4

Exploring Innovative Strategies

The third session of the workshop included 10 speakers who presented innovative strategies for addressing obesity and overweight in specific populations within the armed forces. Session moderator Anne Utech, acting national director of nutrition and food services at the U.S. Department of Veterans Affairs, explained the speakers had been instructed to describe their program’s largest impact, contributors to its success, and outcomes achieved, as well as future initiatives. Noting that speakers would not have enough time to provide complete information about their programs, she directed participants to a handout of abstracts for more details (see Appendix C).

POLICY AND OFFICE OF SECRETARY OF DEFENSE STRATEGY

CAPT. Andy Vu, deputy director, Operation Live Well, opened the session with a leadership perspective on policy, data, and strategic planning. Vu’s office supports the Office of the Under Secretary of Defense for Personnel and Readiness in aligning policies and programs along the Total Force Fitness Framework across the U.S. Department of Defense (DoD), said Utech.

The Office of Joint Force Fitness is positioned for success, said Vu, because in 2016 the portfolio of Operation Live Well migrated from the Defense Health Agency, which focuses primarily on the clinical aspect of readiness, to Personnel and Readiness, which focuses more broadly on the readiness aspect of obesity and other disease and nonbattle injury conditions. Furthermore, said Vu, the office is ideally situated to work collaboratively to influence policy, doctrine, materiel, personnel, and facilities because of the broad, enterprise-level scope of its mission to assess readiness issues for military service members.

Supporting military service members in navigating the challenges of military life requires a comprehensive approach to well-being throughout a service member’s career, Vu declared. He described this support as including a holistic assessment of well-being and readiness based on a Total Force Fitness Framework that encompasses eight domains of fitness—social, physical, environmental, medical and dental, nutritional, spiritual, psychological, and behavioral—that together best portray the readiness level of military service members across the deployment cycle (see Figure 4-1). A key challenge, Vu remarked, is that 64 percent of the total force is the U.S. Army, 10 percent of which (or 100,000 soldiers) is nondeployable, mainly because of medical conditions.

According to Vu, his office is prototyping the development of a Readiness Prediction Model (RPM), a machine learning model with the capability to quantify individual readiness, predict and report the level of deployability DoD can achieve, and identify the root causes of nondeployability. “We are partnering with the services to essentially consume their data and develop machine learning algorithms that are going to help us identify these three metrics,” he explained.

Min Yi, lead data scientist for the initiative, explained that the initial outcomes of this model indicate the Army programs that may help mitigate the root causes of nondeployability or incomplete deployments. He gave the example of Army Wellness Centers, which help service members stay fit and mitigate musculoskeletal-related injuries, explaining that the RPM analysis identified these types of injuries as a frequent medical point of failure for service members who return home early from deployment. Moreover, he added, the RPM was able to suggest that the use of wellness care appointments at Army Wellness Centers decreased deployment incompletion rates, that is, the likelihood of premature return from deployment.

According to Yi, the Office of the Under Secretary of Defense for Personnel and Readiness has also leveraged open public and other federal datasets to understand readiness risk factors. He referenced an internal assessment indicating that data from the Centers for Disease Control and Prevention (CDC) on health-related quality of life were a good proxy for individual readiness. A model was then built using 19 different community-level readiness risk factors (including such obesity-related risk factors as the food environment index, physical inactivity, and the prevalence of adult

obesity), with the goal of identifying DoD populations that may be at risk of failing to meet readiness standards. Three health-related quality-of-life outcomes were modeled, Yi said, which were poor or fair health, poor physical health days, and poor mental health days.

Yi went on to explain that open datasets have also helped identify risk levels for poor health outcomes in communities where reserve components or geographically dispersed service members are located. As an example, he referenced a seven-state pilot called Building Healthy Military Communities being conducted by the Uniformed Services University of the Health Sciences with support from Operation Live Well. By identifying the risk level in such a community, Yi suggested, “we can help tease out some of the different root causes that might be contributing to that community’s poor health outcomes.” He added that further analyses showed obesity-related factors to be correlated with mental health, not just physical health.

Turning the presentation back over to Vu, Yi emphasized that machine learning and data science techniques will help quantify the benefit of various programs and interventions in improving the health and readiness of the armed forces.

Vu then highlighted the impact of poor nutritional fitness on treatment costs, recruitment, retention, readiness, and resiliency, stressing the need for an “enterprise approach” to address the drivers of the armed forces’ weight problems. He added that such an approach requires attention to how food is procured, prepared, and promoted, and might even include such practices as scheduling recess prior to lunch in DoD schools, based on evidence indicating that doing so can reduce food waste and improve cooperation and attention. He also further described the “rapid needs assessment” of the Building Healthy Military Communities pilot, which has a goal of supporting reserve component service members in achieving the same access to care, resources, and facilities as active duty members. He noted that the reserve component represents 50 percent of military service members, who increasingly live away from military installations but are expected to maintain the same readiness standards and deploy at a similar rate relative to active duty members.

JOINT NUTRITION INITIATIVES

Lieutenant Colonel (retired) Tammy J. Lindberg, nutrition program manager at the Headquarters Air Force Medical Operations Agency, and Beth Moylan, director of performance nutrition for the Consortium for Health and Military Performance at the Uniformed Services University of the Health Sciences, described joint nutrition initiatives that affect the feeding environment in all branches of the military.

Military Nutrition Environment Assessment Tool and Joint Buyer’s Guide

Lindberg discussed two initiatives that she said have begun to lead to a culture change; improve communication of food and nutrition needs in the military environment; and break down the silos in which the food programs of the armed forces operate to spur collaboration, pool resources, and leverage stakeholder assets for collective impact. The Military Nutrition Environment Assessment Tool (mNEAT) is used to assess environmental factors and policies that support healthy eating on military installations. The proposed Joint Buyer’s Guide¹ is intended as a tool for use by the food programs of the Army, Air Force, Navy, and Marine Corps to leverage their purchasing power and communicate to the food and beverage industry the detailed guidance and specifications provided to the Defense Logistic Agency’s troop support, which acts on behalf of the services to purchase food in the services’ dining facilities.

According to Lindberg, these two tools have begun to increase the availability of healthy options on military installations and lead to the use of commanders’ leadership and service members’ feedback to drive solutions to challenges. She cited as one promising change an increase in fruit consumption as a result of offering cut fruit on a salad bar in an environment in which service members had limited time to eat.

The proposed Joint Buyer’s Guide would facilitate the incorporation of specific dietary guidelines and requirements into all the services across the globe, Lindberg continued. As an example, she described a time when the services had to implement new menu guidelines that required providing more whole grains. She explained that the Air Force purchasing catalogue did not include the option to purchase what was needed to meet this guideline, but the Joint Buyer’s Guide would be able to provide specifications to meet those requirements.

What has made these two tools helpful, according to Lindberg, is that they have led to more collaboration among stakeholders, such as dietitians, who deal with many of the same issues across military installations. She added that the tools have also helped enable standardized implementation of common policies and joint communication of DoD requirements to industry. A challenge she identified was when the Air Force began using mNEAT, it did not have the personnel needed to complete the entire assessment, which may have skewed results. However, she observed, even after 3 years of collecting mNEAT data, the food environment still does not sufficiently support healthy eating. In the future, she said, mNEAT will look beyond whether healthy foods are available and begin implementing the

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¹ At the time of the workshop presentation, Lindberg described parts of the guide that have been proposed, including that addressing meats. The complete Joint Buyer’s Guide has not yet been published.

U.S. Department of Health and Human Services’ Food Service Guidelines for Federal Facilities, which address placement, pricing, and promotion of healthy options, and the proposed Joint Buyer’s Guide would be expanded to include more food categories.

Go for Green® 2.0

Moylan described Go for Green® 2.0 as a joint service performance nutrition initiative targeting military dining facilities to optimize the performance, readiness, and health of military service members (aged 18–35). As the owner and operator of military dining facilities, she explained, DoD has control over what food can be served. Based on evidence from behavior change research, she elaborated, the program uses the tactics of food labeling and placement to nudge diners toward healthier food and beverage selections in military dining facilities without restricting their personal choice, and focuses on performance outcomes as the core of its message.

The initiative’s most salient feature, according to Moylan, is its use of stoplight color labeling to mark food choices as “eat often” (green), “eat occasionally” (yellow), or “eat rarely” (red) based on a coding algorithm that emphasizes minimally processed, nutrient-dense foods. Of note, she said, is that sodium is separated from the green, yellow, and red designation because the target population is very active, and restricting sodium is not healthful for such individuals in some cases. At least 30 percent of a dining facility’s offerings must be green-coded for the facility to be branded as adopting Go for Green®, she explained, adding that at least one item at every station in the dining facility is expected to be coded green. The figure of 30 percent was chosen based on expected feasibility and input from each service, she observed, as well as the Armed Forces Recipe Service (a compendium of high-volume food service recipes). Green-coded items are strategically placed in more prominent locations within Go for Green® facilities and are accompanied by marketing messages about how the food positively impacts performance.

According to Moylan, Go for Green® began almost 10 years ago and has been revised since, and in 2015 was pilot tested as part of a broader performance initiative. She reported that the pilot testing resulted in increased availability and promotion of healthy food options and increased presentation of nutrition information. She added that qualitative feedback suggested the beginning of a culture shift among soldiers as they began to pay more attention to food choices and how they impact performance. Focus group findings revealed that service members noticed that food was being rearranged, and they still wanted more healthy choices. Based on the pilot findings, Moylan continued, requirements for version 2.0 of the program were published, and implementation is in progress, with the services

at various stages of adopting their plans for the program. She also informed the audience that in the future, a collaborative research effort will examine the program’s effectiveness in changing soldiers’ dietary choices and attitudes and their knowledge about nutrition.

Moylan stressed the importance of standardized dissemination of the program across all the services, which she said will facilitate the uniform adoption of its requirements and allow dining facility managers at every installation to access the same online training. Staff training is an important component, she explained, because people at all levels of the dining facility will need to understand the program for it to be implemented successfully. She added that tools and checklists have been developed to assist dining facilities in implementing the program with the greatest fidelity possible. It is “not a matter of initiative,” she said, “but it is also a matter of time … running a dining facility is a busy operation … we have done as much as possible behind the scenes.”

Moylan acknowledged that it remains challenging to implement Go for Green®, predicting that future success will require a continued culture change around nutrition accompanied by demand for healthy options. Success will also require supporting the policy not just at the DoD level, she argued, but also at the operational and technical levels, such as by tying the dining facility manager’s performance to aspects of program implementation. She believes that such policies will naturally institutionalize the program and make it more sustainable. Finally, she cited the need for better technology infrastructure that can push nutrition information from a central location to dining facilities at various military installations.

SERVICE-SPECIFIC INITIATIVES

Six speakers highlighted specific initiatives to address obesity and overweight among members of each military service, as well as veterans.

Army Public Health Center’s Health Promotion and Wellness Initiatives

The first of these six speakers was Major Tamara Osgood, division chief, health education and application at the U.S. Army Public Health Center. Osgood reported that the Army is addressing the threats of poor nutrition, suboptimal activity, and obesity with strategic and tactical public health initiatives at multiple levels of the social ecological framework and along various points within the continuum of care. She stressed that coordinated, holistic, science-based approaches are essential to change behavior and improve health outcomes, and that ongoing evaluation is critical. She then described four initiatives targeting the “total Army family,” including active duty service members, members of the National Guard and the

reserve component, and Department of the Army civilians, retirees, and family members.

The first initiative Osgood described was Fit for Performance, an evidence-based, standardized, clinically based six-session lifestyle and behavior modification program with acute targets for weight loss and achievement of body fat standards at the individual level. She noted that the program was created and modified based on the Navy’s ShipShape program—an example of collaboration among the services. According to Osgood, evaluations of the Army’s standardized weight management programs have shown that soldiers who complete all of the sessions experience statistically and clinically significant weight loss. However, she said, soldiers are required to meet with a dietitian only once, and one of the program’s greatest challenges is getting them to attend all six sessions: “If you can imagine putting yourself in a soldier’s shoes—any time that you are coming to the hospital to meet with a dietitian, you are taking time away from training and working with your team, which is affecting the mission.” She cited that another major challenge for Fit For Performance was the inability to implement the standardized program at military treatment facilities because of variance in staffing and what facilities have available.

Second, Osgood discussed Army Wellness Centers (AWCs), which are located outside of most military treatment facilities and provide standardized primary prevention programs and health coaching services designed to build and sustain good health through changes in lifestyle behaviors. She explained that AWCs tend to be closer to where soldiers work and have available standardized equipment, such as BOD POD®s (used to measure body composition) and metabolic testing. Three-quarters of AWC clients come in with a desire to lose body fat, she reported. She shared results from an AWC client outcome evaluation conducted in fiscal years 2015 to 2017 among approximately 6,800 clients with at least one follow-up assessment, noting that a majority experienced improvements in body fat percentage and body mass index (see Figure 4-2).

The third initiative Osgood described was the Performance Triad, which was designed to improve readiness and resilience by targeting the interconnected behaviors of sleep, activity, and nutrition and has evolved into a marketing campaign. She pointed to lessons learned as the program went on. For example, it was found that distributing fitness trackers did not result in improvements; that soldiers look to their leaders to model these three healthy behaviors; and that knowledge and awareness alone are not enough to change behavior, but adjusting the installation environment is critical to making the healthy choice the easy choice.

On that note, Osgood went on to mention a fourth initiative, Healthy Army Communities. She explained that this coordinated, Army-wide effort, in addition to a focus on reducing tobacco use and improving physical ac-

tivity, is using the mNEAT tool described earlier to assess the food environment on installations. She added that food stakeholders convene to discuss results and implement potential improvements to the food environment to facilitate healthier choices. Osgood closed her presentation on an enthusiastic note: “All these stakeholders have come to the table, which is a pretty amazing fact because they are all competing against each other financially.”

Air Force Initiatives

The Air Force has used the CDC’s Community Guide to select programs that incorporate guidelines and recommendations of the Community Preventive Services Task Force, said Utech as she introduced Lieutenant Colonel Jennifer Harward, deputy chief, Air Force health promotion, at the Air Force Medical Support Agency. Harward presented five initiatives that the Air Force is testing at different locations to improve health behaviors among active duty service members, dependents, and retirees.

Harward first described Tele-Medical Nutrition Therapy (Tele-MNT), which connects registered dietitians with patients via telephone and video teleconferencing, thus filling gaps in the availability of medical nutrition therapy services at locations lacking a registered dietician or having limited capacity. The registered dieticians at eight “hub” sites provide services to beneficiaries at both hub and “spoke” locations, each hub working with two or three spoke sites stateside or about four spoke sites overseas. Harward noted that the establishment of these locations represents both a success and a challenge, the latter referring to the logistics involved in launching the three spoke sites established to date. The next step is to provide Tele-MNT to patients in their homes, she said, adding that as the program gets under

way, the Air Force will examine outcomes including patient satisfaction, program completion, and changes in weight and patient behaviors.

Second, Harward described Healthcare to Health, an umbrella for two programs: Group Lifestyle Balance and the Military Families 5-2-1-0 campaign discussed by Karen Hawkins during Session 1 (see Chapter 2). Group Lifestyle Balance is based on the Diabetes Prevention Program and is aimed at preventing or delaying diabetes. Harward reported that nearly 1,800 participants had lost 2.2 percent of their body weight at the 3-month mark, and that those who stayed in the program for a year achieved a 6.7 percent weight loss. She also reported significant improvements in blood lipid and glucose profiles, significant decreases in abdominal circumference, and the education of 3,000 families in healthy lifestyles. At the same time, she highlighted the challenges of participant attrition and of gaps in service due to contractor turnover, which creates the need to identify and train new service providers.

A third initiative discussed by Harward was health coaching, initiated in 2017. She explained that this initiative, being tested at two bases, allows primary care providers to refer patients to face-to-face or telephone-based behavior change counseling on weight management, physical activity, nutrition, tobacco cessation, and stress management. According to Harward, providers are happy that they can refer their patients to receive these services, and she noted that patients are spending 6 to 12 weeks with the health coaches. It is too early to have outcome data, she stated, but there are plans to examine provider–patient satisfaction and measures related to weight loss, tobacco cessation, and physical activity. Gaps in service due to contractor turnover challenge this program as well, she observed.

Fourth, Harward turned to another relatively new effort, the Air Force Smart Fueling Initiative, which involves collaboration with stakeholders who manage various food access points across military installations to improve the availability and accessibility of healthier foods. She stressed that obtaining buy-in from leadership has been key, instead of trying to build the program from the bottom up. She added that the Smart Fueling Initiative also provides an opportunity to test mNEAT 2.0, described earlier, which can be used to assess the food and nutrition environment, establish a baseline, and then measure improvements.

Finally, Harward briefly described a newly developing health promotion program that will target high-risk squadrons (based on previously collected health assessment data) with a standardized, holistic program designed to improve behaviors related to sleep, weight, physical activity, and tobacco use. She showed an example of a Commander’s Health Scorecard (see Figure 4-3), which uses data from the Tri-Service Preventive Health Assessment Questionnaire to help drive conversations with leadership about service members’ health behaviors.

Marine Corps Programs and Initiatives

As a preface to the next presentation, Utech explained that the Marine Corps’s 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. Brian McGuire, deputy director of the Force Fitness Division at the U.S. Marine Corps Training and Education Command, Quantico, Virginia, returned to discuss the changes made to the service’s program based on this process.

McGuire began by telling the audience that the Marine Corps has a 6-week program that trains members to be force fitness instructors—unit-level fitness experts who will help develop programs and refer individuals to dietitians and other health professionals. After cultivating a desired “density” of these instructors, he continued, a success that the Marine Corps has observed is a decreased incidence of injury and assignment to body composition programs and increased general and occupational fitness among service members. Both types of fitness are important, he emphasized, explaining that the latter refers to the ability to execute one’s job responsibilities. For example, he said, “Can you lift the MK19 heavy machine gun from a deck to overhead?”

Moving on, McGuire explained that the strong science supporting performance nutrition as a strategy for increasing endurance, improving

muscle recovery, and reducing injuries has facilitated the practice of providing postexercise nutritional supplements following rigorous activity during entry-level training at recruit depots in Officer Candidate School. Although it was a challenge for some people to change their thinking, he observed, the case was made that nutrition need not be limited to dining facilities, and that it was possible to “bring the chow hall out to the PT [physical training] field” to get nutrition to service members right away. In addition, “performance nutrition packs” are provided to help bridge the gap between the evening meal and the following morning’s early exercise session. According to McGuire, data showing the benefits of these tactics, such as decreased sick call visits, decreased injuries, and increased physical performance, “wins our leadership over.”

In closing, McGuire listed a number of “enablers” that support service members in achieving health and fitness objectives: fitness facilities; periodic health assessments to evaluate individual medical readiness; tactical training; a nutrition education program (Fueled to Fight®); informational resources, such as a supplement safety website; and placement of health educators, dietitians, and strength coaches in training and operational units.

Navy Health Promotion and Wellness Initiatives

James Sherrard, head of health promotion and wellness at Naval Hospital Pensacola, highlighted three of the Navy’s health promotion initiatives targeting the obesity and overweight concerns of active duty and reserve sailors, their families, and DoD civilian staff.

Sherrard began with ShipShape, the Navy’s official weight management program, which is open to all DoD beneficiaries. He explained that this nonclinical, facilitator-led, 8-week course addressing nutrition, physical activity, and mindset (that is, behavior change) is followed by several weeks of follow-up designed to encourage continued adherence to a healthy lifestyle. Echoing a barrier noted by previous speakers, he identified as one challenge getting participants to continue all the way through the program. He then cited one success of the program as that its trained facilitators come from a variety of backgrounds and do not need to have health or medical expertise, although they should model healthy personal lifestyles. He added that command fitness leaders are encouraged to become trained facilitators so they are prepared to provide credible guidance and support to their sailors.

All military treatment facilities are required to offer ShipShape throughout the calendar year, Sherrard observed, and while sailors are not mandated to participate, they are strongly encouraged to do so if they fail either the Physical Readiness Test or its body composition component. He shared an encouraging outcome of the program: surveys of program participants have revealed a 97 percent positive response to the statement, “I now have

the knowledge, skills, and abilities necessary to maintain my weight for the long term.” At the same time, he acknowledged that “whether we see that play out or not is a different story,” commenting that the evaluation results should be further explored. He suggested that greater future success could be realized by requiring that the program be included not only in military treatment facilities but also in other parts of military installations where sailors can easily access it.

The second resource Sherrard discussed is a Health Promotion Toolbox² on the Navy and Marine Corps Public Health Center’s website. The toolbox offers a repository of health and wellness information divided topically into monthly campaigns. Sherrard explained that command-level health promotion staff use these materials to plan health promotion education and events.

Third, continued Sherrard, is a new Health Promotion Interactive Map³ that provides a snapshot of health promotion resources on and surrounding every military installation. Users can select a geographic area and discover the locations of walking paths, cooking classes, tobacco cessation classes, weight management classes, and more. The map is updated as new resources are identified, and Sherrard stated that it is particularly useful when service members deploy or travel and want to know what healthy lifestyle supports will be available at their destination.

U.S. DEPARTMENT OF VETERANS AFFAIRS PROGRAMS

Nearly 80 percent of veterans seen in Veterans Health Administration (VHA) facilities are affected by overweight or obesity, Utech reported in introducing the session’s final two speakers to discuss strategies within the U.S. Department of Veterans Affairs (VA).

MOVE!® Weight Management Program for Veterans

Susan Raffa, national program director for weight management for the VHA, described the MOVE!® Weight Management Program for Veterans, an evidence-based, population-focused initiative that is integrated into the health care system to assist veterans with obesity or overweight who have an obesity-associated condition in achieving clinically significant weight loss. Integration with the health care system is particularly important, she

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² See http://www.med.navy.mil/sites/nmcphc/health-promotion/Pages/health-promotion-toolbox.aspx (accessed July 13, 2018).

³ See https://nmcphc.maps.arcgis.com/apps/webappviewer/index.html?id=fc54c24e21014af5846d42b8072c64e9&extent=-22698739.9196,-7753606.4553,10566654.7901,16236613.4942,102100 (accessed July 13, 2018).

asserted, given that individuals in VHA facilities tend to be older and to have more comorbidities and fewer resources relative to populations not seen in the facilities (including both veterans and nonveterans).

The program has demonstrated effectiveness in three areas, Raffa stated, beginning with near-universal screening and referral. She reported that the percentage of veterans screened for obesity and overweight and then offered weight management treatment exceeded 90 percent from 2010 to 2015. She identified the program’s reach as another major impact, with more than 800,000 veterans participating since its 2005 launch. A third impact, she continued, is the provision of co-pay-exempt, standardized care, delivered as a comprehensive lifestyle intervention based on the Diabetes Prevention Program. She characterized enabling veterans to receive the service without cost as “a huge accomplishment.” The intervention includes at least 12 sessions in 12 months, she elaborated, and is focused on calorie restriction, physical activity promotion, and related behavior strategies. Every VA medical center is required to offer this level of intensity in weight management services for veterans, she explained.

According to Raffa, data collected since 2008 indicate that 15 to 20 percent of new participants have achieved clinically significant weight loss (at least 5 percent of body weight) by the 6-month mark, and at that point in time, about 70 percent are at least maintaining their weight or achieving some degree of weight loss (whether modest [1 to 5 percent of body weight] or clinically significant) (see Figure 4-4). Approximately 30 percent of participants achieve clinically significant weight loss with intense and sustained program participation, Raffa added, which is defined as attending at least eight sessions within 4 months.

Raffa went on to observe that recommendations of the evidence-based VA/DoD Clinical Practice Guideline for Screening and Management of Overweight and Obesity underpin MOVE!®’s success. She also pointed out that the program’s direction is informed by the fact that obesity is a chronic disease requiring a lifelong commitment to treatment and maintenance. Another success factor, she continued, is national program office support, including a national policy that specifies program infrastructure and other core program requirements, as well as the dissemination of standardized program content. Raffa cited as a core program requirement designation of a facility-based coordinator, as well as a champion to liaise between the program and primary care. She explained that these individuals lead program activities, such as weight management group sessions, and tailor programming to the facility’s population. About 75 percent of facility-based coordinators are dietitians, she noted. She identified as a third success factor measurement of key performance indicators (reach, engagement, participation) that provides feedback to the national program office and the facility-based coordinators.

The program could be even more successful, Raffa suggested, with better integration and coordination with other elements of care, such as pharmacotherapy and bariatric surgery. She also highlighted a continuous focus on veteran-driven, veteran-centered care, such as making the program materials more interactive and meaningful for participants. There are plans as well, she noted, to engage veterans in program improvement efforts, including a national telephone survey that will assess their satisfaction with the programming.

Raffa concluded her presentation with a preview of future initiatives. These include improving the MOVE!® data tools to support program staff, educating providers about their prescribing practices, and providing real-time program guidance through a virtual work hub.

Healthy Teaching Kitchen

Veterans and their families across the country can be exposed to new foods and learn healthy cooking skills through the VA’s National Healthy Teaching Kitchen program, said Sean Walsh, a registered dietitian and certified sous chef who co-leads the program. Depending on the facility, he explained, participants obtain hands-on cooking experience or observe cooking demonstrations designed to teach skills that can help them progress

toward their personal health goals. “We really want to teach how to make the foods that are good for us taste good,” he stressed, which he said can help reduce veterans’ reliance on processed and restaurant foods.

According to Walsh, many veterans want to cook and get healthy, but feel trapped because they lack the knowledge to do so. By demystifying the cooking process and appealing to personal and regional food preferences, he explained, the program helps redefine healthy foods as tasty foods that people want to eat. “What if we take a macaroni and cheese recipe and make it healthy?” he asked “Let’s find a way to make that taste like it should, but also be healthy at the same time.” He added that the program also helps veterans stretch their food dollars by showing them how to reduce waste and use leftovers.

According to Walsh, a resource toolkit for dietitians and others who want to start a Healthy Teaching Kitchen program at their VA site is contributing to the program’s success. While he stressed that tailoring the content to individual sites is critical, he noted that the toolkit provides baseline resources, such as lesson plans, recipes, and administrative guidelines for implementing the program. In closing, he stated that qualitative and quantitative evaluation data help refine the program to better serve individual goals and different ethnicities and geographic areas, in which food cultures and regional specialties vary.

DISCUSSION

A brief discussion period followed the presentations summarized above. A majority of the discussion centered on avenues of collaboration among the services and government agencies. Participants also touched on the definition of a healthy diet.

Collaboration and Synergy

Utech informed participants that communication among the services underlies many of the efforts that the session’s speakers had described. As examples, she highlighted the VA’s sharing of the Healthy Teaching Kitchen toolkit with the rest of DoD, as well as the sharing of purchasing power with other government agencies in the VA Subsistence Prime Vendor contract. Osgood highlighted collaboration through a DoD–CDC nutrition fellowship and DoD’s involvement with intergovernmental agency efforts, such as the Federal Food Service Guidelines. She also referenced initial discussions about establishing a single weight control program across the four services.

Moylan mentioned the semiannual meetings of a DoD nutrition committee, which provide an opportunity for many of the leaders across the

services and various organizations to convene to discuss programs and participate in topical working groups. Stakeholders such as dining facility and commissary representatives are also involved, she added. Vu noted that DoD is partnering across the board on multiple health promotion initiatives, including updating the DoD instruction that guides the military services on how they are to construct their policies.

Defining a Healthy Diet

One participant stated that no consistent definition of a healthy diet exists, and asked the speakers what their definition would be. Osgood and Moylan replied that a number of programs are based on the Dietary Guidelines for Americans and incorporate other evidence-based guidance, such as the Military Dietary Reference Intakes, the American Heart Association’s Diet and Lifestyle Recommendations, and consideration of factors such as degree of processing.

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