Weight Loss Strategies Used by Army Reserve Officer Training Corps Cadets: Implication for Student Health and Wellness Services

Abstract

Background: Maintaining a healthy weight is a military requirement for the Reserve Officer Training Corps (ROTC) cadets. Male and female soldiers often have different approaches to maintaining a healthy weight and mobile health (m-health) tools can be harnessed and tailored to the needs of individual cadets.

Objectives: This study examined gender differences in technology use, weight loss strategies, information needed to maintain a healthy weight, and willingness to participate in m-health research and programs.

Materials and Methods: A self-administered survey was completed by 404 cadets from ROTC programs in Florida in 2017.

Results: Most owned smartphones and used them as their primary internet access. Women had significantly lower body mass index than men (p = 0.037). Most used healthy weight loss strategies, including increasing physical activity, reducing sweets, and reducing fried foods. Women were more likely than men to reduce fried foods (p < 0.0003) and sweets (p = 0.020). Most reported a willingness to participate in m-health weight management research and programs, with women more willing to do so (p = 0.038). Most were willing to participate in m-health programs that used text messages, food/activity/sleep apps, smart watches/fitness trackers, and stress management/anxiety apps. Women were more willing to participate in programs that used apps for stress/anxiety management (p = 0.004) and to track food/activity/sleep (p < 0.0001). Most needed information on eating healthy on a budget and eating healthy on-the-run.

Conclusions: Opportunities exist for college health and wellness professionals to use a variety of m-health tools and apps to promote general health and wellness and to help cadets achieve and maintain a healthy weight.

Introduction

Overweight and obesity are at epidemic proportions among all civilian groups in the United States, with ∼71% being clinically overweight or obese.¹ Individuals who are overweight or obese are at high risk for lower life expectancy and higher rates of chronic diseases such as type 2 diabetes, hypertension, heart disease, osteoarthritis, and some types of cancer.^2
–4 Although not as high as in the general population, there has also been a significant increase in overweight and obesity in the U.S. military. Between 1995 and 2008, overweight and obesity increased from 50.6% to 60.8%. This was primarily because of the more than doubling of the obesity rate from 5.0% to 12.7%.⁵ The increase in overweight and obesity, coupled with other unhealthy lifestyle behaviors, has significant impact on military readiness, attrition, and health care cost.^6
–8

Being overweight or obese is the most frequent reason for ineligibility for military service.⁷ Overweight and obesity are assessed in the military using a combination of body mass index (BMI) and the Military Tape Test, which measures body fat percentage.^8.9 According to a recent report, 9 million Americans between 17 and 24 years would be considered too heavy to join the military.⁷ Nationally, ∼11 million young adults between 18 and 24 years are overweight or obese, which negatively affects the nation's ability to build a ready military force.⁷

Recently, the demand of meeting recruiting quota has led to the recruitment of heavier soldiers. Although soldiers lose weight during the rigors of basic training, many regain weight and exceed the weight-for-height requirements after that training is over.¹⁰ Overweight and obesity affect the cost of health care in the military, which continues to grow faster than the civilian health care sector.⁶ Research indicates that service members who are overweight were at greater odds for early discharge because of injuries and associated medical concerns. They were also less likely to be eligible for re-enlistment past their first term.^11
–13 The U.S. military spends ∼$1.1 billion in health care costs associated with overweight and obesity-related illnesses and injuries, and loses hundreds of millions of dollars each year as a result of missed workdays and low productive days.^8,14

The military has made significant investments in developing health-related communication and mobile health (m-health) technologies to improve individual and organizational health.^15,16 Notably, the U.S. army is supporting research using smartphones and other mobile devices and is leveraging m-health technologies to deliver educational programs to support modern warfare.¹⁶ Recent studies have shown the feasibility of using smartphone apps and tools to promote healthy eating habits, promote physical activity, improve sleep, and manage weight.^17
–19 Thus, the use of mobile devices for healthy weight management may be a feasible acceptable safe cost-efficient method to reach a military population regardless of location.⁸

The Reserve Officer Training Corps (ROTC) is one of the primary programs that the military relies on to recruit officers from colleges and universities. The main goal of the ROTC is to train college students (aka cadets) to be future leaders in the armed forces. Upon graduation, cadets are required to enter active military duty for an obligatory period of service.²⁰

Cadets are a hybrid population of military, athletes, and college students who face many of the challenges of being college students, but with the additional military expectation to perform physically and mentally at elite levels. Cadets undergo grueling physical training, but they are also exposed to unhealthy foods and eating habits in the college environment. Studies have reported the tendency for students to gain weight as they enter college and transition to an independent lifestyle and make their own choices.^10,21,22 The pressures to meet the Army Body Composition Program's requirements for physical fitness, weight, and body fat standards,⁹ plus academic demands and being college students may lead many cadets to use unhealthy weight management strategies. This may be especially true for female soldiers and cadets who often experience a high rate of eating disorders, inadequate nutrition, and chronic dieting as they strive to achieve societal ideals as well as the military's body composition and appearance standards.²³

Young adults (18–24 years of age) have one of the highest ownership of smartphones and are high users of social media.²⁴ Thus, cadets may be willing to use m-health technologies to achieve and maintain a healthy weight. Most studies on personal technology use among the military population have focused on active military service members and veterans.^25,26 Thus, this study fills an important gap in the literature by examining smartphone usage, social media engagement, weight loss strategies, information needed to maintain a healthy weight, and willingness to participate in m-health weight management programs among cadets. It also compared differences in these variables between male and female cadets.

Materials and Methods

Participants and Procedures

Data were collected from a convenience sample of cadets from 9 of 11 ROTC programs in Florida in 2017. Two programs did not participate owing to schedule conflicts. Cadets were recruited through their unit commanders who sent an e-mail invitation with an online link to the survey. Two follow-up e-mails were sent to nonrespondents. No incentives were provided. The sample frame consisted of 1,233 eligible cadets; 444 (36.0%) agreed to participate, but 40 surveys were discarded because of missing responses. The final sample was 404 (32.8%) and consisted of 272 men (67.3%) and 132 women (32.7%). The study was approved by the Institutional Review Board at the investigators' institution.

The self-administered online survey was adapted from earlier instruments developed by the authors^27,28 and an extensive review of the literature on military health issues and technology use by military service members. The survey consisted of questions about sociodemographic information, technology use, self-reported weight and height, weight satisfaction, strategies used to lose/maintain weight, information needed to maintain a healthy weight, and willingness to participate in m-health weight research. BMI was calculated using self-reported height and weight [BMI = weight (kg)/height (m)²].² The instrument went through several iterations with input from a doctorally prepared active-duty army officer. The instrument was piloted with 39 cadets at one institution the semester before the study. Question types included “yes/no,” “choose all that apply,” and “fill in the blank.”

The survey was administered through Qualtrics (Provo, Utah) and then was sent directly from the army ROTC professor of military science. Clicking on the embedded survey link showed the online consent form, which included statements regarding voluntary participation, deidentifying information, anonymity of responses, Qualtrics privacy statement, and an option to leave questions blank. Clicking “yes” indicated consent. The survey took approximately 20 min to complete. No incentives were provided.

Data Analysis

Data were analyzed using the Statistical Package for Social Sciences (SPSS) software (version 24.0, Chicago, IL). Surveys were checked for completeness and listwise deletion was used to remove cases with missing responses. Statistical significance was established at the p < 0.05 level for all tests. Frequency tables were computed to check for completeness, range, and consistency. Descriptive statistics summarized the data, and mean values were calculated with standard deviations (SDs). Analyses included chi-square test (χ ²), odds ratio, and independent samples t-test.

Results

Participant Characteristics

The mean age was 20.41 years (SD = 2.74), with a range of 18–34 years. Most cadets were men (67.3%). Cadets self-identified as white (60%), African American/black (14.9%), Hispanic (12.9%), Asian/Pacific Islander (5.5%), American Indian/Alaska Native (1%), and other (5.7%). Student classification was reported as freshman (27.1%), sophomore (24.3%), junior (24.1%), senior (23.1%), and graduate student (2.2%). Mean grade point average was 3.31 (SD = 0.48). Other sociodemographic and military characteristics are given in Table 1.

Table 1.

Participant Characteristics (N = 404)

CHARACTERISTICS	n	%
Florida ROTC unit school
Embry-Riddle Aeronautical University	81	20.0
Florida Agricultural and Mechanical School	27	6.7
Florida Southern College	23	5.7
Florida State University	44	10.9
University of Central Florida	30	7.4
University of Florida	46	11.4
University of South Florida	72	17.8
University of Tampa	49	12.1
University of West Florida	32	7.9
Gender
Male	272	67.3
Female	132	32.7
Enrollment classification
Freshman	109	27.1
Sophomore	94	23.4
Junior	97	24.1
Senior	93	23.1
Graduate	9	2.2
Parent college graduate
Yes	257	63.6
No	147	36.4
ROTC contract status
Scholarship (contracted)	267	66.1
Scholarship (noncontracted)	137	33.9
Simultaneous military program
Yes	44	10.9
No	359	89.1
Family member military service
Yes	227	56.2
No	174	43.1
Intention to pursue a military career
Yes	309	76.5
No	13	3.2
Unsure	82	20.3
Previously deployed
Yes	14	4.5
No	295	95.5

ROTC, Reserve Officer Training Corps.

Device Ownership, Smartphone Use, and Social Media Engagement

Cadets owned a variety of digital devices such as smartphones (96.0%), laptops (94.3%), tablets (38.1%), and e-readers (14.9%). Internet was accessed from smartphones (94.1%), work/school computers (91.6%), home computers (91.1%), and restaurants/cafes (30.4%). Smartphones were used for a variety of tasks: e-mail (93.6%), watch videos (76.5%), check Facebook newsfeed (72.3%), post status/photos on Facebook (59.7%), track physical activity (49.8%), play video games (48.0%), video chat (46.8%), read blogs (40.1%), and track food intake (23.0%). Women were more likely than men to use their smartphones to video chat (p = 0.0006) and post status/photos on Facebook (p = 0.008). Men were more likely than women to use their smartphones to play video games (p = 0.015). Most cadets (64.4%) also reported playing video games on portable gaming devices (e.g., Xbox and PlayStation) in the past 30 days, with men more likely to have done so (p < 0.0001).

Cadets sent a mean of 71.26 (SD = 115.15) texts daily and received a mean of 85.11 (SD = 131.19) texts daily. There were no gender differences in texts sent or received daily. Cadets used several social media sites and tools daily: Facebook (87.9%), YouTube (80.0%), Instagram (70.3%), Skype/FaceTime (44.3%), Google+ (23%), and Twitter (22.5%). Men were more likely to use YouTube daily (p = 0.013), whereas women were more likely to use Google+ (p = 0.004) and Skype/FaceTime (p < 0.0001). There were no gender differences in using Facebook and Instagram daily.

Weight and Body Satisfaction

BMI was calculated based on self-reported weight and height.² Women had significantly lower BMI than men (23.84, SD = 3.82 vs. 24.63, SD = 3.32; p = 0.037). Based on BMI classification,² 6.2% were classified as obese (BMI ≥30), 30.1% as overweight (BMI 25–29.9), 62.7% as normal weight (BMI 18.5–24.9), and 1.0% as underweight (BMI <18.5). Men were more likely to be classified as overweight (p < 0.01) and obese (p < 0.01). Cadets expressed various levels of satisfaction with their weight: very dissatisfied (5.3%), dissatisfied (18.8%), somewhat satisfied (29.2%), satisfied (32.9%), and very satisfied (13.8%). Women were more likely to report being very dissatisfied with their weight (p = 0.044).

Weight Loss/Management Strategies

Cadets were asked to choose “all that apply” from a list of commonly used weight loss/management strategies. Most used strategies such as increasing physical activity (80.4%), reducing sweets (60.9%), and reducing fried foods (58.9%). Other strategies included fasting on water or juices (14.9%), using protein shakes and/or bars (14.4%), and skipping at least one meal (11.6%). Women were more likely than men to reduce fried foods (p < 0.0003), reduce sweets (p = 0.020), and skip meals (p = 0.011).

Information Needed to Maintain a Healthy Weight

Cadets were asked to choose “all that apply” from a list of information they would like to maintain a healthy weight. Information needed included the following: eating healthy on a budget (57.2%), eating healthy on the go (52.7%), healthy snacking tips (48.5%), portion control (45.0%), healthy cooking tips (44.6%), calorie needs (39.4%), grocery shopping tips (35.4%), reading food labels (22.3%), motivational messages (21.5%), stress management (18.8%), and how to increase self-esteem (11.3%). Women were more likely than men to report they needed information on all of the mentioned except for needing motivational messages. There were no gender differences for needing motivational messages (Table 2).

Table 2.

Information Needed to Maintain Healthy Weight by Gender (N = 404)

	MALES	FEMALES
VARIABLES	N (%)	N (%)	χ ²	OR	95% CI	p
Eating healthy on budget
Yes	135 (49.6)	96 (72.7)	19.36	2.71	1.72–4.25	<0.0001^*
No	137 (50.4)	36 (27.3)
Eating healthy on the go
Yes	126 (46.3)	87 (65.9)	13.68	2.24	1.45–3.45	<0.001^*
No	146 (53.7)	45 (34.1)
Snacking tips
Yes	113 (41.5)	83 (52.9)	16.20	2.38	1.55–3.66	<0.0001^*
No	159 (58.5)	49 (37.1)
Portion control
Yes	109 (40.07)	73 (45.1)	8.34	1.85	1.21–2.82	0.003^*
No	163 (59.93)	59 (44.7)
Cooking tips
Yes	106 (39.0)	74 (56.1)	10.51	2.00	1.31–3.04	0.0012^*
No	166 (61.0)	58 (44.9)
Calorie needs
Yes	97 (35.7)	62 (47.0)	4.80	1.60	1.05–2.44	0.029^*
No	175 (64.3)	70 (53.0)
Shopping tips
Yes	86 (31.6)	57 (43.2)	5.20	1.64	1.07–2.52	0.023^*
No	186 (68.4)	75 (56.8)
Reading food labels
Yes	49 (18.0)	41 (31.1)	8.74	2.05	1.27–3.32	0.003^*
No	223 (82.0)	91 (68.9)
Motivational messages
Yes	52 (19.1)	35 (26.5)	2.89	1.53	0.93–2.49	0.90
No	229 (80.9)	97 (73.5)
Stress management
Yes	44 (16.2)	45 (34.1)	16.61	2.68	1.65–4.35	<0.0001^*
No	228 (83.8)	87 (65.9)
Increase self-esteem
Yes	22 (8.1)	24 (18.2)	8.97	2.52	1.36–4.70	0.003^*
No	250 (91.9)	108 (81.8)

p < 0.05.

CI, confidence interval; OR, odds ratio.

Willingness to Participate in M-Health Weight Management Programs

Most were confident (60.4%) in their ability to use the internet to access health information. There were no gender differences with this variable. In the past 12 months, most cadets searched online for information on dieting and weight management (54.2%), with more women more likely to have done so (p = 0.041). Most (55.1%) reported willingness to participate in m-health weight management programs, with women more willing to do so (p = 0.038). Cadets were willing to enroll in m-health weight management programs that used text messages (57.5%), apps to track food/activity/sleep (65.8%), smart watches/fitness trackers (62.4%), apps for stress management/anxiety (57.8%), video health coaching (17.8%), and online support groups (17.3%) (Table 3). Women were more willing to participate in programs that used apps for stress management/anxiety (p = 0.004) and apps to track food/activity/sleep (p < 0.0001).

Table 3.

Willingness to Participate in Different Types of m-Health Research by Gender (N = 404)

	MEN	WOMEN
VARIABLES	n (%)	n (%)	χ²	OR	95% CI	p
m-Health weight program
Yes	112 (41.3)	69 (52.3)	5.01	1.56	1.02–2.36	0.038^*
No	159 (58.7)	63 (47.7)
Text messages
Yes	147 (54.4)	83 (63.9)	3.17	1.50	0.96–2.73	0.07
No	123 (45.6)	47 (36.1)
Food/activity/sleep app
Yes	162 (59.6)	104 (78.9)	14.61	2.52	1.56–4.10	<0.0001^*
No	110 (40.4)	28 (21.1)
Smart watches/trackers
Yes	166 (41.5)	86 (65.2)	0.64	1.19	0.77–1.84	0.42
No	106 (58.5)	46 (34.8)
Stress management app
Yes	142 (52.2)	89 (67.4)	8.41	1.89	1.23–2.93	0.004^*
No	130 (47.8)	43 (32.6)
Video coaching
Yes	44 (16.2)	28 (21.2)	1.54	1.40	0.83–2.36	0.22
No	228 (83.8)	104 (32.6)
Online support group
Yes	142 (52.2)	89 (67.4)	2.07	1.48	0.87–2.51	0.15
No	130 (47.8)	43 (32.6)

p < 0.05.

Discussion

This study fills a gap in research and makes meaningful contribution to the literature in seeking to understand how ROTC cadets use their smartphones and to examine gender differences in smartphone usage, social media engagement, weight loss strategies, information needed to maintain a healthy weight, and willingness to participate in m-health weight management programs. It also contributes useful information that can help the military meet its goals of using communication and health information technology to achieve optimal health, resilience, and military readiness among service members in combat and noncombat zones.¹⁶ As with the nonmilitary population, cadets believed that the internet was useful in helping to make health decisions.²⁹

Based on self-reported weights, most male and female cadets had mean BMI that classified them as being at a healthy weight. Although women had a significantly lower BMI than men, they were significantly more likely to report that they were very dissatisfied with their weight. Body dissatisfaction is often a precursor to chronic dieting, eating disorders, inadequate nutrient intake, and fad diets, which may impact the physical and mental performance of cadets.²³ More than one-third of cadets had BMI that classified them as overweight or obese, with male cadets being more likely to be classified as such. The significantly higher mean BMI in men was not surprising because men tend to be more muscular than women. Furthermore, BMI alone is not an accurate measure of overweight or obesity for elite athletes such as cadets.²

Maintaining a healthy weight is a military requirement, and cadets used a variety of strategies to lose weight or maintain their current weight. Overall, cadets used evidence-based weight loss strategies recommended by the military such as decreasing fat and sugar intake and increasing activity levels.^4,30 However, some used unhealthy practices such as fasting and skipping meals, with women more likely to skip meals. Thus, wellness and weight management initiatives for cadets should address fad diets and unsafe weight loss practices. Cadets should also be provided with information on their calorie needs, portion control, eating healthy on a budget, healthy eating on the go, reading food labels, etc. College health and wellness departments often provide these services, and they can easily tailor messages and information to the ROTC population. In addition, weight loss messages and programs and protocols should not be a one-size-fits-all, and may need to be gender specific. Tailored messages have been shown to be efficacious and may lead to changes in attitudes, self-efficacy, expectations, and behavior change.³¹

Almost all cadets owned a smartphone, which is slightly higher than that reported for young adults 18–25 years of age (96% vs. 94%).³² It also was much higher than that previously reported among soldiers who had never been deployed (96% vs. 64.5%).²⁶ Most cadets used smartphones as their primary internet access, which was comparable with young adults in the general population (94% vs. 97%).³² This high ownership of smartphones provides opportunities for cadets to access nutrition and weight management information, download nutrition/fitness apps, self-monitor weight and physical activity, watch educational videos, and engage with health care providers and their social network.^28,29,33

Most cadets (60%) expressed confidence in knowing how to find helpful health information online. This is comparable with other personal technology studies with military personnel^25,26 and the general population.²⁴ Consistent with other studies, women were also significantly more likely to search online for dieting and weight management information.²⁹ Considering the plethora of health information online, it is imperative that cadets be educated on how to find and evaluate online health information, especially for weight management.

Cadets used several social media sites and tools daily, and had higher usage of several social media sites than the general population.²⁴ Specifically, they had higher usage of Facebook (88% vs. 68%), YouTube (80% vs. 73%), and Instagram (74% vs. 35%). They had comparable use of Twitter (23% vs. 24%). When compared with young adults in the general population, cadets still had a higher use of Facebook (88% vs. 81%) and Instagram (74% vs. 64%), but a lower use of YouTube (80% vs. 91%) and Twitter (23% vs. 40%).²⁴ This suggests that cadets may be willing to participate in m-health research that incorporates social media. Adding a social media component to m-health weight management programs with cadets can encourage peer support, build a sense of community, and alter social norms about appropriate weight management behaviors.³⁴ It may also result in greater weight loss than the standard treatment alone.³⁵

Texting was a part of daily life for cadets and most were willing to receive text-based health messages. Many m-health researches incorporate text messaging because it is an inexpensive communication tool that fits into daily life. Texting allows cadets to send health questions/concerns to providers and researchers, and they can also receive tailored feedback and motivational messages in a timely manner.³⁶ In addition to text message-based weight management research, cadets expressed willingness to participate in m-health research that used smart watches/fitness trackers, smartphone apps, online counseling and support, and web-based health portals to varying degrees. Thus, there are numerous opportunities for practitioners and m-health researchers to use a variety of health communication strategies and mobile devices and tools to help cadets achieve and maintain a healthy weight.

Conclusions

The U.S. military has invested significant resources in the use of health communication technology and the development of mobile resources to assist military health providers in the care of military personnel. However, ROTC cadets do not have access to these resources because they are not active duty personnel. Thus, the high ownership of smartphones and expressed willingness of cadets to participate in m-health weight management programs using a variety of mobile tools provide many opportunities for college health and wellness programs to design innovative m-health apps, tools, games, programs, and interventions aimed at health promotion, behavior modification, and self-management of weight for cadets. In addition, nonmilitary m-health researchers and student health and wellness professionals should be vigilant in addressing privacy and security concerns and explaining to cadets how their electronic footprints will be protected in m-health research and programs.

This study has several limitations. The study used a convenience sample and relied on self-reported information, which limit generalizability of the findings. It is possible that directly obtaining weight and height would have yielded different results. In addition, body fatness was not measured. The study also examined smartphone use at one point in time, and the use of technology continues to change. However, the results may have some practical application to the general population of army ROTC cadets. Opportunities exist for researchers to design and evaluate m-health tools and apps to help cadets achieve and maintain military requirements for weight and body standards.

Footnotes

Disclosure Statement

No competing financial interests exist.

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