Selected weight management interventions for military populations in the United States: a narrative report

Randomized Controlled Trials to Treat Obesity in Military Populations: A Systematic Review and Meta-Analysis

In recent years, overweight and obesity have reached an alarmingly high incidence and prevalence worldwide; they have also been steadily increasing in military populations. Military personnel, as an occupational group, are often exposed to stressful and harmful environments that represent a risk factor for disordered eating, with major repercussions on both physical and mental health. This study aims to explore the effectiveness of weight loss interventions and assess the significance of current obesity treatments for these populations. Three online databases (PubMed, PsycInfo, and Web of Science) were screened to identify randomized controlled trials (RCTs) aiming to treat obesity in active-duty military personnel and veterans. Random-effects meta-analyses were conducted for body weight (BW) and body mass index (BMI) values, both longitudinally comparing treatment groups from pre-to-post intervention and cross-sectionally comparing the treatment group to controls at the end of the intervention. A total of 21 studies were included: 16 cross-sectional (BW: n = 15; BMI: n = 12) and 16 longitudinal (BW: n = 15; BMI: n = 12) studies were meta-analyzed, and 5 studies were narratively synthesized. A significant small overall BW and BMI reduction from baseline to post-intervention was observed (BW: g = -0.10; p = 0.015; BMI: g = -0.32; p < 0.001), together with a decreased BMI (g = -0.16; p = 0.001) and nominally lower BW (g = -0.08; p = 0.178) in the intervention group compared to controls at the post-intervention time-point. Despite limitations, such as the heterogeneity across the included interventions and the follow-up duration, our findings highlight how current weight loss interventions are effective in terms of BW and BMI reductions in military populations and how a comprehensive approach with multiple therapeutic goals should be taken during the intervention.

Translating the Diabetes Prevention Program Lifestyle Intervention to the Military Setting

INTRODUCTION

Diabetes and obesity pose a significant burden for the U.S. military beneficiary population, creating a great need to provide evidence-based diabetes and obesity prevention services for military personnel, retirees, and their dependents. Despite increasing dissemination of the Diabetes Prevention Program (DPP) lifestyle intervention nationwide, formal evaluation of implementation of this highly successful program is limited in the military setting. The purpose of this study is to prospectively evaluate delivery of a direct adaptation of a 1-year DPP lifestyle intervention at a U.S. Air Force medical facility, Wright-Patterson Medical Center (WPMC), to determine the feasibility of delivery of the program in a group of at-risk active duty military, retirees, and family members, as well as assess effectiveness in improving weight and other risk factors for type 2 diabetes.

MATERIALS AND METHODS

A pre/post study design was utilized to evaluate feasibility and effectiveness of the DPP Group Lifestyle Balance (GLB), an up-to-date, 22-session direct adaptation of the DPP curriculum, at WPMC. Participants chose to complete the 1-year program either in coach-led face-to-face groups or via DVD with weekly telephonic coach contact. The study was approved by the University of Pittsburgh and WPMC Institutional Review Boards.

RESULTS

A total of 99 individuals enrolled in the study, with 83 (84%) and 77 (78%) completing 6- and 12-month follow-up assessments, respectively. The mean age of participants at baseline was 57 (range 20-85 years), with 63% being female. The group was comprised of individuals who were non-Hispanic White (73.7%), non-Hispanic Black (18.2%), and other race or Hispanic ethnicity (8.1%). Within this group, there were 10 active duty military, 37 retirees, and 52 family members. The DPP-GLB program was shown to be feasible to implement in this military healthcare setting as demonstrated by the high engagement over the course of the year-long program. Significant improvements were shown in the two main behavioral goals: mean weight (-12.8 lbs, -6.3%, P < .001) and mean physical activity (PA) (+18.9 Met-hrs/wk, P < .001). In addition, significant improvements in other diabetes and cardiovascular risk factors including low-density lipoprotein cholesterol, fasting insulin, diastolic blood pressure, and waist circumference were noted, as well as improvement in health-related quality of life.

CONCLUSIONS

These results demonstrate that the DPP-GLB program delivered via face-to-face groups or DVD was feasible and effective in improving weight, PA levels, and diabetes and cardiovascular risk factors in this group of active and retired military personnel and their family members. The program was well received by the program participants as well as the WPMC team. These findings offer a model for provision of the DPP-GLB program throughout the Military Health System.

Effectiveness of nutrition interventions on improving diet quality and nutrition knowledge in military populations: a systematic review

CONTEXT

Optimizing nutrition in military groups through improved diet quality and nutrition knowledge is key in supporting the high physical and cognitive demands.

OBJECTIVE

The objective of this investigation was to systematically review the effectiveness of nutrition interventions among military personnel in improving diet quality and/or nutrition knowledge.

DATA SOURCES

Medline, Embase, CINAHL, and Scopus were searched from the earliest records to May 2020.

DATA EXTRACTION

Data were extracted by 2 reviewers. The primary outcomes were diet quality and/or nutrition knowledge.

DATA ANALYSIS

Twenty studies were included. The main intervention approaches identified were nutrition education of individuals (i.e., education-based studies; EB) (n = 12), and manipulation of the food service environment (i.e., dining facility studies; DFACs) (n = 8). The most common strategies were face-to-face lectures (n = 8) for EB, and healthier menus (n = 7) and education of catering staff (n = 6) for DFAC interventions. Most studies (18/20) demonstrated favorable within-group effects; however, dietary changes were inconsistent. Five of 10 studies using a comparator group demonstrated positive between-group differences.

CONCLUSION

Although potential exists for improving diet quality and nutrition knowledge in military populations, the heterogeneity of the studies to date limits conclusions on the most efficacious strategies.

Characteristics of Active Duty Service Members Referred to the Navy's Weight-Management Program

INTRODUCTION

Rates of overweight and obesity have increased in the military, particularly in the U.S. Navy. While the Navy has implemented weight-management programs like ShipShape, findings on the effectiveness of these programs are mixed. Further knowledge on the characteristics of service members (SMs) who participate in these programs may help inform course curricula and improve outcomes. This study aimed to (1) examine characteristics of SMs referred to the Navy's ShipShape program at a large military treatment facility, (2) compare these characteristics among SMs who did and did not enroll in a randomized clinical trial of ShipShape (ShipShape study participants), and (3) compare demographic and health characteristics of ShipShape study participants to that of a random and similarly sized sample of Navy SMs who responded to the 2015 DoD Health-Related Behaviors Survey (HRBS).

MATERIALS AND METHODS

Data from active duty Navy SMs referred to the ShipShape program at a large military treatment facility were evaluated (n = 225). A subset of these SMs enrolled in the ShipShape study (n = 187). Among enrolled SMs, data from 147 who completed all measures were compared to that of HRBS respondents. Univariate ANOVA and chi-square analyses were used to examine (1) demographic and motivational differences between SMs who did and did not enroll in the ShipShape study and (2) differences in demographics and medical and mental health conditions between ShipShape study participants and Navy HRBS respondents.

RESULTS

The majority of SMs referred to ShipShape were female with an average age of 28.3 years. Compared to SMs who did not enroll in the ShipShape study (n = 38), ShipShape study participants were more likely to be female, less likely to be Hispanic, and had higher motivation and emotional eating scores. Compared to Navy HRBS respondents (n = 164), ShipShape study participants (n = 147) were younger, more likely to be female, non-Hispanic, enlisted, and obese. Further, ShipShape study participants reported significantly fewer medical health conditions but higher rates of probable depression, anxiety, and PTSD and were more likely to report receiving current mental health treatment than HRBS respondents.

CONCLUSION

Overweight or obese SMs seeking weight loss in the ShipShape study were relatively young, female, non-Hispanic, motivated, but with greater emotional eating. ShipShape study participants endorsed few medical health conditions but had higher rates of probable mental health conditions compared to the HRBS sample. These findings suggest that SMs referred to Navy weight-management programs are likely experiencing comorbid mental health conditions which may interfere with the effectiveness of their weight loss efforts. The descriptive nature of this study and the focus on Navy SMs in only one ShipShape program may decrease the generalizability of our findings to participants at other locations. Nonetheless, these findings demonstrate the potential need for Navy weight-management programs that incorporate mental health treatment and address the specific needs of female and diverse SMs. A more comprehensive curriculum could improve the results of weight-management efforts, increase SM quality of life and fitness and thereby operational readiness.

Randomized trial of a novel lifestyle intervention compared with the Diabetes Prevention Program for weight loss in adult dependents of military service members

BACKGROUND

Lifestyle interventions are the first-line treatment for obesity, but participant weight loss is typically low.

OBJECTIVES

We evaluated the efficacy of an alternative lifestyle intervention [Healthy Weight for Living (HWL)] compared with a modified Diabetes Prevention Program (m-DPP). HWL was based on a revised health behavior change model emphasizing hunger management and the development of healthy food preferences. m-DPP was a standard Diabetes Prevention Program implemented with counselor time matched to HWL. Participants were adult dependents of military personnel and had overweight or obesity.

METHODS

Participants were randomly assigned to HWL (n = 121) or m-DPP (n = 117), delivered primarily by group videoconference with additional midweek emails. The primary outcome was 12-mo weight change. Secondary outcomes included 6-mo changes in cardiometabolic risk factors and diet. Intention-to-treat (ITT) and complete case (CC) analyses were performed using linear mixed models.

RESULTS

Retention did not differ between groups (72% and 66% for HWL and m-DPP at 12 mo, respectively; P = 0.30). Mean ± SE adjusted 12-mo weight loss in the ITT cohort was 7.46 ± 0.85 kg for HWL and 7.32 ± 0.87 kg for m-DPP (P = 0.91); in the CC cohort, it was 7.83 ± 0.82 kg for HWL and 6.86 ± 0.88 kg for m-DPP (P = 0.43). Thirty-eight percent of HWL and 30% of m-DPP completers achieved ≥10% weight loss (P = 0.32). Improvements in systolic blood pressure, LDL cholesterol, triglycerides, fasting glucose, general health, sleep, and mood were similar across groups; improvements in diastolic blood pressure were greater in m-DPP. Adjusted group mean reductions in energy intake were not significantly different between groups, but HWL participants were more adherent to their dietary prescription for lower glycemic index and high fiber and protein (P = 0.05 to <0.001 for ITT).

CONCLUSIONS

HWL and m-DPP showed equivalent and clinically impactful mean weight loss with cardiometabolic benefits. These results identify an alternative approach for behavioral treatment of overweight and obesity.This trial was registered at clinicaltrials.gov as NCT02348853.

Effectiveness of Lifestyle Interventions in an Active Duty Air Force Population

PURPOSE

To examine the effectiveness of 3 lifestyle intervention programs in an active duty military population.

DESIGN

Experimental design with stratified random assignment to 1 of 3 intervention groups. Measures were taken at baseline, 3 months and 6 months.

SETTING

A Military Treatment Facility in the western U.S.

SUBJECTS/INTERVENTION

122 active duty service members were enrolled and randomly assigned to 1 of 3 lifestyle intervention programs: the Diabetes Prevention Program-Group Lifestyle Balance (DPP-GLB), the Better Body Better Life (BBBL) program or the Fitness Improvement Program (FIP).

MEASURES

weight, abdominal circumference, lipid and HbA1c levels, physical activity, and well-being as measured by the RAND SF-36 questionnaire.

ANALYSIS

Statistical analyses were performed to assess changes over time.

RESULTS

83 participants completed the study (BBBL N = 23, FIP N = 30, DPP-GLB N = 30). The DPP-GLB participants had statistically significant decreases in weight (-3.1 pounds, p = .01) and abdominal circumference (-0.9 inches; p = .01) over time. HbA1c was also significantly lower in this group at 6 months compared to baseline (p = .036). There were no statistically significant changes in weight, abdominal circumference, or HbA1c in the FIP or BBBL groups. No significant changes were observed in lipids in any of the groups.

CONCLUSION

Results from this study indicate that the DPP-GLB program may be effective in reducing weight, abdominal circumference, and HbA1c in an active duty U.S. military population.

Efficacy of Weight Loss Interventions in United States Active Duty Military Populations: A Systematic Review

BACKGROUND

Since the beginning of overseas contingency operations, the percent of service members who are considered overweight or obese has tripled to 15% for men and 20% for women. This has implications for national security if the country is unable to staff its military with fit-to-fight individuals. The purpose of this systematic review is to move policy efforts forward by illuminating the efficacy of several lifestyle interventions for active duty service members since 2001. It aims to both identify common aspects of successful interventions and also identify interventions without success so DoD leaders may replace those initiatives.

MATERIALS AND METHODS

The electronic database PubMed was searched from September 11, 2001 to May 15, 2020. Studies were included if the target population was United States active duty service members from any branch, the study included an intervention, and the measured outcome was weight loss. Seven studies met final inclusion criteria.

RESULTS

Interventions with corresponding weight loss data are summarized in Table III. This review found that there is not a sufficient body of evidence to determine if interventions to aid active duty service members in losing weight are effective.

CONCLUSION

However, as a collection, the studies could support the notion that military members get the best results when interventions are convenient, modern, personalized, and accessible. More studies are needed, and future studies with larger sample sizes and longer durations would be valuable in determining efficacy of weight loss interventions. Undoubtedly, enrollment and compliance is difficult with military member moves and competing mission requirements. Ideally, the DoD should work to aggregate the efforts in this field, as many initiatives are not captured, shared, and utilized by other installations or other services. Data silos and unpublished or underdeveloped research reactively addresses issues and does not proactively address them. Policy change will need to be nested in further research, as well as consider the food environment on bases and possible prevention efforts.

Weight Loss Intervention Impact on the Physical Fitness Test Scores of Air Force Service Members

INTRODUCTION

Overweight and obesity are a major public health concern in the United States, including among active duty military personnel. Approximately 51% of active duty personnel are classified as overweight and 15% are classified as obese. This may impact military readiness. The current study aimed to determine if a weight loss intervention impacted fitness test scores among Air Force personnel.

MATERIALS AND METHODS

From 2014 to 2016, 204 Air Force members with overweight/obesity were randomized into either a Self-paced or counselor-initiated arm in a weight loss program. Study procedures were approved by the Institutional Review Board of the 59th Medical Wing in San Antonio and were acknowledged by the Institutional Review Board at the University of Tennessee Health Science Center. Fitness test scores from before, during, and after the intervention were used to determine if the intervention resulted in improvements in overall fitness test ratings and scores on individual components of the test.

RESULTS

Participants who lost at least 5% of their weight had better fitness ratings during the intervention compared to individuals who did not lose 5%. However, in the overall sample, fitness ratings worsened from preintervention to during the intervention, and from during to postintervention. Participants with overweight had better aerobic scores pre- and postintervention as well as better abdominal circumference scores and better fitness test ratings preintervention, during the intervention and postintervention compared to participants with obesity.

CONCLUSIONS

Behavioral weight management interventions that achieve 5% weight loss may help improve military fitness test ratings.

"Making weight" during military service is related to binge eating and eating pathology for veterans later in life

PURPOSE

"Making weight" behaviors are unhealthy weight control strategies intended to reduce weight in an effort to meet weight requirements. This study aimed to examine a brief measure of making weight and to investigate the relationship between making weight and weight, binge eating, and eating pathology later in life.

METHODS

Participants were veterans [N = 120, mean age 61.7, mean body mass index (BMI) 38.0, 89.2% male, 74.2% Caucasian] who were overweight/obese and seeking weight management treatment. Participants completed the making weight inventory (MWI), a measure of making weight behaviors engaged in during military service, and validated measures of eating behavior. Analyses compared participants who engaged in at least one making weight behavior (MWI+) versus those who did not (MWI-).

RESULTS

The MWI had good internal consistency. One-third of participants were MWI+ and two-thirds were MWI-. The most frequently reported behavior was excessive exercise, reported in one-quarter of the sample, followed by fasting/skipping meals, sauna/rubber suit, laxatives, diuretics, and vomiting. MWI+ participants were significantly more likely to be in a younger cohort of veterans, to be an ethnic/racial minority, and to engage in current maladaptive eating behaviors, including binge eating, vomiting, emotional eating, food addiction, and night eating, compared to the MWI- group. Groups did not differ on BMI.

CONCLUSIONS

One-third of veterans who were overweight/obese screened positive for engaging in making weight behaviors during military service. Findings provide evidence that efforts to "make weight" are related to binge eating and eating pathology later in life. Future research and clinical efforts should address how to best eliminate unhealthy weight control strategies in military service while also supporting healthy weight management efforts.