Physical Activity and the Health of a Nation: A National Challenge and Collective Response

Abstract

Historic recruitment and retention challenges confront the U.S. military. In an invited panel discussion at Lifestyle Medicine 2023, we argued that widespread physical inactivity is contributing to these challenges, and that Lifestyle Medicine approaches should be part of the solution. Our aim in this commentary is to recapture the most salient messages from that discussion. First, we summarize significant epidemiologic studies that describe the scope of the problem among future recruits, current service members, and Veterans. Then, in the optimistic spirit that characterizes both the armed forces and Lifestyle Medicine communities, we outline several potential solutions. By increasing physical activity during the school day, using wearable technology to monitor and prompt health behaviors, addressing the other pillars of Lifestyle Medicine (especially sleep, nutrition, and stress management), aligning efforts with current health frameworks in the Departments of Defense and Veterans Affairs, and recruiting Lifestyle Medicine professionals, we are convinced that we can improve the health of our nation and, in so doing, strengthen military readiness and national security.

“Lifestyle Medicine professionals can serve their nation invaluably by promoting a healthy civilian population that is physically and mentally prepared to confront any adversary.”

Introduction

The U.S. Senate Committee on Armed Services received testimony in May 2023 from senior military leaders regarding the readiness posture across the armed forces. Amidst strategic-level discourses on current military capabilities, an underlying theme emerged: recruiting and retaining mission-ready warfighters remains critical for operational success. Alarmingly, given the shortage of young Americans who possess both the propensity and qualities to serve in the armed forces, the personnel landscape is bleak. Reflecting on the “troubling … levels of recruitment and the failure [of the Services] to achieve many of the recruiting goals,” Senator Blumenthal bluntly summarized the present challenge: “Only 23% of Americans aged 17 to 24 are qualified to serve without a waiver,” he stated, “which I think is a pretty damning indictment of education, health, however you want to characterize it.” ¹

As panelists at Lifestyle Medicine 2023, we had the privilege to address this challenge. We were asked by the conference committee to explore the value of physical activity in the context of our nation’s health, military readiness, and security posture. Our discussion, albeit broad ranging, returned continually to the idea that physical activity and the other Lifestyle Medicine pillars are foundational to the health and readiness of our current and future armed forces. This applies to both the active and reserve components of all service branches, including the Army, Marine Corps, Navy, Air Force, Space Force, and Coast Guard. ² In this commentary, we aim to summarize the key points of our panel discussion. We begin by defining the problem of physical inactivity and unhealthy lifestyles across the population—including among future recruits, current service members, and Veterans—and proceed to offer myriad solutions at the individual and population levels to tackle it.

Defining the Problem

Recent epidemiologic studies have demonstrated that inadequate physical activity is a widespread problem with implications for former, current, and future service members. Among a representative sample of military-aged civilians across the United States surveyed between 2015 and 2020, just 34% were eligible by body mass index and reported adequate physical activity for military enlistment. In other words, even if everyone between the ages of 17 and 42 met all other enlistment criteria and desired to serve, just one in three would be physically ready for basic military training. ³

The importance of physical preparedness before basic military training was highlighted in a pair of U.S. Army studies. Over a four-year timespan (N = 131,403), recruits who hailed from the South—a region responsible for higher levels of recruitment than the West, Midwest, and Northeast—were less physically fit on arrival and more likely to sustain a musculoskeletal injury during basic training. ⁴ In a follow-up analysis (N = 99,335), Southern recruits were again found to have a higher incidence of training-related musculoskeletal injuries than their peers, accounting for nearly half of all injury-related fiscal costs. ⁵

While physically salutary in the short term, completion of basic military training does not portend enduring health benefits. A study in the U.S. Air Force (N = 47,054) found that Airmen gained an average of 14.6 lb (6.6 kg) of body weight and 1.2 in (3.1 cm) of waist circumference during their first four years of active-duty service after basic training. Compared to 3.9% of Airmen who transitioned to a lower body mass index category during their first enlistment term, 37.3% transitioned to a higher category (i.e., from normal to overweight/obese, or from overweight to obese). ⁶

Habits that accrue before and during military service may persist beyond separation or retirement. Despite having served in uniform and retaining greater access to health care, Veterans are more likely than their demographically matched peers to report leisure-time physical inactivity, tobacco use, and heavy alcohol consumption. ⁷ Increasing physical activity and reducing substance use may decelerate or even reverse the rising health care costs for Veterans, estimated to exceed 139 million outpatient encounters and 1.1 million inpatient visits in 2024 and beyond. ⁸

Responding with Solutions

Increasing Physical Activity Among Youth During School Days

The military is comprised largely of young people. Nearly 90% of applicants are aged 17 to 24 years at enlistment, ⁹ meaning that most 2030 candidates are currently in middle and high school, while most 2035 candidates are in elementary school. To our dismay, however, many of these children and adolescents are not enrolled in physical education courses. Currently just six states require physical education at every grade level, from kindergarten through high school, and only Oregon and the District of Columbia meet national guidelines for total weekly physical education time. ¹⁰ In addition to increasing opportunities for physical activity during the school day, we advocate for policies to promote active commuting to and from school (e.g., Safe Routes to Schools), classroom-based physical-activity breaks, intramural and organized sports, and physically active clubs. ¹¹ As U.S. Surgeon General Vivek Murthy ¹² recently wrote, physical activity—and particularly organized sports—is an incredibly powerful tool to improve academic performance, build resilience and social-emotional skills, and reduce mental health issues in youth.

Incorporating Technology

Wearable technology has the potential to help service members monitor health behaviors, such as sleep quantity and quality, and provide motivation to meet device- or user-defined goals, such as steps per day. The U.S. Space Force, for example, is experimenting with a “Continuous Fitness Assessment” as an alternative to the periodic fitness assessment practiced historically across the armed services. Currently in the data collection phase, this initiative allows Guardians to track their physical activity with wearable fitness devices. The premise, which is intuitive but still empirically unverified, is that continuous data monitoring more effectively promotes a perennial culture of physical fitness than an annual or biannual fitness assessment. Rather than serving as a measure, the fitness assessment becomes the target—a classic example of Goodhart’s Law (i.e., when a measure becomes the target, it also becomes ineffective as a measure). Although geo-positioning and other data privacy challenges associated with these devices are real, the Space Force initiative has already demonstrated that cybersecurity compliance is possible. ¹³

Addressing Sleep, Nutrition, and Stress

Acknowledging that physical activity is synergistically related to the other Lifestyle Medicine pillars, we also discussed the importance of sleep, nutrition, stress management, social connections, and substance avoidance, with an emphasis on the first three behaviors. Perhaps due to an undervaluation in the military tradition, sleep may be the most neglected Lifestyle Medicine pillar among current service members. Two-thirds of active component U.S. Army personnel in a recent survey reported fewer than 7 hours of sleep nightly, and 14% had a diagnosed sleep disorder. ¹⁴ Inadequate sleep has been associated with less physical activity and greater prevalence of tobacco use among soldiers, demonstrating synergy between the Lifestyle Medicine pillars. ¹⁵ Improving sleep health for service members may require a multi-pronged approach, including improved education on mission ramifications of sleep deprivation, novel strategies to maximize sleep opportunities for shift workers, increased access to cognitive-behavioral and other therapies for insomnia, and development of a leadership milieu that values sleep. To the lattermost point, we were encouraged when the National Guard Bureau recently issued a sleep challenge. ¹⁶

The military food landscape is complex. Food outlets on military installations include both Congressionally-appropriated sources (e.g., commissaries and mess halls) and non-appropriated fund outlets (e.g., clubs and franchise restaurants); food is also frequently served at unit events, such as ceremonies and potlucks. ¹⁷ A dietary pattern that minimizes processed foods and added sugars and emphasizes a whole-food, plant-predominant approach is vital for the health of service members—including reduction of cardiometabolic disease and musculoskeletal injury and enhanced mental clarity and cognitive ability. Improving the nutritional environment in military units may include adjusting the choice architecture (i.e., making the healthier food choice more affordable and accessible), inspiring leaders to provide healthier foods at military events, and educating personnel on the health and performance ramifications of their diet, both in-garrison and while deployed. ¹⁸

Service members frequently operate in high stress environments. Some who enter the armed forces have a history of adverse childhood experiences or other traumatic backgrounds—the scars of which can be exacerbated by service-related stressors. To protect the mental, emotional, and spiritual health of service members, we endorse several strategies: embed mental health experts within operational units to remove barriers to care and to build trust through frequent face-to-face interactions; normalize the experience of stress and emphasize the value of early intervention; involve family members in behavioral care; reimagine physical training sessions to incorporate physical activities that also foster mindfulness and psychosocial resiliency; and offer mental health strategies in packages that are acceptable to service members. As one of us quipped, a simple marketing technique is to append a martial adjective to the health behavior, such as tactical breathing, warrior yoga, or strategic napping.

Aligning with Current Military and Veterans Programs

Current frameworks employed by the Departments of Defense and Veterans Affairs, such as Total Force Fitness and the Whole Health Program, ¹⁹ acknowledge that health and performance should be approached holistically. When introducing Lifestyle Medicine strategies for service members and Veterans, we advise mapping initiatives onto these extant frameworks while considering four factors. First, understand that military readiness is not necessarily synonymous with general good health, but rather reflects the ability of a unit or individual to accomplish a specific mission set. Second, recognize that the military population encompasses tremendous heterogeneity, with its myriad career fields encountering different mental, physical, nutritional, and environmental stressors. Third, grasp the complexity of the health landscape, which includes differences between in-garrison and deployed locations and differences between the active and reserve components. Finally, realize that change in military and Veteran health care often transpires slowly—“glacially,” as one of us described it—requiring unwavering persistence and commitment.

Recruiting Lifestyle Medicine Professionals

Wearing the military uniform is not the only way to serve. Lifestyle Medicine professionals can serve their nation invaluably by promoting a healthy civilian population that is physically and mentally prepared to confront any adversary. As we concluded our panel and as we conclude here, we wish to speak directly to you, the Lifestyle Medicine professional. In the spirit of the epochal Uncle Sam recruiting poster from World War I, we want you! Here are just a few ways to serve.

1. Model healthy behaviors. Although it may sound trite, you are a role model for your patients, colleagues, and family members. Studies have consistently demonstrated that physically active health care providers are more likely to provide physical-activity counseling and to influence the behavior of their patients. ²⁰ If you are not doing so already, we encourage you to meet national recommendations by getting at least 150 weekly minutes of moderate-intensity equivalent aerobic activity and conducting at least 2 weekly episodes of muscle-strengthening activity. ²¹

2. Ask all patients about their military service and family military affiliation. At any given time, approximately half of U.S. service members are in the reserve component (i.e., Reservists and National Guardsmen not on active duty). Living and working in your community as teachers, nurses, cashiers, and firefighters, their military affiliation may remain hidden unless you ask. Pediatric providers should also inquire as to family military service. The majority of new recruits report an immediate family member who served in the armed forces, with over a quarter having a parent who served. ²² This may provide an opportunity to discuss physical activity and the other Lifestyle Medicine pillars, thus preparing future recruits for the rigors of basic training and military service.

3. Use ancillary services. With high patient volumes and busy schedules, it can be challenging within a clinic visit to provide guidance on all the Lifestyle Medicine pillars. Offload some of this counseling to trusted partners in the health care space and in the community. For Lifestyle Medicine providers within the Departments of Defense and Veterans Affairs, we urge you to leverage ancillary services within the health care network (e.g., registered dietitians, athletic trainers, and strength and conditioning coaches) and beyond it, such as Armed Forces Wellness Centers and local community resources.

4. Advocate in your community. Use the cachet you have earned as a health care professional to make positive changes in your community. This might entail volunteering at your local school to provide nutritional education, meeting with the school board to explain the impact of physical education classes on academic performance, or working with the community gym to develop basic training preparatory fitness classes for aspiring recruits. It might mean supporting or even applying for state and local health-promotion grants, such as those funded by the Centers for Disease Control and Prevention. ²³ It might involve bridging the gap between science and practice by advocating for policies, systems, and environments that improve community design and choice architecture. As repositories of best practices, the Community Guide, ²⁴ National Physical Activity Plan, ²⁵ and National Youth Sports Strategy ²⁶ provide a good starting point. Finally, when advocating to policymakers, we recommend conveying that physical inactivity is not just a public health problem, but truly a national security issue as well.

5. Understand the military ethos. Selfless, mission-oriented, and deeply committed to their comrades, service members and Veterans may respond to different incentives than their civilian peers. A Veteran may scoff at the notion of losing weight for his health and longevity, but he might embrace the challenge of losing 10 pounds in order to witness his granddaughter graduate from high school. Likewise, an aircraft maintainer may disregard your encouragement to obtain more sleep to benefit her personal health, but she might prioritize getting 7 h nightly to increase the safety of her flight mates.

Conclusion

The recruitment and retention challenges outlined by senior military leaders before the U.S. Senate Committee on Armed Services are complex and multifactorial. We are under no illusion that the Lifestyle Medicine solutions offered in this commentary are the panacea. Nonetheless, the evidence clearly demonstrates that a physically active population is a healthier population—and that the nation’s health is integrally connected to the nation’s security. When Major General Johnny Davis was asked in a December 2023 interview how he might counsel a teenage version of himself, the commander of U.S. Army Recruiting Command did not hesitate: “Never underestimate your potential in this wonderful nation.” ²⁷ Lifestyle Medicine approaches individual and population health with a similar optimism—a “pathologically optimistic” viewpoint, as one of us noted on stage. For the physical and mental health of our Veterans, for the operational readiness of our current service members, and for the physical and academic fitness of our future recruits, help us advocate the singular importance of physical activity across this wonderful nation.