The document discusses establishing a "Total Force Plus Life-Cycle Health Readiness System" to monitor and improve the health and readiness of all military members, recruits, and their families. It addresses key issues like defining human performance boundaries and measurable outcomes. It argues such a system is needed because many health issues are chronic and invisible, and monitoring across a person's life cycle could provide feedback to build an effective investment strategy. The system would integrate concepts like medical care, nutrition, fitness and resilience across monitoring, training, delivery and supply chain management.

1. Conserve the Fighting Strength
Total Force Plus
Life-Cycle
Health Readiness
System
One Team; One Fight
Jim Larsen
Jelarsen1@cox.net

2. Issues
1. Where are the ‘human performance’ boundaries? What do we include/exclude?
2. What are the measurable outcome criteria? Combat performance or health-wellness?
Operational Readiness (OR) rates?
3. CAUTION: Statistics may NOT tell us if it is:
• Nosocomical
• A marker
• A causal agent
1/26/10 2

3. Total Force Plus Life-Cycle Health Readiness System:
Impacts
• The Total Force Plus* health status affects:
– Force mission accomplishment
– Force readiness and deployability
– Force manpower levels
– Recruiting
– Costs
By 2020, 52.5% of recruitable population will be medically disqualified
“Impact of Physical, Behavioral, and Moral Disqualification of Prime Market” 2005
* Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children,
1/26/10 and retirees/vets. 3

4. Total Force Plus Life-Cycle Health Readiness System:
Why Total Force Plus?
• All members affect the Total Force.
• Most diseases and conditions are chronic and relatively
invisible in the short-term.
• “Downstream” issues highlight “upstream” issues.
• Retiree Cardio Vascular Disease (CVD) may reflect years of high LDL
cholesterol.
• Child lead levels may reflect service member range safety issues.
* Total Force Plus = AC-RC Service members, recruits/cadets, spouses, children,
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and retirees/vets.

5. Total Force Plus Life-Cycle Health Readiness System:
Why Do We Need a Comprehensive Life Cycle System? *
• Recruits enter the system with undiagnosed health issues (e.g. dental
status, osteopenia, depression, alcoholism, etc.).
• Recruits/Soldiers may be under-nourished, affecting performance, injury
rates, attrition, and costs.
• High injury rates affect deployability, manpower levels, attrition, future
injury rates, and costs.
• No comprehensive life cycle monitoring system means no evidence-
based feedback process to build an investment strategy.
“By mid-December, more than 25,803 American service members had been evacuated from Iraq since the war began
nearly three years ago, according to Pentagon officials. Nearly 80 percent of them were shipped out because of
routine illnesses and injuries unrelated to combat.”
VA 2010 budget request is nearly $113 billion
1/26/10 * See references in Notes 5

6. Less than 3 of 10 (17-24 y/o) are fully qualified to serve
Less than 3 of 10 (17-24 y/o) are fully qualified to serve
36
Incarcerated 0.6
30 Numbers BEFORE
Propensity is
8.8 considered
Disqualified 13.9
• Medical10.7
24
• Mental
• Moral
5.2 Recruiters
Millions
18 6.1 must focus
on finding
In-Military 1.1
14 M the 7.1%
30.8 M (Prime
12
Non-HSDG 3.1 Market)
HSDG < CAT IIIB 2.6 8.3 M
HSDG IIIB 1.9 HSDG IIIB 1.9
6
HSDG Female I-IIIA HSDG Female I-IIIA
3.0 3.0
2.2 M
HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 3.4 HSDG Male I-IIIA 2.2
0
Youth Market Potential Market Qualified Market Prime Market
17-24 YO Youth Total Market minus Potential Market minus Qualified Market minus
Population (M/F) - Disqualified - Cat IV - IIIB
- Non-HSDG - I-IIIA Females
1/26/10 - No Waivers (1.2 M) 6
* Estimate based on 2005 Camber Prime Market Study; 2005 DOD QMA Study; 2005 Woods & Poole (2006 projections)

7. Obesity
Obesity
% 17-20 y/o Who Do Not Meet Army Accession Weight Standards
Source: Nolte et al, “U.S. Military Weight Standards: What Percentage of U.S. Adults Meet the Current Standards?” The
1/26/10
American Journal of Medicine, Vol 113, Oct 15, 2002 7

8. Obesity
Obesity
% 17-20 y/o Who Will Not Meet Army Accession Weight Standards in 2015
1/26/10 Projection based on 35% increase predicted by bariatric experts. 8

9. Osteopenia
Osteopenia
Source: Dr. Rivero study at Great Lakes Naval Training Center (2001-2002).
• High rates of osteopenia in stress fracture cases.
• Women have higher rates of osteopenia and multiple stress fractures.
Note:
• PT studies may have results that vary by gender.
12/23/09
• Differing osteopenia rates may partially explain that. 9

10. Quantitative Ultrasound Screen (QUS) re Stress
Fractures in Female Army Recruits
• QUS calcaneal measurements on 4,139 female Army recruits at Basic Training (BT)
start.
• The incidence of stress fractures were 4.7%.
• The highest risk of stress fracture was found in white women in Q1 of SOS who
smoked and didn’t exercise (RR, 14.4).
• The combination of QUS measurements with evaluation of individual risk factors can
identify recruits who are at the very highest risk of stress fracture.
Note:
1.The bone strength ‘gold standard’ is Bone Geometry (USARIEM) (Peripheral quantitative computed
tomography (pQCT).
2.The U.S.-adapted W.H.O. FRAX (fracture prediction) algorithm is available on the NOF website
12/23/09
(www.NOF.org) and atwww.shef.ac.uk/FRAX (note criticisms of FRAX) 10

11. Total Force Plus Life-Cycle Health Readiness System:
Program Structure
• Monitoring systems
• Training/Education
• Delivery Systems
• Supply Chain Control
1/26/10 11

12. Total Force Plus Life-Cycle Health Readiness System:
Program Structure
Medical Nutrition Fitness Resilience
Concept
Monitoring
Training/Education
Delivery
Supply Chain
One Team; One Fight
1/26/10 12

13. Total Force Plus Life-Cycle Health Readiness System:
Medical
Medical Nutrition Fitness Resilience
Integrated Medicine* approach
-Improved Stds of Care
Concept -Improved Clinical Practice Guidelines
-Team-based rehabilitation doctrine
"The problem with sudden
"The problem with sudden
• Comprehensive Blood Chemistry Plus** at defined life cycle points. cardiac death is that, of all
cardiac death is that, of all
Monitoring • Injury/disease database (AHLTA Plus) ICW VA & Tricare the people that have heart
the people that have heart
disease ... half of the time
disease ... half of the time
• NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD the first symptom is a
the first symptom is a
Training/E Schools/ local HS with mil pop) heart attack," said Dr.
heart attack," said Dr.
• Embedded training (posters, Jody calls, etc.) Stephen Kopecky,
ducation • Diagnosis-based prescriptive (link to Ed Svcs)
Stephen Kopecky,
professor of medicine and
professor of medicine and
a cardiologist at the Mayo
a cardiologist at the Mayo
• Combat-model fix forward treatment (see USMC SMIP ATC) Clinic in Rochester, Minn.
Clinic in Rochester, Minn.
• Enhanced Specialty/MOS/ASI skills "And half of that half will
"And half of that half will
Delivery • Enhanced MWR staff skills and programs [die] within an hour."
[die] within an hour."
• Enhanced Ed Svc skills and programs
• Joint programs with CDC
Supply • Mixed DODMERB-MEPCOM entry screening model
Chain • Recruiting/IET based ‘get ready’ programs
*Health-focused medicine that treats the whole person (body, mind, and spirit), examining symptoms and causes.
Ex. 1: Treating a stress fracture with casting and reduced activity and looking at bone health, nutritional deficiencies, diet, and exercise
regimens.
** TBD
1/26/10 13

14. Admiral Nelson 11 March 1804 to Dr. Mosely:
Admiral Nelson 11 March 1804 to Dr. Mosely:
“The greatest thing in all military service is health; and you will agree with me that it is easier for an
“The greatest thing in all military service is health; and you will agree with me that it is easier for an
officer to keep men healthy than it is for a physician to cure them”.
officer to keep men healthy than it is for a physician to cure them”.
• BCT (CHPPM)
– Males: 19-37% are injured in a 9-wk cycle
– Females: 42-67% are injured in a 9-wk cycle
• Most injuries are overuse, compared to traumatic
– Males: 75%
– Females: 78%
• Most injuries involve the lower extremity (low back, pelvis, hip
and leg)*
– Males: 83%
– Females: 87%
• Activities associated with injuries in BCT
– Weight bearing activity; predominantly running, marching,
walking
14
1/26/10

15. Femoral Neck Fracture
1. New Clinical Practice Guideline for Hip Pain.
2. Early effective management works:
a. Finding early avoids the fracture.
b. 75% Increase in FNF detection
Source: CPT Short, MAH, FJ ATC
1. Small numbers, but high costs.
2. No visibility at DA level.
3. 100% Medical Board.
1/26/10
15 4. Lifetime of treatment.

16. Fix Forward: USMC SMIP Athletic Trainer Initiative
• Treat Marines forward as Warrior Athletes.
• Sports Medicine Physicians.
• Certified Athletic Trainers (ATC’s)
– Contracted civilians who work for USMC commands.
– GREEN ASSETS (NCAA model)
– Aligned with SMART rehab clinic operations
– Clinically supervised by Navy Sports Medicine MDs when dealing with
injuries
– Emphasis on prevention, education, and treatment
– Collect/enter injury data into TIMS (injury database)
RESULTS
+ Increased Paris Island grad rate (female 68.3% to
• 3 trainers for Parris Island (GIT)/1 ATC for San Diego. 74.7%)
• 3 Athletic Training Room (ATRs) for Parris Island + Increase in BCT Return to Full Duty (RTFD) rates
from rehab:
+ male 55.5% to 64.3%
+ female 37.5% to 52.2%
+ Increase in BCT recycle grad rates (female 63.5% to
75%).
– Decrease in BCT rehab discharge rates (male 13%;
female 24%)
– Decreased musculo-skeletal discharges at Infantry
School (see chart at left).
– Decreased attrition at OCS
− male 8.7% to 3.8%
− female 18.1% to 5.9%)
+ Greater cadre knowledge
+ Critical feedback on sources of injuries leading to
fixes.
+ Conservative estimate of $3.5M in cost avoidance
and $2.9M in Return on Investment in FY04 vs..
FY03.
1/26/10 16

17. Prehabilitation Pre-training Post-training
1. Females are at risk for knee injuries
2. Balancing quad-ham muscles reduces
knee injuries by 80%.
*p< .05
Injury Incidence/
1,000 Player
Exposures
Untrained Trained Males
Females Females
Results: All Sports; All Knee Injuries per 1,000 Athlete Exposures
SportsmetricsTM: the Key to Prevention of Serious Knee Ligament Injuries in Female Athletes, Catherine Walsh, M.S., Women’s Program
1/26/10 Manager Cincinnati Sportsmedicine Research and Education Foundation 17

18. Total Force Plus Life-Cycle Health Readiness System:
M edical
Medical
What Might It Look Like?
1/26/10 18

19. Total Force Plus Life-Cycle Health Readiness System:
Nutrition
Med Nutrition Fitnes Resilienc
ica l s e
Evidence-based nutrition/supplementation focused on military
Concept environment, gender, and tissue monitoring.
Comprehensive Blood Chemistry Plus* and relevant test sampling*
Monitoring
• NCOES/WOES/OES (ACCP) (Spouse /family orientation) (DOD Schools/
local HS with mil pop)
Training/E • Embedded training (posters, Jody calls, etc.)
ducation • Diagnosis-based prescriptive (link to Ed Svcs)
• Cooking classes in AAFES/Commissary/MWR
• Evidence-based menu/recipes optimized for military environment
• Timely access to meals within training OPTEMPO
• Meal/snack frequency based on tissue needs
Delivery • Warrior Bar, Warrior Pak, Warrior Drink R&D concepts
• AAFES, MWR, and Commissary participation
• Enhanced food/supplement inspection and sanitation counter-measures
Supply • Healthy food standards (e.g. salad-bar plus beef)
• Food production guidelines and inspections (management-intensive
Chain grazing)
1/26/10 * TBD 19

20. Army BCT Female Nutrition
• Body iron stores were low pre-BCT (56%) and
decreased further by graduation (84%)
• Iron Anemia was correlated with poor PT
performance
• B vitamin levels were low normal pre-BCT and
“decreased significantly over BCT.”
• Menu was adequate in energy, but inadequate in
B6, folic acid, calcium, magnesium, iron, and zinc.
• Started Soldier Fueling Program.
Source: “Health, Performance, and Nutritional Status of U.S. Army Women during Basic Combat Training,” (1995)
(ADA302042)
1/26/10 NOTE: Study BCT menu governed by the 1985 AR 40-25 20

21. Naval Female Recruits Calcium and Vitamin D Study
Naval Female Recruits Calcium and Vitamin D Study
• Stress fractures occur in 0.2-5.2 % of male recruits and 1.6-21.0% of female recruits.
• Calcium Balance is compromised
− Ca deficient diet upon entry in BT.
Minimum recommended Ca 1,000mg/d
Average Ca intake 19 – 30 yrs 600-700mg/d
Median Ca intake of women during BT 700-900mg/d
− High Ca losses occur in sweat during strenuous activity. Study with collegiate basketball players Klesges, et al.
1996.
• Sample size:
− Enrolled 4,647
− Discharged from Navy 355
− Withdrew from study 1,001
− Completed 2,803
• Treatment:
− Randomized, Double Blind, Placebo Controlled
− 2,000 mg Calcium & 800 IU Vit D
• Results: Supplemented group had a 20% lower incidence of stress fractures
than the control group.
Naval Institute for Dental and Biomedical Research 21
1/26/10

22. Vitamin D Deficiency/Insufficiency
• Military population levels unknown (small USCG study = 60% <30 ng/ml).
• Endpoint decision drives numbers (variation by race and latitude).
• Militarily significant outcomes (AF Flu Outbreak cost $7M).
1/26/10 22

23. Anti-Inflammatory Diet

24. Total Force Plus Life-Cycle Health Readiness System:
Fitness
Medica Nutritio Fitness Resilienc
l n e
Functional/skill and team-based fitness within a quarterly periodization
Concept cycle.
• Annual with local quarterly periods.
Monitoring • Web-based PT & periodization designer & record system.
• Comprehensive injury prevention program (see Notes).
• Fitness ASI.
Training/E • Expanded Fitness School (includes injury prevention and rehab,
nutrition, resilience, etc.).
ducation • Enhanced MWR staff skills.
• Spouse /family orientation.24
• Unit-based. Multiple program choices. Combat parcourse.
Prehabilitation exercises.
• MWR programs ICW PT school & medical (safe lifting posters;
muscle balance guidelines, etc.).
Delivery • National gym contract for geographically separate Ss (e.g. USCG).
• DOD Schools/ local HS with mil pop.
• Portable gym equipment (e.g. Exergenie) and/or gyms (see CONEX-
based Army BU slide ) (ICW AAFES/MWR).
• Incentivize Troops-To-Teachers to support HS PT.
Supply • Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for Tots).
Chain • Expand JROTC.
1/26/10 24

25. Pre-BCT Training Programs are Effective
1. BLUF: The FTU PCU lowers overall discharge attrition by 500-800+ Soldiers (0.4-0.8+%), as well as lowers course
attrition and injury rates.
2. 4%-7% of men and 10%-24% of women fail the RECBN 1-1-1 assessment historically. 50-75% of the PCU at GIT sites
will be female.
3. PCU Results:
a. Lower course attrition: In the “1-1-1 Fail No PCU” group, men are 2.5 times and women are 1.5 times more likely to
attrit from BCT.
b. Lower discharge attrition: In the “1-1-1 Fail No PCU” group, men are 3.0 times and women are 1.9 times more likely
to be discharged from BCT.
c. Lower injury rates.
d. The USMA experimental PCU-X vice the traditional PCU improved female outcomes, but male outcomes were
worse (but still better than no PCU). Recommendation is that USAPFS design a new PCU PT POI.
e. Option: a 12 week BCT PCU company to maximize program flexibility, maintain bonding, provide non-PT training,
get resourced, etc.
1/26/10 25

26. USAPFS Standardized PT Program
Injury
Rates
Good PT design
maintains/exceeds standards
Control Group and lowers injury rates
33% decrease
Standardized PT Program
Injury Control
Week 1 Week 3 Week 5 Week 9
Time (in weeks)
1/26/10 26

27. AM EDDC&S
Operation Aegis
Injury Control
• BCT grads arrived at AIT with high injury rates (approx. 28% men; 48%
women).
• PT running was the primary cause of musculoskeletal injuries.
• Changing the running program
– Reduced Clinic Visits - 36.5%
– Reduced Profiles - 48.6%
– No difference in APFT Scores
– Reduced APFT retakes - 50%
– Saved 612 limited duty days/week/BN
If implemented at all IET/AIT sites:
$9M/yr & 1.5M limited duty days/yr Potential
Savings
1/26/10 27

28. Defence Injury Prevention Program (DIPP)
Defence Injury Prevention Program (DIPP)
Australian Department Of Defence
Australian Department Of Defence
100% 100%
80%Results for Army Basic Training: Injury 80% Results for Army Basic Training: Attrition
Uninjured
60% 60% Training
Successes
40% 40%
1,834 Injuries
20% Prevented 20% 1,260 Discharges Prevented
Injured
Discharged
0% 0%
1994 1995 1996 1997 1998 1999 1994 1995 1996 1997 1998 1999
1. Reducing injuries reduced attrition: 70% reduction over 4 years in rates of injury
and attrition
2. Gives CDRs the tools; harnesses Commander’s knowledge and skills working together
to address their own injury problems.
3. 95% reduction in pelvic stress fracture rates in female recruits.
1/26/10 28

29. Total Force Plus Life-Cycle Health Readiness System:
Resilience
Medica Nutrition Fitnes Resilience
l s
• Positive life skills to adapt to stress and hardships.
Concept • Integrated resilience, Battlemind, and CONOPS sequential
and progressive by level.
Diagnostic test battery based training (e.g. Success Profiler)
Monitoring (individual as appropriate).
Training/E • Enhanced Beh Science Specialist MOS training
ducation
• Pre-enlistment R&D (train in/screen out)
• Pre-BCT ‘get ready’ training
• Chaplain combat-style resilience training in IET
Delivery • Embedded training (posters, Jody calls, etc.)
• NCOES/WOES/OES
• Spouse /family orientation
• Incentivize Troops-To-Teachers to support HS Wellness
program.
Supply • Army ‘theme’ (e.g. America Strong) (e.g. USMC Toys for
Chain Tots)
• Expand JROTC.
1/26/10 29

30. Civilian Population
•
• Our current cohorts of DoD recruits arrive at IET with significant
Our current cohorts of DoD recruits arrive at IET with significant
developmental experiences:
developmental experiences:
– 40% come from ‘non-traditional’ homes without two consistent
– 40% come from ‘non-traditional’ homes without two consistent
parenting figures*
parenting figures*
– 19% of HS students had seriously considered attempting suicide
– 19% of HS students had seriously considered attempting suicide
during a 12 month period**
during a 12 month period**
– 8% of HS students reported making a suicide attempt in the
– 8% of HS students reported making a suicide attempt in the
preceding 12 month period**
preceding 12 month period**
Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army
Institute of Research
1/26/10 30

31. Adverse Childhood Experiences (ACE)
Table shows only 2 factors.
Having 3+ factors does increase risk somewhat, but
does not automatically mean all are ruined.
1. More ACE factors increase risk.
2. Associated high-risk behaviors (sex,
USMC National
Sample Samples drugs, smoking,, etc.)
3. Associated impacts (health, disease, poor
Men Women Men Women job performance, depression, etc.).
Child 4. Diminished brain development.
26.7 38.3 3.2 4.8
physical 5. Treatable.
Child
14.7 51.0* 3-16 12-27
sexual
*Wolfe, J. (1996-2000). Adaptation to First-Term Enlistment Among Women in the Marine Corps. DAMD 17-95-1-5047.
1/26/10 31

32. Adverse Childhood Experiences (ACEs) are
Common in Civilian and Military Populations
Exposures Civilian Army Infantry
Alcohol abuse 23.5% 33.0%
Mental illness 17.5% 21.1%
Battered mother 11.9% 6.8%
Childhood Abuse Civilian Army Infantry
Psychological 10.0% 20.0%
Physical 4.9% 13.8%
Sexual 19.3% 3.8%
•Data from civilian population from CDC ACE study (n=9,508). Infantry population based on AC combat unit
(n=4,602)(WRAIR OIF /OEF behavioral health research project).
Note: Data does not adjust for differences in population demographics.
Source: Charles W. Hoge, COL, MC, Chief, Department of Psychiatry and Behavioral Sciences, Walter Reed Army
1/26/10 Institute of Research 32

33. Attitudes
The Dark Side
1. G1 Insist-Assist Study showed leaders’ attitudes affected attrition rates.
a. “High Attrition Leaders” believe they were ‘gate guarders.’
b. “Low Attrition Leaders” believed they were developing Soldiers.
2. Emotional Events (‘high fear events,’ ‘food deprivation’, ‘sleep deprivation,’ ‘extreme PT,’ etc.) may be
mis-perceived by some as preparing Soldiers for war, or strengthening them to cope with stress.
1/26/10 33

34. Adaptive Thinking
Expert Patterns of Battlefield
Thinking
TLAC training (with classroom
 Keep a focus on mission
instructor) but no OIF/OEF experience
accomplishment and higher
commander's intent.
 Model a thinking enemy.
 Consider effects of terrain.
 Use all elements/systems no TLAC training and
available. OIF/OEF experience
 Include considerations of timing.
 Exhibit visualizations that are
dynamic and proactive.
 Consider contingencies and no TLAC training and no
remain flexible. OIF/OEF experience
 Consider how your fight fits into
the bigger picture from friendly and
enemy perspectives.
Source: ARI
1/26/10 Training critical thinking works! 34

35. Positive Leadership
Attention
Control
Cognitive Goal Peak
Visualizatio
Foundation
s Setting n = Performance
Stress &
Energy Warrior
Mgmt Mindset
Self Regulating
Instinctive Build confidence
Adaptive Control attention
Emotional
Agile Recover energy
USMA Peak Performance Mental Effort Mental ‘See’ the battlefield
Model: Self critical Tactical
Combat PT
Training the Warrior Analytical Technical 8-Step AAR
Judgmental
Pentathlete Physical effort Physical
Rote Repetition
ARI – Infantry Forces Research Unit United States Olympic Committee 1998
The most critical training that prepared Soldiers for Human performance at elite levels is heavily dependent
efficient and effective task accomplishment under life- upon intangible, mental factors, i.e.
threatening, fast-paced, and stressful conditions are: • Confidence despite setbacks,
• Time management • Concentration amidst distractions,
• Command of the basics • Composure during times of stress.
• skill mastery
• Combat focus
• Visualization
• Repetition, and
• Use of job aids
1/26/10 35

36. Total Force Plus Life-Cycle Health Readiness System:
Outcomes
• Force mission accomplished
• Force ready and deployable
• Force manpower levels met
• Costs equal or lower
1/26/10 One Team; One Fight 36