Weight change, lifestyle, and dietary behavior in the US Military's Warrior in Transition Units.
Subject: Obesity (Military aspects)
Military bases (Military aspects)
Body mass index (Military aspects)
Soldiers (Surveys)
Soldiers (Behavior)
Soldiers (Military aspects)
Authors: Kieffer, Adam J.
Cole, Renner E.
Pub Date: 10/01/2012
Publication: Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 U.S. Army Medical Department Center & School ISSN: 1524-0436
Issue: Date: Oct-Dec, 2012
Product: Product Code: 9104131 Military Bases NAICS Code: 92811 National Security
Accession Number: 309980588
Full Text: The Warrior in Transition Unit (WTU) program is a comprehensive continuum of care for service members and their families, with WTU units located at US military installations throughout the world. A Warfighter who requires significant medical treatment or rehabilitation anticipated lasting 6 months or more in order to return to duty or successfully transition to veteran status is assigned to a WTU. (2) The WTU achieves individualized care by assigning a "triad" to each service member: the primary care manager, nurse case manager, and squad leader or platoon sergeant. (3) This collaboration of both military and civilian leadership ensures a centralized support network for the Warfighters and their families, streamlined appointments and treatments, and efficient documentation. (4) The length of stay in the WTU is dependent on the severity of illness or injury and the extent of treatment required. (3) As of April 2010, there were 9,200 Soldiers in the 32 WTUs throughout the United States. (5)

Body weight is a polarized issue in any hospital setting, depending on the stage of healing. Preventing weight loss is a concern for patients and Warfighters who have experienced severe trauma, burns, and/or amputation. They are encouraged to consume adequate calories to meet their increased resting metabolic demands. (6,7) Once released from the inpatient setting and enrolled in the WTU, the concern becomes preventing unwanted weight gain as metabolic needs return to normal after healing. In the outpatient setting, excess body weight is detrimental, increasing the Warfighter's risk for delayed wound healing, hyperlipidemia, type 2 diabetes, and cardiovascular disease. (8,9)

Department of Defense (DoD) Directive 1308.3 (10) provides guidelines on body weight standards for the military services. The directive states that service members must maintain a combat-ready body weight and body fat. Assessment of this standard includes body fat testing, from which WTU participants are exempt while healing. Specifically for the Army, the Army Weight Control Program requires Soldiers to maintain a healthy weight-for-height and body fat percentage based on age and gender. (11) A healthy weight-for-height is assessed with the use of body mass index (BMI; kg/[m.sup.2]). (12) The Army allows for a higher BMI (up to 27.5 kg/[m.sup.2]) in Soldiers compared to nationally accepted civilian classification for normal BMI (up to 25 kg/[m.sup.2]) due to an expected higher lean body mass. (11) Soldiers can face disciplinary action, including discharge, if they do not meet these standards. For example, in 2010 the Army released approximately 1,200 initial enlistees within the first year of service for not meeting weight for height standards. (14) Gaining weight while in the WTU may have a negative effect on a Warrior's transition back to duty. On the other hand, many WTU Warfighters are released from active duty and enter the national pool of veterans. Research assessing veteran weight status, including veterans from the Gulf, Iraq, and Afghanistan wars, indicates that veterans have a higher prevalence of overweight rates than the national norm with 73% of male and 54% of female veterans being overweight. Further, in those studies, veterans tended to gain 2.2 kg/year more than those still on active duty over a 6-year period of assessment. (15-18)

Although observations suggest that Warfighters gain weight while in the WTU, no published information currently exists regarding their dietary habits, lifestyle factors, and weight trends. It can be reasonably assumed that significant changes in the Warfighter's life (such as new residence, injuries, limited access to food preparation, inactivity) could dramatically affect lifestyle and eating behaviors. Weight gain can be detrimental to recovery and may contribute to health-related comorbidities, prolonging the Warfighter's recovery. (2) By assessing the WTU weight change, lifestyle behaviors, attitudes, and access to healthy food and preparation equipment, a nutrition intervention can be tailored to the WTU to increase the speed of recovery. A tailored intervention could provide them with sufficient tools to increase their quality of life while assigned to the WTU and assist in their transition back to duty or return to civilian life. The objective of this study was to determine what lifestyle factor changes, following injury and enrollment in the WTU, may affect their weight status.

SUBJECTS

Four hundred twelve Warfighters assigned to WTUs were recruited across 4 locations: San Antonio Military Medical Center (SAMMC), Fort Sam Houston, Texas; William Beaumont Army Medical Center (WBAMC), Fort Bliss, Texas; Carl Darnell Army Medical Center (CDAMC), Fort Hood, Texas; and Dwight D. Eisenhower Army Medical Center (EAMC), Fort Gordon, Georgia. These WTU locations were chosen to reduce geographical bias and increase diversity in the sample population. The only inclusion criterion for this study was age of 18 years or older. There was no exclusion criterion.

Study participants were recruited and data collected from February through July 2009.

METHODS

The study was a multicenter, cross-sectional, descriptive design. To assess weight change and lifestyle factors, a self-reported questionnaire was created. The survey consisted of 5 sections totaling 24 questions with 142 possible variables: demographic (gender, height, weight, length of time in WTU, etc); living arrangements and transportation (such as access to transportation, type of lodging); tobacco habits; weight and lifestyle behaviors (for example, perceived weight, perceived weight gain or loss post injury, changes in lifestyle factors post injury, physical activity); and food and nutrition (number of meals consumed per day, location of consumption, changes to dietary habits post injury, etc). The WTU Warfighters were classified above and below a BMI of 27.5 kg/[m.sup.2] as well as by the National Heart, Lung, and Blood Institute's (NHLBI) BMI classifications14: underweight (BMI <18.5 kg/[m.sup.2]); normal weight (BMI 18.5 to 24.9 kg/[m.sup.2]); overweight (BMI 25.0 to 29.9 kg/[m.sup.2]); and obese (BMI [greater than or equal to] 30.0 kg/[m.sup.2]). Access to basic food preparation equipment was assessed through a 12-variable question to identify what aspects of food preparation were within the WTU Warfighter's control, and ranged from no access beyond a dining facility to items such as refrigerator, microwave, cookware, silverware, and food storage area. The survey was pilot tested by subjects representative of the population and SAMMC health professionals to assess content validity prior to distribution. Recruitment occurred at primary care appointments and WTU information sessions. The study followed a protocol approved by the Institutional Review Boards at SAMMC (also covering CDAMC), WBAMC, and EAMC, and was classified as an exempt protocol. Warfighters who volunteered to complete the survey received a free water bottle as an incentive, funded by the SAMMC Department of Clinical Investigation.

STATISTICAL ANALYSIS

The sample size was determined by a margin of error at the 95% confidence interval for a probability estimate of 50%. The 95% confidence interval (CI) for a binomial probability was calculated from the Wald equation yielding the need for 384 subjects to estimate a probability of 0.50 with a 95% CI of 0.50[+ or -]0.05 (5% error). To allow for a 5% margin of error, a target sample size of 400 completed surveys was chosen.

Data were analyzed using SPSS version 16.0 (SPSS Inc, Chicago, Illinois). Descriptive statistics and frequencies were utilized for nominal data. Chi-square analysis was conducted comparing BMI [greater than or equal to] 27.5 kg/[m.sup.2] (overweight), BMI <27.5 kg/[m.sup.2] (normal weight), and NHLBI BMI >25 kg/[m.sup.2], with current accommodations, injury, changes in lifestyle habits, amount of activity, food prep/cooking access, and Soldier demographics of those who gained weight compared to those who lost weight following injury. Spearman's rho correlation analysis was completed on the continuous BMI scale data and various categorical data.

RESULTS

Demographics

The demographic descriptive results (Table 1) show that wounded Warfighters within the 4 locations were predominately US Army Soldiers (97.6%), most likely white males aged 23 to 43 years in the ranks of specialist (E-4) to staff sergeant (E-6). A variety of injuries were listed, with 24% requiring assistance for ambulation, 30% with a traumatic brain injury, and 7% resulting in extremity amputation. The majority of participants (66.4%) reported having basic access to food preparation equipment such as a refrigerator, microwave, and cooking supplies, and that participants living in the barracks/billets were more likely to report insufficient access compared to Soldiers living off-post (P <.05). Location of residence differed greatly among installations, but overall, 50% were assigned to individual on-post housing (barracks/billets) and 50% to family housing.

Weight Change

Two hundred two participants (51.1%) had BMI values [greater than or equal to]27.5 kg/[m.sup.2] and did not meet height and weight standards specified by Army Regulation 600-9 (11) The BMI distribution across the WTU military installations is presented in the Figure. Using NHLBI criteria for categorizing BMI, 4% of participants were underweight, 23.1% were normal weight, 42.6% were overweight, and 33.2% were obese. The majority of participants (51.1%) self-reported themselves as overweight. The BMI was positively correlated with WTU length-of-stay (P=.017; r=0.121) and age (P=.002; r=0.157). Men were more likely to gain weight than women while in the WTU (P<.05).

No significant trend was found to support that weight was only gained during deployment and following injury. Some participants reported weight gain while others reported weight loss before and after their injury/illness. Prior to entering the WTU, 37.5% of participants experienced weight change. Deployment, stress, desire to lose weight, and illness were the main reasons for weight loss; while stress, illness, medications, and limited activity were cited for causes of weight gain. The majority (85%) of participants experienced a weight change following their injury (n=342); 63.3% gained weight while 21.9% lost weight. Limited activity and medication use were listed as the main reasons for weight gain (66% and 46% respectively). Deployment was listed as the main reason for weight loss prior to injury (21.7%).

Lifestyle Factors that May Contribute to Weight Change

Warfighters with a BMI [greater than or equal to] 27.5 kg/[m.sup.2] were more likely to make lifestyle changes following injury (P=.000; r=-0.206). More than 50% of participants changed at least one of the following lifestyle factors (Table 2): skipping meals, eating snacks, eating at sit-down restaurants, performing aerobic and anaerobic physical activity. Warfighters usually consumed 3 standard meals at their assigned housing (38% to 56%) or the dining facility (25% to 34%). They reported that the meal typically skipped was breakfast and about 50% consumed snacks throughout the day. Approximately 57% of participants reported ambulating daily, whereas only 20% of participants reported performing physical activity 4 to 5 times weekly. No statistical differences existed between lifestyle factors (dietary or physical activity) and residence, meal frequency, BMI, or other demographic variables.

Interest in Specific Health Topics

Sixty-one percent of participants reported wanting to lose weight. Participants were asked to rate their level of interest (none, somewhat, very) in the following topics: healthy foods, healthy shopping, cooking, meal planning, weight management, sports nutrition, healthy snacks, and supplements. All topics received interest (>50%), however, learning about healthy foods and snacks created the strongest interest.

COMMENT

The results from this study support the hypothesis that Warfighters experience weight change following injury; 63 % of Soldiers gained weight postinjury, and 61% were trying to lose weight. To date, this is the first study published evaluating lifestyle factors contributing to weight change in the WTU following their injury.

At the time of the study, DoD Directive 1308.3 (10) did not address weight standard adjustments for excess weight gain during the rehabilitative process. It is unknown how an elevated BMI would affect a WTU Warfighter's reintegration process especially when faced with the burden of negative administrative consequences of failing to meet current weight-for-height standards. This study found that nearly 51% of WTU Warfighters did not meet Army standards for BMI and over 60% did not meet NHLBI criteria for normal weight BMI. It has been established that unintentional weight gain can affect the recovery of patients receiving treatments. (8,9) Being overweight or obese (BMI [greater than or equal to]25 kg/[m.sup.2]) can increase the risk for impaired glucose tolerance, hyperlipidemia, and cardiovascular disease and is associated with increased mortality and delayed wound healing. (8,9,19-22) Nearly half of the WTU Warfighters believed that medications contributed to their weight change. Although some behavior health medications are shown to cause weight gain, obesity may be burdensome and require patients to take additional medications to combat side effects of that obesity. (23-25) Recent research suggests that emotions, environmental triggers, stress, medication use, and sleep deprivations contribute to the weight management challenges by interrupting the homeostatic and hedonic system balance of food intake. (19-20,26-35,50) It is plausible that all of these unconventional factors can effect WTU Warfighters in their recovery efforts and thus warrant further investigation.

Results showed that more than 50% of WTU Warfighters changed their meal patterns, timing, and frequency including skipping meals, eating snacks, and eating at sit-down restaurants. Skipping meals, especially breakfast, has been shown to hinder weight control. (36-38) Additionally, regular frequency of meals and structured meal patterns have been associated with decreased appetite, increased nutrient utilization, and increased weight control compared to irregular eating patterns. (39-49) Promotion of these behaviors may assist with weight control in the WTU.

Beneficial changes are continually improving the WTU accommodations, but this study found that WTU Warfighters living in the barracks were less likely to have sufficient access to food preparation equipment compared to WTU Soldiers living off-post or in family housing. Even though some WTU facilities have access to a central kitchen with adequate food preparation and cooking supplies, Warfighters may not have the cooking skills or adequate nutrition knowledge to develop healthy meal options. Although participants' nutrition knowledge was not assessed, heavy marketing and access to quick, high calorie food outlets, such as fast food restaurants, have a direct effect on weight control balance. (50) Future research could focus on how to encourage awareness of and use of food preparation in the barracks and assess effect on weight change following injury. Nutritional programs aimed at smaller meal consumption, inclusion of breakfast, making healthier food choices, and cooking with limited access to kitchen utilities could improve Warfighters' rehabilitation while in the WTU. Dining facilities were reported as the second most common site for meal consumption, thus targeting the dining facility with programs such as the "Go for Green" nutrition performance program. (51) The dining facility can indeed be a beneficial resource for the WTU Warfighter in promoting healthier meal choices.

Physical activity plays a key role in weight management, (52-54) and our study determined that less than 30% of Soldiers in the WTU met the minimum recommendation for physical activity (30 minutes of moderate-intensity exercise most days of the week) established by the American College of Sports Medicine. (55) More than 50% of Soldiers indicated decreased physical activity as the main reason for their weight change. Physical activity should be promoted and tailored based upon factors such as injury and medical procedures. It is possible that a Soldier may have to learn to use unfamiliar exercise method and equipment to accommodate a specific injury. As wounded Warfighters transition to the WTU, physical activity alterations as part of their rehabilitation may assist their weight management efforts as well as promote healing.

Limitations of this study include: biases associated with self-reported BMI, inability to adjust BMI for percent body weight amputations (7% of total injuries reported), differences in WTU accommodations among installations, and questionnaire-design inability to verify the motivation for lifestyle change. On the other hand, a major strength was multicenter WTU sampling.

Overall, this study found that lifestyle factors (dietary and physical activity) changed following injury regardless of reported weight gain or loss. Warfighters with a BMI [greater than or equal to]25 kg/[m.sup.2] made more lifestyle changes than Warfighters with a BMI <25 kg/[m.sup.2], possibly because overweight Warfighters were more likely to try different methods to lose weight. Understanding their motivation for lifestyle change would help tailor an intervention specific to their needs. The majority of Soldiers indicated the desire for classes or additional training/ information regarding weight management, healthy activities, and lifestyle changes. With the prevalence of weight change in the WTU and with weight gain being a health concern, optimal treatment should include weight management and physical activity strategies; providing individualized nutrition and physical education may promote a healthy lifestyle.

CONCLUSION

This study determined that Soldiers have significant weight changes while in the WTU. A majority of Soldiers consider themselves overweight and want to lose weight. Lifestyle factors change upon entry into the WTU and specific reasons behind these changes should be further studied. Physical activity is significantly reduced following injury and may contribute to weight gain. There is a need for more focused nutrition-related and physical fitness-oriented interventions and program for Warriors to aid recovery, promote rehabilitation, and decrease length of time in the WTU. Although current healthcare practices for WTU Warfighters is praiseworthy, it is important to address the Warfighter's weight gain and possible effects it may have on their return to duty. Dietitians reinforce nutritional supplements and adequate energy needs while inpatient to promote healing, but Warfighters are not necessarily educated on how to make adjustments in caloric intake as healing and energy needs subside, nor habits to support long-term proper weight management. Establishing a nutrition education intervention as the Warfighter transitions from inpatient to the WTU outpatient setting for rehabilitation may promote effective weight management and prevent interruptions to the reintegration process.

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AUTHORS

CPT Kieffer is Chief, Nutrition Care Division, Reynolds Army Community Hospital, Fort Sill, Oklahoma. When this study was conducted, he was a student in the US Military-Baylor Graduate Program in Nutrition, Fort Sam Houston, Texas.

MAJ Cole is Program Director, US Military Dietetic Internship Consortium, Army Medical Department Center and School, Fort Sam Houston, Texas. She is also an Associate Professor, Baylor University, at the US Military-Baylor Graduate Program in Nutrition.

CPT Adam J. Kieffer, SP, USA

MAJ Renee E. Cole, SP, USA
A Warrior in Transition is a Soldier who is assigned/
   attached in a Warrior Transition Unit and whose primary
   mission is to heal. (1)


Table 1. Demographics of WTU Warriors (N=412 *)

Location                                n (%)
  Fort Sam Houston, TX                 134 (32.6)
  Fort Gordon, GA                      117 (28.5)
  Fort Hood, TX                        111 (27.0)
  Fort Bliss, TX                        49 (11.9)
Gender
  Male                                 363 (89.0)
  Female                                45 (11.0)
Military Service
  Army                                 402 (97.6)
  Marine Corps                              4 (1)
  Air Force                               1 (0.2)
  Navy                                    1 (0.2)
  Not indicated on survey                   4 (1)
BMI (mean =28.3 kg/[m.sup.2],
SD [+ or -]5)
  BMI < 27.5 kg/[m.sup.2]               193 (48.9)
    (%) ([dagger])
  BMI [greater than or equal to]        202 (51.1)
    27.5 kg/[m.sup.2]
    (%) ([double dagger])

Mean Age   33 years, SD[+ or -]10)

Race/Ethnicity
  Black                                  75 (18.4)
  White                                 229 (56.3)
  Hispanic                               66 (16.2)
  Asian                                    4 (1.0)
  Other                                   33 (8.1)
Length of stay in WTU
  0-6 months                            177 (44.3)
  6 months-1 year                       109 (27.3)
  1 year-2 years                         90 (22.5)
  >2 years                                24 (6.0)
Military Rank
  E1-E3                                   32 (8.0)
  E4-E6                                 298 (74.1)
  E7-E9                                  50 (12.4)
  O1-O3                                   13 (3.2)
  O4-O6                                    7 (1.7)
  WO1-WO5                                  2 (0.5)
Highest education attained
  High school                           125 (30.9)
  Some college                          183 (45.2)
  Associates degree                      42 (10.4)
  Bachelors degree                       45 (11.1)
  Graduate degree                         10 (2.5)
Residence
  Barracks/Billets                      195 (46.6)
  On-post family housing                  32 (7.8)
  Fisher House                             6 (1.5)
  Guest house                             25 (6.1)
  Off-post family housing               151 (36.8)
Injury/Illness
  Traumatic brain injury (TBI)            29.5%
  Burn                                     5.3%
  Amputation                               7.3%
  No amputation                           33.2%
  Other                                   56.2%
Require assistance for moving             24.0%

* Not all questions in each category were completed
by all participants. Percentages are calculated
for total responses in the category.

([dagger]) Allowable BMI per Army Regulation 600.9

([double dagger]) Overweight BMI per Army Regulation 600.9

Table 2. Percentage of subjects who indicated changes (or
none) in lifestyle factors following injury.

                                              More   Less    No
                                                           Change

Attend a weight loss program                   5.5    7.3   86.7
Used diet/low calorie food                    22.5    9.3   68.2
Ate smaller portions                          37.0   11.6   51.4
Skipped meals *                               38.1   13.6   48.3
Ate snacks *                                  23.6   26.4   50.0
Drank alcohol                                  8.3   24.5   67.2
Ate carbohydrates                             20.0   20.8   59.2
Ate sweets                                    16.2   27.9   55.9
Drank sugary beverages                        17.8   28.2   54.0
Ate high fat foods                            17.2   25.9   56.9
Ate fruits                                    33.5   14.7   51.8
Ate vegetables                                34.7   12.3   53.0
Ate at fast food restaurants                  18.3   30.0   51.4
Used sugar-free sweeteners                    15.5   10.9   73.6
Ate at buffets                                 8.4   30.9   60.7
Ate at sit-down restaurants *                 22.6   28.7   48.7
Drank crystal light or sugar-free beverages   13.5   17.9   68.3
Took dietary supplements                       7.3   11.4   81.3
Drank sports beverages                        25.6   18.2   56.2
Performed aerobic activity *                  26.3   35.5   38.2
Performed anaerobic/strength activity *       21.7   39.5   38.8

* 50% or more of the subjects changed this lifestyle factor.

THE ARMY MEDICAL DEPARTMENT JOURNAL

                          Body Mass Index

                    Normal   Overweight   Obese

Fort Sam Houston     40.7     32.7         26.5

Fort Gordon          26.4     24.4         37.9

Fort Hood            22       25.6         29.5

Fort Bliss           11       17.3          6.1

Note: Table made from bar graph

Body mass index distribution of WTU study subjects by military
installation.
Gale Copyright: Copyright 2012 Gale, Cengage Learning. All rights reserved.