While the vast majority of soldiers maintain healthy weights, bad habits developed during deployment and on military bases follow them after retiring from the Army. In fact, more than 70% of veterans end up overweight. To combat that trend, the Army is pilot-testing a Performance Triad program where non-commissioned officers take the lead in teaching healthy habits.
By Stephen Spotswood
WASHINGTON — When Lt. Gen. Patricia Horoho, U.S. Army surgeon general, visited Afghanistan, she observed troops doing their best to cope with the stresses of being in theater: They ate what was available, regardless of nutritional content, and downed a steady stream of caffeine and supplements to help keep them alert and awake.
Not only did the servicemembers’ health suffer while they were deployed, but they also brought these patterns of behavior home with them to military bases around the country. The lack of sleep, irregular activity and poor eating habits put soldiers at risk of obesity, no matter how fit they were after basic training.
Nutrition is one of three components of the Performance Triad. Military food service centers across the country are changing menus to urge healthier eating with more vegetables, fruits and whole grains, along with plant-based and lean animal protein sources like fish, beans and nuts.
The problems continue after a return to civilian life. Veterans who have recently made the transition out of military service often present sudden weight gain, which can lead to high blood pressure, diabetes and other health problems.
In response, the Army is attempting to make a slow sea change in health literacy among soldiers, hoping that by seeding behavioral changes now, they can reap benefits down the line.
Squad Leaders in Charge
In fall 2012, Horoho began a strong push to find ways to ensure Army personnel had the correct balance of sleep, nutrition and activity — the key components to health the Army has labeled the “Performance Triad.” The goal is to find ways to embed healthy activity, nutrition and sleep information and behavior into the everyday patterns of soldiers on base.
Army experts spent a year work-shopping the program, exploring ways to approach soldiers that would not look like just another public relations push.
In September 2013, having settled on an approach they believed would be successful, the Army launched the Performance Triad Pilot program at three Army sites — Joint Base Lewis-McChord in Washington, Fort Bliss in Texas and Fort Bragg in North Carolina. A select group of soldiers at each base was targeted for participation.
More specifically, squad leaders were chosen to participate — the noncommissioned officers (NCOs) who are the first rung of the chain of command and the closest to the soldiers they supervise.
“We looked at how we train soldiers,” explained Barbara Ryan, a retired Army lieutenant colonel and registered nurse who is the lead for Performance Triad training, education and communications. “Squads are considered a force-and-combat multiplier. Now that they’re back in a garrison environment, it’s the NCOs who have to make mission decisions every day. We empowered those squad leaders. They’re the ones responsible for taking care of their soldiers and for their well-being. We thought they had the most influence.”
Content was not the question, Ryan explained. The healthcare information regarding sleep, nutrition and activity has long been well-understood and well-documented. What was in question was the vector through which that information reached the soldiers. By putting the information in the hands of the NCOs, Ryan and her colleagues believed that not only would servicemembers be more receptive, but also the NCOs would be better able to track soldiers’ lifestyles and health choices.
Spc. Christina Seabrook, from the 189th Combat Service Support Battalion, gets some hands-on activity training as a member of the Army’s Performance Triad pilot program at Fort Bragg, NC. Photo by Reginald Rogers.
“They’re responsible for training and motivating, and really for that mission accomplishment,” Ryan said.
The squad leaders trained for two weeks on ways to motivate their soldiers to eat, move and sleep better. They will, in turn, drill that knowledge into the men and women under them.
“In the training, they get scenarios: How do I influence my soldier?” Ryan explained. “We worked with psychologists and built motivational interviewing techniques. It wasn’t ‘Don’t do that.’ It was ‘We want you to think about this and the choices you make.’”
Changing the Base Environment
The program also is looking at the environment in which soldiers and their families find themselves when living or working on base. Like many civilians, servicemembers can be sedentary for much of the day yet burdened with a schedule that pushes them to find the fastest, most convenient source of food.
“We’re doing an environmental scan [as part of the program],” Ryan said. “We’re looking at how we’re set up in camps and stations to support healthy activity. What [fast foods] are on post? What do these soldiers and families have access to? How do we set up in camps and stations to support healthy activity?”
Fast food outlets such as McDonald’s, Burger King, Pizza Hut and Taco Bell can all be found on military installations. While there has been a recent run of fast food restaurant closures, those reportedly had more to do with new laws on pay and health insurance than on health.
“We have a supplement culture. We have an energy drink culture,” Ryan said, pointing out that the military “just came out with a pizza MRE, much to the chagrin of our nutrition [experts].”
This has Ryan and her colleagues looking for any leverage they can use to change the public health environment. They took great interest in the news that pharmacy giant CVS would be taking tobacco products out of their stores in the interest of promoting health and are wondering whether something similar can happen with base exchanges.
This concern about soldiers’ environment and day-to-day living is a reflection of the realities of how little interaction soldiers have with the military health system — only 100 minutes a year, Ryan said. If the Army wants to have a deep and lasting impact, it will have to take a close look at where servicemembers spend the vast majority of their time.
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The Performance Triad program also is designed to help keep soldiers’ weight and other health markers in control after leaving the service.
In 2012, 2,300 soldiers were discharged due to being overweight, costing the Army upward of $63 million in lost expertise.
As of fall 2013, however, only 13,320 active duty members of the Army were categorized as overweight, while 20,221 members of the Reserves were overweight. Compared to the size of the entire force —539,675 in the Army and about 199,000 in the Reserves — these are small percentages. They are much lower than the average number of overweight and obese individuals in the civilian population (35% obese, 70% overweight).
That can change once the soldiers begin the transfer to civilian life. Without a solid foundation of the kind of habits the Performance Triad stresses, new veterans can quickly find themselves gaining weight. In fact, according to the national Centers for Disease Control and Prevention, Atlanta, about 70% of veterans are overweight or obese.
“We know our retiree population in 12 to 24 months of retirement — 86% break out into the overweight or obese [categories],” Ryan said. “We’re trying to influence them today to think about the long term. We’re trying to figure out how to influence our younger soldiers and how we get them to the point of transition. How do we them to think about health in the long term?”
The Army will be taking notes on the effort’s results. The Performance Triad pilot includes a longitudinal study that will track health markers of 1,000 participants for five to seven years. The study also will eventually include cognitive and laboratory components.
Data analysis on the Performance Triad will begin this summer, with initial results expected in August and September.
At this point in the process, Ryan said, it’s less a question of whether the pilot will expand into a full-fledged effort than how quickly it will expand, noting that units outside the pilot sites already are requesting program materials.
“There’s been a groundswell of interest. People are running with the material,” Ryan said. “We’re seeing people awakened to the tenets [of the program].”
Ryan and her colleagues plan to use the summer to help further promote the Performance Triad. A Women’s Health Week in May and a Men’s Health Awareness Week in June, and August will be Performance Triad Month. Ryan said she hopes the back-to-back opportunities will give medical treatment facilities the opportunity to feature local stories about public health awareness and reach people who have not yet heard about the Performance Triad.
“Did we think we were going to have a 180 [degree change] and everybody would be healthier?” No,” Ryan said. “But we’re hoping to turn the dial by degrees.”
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