copyright © National Academy of Sciences. All rights reserved.

Catherine M. Angotti, Occupational Health, National Aeronautics and

Although the reviewers listed above have provided many constructive

Copyright © National Academy of Sciences. All rights reserved.

This publication is the latest in a series of reports based on reviews of the

HISTORY OF THE COMMITTEE

Copyright © National Academy of Sciences. All rights reserved.

that would remedy these deficiencies; to recommend approaches for studying

Similar recommendations had been made in a 1992 CMNR report, Body

Copyright © National Academy of Sciences. All rights reserved.

required physical tasks and secondarily on long-term health implications, and

THE COMMITTEE’S TASK

• Share knowledge and experience in managing weight control within the

The subcommittee was charged to identify the most effective interventions

1. What are the essential components of an effective weight/fat loss pro-

Copyright © National Academy of Sciences. All rights reserved.

ventions, or only monitoring and guidance? Should military programs be more

To accomplish this task, the subcommittee’s workshop brought together the

ORGANIZATION OF THE REPORT

Copyright © National Academy of Sciences. All rights reserved.

conclusions and recommendations and identifies research needs. The workshop

RICHARD L. ATKINSON, Chair

Copyright © National Academy of Sciences. All rights reserved.

Copyright © National Academy of Sciences. All rights reserved.

EXECUTIVE SUMMARY ..................................................................................1

1 BACKGROUND AND CONTEXT OF THE OVERWEIGHT

2 MILITARY STANDARDS FOR FITNESS, WEIGHT, AND

3 FACTORS THAT INFLUENCE BODY WEIGHT ................................57

Copyright © National Academy of Sciences. All rights reserved.

4 WEIGHT-LOSS AND MAINTENANCE STRATEGIES……………….79

5 RESPONSE TO THE MILITARY’S QUESTIONS..............................113

6 PROGRAMMATIC AND RESEARCH

A Workshop Agenda and Abstracts, 179

Copyright © National Academy of Sciences. All rights reserved.