October 2023

Combating
Military Obesity:
Stigma's Persistent
Impact on Operational
Readiness
WHITE PAPER

Combating Military Obesity

In Brief:
Obesity poses a complex challenge to recruitment, readiness, and retention within the U.S. Armed Forces.
Amidst an escalating military recruiting crisis, pre-accession weight loss programs are helping services
meet enlistment goals. Rapid and sustained recurrence of obesity across all services, ranks, and positions
now poses a dire threat, especially for at-risk populations and those in critical combat roles. To effectively
tackle the military obesity crisis, the Department of Defense must significantly improve its research andreporting. In the meantime, replacing military appearance regulations with evidence-based health policies
can facilitate a shift to treating obesity as a chronic disease rather than an administrative checkmark.

KEY FINDINGS••••

68% of active-duty service members have overweight or obesity. Obesity is the leading disqualifierof military applicants and a primary contributor to in-service injuries and medical discharges.
Military obesity rates across the active duty have more than doubled over ten years, from 10.4% in2012 to 21.6% in 2022. Eating disorders increased by approximately 79% between 2017 and 2021.
Despite being a chronic disease with several FDA-approved treatment options, antiquated bodycomposition policies and stigma prevent effective treatment of obesity within the Armed Forces.
The removal of body mass statistics from military recruitment and disability reports used by DoD
stakeholders and Congress has resulted in incomplete and misleading conclusions. This data isneeded to identify at-risk populations and design effective, evidence-based interventions.

RECOMMENDATIONS
1. The Defense Health Agency should promote and enforce awareness, diagnosis, and treatment ofobesity as a chronic disease across the armed services.
2. Body composition and military appearance regulations should be wholly reviewed and brought in linewith evidence-based research. Policies allowing commanders to arbitrarily assign or exempt obese
service members from medical intervention should be rescinded.
3. All services should seek to close the gap between high recordings of obese BMI during military
health and fitness evaluations and low obesity diagnosis and treatment rates.
4. All service members with obesity should be referred to a credentialed obesity physician, registereddietitian, or bariatric physician for accurate diagnosis and treatment.
5. Military reports on disqualifications, disability, and medical discharge should include BMI data until
overweight and obesity diagnoses reflect real obesity rates of the force. Body mass data should be
reintroduced within annualized reports evaluating recruitment, retention, and retirement trends.
6. The Defense Health Agency should significantly improve frequency of military obesity reports or
broaden the pool of researchers and academics who can access military weight data.

About the Author
Courtney Manning is a National Security Research Fellow at the American Security Project. She currently leads ASP's
research on military recruitment and readiness, strategic competition with China, and emerging technology risks. Before ASP,
she worked as a geopolitical risk consultant on international human rights law, political risk, and climate security in New
York and spent seven years as a public sector nutrition consultant. She holds an M.I.A. in international security policy from
Columbia University and a B.A. in international relations from the University of Denver Korbel School.

Introduction
Across the United States, military recruiters grapple with two national security crises: dwindling interest among
qualified individuals in joining the armed forces and an increase in applicants failing to meet the physical requirements
for enlistment. In 2018, the American Security Project published “Obesity: An Epidemic that Impacts our National
Security” to highlight obesity’s impact on the recruiting crisis and the importance of military health and fitness on
personnel readiness. In a 2022 follow-up report, “Obesity's Increasing Threat to Military Readiness,”ASP exploredthe impact of the COVID-19 pandemic, with recommendations to adjust requirements for specialized positions andexpand pilot programs to increase enlistment of otherwise-qualified applicants.
At the time of the 2018 report, 44% of Americans aged 18 to 25
were too overweight to serve in our armed forces. Today, 57% areeither clinically overweight or have obesity.1 As disease rates rise
across all demographics, pre-accession fitness programs
demonstrate promise in getting otherwise-qualified applicants
through the door. Unfortunately, obesity rapidly recurs across allservices, ranks, and positions after enlistment and is now pervasive
throughout active-duty, reserve-duty, and veteran populations. The
Centers for Disease Control and Prevention estimate that the
Department of Defense spends $1.5 billion annually on obesityrelated healthcare for service members, veterans, and their families.

U.S. Air Force photo by Tech. Sgt. Jeffrey Grossi

The growing prevalence of obesity in service members reduces the readiness of the all-volunteer military, but it isn’t
a moral failing; it’s a health crisis. Framing obesity as an issue of insufficient willpower or discipline prevents soldiersfrom seeking and receiving treatment, makes commanders and healthcare workers less inclined to intervene, andworsens health outcomes across the services. Persistent social stigmas result in administrative punishments thatprevent service members from reaching their potential and fail to address their underlying conditions. At-risk
populations and those in critical combat roles are particularly affected by policies targeting physical appearance over
operational readiness and health indicators.
Designing an effective strategy to monitor and tackle obesity within the U.S. military begins by treating it like anyother chronic disease: consistently recording accurate data and leveraging that data to design effective medical
interventions. The Department of Defense's influence over the active-duty environment allows it to successfully
mitigate this crisis by applying evidence-based treatments and controlling contributing factors such as diet, exercise,sleep, and stress. As revolutionary new treatments improve long-term weight management for soldiers and veterans,
services have more opportunity than ever to treat obesity as a health condition instead of an administrative checkmark.
This report illustrates stigma's effects on the collection, analysis, treatment, and consequences of obesity within the
U.S. military and provides recommendations for improvement.
A Note on Defining Obesity: ‘Obesity’ is a chronic disease that manifests in abnormal or excessive fat
accumulation in the body. Diagnoses are generally associated with a Body Mass Index (BMI) of 30.0kg/m2 and above as measured by a person's weight in kilograms (or pounds) divided by the square ofheight in meters (or feet). However, excessive body fat can also be determined by skinfold measurements,
body circumference, dual X-ray absorptiometry scans, and other means.

1Military Obesity from Recruitment to Retirement
Forty-two percent of adults and twenty percent of children in the United States are affected by obesity.2 By causing
insulin resistance, high blood pressure, hyperlipidemia, vascular dysfunction and more, obesity imposes an aggregated$260.6 billion in medical costs to U.S. citizens each year.3 Excess fat increases the risk of multiple debilitating anddeadly comorbidities including cardiovascular disease, type 2 diabetes, stroke, osteoarthritis, and cancer.4 Contrary tofilm and television depictions of heightened health and fitness in the active-duty military, 67% of service members
across the U.S. Department of Defense are either overweight or obese.5

Obesity’s Effects on Recruiting
Obesity has been the leading disqualifier of U.S.
military applicants for over a decade.6 Between 2003
and 2011, 36% of male and 30% of female applicants
were overweight or had obesity based on their bodymass index (BMI), or weight-to-height ratio.7 Whilemodern body composition requirements allow mostoverweight applicants to enlist, both services andhealthcare providers use a BMI measurement of 30
and above (or ≥30 kg/m2 body mass) to determine
obesity.8 When last published in 2017, over 17% of
medical disqualifications at Medical Entrance Processing Stations (MEPS) were due to obesity.9
Weight-related disqualifications are discouraging, but often temporary. Approximately 3.4% of applicants who are
not overweight by BMI are rejected for exceeding military weight standards, predominantly women; these applicants
can be re-measured using alternatives such as abdominal circumference, bioelectrical impedance analysis, dual-energy
x-ray absorptiometry, or by being determined “highly fit.”10 While “weight waivers” are only regularly issued by the
Marine Corps, these account for nearly half of all medical waivers granted.11 All services allow applicants to
temporarily delay basic training while they lose weight.12 For these applicants, guides like the Air Force Aim High app
provide nutrition and fitness schedules that mimic those of boot camp.13

Pre-Accession Fitness Programs
Despite ongoing modifications to body composition
standards and policies since the 1990s, the pool of
Qualified Military Available (QMA) continues toshrink each year. To determine whether fitness
standards should be relaxed further, the Assessmentof Recruit Motivation and Strength (ARMS) program
granted enlistment waivers for otherwise-qualified
candidates with a body fat percentage two percent orless above regulation from 2005 to 2009.14 The
program increased male applications at study sites by
21% and female applications by 28%, withoverweight enlistees demonstrating only slightly higher attrition rates after 18 months.15
ARMS 1.0 was discontinued in advance of assumed improvements in recruiting conditions following the 2008
financial crisis.16 Before 2008, high unemployment rates were strongly correlated with increased applications to the2

U.S. Armed Forces. Instead, military applications
declined 33% over the next ten years, leading to thesecond iteration of ARMS in 2019.17 ARMS 2.0
introduced the Future Soldier Preparatory Course, a
pre-accession weight-loss program that provided
applicants a controlled environment of diet andexercise until they met weight standards.18 Pilot
programs have been very effective, with 87% ofparticipants meeting fitness requirements within thefirst three weeks and 95% successfully enlisting
within 90 days.19 The Navy launched the Future
Sailor Preparatory Course in March 2023, and the
Army broadened its eligibility requirements to include those unable to pass aptitude testing in June.20

Obesity Rates Within the Active Duty
As a result of waivers, policy modifications, and preaccession fitness programs, a high number ofenlisted applicants enter active duty with either
overweight or obesity. Standardized data from the
Army Injury and Health Outcomes Database andDefense Manpower Data Center reflect that 40.9%of those who successfully accessed into the Armyfrom 1989-2012 had a BMI above 25 during entry
medical assessments.21
Service members across all services, ranks, and occupations experience sustained and recurrent weight gain beginning
shortly after enlistment. By the time Active Component (AC) recruits are 21 years old, 15% have obesity.22 By age 35,
the AC obesity rate climbs to 28%.23 As a majority of AC personnel are under 30 years of age, the reported obesity
rate across all active-duty service members is skewed downwards to 21%.24 However, military obesity rates havedoubled over ten years, from 10.4% in 2012 to 21% in 2022.
Obesity rates vary across services; the Air Force has
a reported obesity rate of 11%, while the Navy has
a reported rate of 27%. AC men are twice as likely
to have obesity as AC women.25 At 41%, those fromthe Pacific Islands are at greatest risk of obesity;
those of Asian descent have the lowest obesity rate
at 14%. Enlisted personnel, including combat
support (military police/intelligence), combat arms
(infantry/artillery), and combat service support(transport/maintenance), are 7% more likely toexperience obesity than officers.26

Regular Health and Fitness Assessments
All service members in the Department of Defense are required to schedule an annual Periodic Health Assessment(PHA) to record their BMI and other health metrics. This data is assembled into annual and supplemental reports
published by military agencies.27 Soldiers also undergo Physical Fitness Tests (PFT) that vary by service:3

Service

Assessment Details

Army

Annual fitness exercises and BMI testing, plus surveys inquiring about physical activity.28

Navy

Annual Physical Fitness Assessment. Recent ban on exemptions for Sailors who previously earned
overall performance levels of excellent or above.29

Air Force
Marine Corps

Annual physical fitness exercises wherein no body composition measurements are taken. Aviators may
substitute core test activities with an alternative activity.30
Twice-annual fitness test; Marines must meet entrance requirements at all times.31

Weight Management Programs
Service members who exceed height-to-weight requirements during their PHA or PFT are referred to a weight control
program at the discretion of their chain of command.32 Each service maintains its own program standards andrequirements:
Service

Program Name

Program Details

Army

Body Composition
ProgramMandatory program. Soldiers must lose a specific number of pounds eachmonth and are weighed every six months until standards are met. Armyprovides personal counseling to help develop a fitness and nutrition routine.33

Navy

ShipShape Program

Voluntary but “highly recommended” program for active duty and reserve
Sailors who fail the PFT, plus civilian employees and their beneficiaries.34

Air Force

Body Composition
Improvement Program“Informal, self-directed” 12-month program. Aviators are referred to a medical
treatment facility for an evaluation and assessed for additional risk factors.35

Marine Corps

Body Composition
ProgramMandatory program, with exemptions for Marines who excel in their combat
test and fitness test and additional exemptions for good military appearance.36

Separation from Service
Failure to meet body composition standards makes service members ineligible for promotion, transfer, reenlistment,
or enrollment in professional schools.37 After six to twelve months of unsatisfactory progress in a weight control
program, a separation authority—typically the first lieutenant colonel in the chain of command—determines whether
the soldier can remain in service. When separated for weight control failure, active duty enlisted with more than 180
days of service are honorably discharged, those with fewer than 180 days of active-duty service receive an
uncharacterized discharge, and those demonstrating less-than-ideal conduct are given a general discharge.38
Administrative discharges are kept separate from health and BMI records, making it difficult to determine how many
separations are weight related.39 The Navy has not discharged for body composition since 1999, and only 878
personnel who failed to meet body weight standards between 2018-2019 were separated from service by August2021.40 This suggests that an increased number of obese service members are being retained despite unsatisfactory
progress. A presentation by the Veterans Health Administration, however, listed 12,429 administrative separations in2018 due to “unqualified for active duty, other,” defined as “did not meet medical fitness standards, no disability,”suggesting that weight-related discharges are high.41 This contradiction may be a result of improper classification; in
2015, the Government Accountability Office observed broad mixing of obesity and mental health conditions under
the same separation codes.42
4

In addition to being administratively separated,soldiers can receive a medical discharge for obesity
or its associated conditions. While obesity
discharges are unreported, the broad category“musculoskeletal” comprises between 36% (Navy)to 65% (Army) of medically discharged service
members annually, with osteoarthritis and limited
range of motion comprising the majority ofdiagnoses.43 These conditions are highly correlatedwith obesity, and their impact on overall separation
is significant; of the 94,036 service members
diagnosed with osteoarthritis from 2016 to 2020,
17.9% were medically separated by August 2021.44

Challenges with Evaluating Obesity in the U.S. Military
Data-driven decision-making is critical for combatting obesity in the active duty. While the Department of Defense
uses various monitoring mechanisms to evaluate obesity and weight management initiatives, frequent changes inclassification systems, reporting mechanisms, and nomenclature introduce inconsistencies and gaps in this data. This
makes it challenging to analyze trends and produce recommendations.

Removal of Body Composition Data from Accessions Reports
Understanding where applicants fail to meet enlistment standards is the first step to resolving the recruitment crisis.
Permanent disqualifications (DQs) and temporary disqualifications (TDQs) are recorded at MEPS. From 2002-2016,
TDQs were defined as “disqualifications that can be remediated by the applicant, such as being overweight,” withmost TDQs falling under “failure to meet body fat standards.”45 Starting in 2016, the agencies tasked with evaluatingchanges in accessions and accession policies removed body composition data from all annual reports. The definitionof TDQ changed to “disqualifications that can be remediated, such as surgical meniscal repair.”
While no explanation was provided, body mass was changed
again from a “medical” to an “administrative”
disqualification in 2019. As a result of this policy change, aslong as applicants are not diagnosed with a specific condition,
applicants entering the U.S. military with overweight orobesity are now initialized as medically qualified.46 A
disclaimer in a 2020 report stated, “other types of DQs may
be identified at MEPS, such as unmet height and weightstandards... These DQs were excluded.”47 While it is assumed
that those who fail to meet weight are administratively
disqualified, administrative disqualifications are notpublished by any agency. Omitting this data from annual reports greatly restricts the ability of policymakers andstakeholders to understand barriers to recruitment.

Lack of Transparency Within Department of Defense Clinical Codes
In 1979, the United States government adopted the International Classification of Diseases (ICD) to precisely andconsistently monitor diagnoses and treatments across the nation. While “obesity” has been an ICD clinical code since51948, “failure to make weight/body build” was reported by the Department of Defense until 2014.48 In 2015, military
services began recording “obesity and other hyperalimentation” and “abnormal weight loss/underweight” separately
in response to the evolving societal understanding of obesity as a global health crisis.49
In 2016, however, underweight, obesity, and related
conditions were combined again into the category“nutritional, endocrine, and metabolic disorders.”50
Annual reports state that this change occurred as aresult of the transition from ICD-9 to ICD-10,
though neither revision uses this code for obesity.51
From 2016 to 2018, this category was comprised of“primarily weight-related disqualifications (i.e.
obesity).”52 One year later, diagnoses were reported
within broad “body systems” such as“musculoskeletal” and “respiratory,” and weightrelated DQs were removed entirely.
While categories that include obesity lead each year in diagnoses, frequent and ongoing changes in weight classification
make it challenging for researchers to track obesity trends.53 Reporting the most common ICD codes would prevent
obesity diagnoses from being buried within broad categories. Unfortunately, as few service members with a recorded
BMI ≥ 30 kg/m² receive a formal obesity diagnosis, reporting ICD diagnoses without body mass data underestimatesobesity in the Armed Forces.54 Furthermore, use of analogous or improper codes for obesity-related conditions acrossthe services make year-to-year and cross-service comparisons impossible.55

Recategorization of Obesity Data within Medical Discharge Reports
Reliable information on separations is vital for policymakers and the public to understand military retention and its
causes and challenges. The impact of medical disqualifications on personnel separations are evaluated in annual
DESAR reports, which “inform DoD retention and disability policy decisions to improve readiness and lethality by
reducing attrition, streamlining the disability evaluation process, and decreasing replacement time and cost.”56
Most documented unfitting conditions—such as limitation of motion, joint disorders, and arthritis—are impacted orcaused by obesity. The 2019 recategorization of body composition metrics removed weight data from DESAR reports
and in 2022, the report was “updated” to fully exclude all administrative DQs, unmet weight included.57 Removing
this data reduced multiple disability categories by half, leaving much of the remaining data on disqualifications,disability discharges, and separations either incomplete or misleading. For example, the new top medical disqualifiers
are eye and vision conditions, psychiatric conditions, and “miscellaneous conditions of the extremities.” As mostdisability discharges remain obesity-related conditions, recent reports have naturally found “little to no concordance
between DQ/waiver and reason for disability discharge.”58 As the removal of body mass and obesity data frommedical reports is ostensibly permanent due to DoD changes in classification, annual reports on accessions andseparations no longer publish or analyze the most significant issue affecting recruitment and retention.

The Defense Medical Surveillance System
The Defense Medical Surveillance System (DMSS) manages health-related information on military service members
in tandem with the Defense Manpower Data Center. To access DMSS data, researchers must work under a U.S.
military organization and publish alongside a military principal investigator. DMSS researchers report ongoing
concerns with data collection and transfer, including underreporting of diagnoses, differences in services’ systems andmethods, and unexplained changes to data or policies that are not relayed back to services.59 In a 2023 editorial
6

comment titled, “Increased Missing Data Affects Burden Estimates,” military researchers note that “much of thedata” available on “certain routinely reported elements” is currently missing or incomplete within the DMSS.60
Due to the reclassification of BMI from a medical to an
administrative category in 2016, published research on BMI
data has been limited. As a result, annual reports on military
health have declined in length and frequency.61 The U.S. Army
Public Health Center's Health of the Force report is now themost reliable obesity resource for policymakers. However, due
to data decrements and ongoing changes in methodology, its
metrics cannot be compared with prior years nor acrossmilitary installations or services.62

Stigma’s Impact on the Military Obesity Crisis
Assumptions that overweight people are unmotivated, incompetent, or weak-willed cause individuals and services toconceal, obscure, and downplay military obesity. This social stigma has historically resulted in policies that emphasize
individual responsibility and self-discipline over evidence-based research on weight management.63 While much ofthis behavior is well-intentioned, either to protect the dignity of service members or to project a strong image of the
U.S. Armed Forces, treating obesity as a deviant behavior and not as a chronic disease increases comorbid medical
conditions, injury, permanent separation, and all-cause mortality across the services.

Individual Underreporting of Obesity
Mitigating obesity in the active-duty population necessitates accurate health data provided by service members andhealthcare personnel on its prevalence and causes. Unfortunately, from 2018-2021, only 60% of active-duty service
members had their BMI recorded by a military health worker.64 The most recent DoD Survey of Health Related
Behaviors received an 8% response rate.65 In 2021, only 54% of active duty soldiers had their height and weightrecorded during an outpatient healthcare visit.66 To explain this trend, the Defense Centers for Public Health suggest
that, “although unverified,” soldiers with obesity may be more likely to have an outpatient visit than soldiers withoutobesity, resulting in an overestimation of the disease within the active duty population.67
In reality, perceived judgment from healthcare workers, internalized shame, or negative prior experiences mean that
individuals with overweight and obesity are statistically less likely to access healthcare services than their normalweight counterparts.68 The National Academy of Sciences found that “the consequences of being categorized as
exceeding weight standards, such as being forced into a weight-control program, losing access to promotions, or being
separated from service” prevent overweight enlisted from seeking and obtaining medical treatment.69 The 2015 DoD
Health Related Behavior Survey stated its low response rate was a partial result of covering “very sensitive topics,
including some that could result in a service member being dismissed from the military.”70
Concealment of obesity and obesity-related health conditions is associated with an increased risk of attrition. This isespecially true among women, recruits with low education or poor aptitude test scores, and enlistees with medical
waivers.71 This suggests that service members feel they must compensate for other social stigmas, such as gender, low
education, or disability status, by obscuring their weight. Harassment by commanders and fellow soldiers, mental
health conditions such as binge eating disorder and depression, and higher rates of PTSD have also been associatedwith avoiding treatment, making overweight service members at these intersections especially vulnerable tounderreporting or misrepresenting weight data.72
7Service-wide Underreporting of Obesity
Due to being removed as a medical disqualifier, BMI is now miscategorized or omitted entirely from medical andfitness testing. This results in artificially low reported obesity rates across the services, starting at the point ofenlistment and continuing until separation.73 Because soldiers and commanders have a vested interest in soldiers being
found in compliance with weight standards, a military report found that both groups “consistently seek to present
anthropometric measurements as favorably as possible,” including through well-known “tricks” to cause inaccurate
readings.74 Enlisted who receive a medical exemption from body mass standards are categorized as “within medical
standards” even if they are overweight or have obesity.75 Despite obese BMI on record, healthcare workers often opt
to avoid diagnosing or diagnose comorbidities such as diabetes, osteoarthritis, and high blood pressure instead.76
Reports on military obesity published by the Department of
Defense generally include a disclaimer stating that BMI may
overrepresent obesity rates due to "high muscle mass,"
occasionally followed by a reference to a study of civilian
firefighters.77 However, evidence suggests that BMI is much
more likely to underreport obesity than overreport it, including
in military populations. After undergoing more accurate body
fat analysis, the CDC found that around 3% of women and 11%of men categorized by BMI as “obese” had healthy levels of fat
mass, but 31% of individuals classified as “normal weight” by
78
BMI had obesity. A 2021 Military Medicine study revealed that BMI significantly underestimated excess body fat insoldiers when compared to more accurate methods like X-ray absorptiometry and bioimpedance analysis.79 After alengthy and expensive effort to replace “tape tests” that were assumed to overstate obesity, the Army found thatsoldiers had up to 8% more body fat according to the new body scanning machines.80
The misconception that body measurements frequently categorize healthy soldiers as obese harms military
populations. A 2016 examination by healthcare providers found that a significant proportion of soldiers withoverweight and obesity were not being treated for these conditions due to commanders and services ignoring BMI
recordings.81 Despite 47.3% to 56.0% of active-duty service members meeting prediabetes screening criteria based on
TRICARE appointment data from 2014 to 2018, less than 7% were subsequently screened, and fewer received
preventative interventions.82 Disregarding body mass data leaves individuals unaware of their nutritional needs andhealth risks, increasing risk of injury and disease as well as likelihood of separation and disability discharge.

Discretionary Policy Enforcement Based on Physical Appearance
Weight-control policies in the Armed Forces are frequently tied to “military appearance” instead of evidence-based
indicators of health and fitness.83 Military appearance is an intangible, self-descriptive condition determined throughvalue judgments made by commanders. As U.S. Marine policy explains, “Marines may meet all established standards
yet still fail to present a suitable military appearance.... Simply put, Marines who do not present a suitable military
appearance fail to possess the qualities necessary to effectively lead Marines.”84 Other definitions include “squaredaway,” “commensurate with the high standards traditionally associated with Army service,” and “contributes to afavorable Military image.”85 According to the Air Force, these policies exist because “the American public and its
elected representatives draw certain conclusions on military effectiveness based on the image of Airmen present.”86
These regulations do not identify what specific determinants beyond “all established standards” necessitate correction,or why those determinants would make one less effective in leadership roles. Regardless, commanders are granted
broad discretion in using “good military appearance” to exempt soldiers and each other from obesity determinations,leading to military health policies being inconsistently enforced.87
8In addition to the fact that external
appearance is an unreliable way ofdetermining internal health status,
judgments of “good military
appearance” may be affected bystereotypes based on age, race,
gender, and sexual orientation. For
these reasons, some services haveamended their policies to allow forevaluation by a medical professional
when
determining
obesity.88
However, commanders are still
authorized to use “military
appearance” to determine who isselected for these evaluations, aswell as who enters weight
management programs and who is89
ultimately separated from service. Multiple studies have concluded that soldiers and commanders favor lean or
muscular appearances regardless of actual physical fitness, and both groups rank overweight soldiers lower in nonphysical qualities like intelligence.90 Senior leaders at the U.S. Army War College have been shown to associate
overweight appearance with poor leadership skills, lack of self-discipline, and low ability to mentor subordinates.91

Ambiguous Weight-Loss Programs
In 2003, the Subcommittee on Military Weight Management foundthat “data on weight management programs recidivism or longterm success are not systematically compiled by any of the services,a situation that is, at least in part, intentional,” as “services attempt
to minimize the stigma associated with participation in these
programs by purging records.”92 It determined that mostparticipants received minimal counseling from a dietitian and that
services were inconsistent in determining which applicants received
punitive consequences versus medical treatment.93 In 2021, nearlytwenty years later, a review by Miggantz et al. found minimal andcontradictory studies on the success of military weight loss
programs and only a single study on the demographics ofparticipants in those programs.94 Within these studies, Malkawi etal. (2018) noted improvement in body composition over the 12 months following enrollment in military weight-loss
programs, Murray et al. (2017) found no significant improvement after six months, and Wisbach et al. (2018) foundthat less than half of those enrolled in Naval programs met physical fitness standards within their next three PFAs. 95
As of 2022, an artificial intelligence algorithm called the Readiness Prediction Model translates nutrition, wellness,and other fitness metrics into marginal impacts for commanders.96 However, there is little information on the functionof this model, its outputs, or whether it is in full or partial use by all the services.

Ineffective Nutrition and Fitness Initiatives
Military health programs are influenced by movements to improve self-perception and reduce discrimination due tobody size. As the belief that weight gain is a moral failing becomes less pervasive, new misconceptions have risen in9

popularity, including that body fat is uncorrelated with health and that alluding to weight and body fat contributes tonegative social stigma.97 As a result, while nutrition and fitness programs still emphasize individual responsibility andself-discipline, recent DoD initiatives have minimized the use of terms such as “fat,” “obese,” “diet,” and “morbid,”
instead using “wellness,” “mindfulness,” “fitness,” or “performance.”98 Service members remain penalized forexceeding weight standards, but diet and exercise are deprioritized within provided solutions, with “spiritual, mental,
and social fitness” gaining in prominence.99
By downplaying the role of diet and exercise in weight management
and prioritizing “holistic” factors such as extended sleep, low stressenvironments, access to fresh produce, and regular counseling, DoD
fitness initiatives portray lifestyles incongruent with the active duty as
critical for weight loss.100 The DoD's Total Force Fitness Guide,
initiated to help active duty enlisted meet weight standards, includes
recommendations such as “saving room for a margarita,” cooking
with family members, eating mostly fresh fruits and vegetables, andsleeping when tired.101 Providing these recommendations as solutions
instead of adjusting daily diet, sleep, and exercise standards—
particularly during training and deployments—leads to disorderedeating and other harmful behaviors when active-duty soldiers areunable to follow impractical or infeasible recommendations.102

Obesity’s Effects on Readiness and Retention
The Department of Defense spends $1.5 billion annually on obesity-related healthcare.103 Overweight soldiers leave
service 18 months earlier than their normal-weight counterparts on average, and veterans are significantly more likely
to have overweight and obesity than civilians.104 Exponential increases in recruitment, training, and weight
management costs, combined with declining retention and readiness rates of recruits who exceed body fat standards,
will significantly impact the long-term operational readiness of the all-volunteer force if these trends continue.

Internal Health Complications
While self-directed diet and exercise programs can be sufficient to maintain a healthy weight, obesity would not be a
global epidemic if it were not a disease with chronic, recurrent, genetic, and neurobehavioral affects. Body mass levelsof 30 kg/m2 and above can cause insulin resistance, high blood pressure, hyperlipidemia, and vascular dysfunction,even in the absence of other conditions.105 When excess fat is centralized in the abdominal area and between vitalorgans, adverse metabolic and endocrine activities make it more difficult for the body to regulate insulin, maintainorgan function, and manage signals for hunger and satiety.106 Stress and sleeplessness, common in the active duty, dull
reward processing in the brain’s hypothalamic-pituitary-adrenal axis and cause individuals to chase food highs, making
it more likely that they will .107 Cyclical weight loss caused by extreme fasting to meet body composition standards
followed by increases body fat retention, worsening health outcomes in the long run.108

Decreased Combat Readiness of the Force
The physical effects of obesity negatively impact combat readiness, with effects varying across tasks and occupations.
In fitness tests conducted by the U.S. Army Public Health Center, higher-BMI soldiers demonstrated increased load
bearing and lifting ability but decreased speed and agility than lower-BMI service members.109

10While individuals can maintain high musculature and visceral fat levels simultaneously, high musculature does notcounteract the adverse effects of excess weight. Being overweight increases a service member's risk of injury, stroke,and musculoskeletal injuries by up to 47% while in service.110 The respiratory, circulatory, and osteoarthritic impactsof obesity lead to shortness of breath, fatigue, vascular dysfunction,and pressure on joints and bones, reducing exercise function.
Individuals with excess body fat are at significantly higher risk ofacquiring asthma in the first two years of military service.111 If left
untreated, excess body fat can trigger health events such as strokes,
heart attacks, and pulmonary embolisms, which can cause
permanent disability or death when overweight soldiers are given
waivers to deploy abroad.112 Soldiers need to be physically lifted ifthey are incapacitated in a combat zone, but the absence of a
maximum weight for otherwise-fit service members means that
individuals with high fat and muscle mass may not be safely removed
Air Force Staff Sgt. Johnny White, DoD photoin time to receive medical treatment.113

Lack of Qualified Military Available for Technical and Specialist Roles
Roles that require advanced skills and training are more difficult to fill than infantry and support roles. As obesity
rates rise nationwide, the pool of qualified candidates for these positions declines in both quality and quantity. Afterenlistment, inability to meet fitness standards leads to attrition and separation of occupational specialists, reducing
services’ return on investment as these service members receive particularly expensive and time-consuming training.
As more military activities become computerized, desk-based occupations are increasingly prevalent. Some specialists,
like those in intelligence and communications, are required to be sedentary for hours or days at a time during
deployments.114 As they receive the same meals as other active-duty service members, a high level of physical fitness
becomes more challenging to meet. If overall proclivity to join the armed forces continues to decrease, thecombination of operating environments being conducive to obesity and restrictive weight standards causing stressand healthcare avoidance will significantly impact the recruitment, health, and retainment of occupational specialists.

Disordered Eating
Pressuring service members to “make weight” through willpower instead of medical treatment leads to increased
prevalence of harmful and disordered eating behaviors.115 A 1994 study of military body composition standards foundthat 50% of male and 62% of female service members used diuretics, vomiting, fasting, under-the-table diet pills, or
laxatives to meet weight standards.116 Twenty years later, 30% of enlisted reported they regularly smoked cigarettes“to avoid gaining weight” and “to reduce the amount I eat.”117 Cycles of fasting and feasting before and after weighins have been associated with severe eating disorders in veterans that remain long after their service has ended.118
Active duty and veteran service members face disproportionately high eating disorder rates compared to civilian
populations, with total incidence rising 79% between 2017 and 2021.119 Disordered eating is more common in womenand people of color, as their weight and body mass are more likely to fall outside military body mass standards.120
However, behaviors such as vomiting, strenuous exercise, and abuse of saunas or steam rooms are around four times
more common in men.121 While these activities temporarily reduce weight by causing dehydration, they can lead tonumerous mental and physical complications such as intestinal disorders, throat and mouth cancers, and cardiac
arrest.122 Eating disorders have been associated with cognitive functioning impairment, reproductive and skeletal
problems, depression, and increased suicide risk in soldiers and veterans.123
11Strategic Recommendations
Body composition policies in the all-volunteer active-duty military should facilitate high performance in adverse
environments, protect the health and safety of service members, and lead to cost-savings for agencies and taxpayers.
Active duty enlisted should be empowered to excel at their assigned duties and leave service healthy and well-adjusted.
By designing policies that recognize the medical causes and contributors of obesity, the Department of Defense canachieve these goals while reducing the influence of longstanding assumptions about individuals with obesity.

Educate Commanders and Healthcare Workers on Obesity
Genetic predisposition to obesity was first proposed in 1989.124 Several genetic, biological, and environmental factors
were soon uncovered by scientists, resulting in the broad designation of obesity as a chronic disease. The rapid paceof these discoveries means most commanders and healthcare workers today were taught outdated information on
obesity, including recommendations now known to worsen health outcomes.125 These individuals are granted broad
discretion in identifying individuals with obesity and deciding whether they receive treatment.
Recommendation 1. The Defense Health Agency should conduct an educational campaign promoting
awareness, diagnosis, and treatment of obesity across the services. Materials on enlisted health outcomesshould be disseminated to commanders and healthcare providers to facilitate educated decision-making.

Replace Appearance-Based Regulations with Evidence-Based Equivalents
The longstanding belief that obesity is the result of insufficient willpower, lack of discipline, or poor lifestyle choices
led to the creation and enforcement of punitive sanctions in lieu of medical treatments for service members withobesity.126 Inconsistently applied, these regulations motivate service members to obfuscate, falsify, or misrepresent
weight data, as well as engage in disordered eating and weight loss behaviors that harm themselves and the force.127
Recommendation 2. Body composition and military appearance regulations across the Armed Forces should
be wholly reviewed and brought in line with evidence-based research on health and fitness.128 Policies thatallow commanders to arbitrarily assign or exempt service members from medical intervention and treatmentof obesity based on “military appearance” should be eliminated.

Improve Timely Screenings and Diagnosis
By adequately screening for obesity, military services can develop proactive measures to address obesity. Early
screenings for obesity and related health conditions, such as prediabetes and high cholesterol, are associated withsustained weight loss, better health outcomes, and a lower cost burden on healthcare systems.129 Interventions provento be cost-effective and impactful should be prioritized over initiatives such as social media campaigns, wellness
guides, or experimental treatments for obesity until more evidence supports their use.130
Recommendation 3. The Consortium for Health and Military Performance should be tasked with closing the
gap between high recordings of obese BMI (>30 kg/m2) during military health and fitness evaluations andlow obesity diagnosis and treatment rates.131

Medically Treat Obesity’s Causes and Symptoms
Treating obesity requires more than just weight loss, and many common weight loss methods are detrimental to longterm health and fitness. For example, the Future Soldier Preparatory Course reports an average 1.7% decrease in bodyfat per week.132 However, .5% or more weekly body fat loss is associated with weight cycling and adverse effects suchas persistent endocrine dysfunctions and muscle loss.133 Reductions of just 5 to 10 percent have been found to mitigate
most obesity-associated health, but individuals must maintain a healthy weight long-term to realize these benefits.134
12While dietary interventions are the first line of defense, various interventions are FDA-approved to treat obesity.135
Six medications have been proven to reduce fat absorption, lessen appetite, dull hunger response, or stabilize
dysfunctional hormones in overweight individuals. Around 86.4% of participants in semaglutide clinical trials lost
more than 5% of their body weight over a year and a half, reducing risk of comorbidities such as cardiovascular disease
and diabetes.136 Other treatments vary from intermittent fasting and behavioral therapy to bariatric surgery.
Recommendation 4. Due to the unique health and fitness composition of each individual, diagnosing andtreating obesity requires specialist care. All service members with a BMI recording over 30 should be referred
to a credentialed obesity physician, registered dietitian, or bariatric physician to determine treatment.137

Reduce Obesogenic Factors in the Active Duty
While between 40% and 70% of excess weight can be tied to genetic indicators, environmental factors also affectweight gain.138 Limited agency in daily routines and ready availability of low-quality, calorie-dense foods contribute toweight gain. Twenty-four percent of active-duty service members stated they had insufficient access to quality meals
between 2020 and early 2021.139 As posts and roles become increasingly sedentary, obesity rates are expected to rise,
particularly in specialized roles and those with certain genetic markers.140
Recommendation 5. The Consortium for Health and Military Performance should use the most updated
recommendations provided by the Academy of Nutrition and Dietetics to formulate diet, sleep, and exercise
plans tailored to specific active-duty roles and demographics across the Armed Services.

Improve Transparency and Reporting of Obesity Data
Civilians, policymakers, and DoD stakeholders rely on data from the DMSS to understand military health trends andcraft policy solutions. Services should increase cohesion and interoperability of body composition readings andconsistently analyze these metrics for their impact on recruitment and retention over time.
Recommendation 6. Military reports on disqualifications, disability, and medical discharge should include
data on “unmet weight standards” despite its administrative classification. Data on obesity should be
reintroduced within reports evaluating recruitment, retention, and retirement trends.

Due to the stigma surrounding obesity in the military, researchers are incentivized to present metrics demonstratinga favorable view of military health and readiness, even if those metrics result from data errors, inaccurate reporting,or data decrements.141 These factors impact the reliability and usability of military reports. 142
Recommendation 7. The Defense Health Agency should either significantly improve transparency andfrequency of military obesity reports or broaden the pool of researchers and academics who can accessanonymized DHSS data. A civilian auditing mechanism could ensure accuracy of reported figures.

Conclusion
Obesity is a chronic disease, not a lapse in personal discipline. Despite this reality, the enduring stigma against
overweight soldiers continues to result in punitive measures in lieu of medical treatment. While eliminating outdated
ideologies is the first step to fostering a healthier and more equitable service, loosening BMI standards and obscuringobesity data only worsens obesity’s impacts on recruitment, readiness, and retention. To ensure the long-term strengthand operability of the armed forces, services must decisively and cohesively address obesity within their ranks,
maintain strong body composition standards, and bring health policies in line with evidence-based recommendations.
Identifying, diagnosing, and treating obesity within soldiers at the front lines of our national defense may ultimately
determine the long-term survival of the force. It may not be easy, but it is long overdue.
13

Endnotes
1

Kristen Monaco, “In America, the Average Young Adult Is Now Overweight,” MedpageToday, November 23, 2021.
“HOP 2023,” Centers for Disease Control and Prevention, January 18, 2023; “Prevalence of Obesity Among Adults andYouth: United States, 2015–2016,” Centers for Disease Control and Prevention, October 2017.
3
John Cawley et al., “Direct medical costs of obesity in the United States and the most populous states,” Journal ofManaged Care and Specialty Pharmacy 27, No. 3 (March 2021), 354-366.
4 “Health Effects of Overweight and Obesity,” Centers for Disease Control and Prevention, September 24, 2022.
5 Regan A. Stiegmann et al., “Increased prevalence of overweight and obesity and incidence of prediabetes and type2 diabetes during the COVID-19 pandemic, active component service members, U.S. Armed Forces, 2018 to
2021,” Medical Surveillance Monthly Report 30, No. 1 (January 2023).
6
Weight and body build” was the leading category for medical disqualification from 2010-2015, accounting for 19%
of active duty and 20% of reserve disqualifications. See “Attrition and Morbidity Data for 2015 Accessions,”
Accession Medical Standards Analysis & Research Activity, April 2017, 33. Being overweight is now by far the leading
medical reason for rejection, and between 1995 and 2008, the proportion of potential recruits who failed their
physicals each year because they were overweight rose nearly 70 percent. See “Too Fat to Fight,” Mission: Readiness,
April 1, 2010, 2. Weight disqualification data is no longer being reported as of 2017. See “Medical Disqualifications,
Medical Waivers, Accessions and Outcomes among FY 2016-2020 Military Applicants,” Accession Medical Standards
Analysis & Research Activity, April 2023. In 2017, “nutritional, endocrine, and metabolic disorders,” a category that ismainly composed of weight-related conditions (i.e., obesity), was the most frequent disqualification for allcomponents. See “Attrition and Morbidity Data for 2017 Accessions,” Accession Medical Standards Analysis & Research
Activity, 2018, 8. These trends have worsened since the COVID-19 pandemic. See Regan A. Stiegmann et al.,“Increased prevalence of overweight and obesity.”
7
Between 2003 and 2011, 36 percent of male and 30 percent of female applicants had a BMI above 25 kg/m. See“Implications of Trends in Obesity and Overweight for the Department of Defense,” Defense Health Board,
November 22, 2013, 31; Marlene Gubata et al., “Accession Medical Standards Analysis and Research Activity 2012
Annual Report,” Walter Reed Army Institute of Research, March 2013. Crude prevalence of overweight and obesity
among 18-year-old civilian applicants to U.S. military service rose from 25.6% in 1993 to 33.9% in 2006. See“Trends in Overweight and Obesity Among 18-Year-Old Applicants to the United States Military, 1993–2006,”
611.
8“Overweight” is categorized by medical professionals at BMI >25 kg/m2. The U.S. military cutoff for Excess
Body Fat (EBF) ranges between 24.9-27.5 kg/m2 depending on age and gender. See Adela Hruby et al., "Trends inoverweight and obesity in soldiers entering the U.S. Army, 1989‐2012,” Obesity 23, no. 3 (March 2015), 665.
9
The proportion of those rejected for being overweight or obese each year increased by 69.4 percent from 12.3
percent in 1995 to 20.8 percent in 2008. See “Too Fat to Fight,” Mission: Readiness, April 1, 2010, 11. In 2014,“Weight, body build” disqualified 15.7% of medically disqualified MEPS applicants. See “Attrition and Morbidity
Data for 2014 Accessions,” Accession Medical Standards Analysis & Research Activity, 64. In 2017, 17.3% of medicallydisqualified MEPS applicants were disqualified for obesity. See “Attrition and Morbidity Data for 2017 Accessions,”
Accession Medical Standards Analysis & Research Activity. Weight disqualification data is no longer being reported as of2017; however, according to TRADOC Command Sgt. Maj. Daniel Hendrex, “Each year, an estimated 110,000
individuals meet recruiters with an interest in joining the Army. Before the COVID-19 pandemic, 30% to 40% of
those interested in joining were disqualified for service for several reasons. Since COVID, that rate has increased tonearly 70% in the first 48 hours of screening. Obesity, drug use, and poor academics drove most of thedisqualifications.” See Todd South, “Test scores drop, disqualification rates rise at Army recruiting shops,”
ArmyTimes, September 15, 2022.
10
Services have different standards for their “highly fit” determination. Marines who score 285 and higher on both
the Marine Corps Physical Fitness Test (PFT) and Marine Corps Combat Fitness Test (CFT) are given “highly fit”
exemptions. See Stew Smith, “USMC Weight Charts,” Military.com. The Army provides weight exceptions for “goodmilitary appearance.” See “2022 Health of the Force Report,” Defense Health Agency, May 10, 2023, 30. For Air Force,see “How to Join,” Air Force, accessed August 27, 2023.
2

14

11

There is a discrepancy between how the Marine Corps and the other Services categorize weight waivers. The
Offices of the Under Secretary of Defense for Accession Policy believes the Marine Corps incorrectly reports its“weight exceptions” as medical “weight waivers.” The Marine Corps believes that it is correctly reporting these
medical (weight) waivers and that the other Services are incorrectly reporting their weight waivers as “exceptions.”
Exception statistics are not published by any of the services. See Shannon Desrosiers and Kyle Neering,“Evaluating Suitability Across the Services: ELS Length and the Relationship Between Enlistment Waivers andSeparation Outcomes,” Centers for Naval Analysis, June 2020, 7.
12Michael Lee, “Army expands program for recruits who don't meet weight and test requirements as recruitingcrisis deepens,” Fox10, January 12, 2023.
13“Addressing Health Barriers to Military Service,” House Report 117–88, Page 338, Accompanying H.R. 4432, theDepartment of Defense Appropriations Bill 2022, May 2022, 12.
14“Body Fat Waiver Available to Otherwise Fit Recruits,” Association of the United States Army, October 7, 2019.
15
ARMS had no statistically significant effect on within-weight Army applicants or accessions. Regardless of ARMS
participation, the attrition rates of all individuals categorized as overweight at their 18-month evaluation postenlistment were 2.5% higher than non-overweight applicants. See David S. Loughran and Bruce R. Orvis, “The
Effect of the Assessment of Recruit Motivation and Strength (ARMS) Program on Army Accessions and Attrition,”
RAND Health Quarterly 2011, 1(3), 10.
16David S. Loughran and Bruce R. Orvis, “The Effect of the Assessment of Recruit Motivation and Strength(ARMS) Program on Army Accessions and Attrition,” RAND Health Quarterly 2011, 1(3), 10.
17
Before 2008, a strong negative correlation existed between civilian unemployment and enlistment applications [r= 0.7395, p-value 0.000001328]. Since 2008, this correlation has been statistically insignificant [r = 0.4819, p-value
0.0954]. Calculated from Active Component Enlisted Accessions Data from the Center for Naval Analysis from
1976-2020 and unemployment data from the Bureau of Labor Statistics using a two-tailed Pearson correlation test.
18
Ryan Morgan, “Army starting new program for recruits who fail body fat and academic standards,” American
Military News, July 27, 2022.
19
Hunter Rhoades Center for Initial Military Training Public Affairs Office, “Future Soldier Preparatory Course toexpand based on initial success,” army.mil, January 9, 2023; Doug Ware, “Army prep course has seen 95% grad rate,$15M in bonuses in 1st year,” Stars and Stripes, August 7, 2023.
20
Doug Ware, “Recruits can now take academic and fitness tracks in new basic training prep course, Army says,”
Stars and Stripes, June 2, 2023.
21
Adela Hruby et al., “Trends in Overweight and Obesity in Soldiers Entering the U.S. Army, 1989-2012,” Obesity
23, No. 3 (March 2015).
22“2022 Health of the Force Report,” Defense Health Agency.
23
28.1% of service members aged 35 were classified as obese in 2021. See “2022 Health of the Force Report,”
Defense Health Agency.
24“2022 Health of the Force Report,” Defense Health Agency, page 44.
25
In 2021, obesity prevalence among female service members was 11% compared to male service members at 22%.
See “2022 Health of the Force Report,” Defense Health Agency.
26
Regan Stiegmann, Chelsea Payne, Mary Anne Kiel, and Shauna Stahlman, “Increased Prevalence of Overweightand Obesity and Incidence of Prediabetes and Type 2 Diabetes During the COVID-19 Pandemic, Active
Component Service Members, U.S. Armed Forces, 2018 to 2021,” MSMR 30, No. 1 (January 2023).
27
Common data reporters include the Walter Reed Army Institute of Research, the U.S. Army Public HealthCenter, and the Centers for Naval Analysis. See “2019 Annual Report: FY 2013-2018 Applicants, Accessions andOutcomes,” Accession Medical Standards Analysis & Research Activity, April 30, 2020, 9.
28“Addressing Health Barriers to Military Service,” 8. “Physical Fitness Requirements and Test,” GoArmy.com,
accessed August 29, 2023.
29“Guide 5: Physical Readiness Test,” U.S. Navy, accessed August 29, 2023; Diana Stancy Correll, “Navyannounces single physical fitness assessment cycle in 2023,” Navy Times, November 14, 2022.
30
Ryan Guina, “2022 Air Force Fitness Test Standards & Score Charts,” Officer Assignments, May 30, 2022.
31“Physical Requirements,” Marines.com. Accessed August 27, 2023.
32“Chapter 18 - Failure to Meet Body Fat Standards,” Fort Knox Field Office. Accessed August 27, 2023.
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Stew Smith, “What You Should Know About the Army Weight Control Program,” Military.com.
“Navy Medicine: ShipShape,” U.S. Navy, accessed on August 11, 2023.
35
Secretary of the Air Force Public Affairs, “Department of the Air Force outlines new Body Composition Programfor Airmen, Guardians,” Air Force, January 9, 2023.
36
Stew Smith, “Marine Corps Body Composition Program,” Military.com.
37
Stew Smith, “What You Should Know About the Army Weight Control Program,” Military.com.
38
Department of Defense, “Enlisted Administrative Separations, Incorporating Change 7 on June 23, 2022,” DoDI
1332.14 (Washington, DC: January 27, 2014).
39“Veterans' Medical and Health Records,” National Archives, accessed August 31, 2023.
40
Regan Stiegmann et al., “Obesity Prevalence”; For 1999-2002 data, see Institute of Medicine, Weight Management:
State of the Science and Opportunities for Military Programs (Washington, DC: The National Academies Press, 2003), 42.
41
In 2012, more than 6,100 soldiers, sailors, airmen and marines were discharged because of failure to meetweight standards. See “Implications of Trends in Obesity,” Defense Health Board, 41. “Deployment and Separation
Data,” U.S. Department of Veterans Affairs Office of Research and Development, October 3, 2019, 17. On definition of term,see “Citation Nr: 1312752, DOCKET NO.10-47 041A,” On appeal from the Department of Veterans Affairs
Medical Center in Houston, Texas, April 17, 2013.
42“Defense Health Care: Better Tracking and Oversight Needed of Servicemember Separations for Non-Disability
Mental Conditions,” GAO, February 13, 2015. MSMR researchers track separations using administrative codes ISC
1017 and 2017 (failure to meet weight or body fat standards). See Regan Stiegmann et al., “Obesity Prevalence”.
Some agencies report separations under ISC 1016 (Unqualified for Active Duty - Other). See “Deployment and
Separation Data,” U.S. Department of Veterans Affairs.
43
Disability Evaluation System Analysis and Research, “2021 Annual Report,” Walter Reed Army Institute of Research,
March 13, 2022, 56; Accession Medical Standards Analysis and Research Activity Preventive Medicine Branch,“Disability Evaluation Systems Analysis and Research Annual Report 2014,” Walter Reed Army Institute of Research.
44
M. A. Treshchynska, “Dorsopathy: Back Pain Management,” December 15, 2020; Woojin Park et al., “Obesity
Impact on Range of Motion,” Ergonomics, 53, No. 1 (January 2010). Valerie Williams, Saixia Ying, and Shauna
Stahlman, “Surveillance Snapshot: Medical Separation from Service Among Incident Cases of Osteoarthritis andSpondylosis, Active Component, U.S. Armed Forces, 2016–2020,” MSMR 29, No. 3 (March 2022), 22. D. N.
Cowan et al., "Musculoskeletal injuries among overweight army trainees: incidence and healthcare utilization,"
Occupational Medicine 61, No. 4 (June 2011), 247-252; Valerie Williams et al., “Surveillance Snapshot: Medical
Separation from Service Among Incident Cases of Osteoarthritis and Spondylosis, Active Component, U.S. Armed
Forces, 2016–2020,” MSMR 29, Vol. 3 (March 2022).
45
Accession Medical Standards Analysis & Research Activity, “Attrition and Morbidity Data for 2017 Accessions,”
Walter Reed Army Institute of Research, 2018, 32. From 2011 to 2018, the most common reason for D.Q.s (permanentor temporary) was unmet DoD weight and body fat standards. See Disability Evaluation System Analysis andResearch, “2019 Annual Report,” 2-28.
46
Accession Medical Standards Analysis & Research Activity, “2021 Annual Report: Medical Disqualifications,
Medical Waivers, Accessions and Outcomes FY 2016-2020 Military Applicants,” 2022, 5; Accession Medical
Standards Analysis & Research Activity, “2022 Annual Report: Medical Disqualifications, Medical Waivers,
Accessions and Outcomes among FY 2016-2020 Military Applicants,” 2023, 5. Note: while published separately as“2021 Annual Report” and “2022 Annual Report,” both reports analyze data from FY 2016-FY 2020 as AMSARA
did not receive FY 2021 applicant data from USMEPCOM at the time of publication.
47
Accession Medical Standards Analysis & Research Activity, “2020 Annual Report: Medical Disqualifications,
Medical Waivers, Accessions and Outcomes among FY 2016-2019 Military Applicants,” 2021, 3.
48
Accession Medical Standards Analysis and Research Activity, “Annual Report 2015: Attrition & Morbidity Data
for 2014 Accessions,” March 11, 2016, 64.
49
Significantly, the American Medical Association (AMA) designated obesity as a disease in 2013. See Theodore
Kyle, Emily Dhurandhar, and David Allison, “Regarding Obesity as a Disease: Evolving Policies and Their
Implications,” Endocrinology and Metabolism Clinics of North America 45, Vol. 3 (September 2016), 511–520.
34

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“Transition to ICD-10,” Office of Workers' Compensation Programs, accessed August 27, 2023; Accession
Medical Standards Analysis and Research Activity, “Annual Report 2017: Attrition & Morbidity Data for 2016
Accessions,” August 2018, 41.
51
The full disclaimer states, “In previous years, DQs were reported using International Classification of Diseases,
9th revision (ICD-9) codes. United States Military Entrance Processing Command (USMEPCOM) transitioned
from ICD-9 to ICD-10 codes effective fiscal year (FY) 2016 (starting 01 Oct 2015). Because Military Entrance
Processing Station (MEPS) physical examinations are valid for 2 years, a mixture of ICD-9 and ICD-10 codes is
expected to persist in our database through FY 2022. To allow for comparisons over the transition period,
AMSARA utilized Clinical Classifications Software (CCS) codes, developed at the Agency for Healthcare Research
and Quality (AHRQ). Some CCS categories were adapted to better describe disqualifications in relation to DoDI
6130.03.” See Accession Medical Standards Analysis and Research Activity, “Annual Report 2018: Attrition &Morbidity Data for 2017 Accessions,” 2018, 28. From 2006-2013, however, reports inconsistently use “Weight,
body build” (no ICD code) and “Obesity and other hyperalimentation” (ICD category encompassing E65-E68) for
obesity. The clinical category for ICD-9 and ICD-10 is E66, “Overweight and obesity.” See “Chapter IV:
Endocrine, nutritional and metabolic diseases (E00-E90),” International Statistical Classification of Diseases andRelated Health Problems 10th Revision. In ICD-8, obesity was categorized under 277, “Obesity.” In ICD-7,
introduced in 1955, obesity was categorized under code 287, “Obesity”.
52
AMSARA, “Annual Report 2018,” 28.
53
According to the Centers for Naval Analysis, “Because DMDC data do not report specific International
Classification of Diseases (ICD-10) medical conditions, we cannot tell whether the increase in medical conditions isdue to an increase in physical or mental health conditions.” See Shannon Desrosiers and Kyle Neering, “Evaluating
Suitability Across the Services.”
54“2017 Health of the Force Report,” Defense Health Agency, 50.
55“High utilization of analogous codes, particularly among Service members with musculoskeletal disabilities, andlack of formal MEB medical diagnosis in the electronic file, precludes the evaluation of the association of certain
types of disability with specific medical conditions.” See Disability Evaluation System Analysis and Research, “2019Annual Report: Key Metrics Disability Evaluations FY2013-2018,” Walter Reed Army Institute of Research, March 13,
2020, 56. The Centers for Naval Analysis found that Navy physicians misused “condition, not disability” codes as afaster and less costly separation reason for Sailors and Marines who should have received disability ratings withcompensation. See Shannon Desrosiers and Kyle Neering, “Evaluating Suitability Across the Services,” page v.
56
Natalya Weber et al., “2022 Disability Evaluation System Analysis and Research (DESAR) Annual Report,” Walter
Reed Army Institute of Research, January 10, 2023.
57
The DoD's 2020 disability report tracked "unmet weight" within accessions but not within service or separations.
See William Washington et al., “2020 Annual Report Disability Evaluation System Analysis and Research,” Walter
Reed Army Institute of Research, 43. “The proportions among 2019 disqualified applicants for both the endocrine andmiscellaneous categories were approximately half the proportions in 2016 and 2017; these changes may be due
medical standard changes.” See AMSARA, “2020 Annual Report,” 16; Natalya Weber et al., “2022 DESAR,” 47.
58
William Washington et al., “2020 DESAR,” page IV.
59
Sarah Meadows et al., “2015 Department of Defense Health Related Behaviors Survey (HRBS),” RAND Health
Quarterly 8, No. 2 (2018). Another RAND study sponsored by the Department of Defense found that “differences
between services' systems and methods often leads to incorrect data in systems of record” and “the Defense
Manpower Data Center will often change D.D. Form 214 data without relaying those changes back to the services.”
See Michael Schwille et al., “Service Member Separation: Updating the D.D. Form 214,” RAND, 2019. Reserve
component separation codes differ from active component codes, making them incomparable. A spokesperson for
the Department of Defense told Reuters that medical diagnoses from 2016-2020 were underreported in DMED,
which resulted in an apparent significant increase when comparing the figures with data from 2021. See “Fact
Check-DoD says data error caused spike in numbers of medical diagnoses in their medical database for 2021,”
Reuters Fact Check, February 23, 2022. Overweight and obese data cannot be compared to benchmarks as “no clear
benchmarks for the military exist.” See Sarah Meadows et al., “2015 Department of Defense Health Related
Behaviors Survey,” page xlii. CNA also found that “erroneous enlistment is primarily used by the Navy, fraudulent
entry is primarily used by the Marine Corps, and failed procurement standards is the reason primarily used by the 17

Army and the Air Force.” See Shannon Desrochers and Kyle Neering, “Evaluating Suitability Across the Services,”
page viii.
60“Increased Missing Data Affects Burden Estimates,” MSMR 30, No. 6 (June 2023), 2.
61
For example, annual AMSARA reports shrank from 144 pages in 2015 to 61 pages in 2019. The website for the
DOD Survey of Health-Related Behaviors, “the predominant source of health behavior information for the military
since 1980,” has not been updated since 2015. See “Survey of Health-Related Behaviors,” Health.mil, accessed
August 29, 2023.
62“The IHI should not be compared with prior years due to changes in data sources and methodology.” See “2022Health of the Force Report,” Defense Health Agency, 88. “Installations are separated by electronic health record
system and should not be compared across systems due to known data decrements resulting from the installationtransition from AHLTA to MHS GENESIS.” See “2022 Health of the Force Report,” Defense Health Agency, 89.
63
Rebecca Puhl and Chelsea Heuer, “Obesity Stigma: Important Considerations for Public Health,” American Journalof Public Health 100, No. 6 (June 2010), 1019–1028.
64“70% of active-duty service members had recorded periodic health assessments during this period, and 10% of
those assessments contained missing or invalid BMI data.” See Regan Stiegmann et al., “Obesity Prevalence.”
65
Sarah Meadows et al., “2015 Department of Defense Health Related Behaviors,” page 15.
66“2022 Health of the Force Report,” Defense Health Agency, 152.
67
“Although unverified, obese Soldiers may be more likely to have an outpatient visit than a non-obese Soldier; thiswould result in an overestimation of obesity prevalence for the A.C. Soldier population.” See “2022 Health of theForce Report,” Defense Health Agency, 165.
68
Christine Aramburu, Alegria Drury, and Margaret Louis, “Exploring the association between body weight, stigma
of obesity, and health care avoidance,” Journal of the American Association of Nurse Practitioners 14 (December 2002),
554–561; Mary Forhan, Cathy Risdon, and Patricia Solomon, “Contributors to patient engagement in primary healthcare: perceptions of patients with obesity,” Primary Health Care Research & Development 14 (December 2012), 367–372;
S. M. Phelan et al., “Impact of weight bias and stigma on quality of care and outcomes for patients with obesity,”
Obesity Review 16 (April 2015), 319–326.
69
Military personnel are likely to enroll in commercial weight-reduction programs or to self-treat with supplementsor over-the-counter medications rather than call attention to their weight, which invites possible disciplinary action
or separation from the service with loss of benefits. See Weight Management: State of the Science and Opportunities, 39.
70
Sarah Meadows et al., “2015 Department of Defense Health Related Behaviors Survey,” page xliii.
71
AMSARA, “Attrition & Morbidity Data for 2015 Accessions,” 3. Approximately 1200 first-term enlistees
separated from the military service before finishing their contracted period because of failure to meet weightstandards, which cost the DoD $61 million. See Tim Dall et al., “Cost Associated With Being Overweight and With
Obesity, High Alcohol Consumption, and Tobacco Use Within the Military Health System's TRICARE Prime–
Enrolled Population,” American Journal of Health Promotion 22, Vol. 2, 120-39 (November 2007).
72
Patricia H. Rosenberger and Lindsey Dorflinger, “Psychosocial factors associated with binge eating among
overweight and obese male veterans,” Eating Behaviors 14, No. 3 (August 2013), 401–404; Katherine D. Hoerster etal., “PTSD and depression symptoms are associated with binge eating among U.S. Iraq and Afghanistan veterans,”
Eating Behaviors 17 (April 2015), 115–118. Overweight individuals in the general population frequently encounterbarriers to employment, lower wages, denial of promotions, and pejorative humor and comments from co-workers.
See Cory W. Rudolph et al., “A meta-analysis of empirical studies of weight-based bias in the workplace,” Journal of
Vocational Behavior 74, No. 1 (February 2009), 1–10; Katrin Elizabeth Giel et al., “Weight bias in work settings—Aqualitative review,” Obesity Facts 3, No. 1 (February 2010), 33–40; Rebecca M. Puhl and Chelsea A. Heuer, “Thestigma of obesity: A review and update,” Obesity 17, No. 5 (May 2009), 941–964.
73
At enlistment, obese individuals with no recognized disabilities are categorized as “medically qualified.” “Theproportions among 2019 disqualified applicants for both the endocrine and miscellaneous categories wereapproximately half the proportions in 2016 and 2017; these changes may be due medical standard changes.” See
AMSARA, “Annual Report 2020,” 16.
74
Evan Trivette, “Obesity and Army Readiness,” U.S. Army Command, 2019; Rachel Nostrant, “DoD overhauls its
body composition and fitness policy,” MilitaryTimes, March 21, 2022.
75“Exception to Policy: AR 600-9 Army Body Composition Program,” army.mil, accessed August 27, 2023.
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Darren Yang et al., “Relationship Between Body Mass Index and Diagnosis of Obesity in the Military Health
System Active Duty Population,” Military Medicine 187, No. 7-8 (July-August 2022), e948-e954.
77
For examples, see “2014 Health Related Behaviors Survey of Active Duty Personnel,” Defense Health Agency, Fall
2015, 29; “2022 Health of the Force Report,” Defense Health Agency, 152; “2021 Health of the Force Report,” Defense
Health Agency, 25. “Muscular service members may have been misclassified as overweight or obese. Recent researchon male firefighters, who may be more similar to military personnel than other occupational cohorts, foundsignificant misclassification, both false positive and false negative, of obesity when comparing BMI-based measureswith more-sensitive measures, including percent body fat and waist circumference (Jitnarin et al., 2014).” See “2015
Department of Defense Health Related Behaviors Survey,” RAND, 47. In the firefighters study, the demographics
evaluated were not similar to that of active duty service members. It concluded that “rates of false positives (i.e.,labeling someone as obese based on BMI when they are not based on Body Fat Percentage or Waist Circumference)
were very low.” See Nattinee Jitnarin et al., “Accuracy of Body Mass Index-defined Obesity Status in US
Firefighters,” Safety and Health at Work 5, No. 3 (September 2014), 161-164.
78
Albert Sun, “How Often is BMI Misleading?” The New York Times, August 28, 2015. Also see Orison Woolcott
and Till Seuring, “Temporal trends in obesity defined by the relative fat mass (RFM) index among adults in the
United States from 1999 to 2020: a population-based study,” BMJ Open 13, No. 8 (August 2023), e071295.
79
Philip Clerc, Stéphanie Mayer, and Sky Graybill, “Overweight BMI (25–29) in Active Duty Military: Excess Fat orMore Lean Mass? A Look at the Evidence,” Military Medicine 187, No. 7-8 (July-August 2022), 201–203.
80
Steve Beynon, “Army Sticking to Flawed Tape Test with Tweaks,” Military.com, March 9, 2023.
81“2017 Health of the Force Report,” Defense Health Analysis, 50.
82
Courtney Clutter et al., “Are We Missing an Opportunity? Prediabetes in the U.S. Military,” Mil Med (July 2022).
83
For example: “Excessive body fat connotes a lack of personal discipline, detracts from military appearance, [and]may indicate a poor state of health, physical fitness, or stamina.” See Department of Defense, Army Regulation 600-9(Washington, DC: Department of the Army, 1986).
84
For weight and fitness requirements, see Department of Defense, MCO 6110.3A W/CH 3 (Washington, DC:
United States Marine Corps, 2021), 1-1.
85
For “Squared away,” see MCO 6110.3, 1-10. For “commensurate with the high standards traditionally associatedwith Army service,” see AR 670–1, 18. For “contributes to a favorable Military image,” see Navy 2101.2.
86
United States Air Force, Department of the Air Force Guidance Memorandum to DAFI 36-2903, Dress and Personal
Appearance of United States Air Force and United States Space Force Personnel, Air Force Policy, 28 February 2023.
87
Multiple sources noted that the Army Regulation (AR) 600-9 Army Body Composition Program (ABCP)
provisions are inconsistent and unevenly enforced. One representative source who wrote while attending theSergeants Major Academy noted, “We have senior leaders in key positions who are not in accordance with AR 6009.” See Keith D. Carmickle, “The Ethical Dilemma of the Army Overweight Program,” United States Army Sergeants
Major Academy (Fort Bliss, TX: January 3, 2008).
88
MCO 6110.3A; Army Regulation 600-9.
89
For example, while Army Regulation 600-9 no longer grants authority to commanders in making healthdeterminations based on appearance alone, it still gives commanders discretion in determining who is evaluated forbody fat based on an individual's “soldierly appearance,” driving subjective and stigma-based decisions that are notbased on real health or body weight metrics. See Department of the Army, The Army Body Composition Program, Army
Regulation 600-9 (Washington, DC: Army Publishing Directorate, 2013).
90
E. K. Gunderson, “Body size, self-evaluation, and military effectiveness,” Journal of Personality and Social Psychology 2,
No. 6 (December 1965), 902–906; R.C. Martin et al., “Validity of self-reported physical fitness and body mass index
in a military population,” Journal of Strength and Conditioning Research 30, no. 1 (January 2016), 26–32; Andrew
Christian, Bina Parekh, and Gilly Koritzky, “Bias and discrimination against men with overweight in the military,”
Health Psychol Open 7, no. 2 (December 2020).
91
Anita H. McCowen, “The Impact of Fitness on Senior Leadership,” U.S. Army War College, April 7, 2003.
92
Weight Management: State of the Science and Opportunities, page 38.
93
Weight Management: State of the Science and Opportunities, page 55.
94Erin L Miggantz, et al., “Characteristics of Active Duty Service Members Referred to the Navy’s WeightManagement Program,” Mil Med 188, No. 1-2 (2023 Jan-Feb), e174–e181.
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AM Malkawi et al., “Dietary, physical activity, and weight management interventions among active-duty military
personnel: a systematic review,” Military Medical Research 5, No. 1 (2018), 1–12; J Murray et al., “Selected weight
management interventions for military populations in the United States: a narrative report,” Nutritional Health 23,
No. 2 (2018), 67–74; Wisbach GG et al., “Are Navy weight management programs ensuring sailor physicalreadiness? An analysis at Naval Medical Center San Diego,” Mil Med 183, No. 9-10 (2018), e624–32.
96“Addressing Health Barriers to Military Service,” House Report, 5.
97
These changes in nomenclature are intended to reduce the stigma surrounding obesity by alleviating body
consciousness, reducing embarrassment, being more inclusive of women and people of color, or granting dignity tomore senior service members. See Rebecca Puhl and Chelsea Heuer, “Obesity Stigma: Important Considerations for
Public Health.”98
For example, the Consortium for Health and Military Performance’s “Get into Fighting Weight” campaign
advocated a four-step program starting with a “wish” for weight loss. CHAMP was granted $7.2 million dollars in
FY2021 for this campaign and an evaluation of omega-3 supplements. See “Department of Defense Cooperative
Agreement HU00012120022,” USASpending.gov; “Department of Defense Cooperative Agreement
HU00012020028,” USASpending.gov; “Lighting the Way: 2021 Annual Report,” Consortium for Health and Military
Performance, November 22, 2021; “Get into Fighting Weight: A Total Force Fitness Guide,” The Consortium for Healthand Military Performance, accessed August 27, 2023.
99“The TFF framework provides a proactive and holistic approach to the management of mission readiness ROIfrom TFF relevant programs (including nutrition and physical fitness programs), otherwise the estimated impact
would/could be miscalculated if other upstream drivers of mission readiness from both an individual andcommunity perspective identified in the TFF framework are not accounted for. The need to look holistically at
fitness and control for the many contributing factors of readiness is why we must account for all the variables
associated with the TFF domains when assessing the marginal impact of specific military physical fitness andnutrition programs.” See “Addressing Health Barriers to Military Service,” House Report, 5. Representative James
Glynn states, “Holistic performance, including spiritual, mental, social, and physical fitness are critical for Marines
and their loved ones, and are a major line of effort for successfully achieving our talent management goals.” See“House Armed Services Subcommittee on Military Personnel Holds Hearing on Personnel Posture One,” America’s
Navy Press Office, March 29, 2023.
100
CHAMP, “Get into Fighting Weight: A Total Force Fitness Guide.”
101
Ibid.
102
Carmen Good et al., “Sleep in the United States Military,” Neuropsychopharmacology 45 (2020), 176–191.
103“Unfit to Serve,” National Center for Chronic Disease Prevention and Health Promotion.
104“Duration of Service after Overweight-related Diagnoses, Active Component, U.S. Armed Forces, 1998-2010,”
MSMR 18, No. 06 (June 2011); Alyson J. Littman et al., “Weight Change Following US Military Service,”
International Journal of Obesity 37, No. 2 (February 2013), 244–253.
105
Philip Ades et al, “High-calorie-expenditure exercise: a new approach to cardiac rehabilitation for overweightcoronary patients,” Circulation 119 (2009), 2671-2678; Ibrahim Akin and Christoph A Nienaber, “The obesity
paradox, weight loss, and coronary disease,” American Journal of Medicine 122 (2009), 1106-1114; Patrick Savage et al.,“Exercise and weight loss improve endothelial-dependent vasodilatory capacity in overweight individuals withcoronary heart disease,” Journal of Cardiopulmonology Rehabilitation 29, No. 264 (2009).
106
William Knowler et al., “Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin,”
New England Journal of Medicine 346 (2002), 393-403; Justo Sierra-Johnson et al., “Prognostic importance of weightloss in patients with coronary heart disease regardless of initial body mass index,” European Journal of Preventive
Cardiology 15 (2008), 336-340.
107
A. Janet Tomiyama, “Stress and Obesity,” Annual Review of Psychology 70 (January 2019), 703-718.
108Maria Stukenborg et al., “Exceeding body composition standards is associated with a more negative body image
and increased weight cycling in active duty U.S. soldiers,” Eating Behaviors 42 (August 2021).
109
Joseph Pierce et al., “Body mass index predicts selected physical fitness attributes but is not associated withperformance on military-relevant tasks in U.S. Army soldiers,” Journal of Science and Medicine in Sport 20 (2017), S79‐
S84.
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Cowan et al., “Musculoskeletal injuries among overweight army trainees.”
Nadia Urban, Michael R. Boivin, and David N. Cowan, “Fitness, Obesity, and Risk of Asthma among Army
Trainees,” Occupational Medicine 66, no. 7 (October 2016), 551-557.
112“Service members must meet the DoDI 1308.3 standards to deploy. These standards include weightrequirements, and, to deploy in violation of these standards, a waiver is required, slowing the process of
deployment. Indeed, waiver-related delays have become so problematic as to prompt consideration of revisions to
DoDI 1308.3.” See “2018 Department of Defense Health Related Behaviors Survey,” RAND, 42. “Sergeant Major(SGM) Keith Carmickle, noted that leaders mandated the removal of flags from overweight soldiers so that they
could deploy, a practice, which at the time, he infers was due to manpower shortages.” See Evan Trivette, “Obesity
and Army Readiness,” 13.
113
Evan Trivette, “Obesity and Army Readiness.”
114“COMSEC: What is your need to know?” McConnell Air Force Base, accessed August 27, 2023.
115
Jeannette Gaudry et al., “Impacts of Marine Corps Body Composition and Military Appearance Program(BCMAP) Standards on Individual Outcomes and Talent Management,” RAND, 2022; Lindsay Bodell et al.,“Consequences of Making Weight: A Review of Eating Disorder Symptoms and Diagnoses in the United States
Military,” Clinical Psychology 21, No. 4 (December 2014), 398–409.
116
Weight Management: State of the Science and Opportunities, 39-45.
117“2014 Health Related Behaviors Survey,” Defense Health Agency, 10.
118 Brooke Bartlett and Karen Mitchell, “Eating disorders in military and veteran men and women: A systematic
review,” International Journal of Eating Disorders 8, No. 48 (December 2015), 1057-1069; Danielle A Touma et al.,“Eating Disorders in U.S. Active Duty Military Members and Veterans: A Systematic Review,” Military Medicine 7-8,
No. 188 (July/August 2023), 1637–1648.
119
Jessica Murray, Sithembile Mabila, and Alexis McQuistan, “Trends in the Incidence of Eating Disorders Among
Active Component Service Members, 2017 to 2021,” MSMR 30, No. 01 (January 2023).
120“Impacts of Marine Corps Body Composition,” RAND.
121
Weight Management: State of the Science and Opportunities, page 40.
122“Physical Complications of Abuse of Laxatives, Diuretics and Diet Pills,” InsideOut Institute for Eating Disorders,
October 2022.
123
Jeannette Gaudry et al., “Impacts of Marine Corps Body Composition and Military Appearance Program(BCMAP) Standards.”
124
The first comprehensive finding on genetic predisposition to obesity was a 1989 study that found that adopted
Dutch infants had body compositions more similar to their biological parents than their adoptive parents despite
controlling for changes in nutrition, dietary standards, and other factors. See Lise Dubois et al., “Genetic andEnvironmental Contributions to Weight, Height, and BMI from Birth to 19 Years of Age: An International Studyof Over 12,000 Twin Pairs,” PLOS One 7, No. 2 (2012).
125“Excessive body fat connotes a lack of personal discipline, detracts from military appearance, [and] may indicate
a poor state of health, physical fitness, or stamina.” See AR 600-9, 1986.
126
The International Classification of Diseases, the American Medical Association, the World Health Organization,and the European Union recognize obesity as a chronic disease.
127
Weight Management: State of the Science and Opportunities, 55.
128
The services themselves include similar recommendations when revising these policies. See: “This document has
been substantially revised and needs to be completely reviewed,” in Department of the Air Force, Personnel Military
Separations, Instruction 36-3211 (Washington, DC: June 24, 2022). Similar disclaimers exist throughout other service
policies.
129
The U.S. Preventive Services Task Force found “convincing evidence” that preventive interventions in persons
diagnosed with prediabetes reduce progression to type 2 diabetes and improve other risk factors such as bloodpressure and lipid levels. See “USPSTF Recommendation: Screening for Prediabetes and Type 2 Diabetes,” U.S.
Preventive Services Task Force Clinical Review & Education, August 24, 2021. Also see “Why Screen for & Treat
Prediabetes,” U.S. Department of Health and Human Services. Prediabetes tests cost under $20 and can be
conducted by anyone in a healthcare setting trained to administer the test; see “Prediabetes Screening: How &Why,” U.S. Department of Health and Human Services, accessed August 27, 2023.
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130

In 2021, CHAMP’s #GetIntoFightingWeight posts received low engagement, with between zero to seven“likes,” “comments,” and “reblogs” each, signifying that the overall reach and impact of this campaign were limited.
CHAMP’s second initiative evaluated omega-3 levels in service members. Omega-3 supplementation has not beenfound to correlate significantly with either weight loss or body fat. See Felipe Mendes Delpino, Lílian Munhoz
Figueiredo, and Bruna Gonçalves Cordeiro da Silva, “Effects of omega-3 supplementation on body weight andbody fat mass: A systematic review,” Clinical Nutrition 44 (August 2021), 122-129.
131
The DoD's Total Force Fitness (TFF) framework prioritizes services and programs to improve military healthand readiness. The Department of Defense granted over $7.2 million in 2021 to the Consortium for Health and
Military Performance (CHAMP) to manage TFF and its Human Performance Optimization program, which assigns
fitness levels to core tasks. See “Addressing Health Barriers to Military Service,” House Report, 5; “Human
Performance Optimization: Moving left of bang,” CHAMP, accessed August 11, 2023.
132
The course reports an average 1.7% decrease in body fat per week. See Doug Ware, “Army prep course has seen
95% grad rate, $15M in bonuses in 1st year.”
133.5% weekly body fat loss or less is generally considered a safe rate of fat loss. During periods of rapid weight loss,
up to 25% of lost mass is muscle tissue. See Kevin Hall and Scott Kahan, “Maintenance of lost weight and longterm management of obesity,” Medical Clinics of North America 102, No. 1 (January 2018), 183–197; Damoon AshtaryLarky et al., “Effects of gradual weight loss v. rapid weight loss on body composition and RMR: a systematic review
and meta-analysis,” British Journal of Nutrition 124, No. 11 (June 2020); Kimberly Neumann and John Morton, “12Ways To Reduce Body Fat,” Forbes Health, April 6, 2023. Within six months to a year, program participants typicallyexperience a weight plateau; within five years, over 80% of lost weight is regained. See Anderson JW et al., “Longterm weight-loss maintenance: a meta-analysis of U.S. studies,” American Journal of Clinical Nutrition 74, No. 5(November 2001), 579–584.
134
Weight losses of 5-10% over the course of at least one year decrease the incidence of diabetes by 58 percent andstabilize blood pressure, cholesterol, and arthritis. See Diabetes Prevention Program Research Group, “Reduction in
the incidence of Type 2 diabetes with lifestyle intervention or metformin,” New England Journal of Medicine 346(2002), 393–403; Donna Ryan and Sarah Yockey, “Weight Loss and Improvement in Comorbidity: Differences at
5%, 10%, 15%, and Over,” Current Obesity Reports 6, No. 2 (June 2017), 187–194; R. Christensen et al., “Weight loss:
the treatment of choice for knee osteoarthritis?” Osteoarthritis and Cartilage 13, No. 1 (January 2005), 20-27.
135“Prescription Medications to Treat Overweight & Obesity - NIDDK,” U.S. Department of Health and Human
Services.
136
Meg Tirrel, “Weight-loss drug Wegovy produces ‘largest benefit ever seen’ for patients with most common formof heart failure, trial finds,” CNN, August 25, 2023; John Wildling et al., “Once-Weekly Semaglutide in Adults with
Overweight or Obesity,” New England Journal of Medicine 384 (March 2021), 989-1002.
137
The health and fitness industries are majority composed of unlicensed “nutrition experts” who are not authorized
to diagnose or treat obesity. Physicians credentialled by the American Board of Obesity Medicine maintainspecialized knowledge in the practice of Obesity Medicine. See “American Board of Obesity Medicine,”
https://www.abom.org/. Registered Dietitians and Registered Dietetics Technicians are credentialed practitioners
required to stay up to date with current nutrition and obesity science. See “About RDNs and NDTRs,” Academy of
Nutrition and Dietetics.
138
Obesogenic influences can be identified as early as infancy and can have significant and ongoing impacts on a
person’s health throughout their lifetime. Factors such as maternal obesity, gestational diabetes, maternal smoking,and inadequate sleep are all risk factors. See Ruth Loos and Giles Yeo, “The genetics of obesity: from discovery tobiology,” Nature Reviews Genetics 23 (2022), 120–133; James Gannon et al., “A Practical Screening Tool to Predict
Early Childhood Obesity Risk: Examining a Birth Cohort,” Clinical Pediatrics 60, No. 3 (March 2023), 178–183.
139
John Donnelly, “Congress barely dents scourge of hunger in military,” Roll Call, January 13, 2023.
140
For example, days at a combat post can be 14 to 16 hours long, with little time for rest or recuperation. See “Dayin the Life,” GoArmy.com; “An Average Day in the Life of a Warrior at a Combat Post,” Combat One.
141
Military reporters optimistically note when obesity “stabilizes” or “improves,” even this is due to changes in
categorization, policy, or improperly recorded or missing data. For example, in 2017, 5-15% of Disability Evaluation
System records went missing, meaning data on obesity and other medical conditions were significantly
underestimated. See DESAR, “Annual Report 2019,” 29. Despite this, annual reports noted improvements in22

several disability categories, for example “The proportion of all Soldiers with a chronic disease has slowly declinedin the last five years” in “Health of the Force Report 2017,” Defense Health Agency, 42. Another report notes“overweight/obesity continued to decrease compared to previous years,” but recategorizations significantly affected
these results. See “2015 Health Related Behaviors Survey,” RAND, 48; AMSARA, “Annual Report 2015,” 2. Some
reports mark progress on metrics that are not meant to be same-year goals. For example, “many fewer active-duty
service members aged 20 or older were obese(15.0 percent), easily achieving the HP2020 obesity target,” when thattarget was meant to be a projected rate five years into the future. See “2015 Health Related Behaviors Survey,”
RAND. Reports have published incremental or stable obesity rates compared to prior years, only for those rates tobe adjusted higher in future reports. See “Decision Brief: Examination of Mental Health Accession Screening,”
Defense Health Board, August 7, 2020; AMSARA, “Annual Report 2016,” 4. This has been a recurring trend since atleast 1995, when combined overweight and obesity rates were published at 19%. See Roberty Bray et al., “1995
Department of Defense Survey of Health Related Behaviors Among Military Personnel,” Research Triangle Institute,
December 1995. This was later corrected to 50.6% in Carolyn Reyes-Guzman, “Overweight and obesity trends” andfuture reports. AMSARA, “Annual Report 2010” states that “The incidence of disqualifications forobesity/overweight (exceeding weight/body fat limits) is lower in 2009 (3,749 per 100,000 applicants) compared tothe previous five years (4,353 per 100,000 applicants).” In AMSARA 2013, "overweight and obesity (9.0% of
disqualifications), a temporary condition, decreased in prevalence among applicants by nearly 50% in 2012 relative
to the previous five years to 1,557 per 100,000 applicants." In AMSARA 2015, these rates were adjusted to 15%. In
DoD Health of the Force 2019, this number climbed to 16.3% using the same dataset.
142
AMSARA and DESAR reports, for instance, are responsible for systematically evaluating military obesity data,
provide context for changes in military health policy, and craft recommendations regarding the effects of excess
body fat on recruitment and retention. However, they are unable to do so because of BMI data being removed frommedical categories. See “Decision Brief: Examination of Mental Health Accession Screening,” Defense Health Board,
August 7, 2020; AMSARA, “Annual Report 2016,” 4; “Impacts of Marine Corps Body Composition and MilitaryAppearance Program (BCMAP) Standards,” RAND.

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