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Innovative Strategies: Abstracts

POLICY AND OFFICE OF THE SECRETARY OF DEFENSE STRATEGY

CAPT Andy T. Vu, D.D.S., Deputy Director, Joint Force Fitness, Operation Live Well, Office of the Under Secretary of Defense for Personnel and Readiness/Personnel Risk and Resiliency

The Secretary of Defense’s strategy to expand the military’s competitive edge focuses on rebuilding military readiness through the development of an agile and resilient force, strengthening alliances and attracting new partnerships, and reforming business practices for greater performance and affordability. The Office of Joint Force Fitness seeks to fulfill that strategy through Operation Live Well’s efforts aimed at increasing the deployability and resiliency of the Joint Force. These efforts are guided by the Total Force Fitness Framework, which addresses eight domains of fitness—psychological, spiritual, social, behavioral, medical/dental, physical, nutritional, and environmental—for military service members and their families.

Joint Force Fitness leverages internal and external partnerships, monitors legislation, conducts research, develops machine learning and data visualization tools, broadens and supports the Global Force Management Data Initiative, and integrates best practices. The portfolio also includes three behavior change campaigns, which focus on tobacco cessation; responsible alcohol consumption; and the reduction of substance misuse among young, active duty military service members.

The objective of Joint Force Fitness is to develop a better capability to

assess the Total Force Fitness Framework among military service members and target interventions to increase individual readiness, decrease individual nondeployability, prevent force loss in theater, and predict force availability for and during deployments. These efforts will enable the department to prioritize programs that enhance readiness and reduce force loss; to increase the readiness and lethality of the Total Force; and to enhance the Total Force’s ability to adapt, fight, and win in every operational environment.

JOINT NUTRITION INITIATIVES

Military Nutrition Environment Assessment Tool (mNEAT) and Joint Buyer’s Guide

Lt Col (ret) Tammy J. Lindberg, M.S., R.D.N., L.D., FAND, HQ Air Force Medical Operations Agency Health Promotion

The Military Nutrition Environment Assessment Tool (mNEAT) is used to evaluate policies and environmental factors at the community level that support healthy eating. The tool was developed by a U.S. Department of Defense (DoD) working group to help commanding officers, health promotion professionals, and other stakeholders measure access to healthy food options. The mNEAT is based on evidence-based recommendations for a healthy eating environment and is in alignment with

• Chief, the Joint Chiefs of Staff’s Total Force Fitness Framework;
• National Prevention Strategy;
• Centers for Disease Control and Prevention’s (CDC’s) Recommended Community Strategies and Measurements to Prevent Obesity in the United States;
• U.S. Department of Health and Human Services’ (HHS’s) 2017 Food Service Guidelines for Federal Facilities; and
• 2015–2020 Dietary Guidelines for Americans.

Evaluation includes 11 different sections: Community Programs, Dining Facility (Permanent Party), Dining Facility (Training), Fitness Center, Restaurant (Fast-Food), Restaurant (Sit-Down or Fast-Casual Restaurant), Snack Shop (located in Billeting/Lodging), Stores (Convenience), Stores (Commissary), Vending (Refrigerated and Non-Refrigerated), and Work-site. Resulting scores are used in the development of a Local Action Plan.

The proposed Joint Buyer’s Guide would be a tool for use by the Army, Air Force, Navy, and Marine Corps food programs to communicate detailed guidance and specifications to the Defense Logistics Agency (DLA) Troop Support, which acts on behalf of the services to purchase the food

used in the dining facilities. The Guide is an ongoing collaboration among the Joint Military Services Buyer’s Guide work group, the Joint Subsistence Policy Board (JSPB), and the DoD Nutrition Committee.

Go for Green Nutrition Labeling System in Military Dining Facilities

Beth Moylan, M.P.H., R.D., C.S.S.D., Director of Performance Nutrition, Consortium of Health and Military Performance, Uniformed Services University of the Health Sciences

Go for Green® 2.0 (G4G) is a joint service performance–nutrition initiative targeting military dining facilities. G4G 2.0 improves the food environment where military service members (MSMs) live and work, with the overall aim to optimize the performance, readiness, and health of MSMs.

G4G originated with the Soldier Fueling Initiative in 2008, where its signature stoplight-color labeling was introduced. From 2014 to 2016, G4G was rebranded as DoD-wide G4G 2.0, with a new logo and entirely new programmatic approach, which incorporates the latest in health promotion science and behavior change. Beyond stoplight-color labeling, G4G 2.0 also includes choice architecture strategies (behavioral design) that nudge diners toward healthier, green-coded choices; menu standards that require a minimum number of green-coded options; promotion of green-coded choices through featured meals, displays, and samples; and a robust marketing campaign through print and social media messages.

Pilot testing and military-specific research have demonstrated how G4G can function within the unique DoD feeding environment to maximize impact on the nutritional status of service members. To achieve replicability and scalability, the program has been standardized, program requirements written, and numerous toolkits developed to support users. A G4G 2.0 website allows seamless access to resources.

G4G 2.0, currently being adopted across all branches of the military, is governed by the DoD Nutrition Committee and Joint Subsistence Policy Board. Currently, the Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences serves as a program office and hub for G4G 2.0-related programmatic developments, resources, research, and training.

SERVICE-SPECIFIC INITIATIVES

Army

MAJ Tamara E. Osgood, M.S., R.D., L.D., Division Chief, Health Education and Applications, U.S. Army Public Health Center Performance Triad, Nutrition Lead

The Army is addressing threats of poor nutrition, suboptimal activity, and obesity through strategic and tactical initiatives at multiple levels of the social ecological framework. These include but are not limited to Fit for Performance (the Army’s standardized weight management program), Army Wellness Centers (AWCs) (standardized wellness initiatives to empower sustainable behavior change through health education and technology), and the Performance Triad (sleep, activity, and nutrition education). Program evaluation studies from these initiatives have yielded promising results related to nutrition and weight-related outcomes among soldiers; findings also reveal challenges with systematic widespread adoption and implementation. For example, similar to civilian weight loss programs, Fit for Performance evaluation activities found difficulties with standardized implementation and participant recruitment, retention, and follow-up. Results from an AWC client outcome evaluation suggest that nearly 60 percent of AWC clients with at least one follow-up assessment experience improvements in body fat percentage and body mass index (BMI). Soldier participation in Performance Triad education activities is associated with improved knowledge and nutrition behavior changes but not changes in BMI. Results of several evaluation studies across these initiatives indicate that soldiers desire improved access to and availability of healthy food options in the installation environment and highlight the importance of policy changes. The Healthy Army Communities initiative is striving to address this gap through a coordinated, Army-wide effort to improve the food environment on military installations via assessment and modifications. Through advocacy, intervention, and evaluation, the Army is implementing multiple solutions to promote and sustain wellness for the total Army family.

Air Force

Lt Col Jennifer B. Harward, M.S., R.D., Deputy Chief, Air Force Health Promotion, Air Force Medical Support Agency

The U.S. Air Force is currently testing initiatives to enhance the health and nutrition of Airmen, dependents, and retirees. One of the resources the Air Force has utilized is the CDC’s Community Guide for the selection of

programs to incorporate Community Preventive Services Task Force guidelines and recommendations.

Tele-Medical Nutrition Therapy was selected to expand medical nutrition therapy services to beneficiaries who did not have access to care from a local registered dietitian. This initiative uses video teleconferencing technology to provide nutrition counseling, behavior therapy, health and wellness coaching, and health education and counseling as components of preventive, therapeutic, and restorative health, to include obesity.

Healthcare to Health, which is an umbrella for two programs—Group Lifestyle Balance and Military Families 5-2-1-0—is also being tested at selected bases. Group Lifestyle Balance is a diabetes prevention program, and 5-2-1-0 strives to improve knowledge and health behaviors in families.

Health Coaching is being tested at two bases within the primary care clinic to give providers a resource for referring their patients for modifiable behaviors to help improve their patients’ health. Patients can select from four standard programs: weight management, stress management, tobacco cessation, and improved physical activity.

The Air Force Smart Fueling Initiative stemmed from a decrease in recruits and active service members meeting the weight standard. The Office of the Secretary of Defense is leading a team of numerous stakeholders in working synergistically to improve the nutrition environment, with the ultimate goal of ensuring that Airmen are afforded healthy food options.

Marine Corps

Brian J. McGuire, M.S., A.T.C., C.S.C.S., Deputy Director, Force Fitness Division, U.S. Marine Corps Training and Education Command

As professional warrior-athletes, all Marines must be physically fit, regardless of age, grade, or duty assignment. Fitness is an essential component of Marine Corps combat readiness. Furthermore, physical fitness is an indispensable aspect of leadership. The habits of self-discipline and personal commitment that are required to gain and maintain a high level of physical fitness are inherent to the Marine Corps way of life and must be a part of the character of every Marine. Marines who are not physically fit are a detriment and detract from the combat readiness of their unit. The Marine Corps Physical Fitness Program is in a continual state of analysis, design, development, implementation, and evaluation in collaboration with fitness, health, and medical subject-matter experts. Based on this process, the Marine Corps has recently made a number of profound changes to its general fitness, occupational fitness, and associated programs to optimize the fitness and health of Marines. Among the more significant of these changes are instituting a Force Fitness Instructor Program, implementing

a Post Exercise Nutritional Supplementation Program, utilizing a Performance Nutrition Pack to complement dining facility offerings, and linking performance on fitness tests to body composition program decisions. There are other enhancements as well, such as placing Civilian Certified Athletic Trainers in training and operational units and expanding the strength and conditioning equipment available to Marines in austere settings. These enhancements are coupled with the enduring setting of high fitness and body composition standards and ensuring of accountability to related policies.

Navy

James Sherrard, Head of Health Promotion and Wellness, Naval Hospital Pensacola

The Navy and Marine Corps Public Health Center (NMCPHC) is the Navy and Marine Corps’s center for public health services. NMCPHC provides leadership and expertise to ensure mission readiness through disease prevention and health promotion in support of the National Military Strategy. Within NMCPHC, the Health Promotion and Wellness Department provides programs to help sailors and their families improve nutrition choices, physical activity, and other lifestyle factors to influence better weight management. These programs are both clinical and nonclinical to improve access to care within the fleet; however, individual participation is usually not mandatory. For active duty sailors with access to a medical treatment facility, one-on-one appointments with a registered dietitian are available; however, some duty locations afford less access to this asset. ShipShape, the Navy’s official weight management program, is a nonclinical, facilitator-led weekly course to address nutrition, activity, and behavioral changes. ShipShape is open to all DoD beneficiaries and can be easily conducted at virtually every location where sailors serve. Additionally, NMP-CHC provides abundant health promotion and wellness (HPW) resources intended to be used for all command-level health promotion efforts. This HPW toolbox is usable by all clinical and nonclinical health promoters throughout the fleet to help improve access to credible information and improve readiness.

U.S. DEPARTMENT OF VETERANS AFFAIRS PROGRAMS

MOVE!® Weight Management Program for Veterans

Susan D. Raffa, Ph.D., National Program Director, Weight Management, National Center for Health Promotion and Disease Prevention, Veterans Health Administration

Nearly 80 percent of veterans seen in Veterans Health Administration (VHA) facilities are affected by overweight or obesity. To address growing rates of overweight and obesity, in 2006 VHA implemented the MOVE!® Weight Management Program for Veterans, an evidence-based, population-focused approach. MOVE!® assists veterans with obesity or overweight who have an obesity-associated condition (e.g., hypertension, type 2 diabetes and prediabetes, dyslipidemia) to achieve clinically significant weight loss. The program adheres to evidence-based recommendations from the Department of Veterans Affairs (VA)/DoD Clinical Practice Guideline for Screening and Management of Overweight and Obesity (CPG),¹ which include comprehensive lifestyle intervention (CLI) as a critical component of successful and sustained weight loss programs. Other VA/DoD CPG recommendations include yearly screening for and documentation of overweight/obesity; pharmacotherapy and bariatric surgery as adjuncts to CLI; shared decision making among providers and patients to support patient engagement based on individual values and preferences; and repeated assessment of response to treatment, with adjustments as needed to ensure clinically meaningful weight change. Facility-based MOVE!® Coordinators and Provider Champions lead program activities and tailor programming to the population of veterans they serve. More than 800,000 veterans have participated in MOVE!® since the program’s inception. Approximately 20 percent of veteran participants achieve clinically meaningful weight loss (i.e., weight loss of at least 5 percent of initial weight). For veterans with intense and sustained participation in MOVE!® (i.e., eight sessions over 4 months), approximately 30 percent achieve clinically meaningful weight loss.

Veterans Affairs Healthy Teaching Kitchen Program

Sean Walsh, R.D., C.S.C. (Certified Sous Chef), Co-Lead National Healthy Teaching Kitchens

Scientific research has shown that nutrition plays an important role in both the prevention and management of common chronic diseases such as cardiovascular disease, diabetes, and hypertension. A healthy diet is a key component of overall wellness for everyone and can be enjoyed by all. One way to promote good nutrition is to experience healthy, nutritious food that is delicious. Culinary education classes can increase self-efficacy related to cooking skills, fruit and vegetable intake, and nutrition knowledge of the participants. Group cooking classes allow a variety of participants to be actively involved in open discussion while learning to cook and discussing healthy food topics. Cooking classes that focus on healthy, quick, and

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¹ See https://www.healthquality.va.gov/guidelines/CD/obesity (accessed September 25, 2018).

affordable meals motivate participants to engage in a healthier lifestyle at home. A culinary program that incorporates hands-on nutrition and culinary skills in a social setting provides a greater chance of behavioral change compared with other education tools. The VHA’s Nutrition and Food Services (NFS) has implemented the Healthy Teaching Kitchen (HTK) initiative to provide culinary education for veterans and family members, with the goals of (1) increasing use of fresh foods, (2) increasing healthy food choices, and (3) imparting skills to progress toward personal health goals. Because there are different levels of implementation, NFS is collecting basic information via the NFS Annual Report, such as costs associated with the HTK program, the number of classes given each fiscal year, and the staff hours required to provide the classes.