September 11 and the 2011 anthrax attacks drew America’s attention to the role of public health in national security. The events of 2011 also led to an overhaul of public health laws that enable governments to respond rapidly and effectively to bioterrorism and other public health emergencies. Yet one of the biggest threats to national security is something much more mundane: America’s obesity epidemic.
In 2010 Mission Readiness, a coalition of retired U.S. military leaders, released a report on the effects of childhood obesity on military recruitment. The report estimated that 27% of 17-24 year olds (nine million young people) were “too fat to fight.” Retired four star U.S. Army General Johnnie E. Wilson concluded that childhood obesity “has become so serious in this country that military leaders are viewing this epidemic as a potential threat to our national security.”
Between 1959 and 2008 the percentage of civilians who exceeded the Army’s enlistment standards for weight and body fat more than doubled for men and tripled for women. One study suggests that a rise of just 1% in weight and body fat would further reduce the eligibility of over 850,000 men and 1.3 million women for military service. Obesity and overweight are now the leading medical reason why applicants fail to qualify for military service, challenging the military’s ability to maintain current personnel levels, and its potential to expand rapidly in response to emerging national security threats.
Of the recruits that do meet enlistment standards, an increasing number struggle to maintain basic physical fitness and to stay within military weight and fitness requirements. In 2008, 70,000 active duty service members received a medical diagnosis of overweight, and from 1995-2008 the proportion of recruits who failed their annual physical exams due to weight status rose by nearly 70%. Physical fitness and body weight are particularly relevant to military duties, with militaries worldwide using a fit appearance as a sign of strength, discipline and professionalism. Excess bodyweight also impairs physical fitness, which is critical to the performance of active duty and to maintaining combat readiness. Consider the efforts of Lance Corporal Todd Corbin, U.S. Marine Corp, when enemy forces used a suicide vehicle to ambush his platoon in Iraq:
[Lance Corporal Corbin] ran to his fallen patrol leader, threw him onto his shoulder and carried him to safety while firing at the enemy with his off-hand. He re-crossed the kill zone, made his way to his fallen corpsman, bound his wounds and began carrying him. As he began to move, the enemy engaged at close range and Lance Corporal Corbin threw himself on a wounded Marine and shielded him as friendly machine gun fire suppressed the enemy. Organizing Marines to suppress and repel the ambush, he then, on five occasions, ran through enemy fire, recovered dead or wounded personnel, and returned them to his truck. When the casualties were loaded onto his heavily damaged vehicle, he activated its emergency systems and drove it out of the kill zone and through the city to a battalion aid station five miles away.
[For his bravery, Lance Corporal Corbin received the Navy Cross in April 2006.]
Obesity presents a series of direct and indirect costs to the defence force. Each year the military discharges over 1,200 new enlistees before their contacts have finished due to weight problems. Each service member released requires an additional recruit to fill the vacancy, with each person costing approximately $50,000 to recruit and train, equating to $60 million each year. TRICARE, the US military health insurance program, spends just over $1 billion annually treating the costs of obesity-related illnesses – more than it spends on illnesses related to tobacco and alcohol consumption combined. Amongst active duty military, overweight and obesity are responsible for an estimated 658,000 missed work days and reduced productivity at work (‘presenteeism’) equating to 17,000 missed work days – a total productivity cost of $105.6 million per year.
Although we might associate military service with an active lifestyle, the US military faces changes in nutrition and physical activity patterns that mirror those found in the civilian population, and which make it more difficult for personnel to maintain a healthy weight. The availability of highly-processed, energy-dense foods and sugary beverages has increased on military installations, and the food options available to military personnel during deployment tend to be very high in calories, posing the risk of weight gain for those not engaged in active combat. Technology has decreased the amount of manual labour associated with many military jobs, and more military employees than ever are in sedentary occupations. Personnel also face challenges in maintaining a healthy weight that are unique to the military environment. Combat, exposure to heavy casualties and war zone deployment place service members at greater risk of stress, depression and anxiety, with poor mental health being linked to excess body weight.
Image from: www.army.mil
The military has responded to the obesity epidemic with a multi-pronged strategy, a key focus of which is childhood obesity. In 2010 Mission Readiness called on Congress to improve the nutritional standards for foods sold and served in schools – a measure that the federal government has recently adopted, along with proposals to ban junk food marketing in schools.
Spurred on by the First Lady’s efforts under the Let’s Move! Campaign, the Department of Defence formed a childhood obesity working group, which developed a strategic action plan to improve the food environment for children in military installations and to encourage physical activity such as walking and biking to school. The Department of Defence has also targeted children and military families for education campaigns that highlight the importance of eating five servings of fruits and vegetables a day, limiting screen time and sugary drink consumption, and making sure children get at least an hour of exercise each day.
A second element of the military’s obesity prevention strategy focuses on increasing physical activity in military personnel. In 2007 the Army initiated a waiver program allowing applicants to enlist without meeting weight standards, with new recruits given one year to comply with the Army’s physical fitness requirements. Although this widens the pool of potential recruits, it also places greater responsibility on the Army to ensure that new recruits lose weight safely, while still training to the same standards as other personnel. To help recruits and existing service members maintain a healthy weight, the Army has redesigned its physical fitness training program, by incorporating crossfit, and focusing on total body training tailored to the types of combat activities soldiers might be expected to perform.
A third prong of the military’s obesity prevention strategy attempts to improve the military food environment. In February 2012 Michelle Obama announced a new Pentagon obesity and nutritional awareness campaign that would change the nutrition standards for food sold and served on military bases for the first time in 20 years. Under the new program, each of the armed services will update their menu standards so that dining halls serve more fruits, vegetables, whole grains, lean meats and lower-fat entrees, as well as offering healthier choices in base schools, vending machines and snack bars – measures that will affect more than 1.5 million service members and 1,100 dining halls across the country.
Through Operation Live Well, established in 2013, the Defense Department offers the military community resources that aim to “make healthy living the easy choice and norm for service members, retirees, DoD civilians and their families,” such as cookbooks, fitness programs and educational material on healthy eating. A second part of the operation is the Healthy Base Initiative, rolled out across 14 installations in the same year, and offering a range of installation-tailored programs to help the defence community maintain a healthy weight and avoid tobacco use. The DoD has teamed up with industry and health representatives, the White House and military leaders to assess installations’ implementation of the initiative in the initial test sites, including healthy commissary offerings, ease of exercising, choices for healthy meals and the availability of healthy snacks in vending machines.
Image from: www.health.mil
The Department of Defense is the largest employer in the U.S., with 1.4 million men and women on active duty in the U.S. military, and an additional 1.1 million individuals in the military reserves. Its obesity-prevention programs represent the opportunity to instill healthy eating and physical activity habits in a significant sub-set of the workforce, as well as in military families, veterans and DoD civilians. The military could be a powerful partner in obesity-prevention programs in the wider population, and its approach to obesity prevention offers lessons that are equally applicable to prevention policies designed for the civilian population:
A comprehensive approach: Through education and information the DoD encourages military personnel and their families to eat healthily and exercise more, but it attempts to create a military environment that supports personnel in making healthier choices. The Defense Department recognizes that an individual-level focus produces limited improvements in population weight status; a better approach is to address the ‘upstream’ drivers of obesity by increasing the availability and affordability of healthy food, as well as opportunities for physical exercise.
Targeting children: Recent research shows a decline in obesity among American children aged 2-5 years, but rates of obesity remain flat among young people overall. Weight gain in children often leads to adulthood obesity and overweight and associated diseases such as diabetes and heart disease. It’s important to maintain a focus on preventing childhood obesity due to its implications for the future health of American adults, as well as its potential impact on national security. This means improving the nutritional quality of food served to children in schools, protecting children from exposure to junk food marketing and facilitating opportunities for outdoor play, walking and biking.
Obesity as a collective problem: It may be easier to see obesity as a collective problem in the military than it is in everyday office life. As Mission Readiness notes, “for military personnel the physical abilities of their colleagues can be the difference between life and death.” A lack of physical fitness impairs the ability of military personnel to support and protect their colleagues, imperilling the effective operation of the unit as a whole. In civilian life, obesity is more commonly seen as an individual problem with individual consequences. But civilians, too, are part of workforces, families and communities that work together and rely upon each of its members functioning to the best of their ability. The most critical lesson from military obesity prevention efforts is the importance of solidarity. Obesity is a collective problem – both for civilians and service members – and demands that we work together to create opportunities for everyone to lead healthier, more active lives.
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.