by Wayne Jonas
Armed with this new information, each post commander was instructed to work with the hospital commander to take care of any problems that were found. And a lot of problems were found. Although generally healthier than the average population, soldiers were found with previously undetected high blood pressure, cholesterol elevation, smoking and excess alcohol use, weight problems, and depression. What were commanders to do? Most sent these soldiers to the medical treatment clinics, where they received “quick fix” solutions from the acute care system: medications and instructions to change their habits. These clinics and hospitals were all set up on the acute care model of health care that I described earlier. Their environments were neither preventive nor particularly healing. In general, clinic doctors, when confronted with a patient with high cholesterol or high blood pressure, would prescribe medications, rather than taking the time to look at the underlying lifestyle causes of the disorder or manage the more complicated process of behavior change. To be fair, even if they took the time to do this, the acute care system was not organized, nor did it have people with the right knowledge and skills, to deliver effective health promotion. So physicians’ hands were largely tied. When commanders realized that a medical solution was not the answer; they created health promotion programs in military units and the community. There was a great need to set up bridges between these two worlds, which was my job. So various “bridging” programs were set up throughout the military and eventually reached the top leadership in all four branches of the military.
In 2007, working with Admiral Mike Mullen, then Chairman of the Joint Chiefs of Staff, my team helped develop an approach called Total Force Fitness. This whole systems science model sought to link healthy behavior not only to health care but also to service members’ deeper psychological and spiritual needs. It was a whole person approach designed to address the body and mind and also the person’s social and spiritual dimensions. (The whole person healing–oriented approach of Total Force Fitness was subsequently implemented military-wide in a variety of programs and is now being expanded to whole communities such as the Healthy Base Initiative, Operation Live Well, and a seven-state Building Healthy Military Communities program.) Samueli Institute worked closely with the military to explore ways of bridging specific health behaviors and meaningful daily life. This was done on the military bases, but also in civilian communities, where most service members and their families come from, live, and return to every day. We also assisted programs to address the specific dimensions of healing behavior such as stress management and healthy eating programs. These included programs such as Healthy Kitchens, Healthy Lives, which taught healthy shopping and cooking skills; the Metabolically Optimized Brain, which connected community food access to resilience and enhanced mental health; and the Family Empowerment program, which set standards for implementing science-based, mind-body stress management programs in schools and worksites, teaching people how to improve the relaxation response and build mental fitness. It was from these programs that I learned the key to unleashing the healing power of behavior and lifestyle: connecting behavior change to a personally meaningful life. I didn’t see this clearly, however, until another patient, Ensign Rogers, gave it to me straight from his hospital bed. He also gave Maria and me the answer we were looking for.
ENSIGN ROGERS
Ensign Rogers had just had a major heart attack. A retired cook and food service supplier with thirty-four years in the Navy, he had become overweight and developed high blood pressure. After he retired, he developed diabetes. Now he was in the hospital, recovering from the heart attack. I visited him there and we discussed what had happened.
Ensign Rogers’ heart attack was, as he put it, “the big one.” His recovery was prolonged. It gave him time to think about his life. Rogers, as they called him when he was on active duty, had provided food for sailors throughout his career, first on ships, starting as a server on the line. Then he became a cook and gradually rose in the ranks to become the main supply person for delivering food to ships—from small patrol boats with fewer than twenty passengers to large aircraft carriers with more than six thousand personnel on board. His duties had gone from peeling potatoes, to overseeing food delivery during training, to supplying food to boats during wartime. Later he was responsible for food for entire Navy communities, including families on bases. He knew a thing or two about food. After he retired from the Navy, he became a consultant for food services for the military. Now he advised all four services on how to provide more fresh fruits and vegetables at low cost. “Health food,” he said, with some irony, “from scratch. Just like in the old days.”
“You know, Doc,” he mused, his heart monitor beeping in the background, “unlike medical care, which you only get when you need it, food has to be there all the time—three times a day and 24/7 for all sailors.” He had never failed in that job. When he first started, they used to peel the potatoes and cut the vegetables themselves. He learned how to cook then, “from scratch” as he put it. He wasn’t a bad cook; not a gourmet chef, but he could put a meal together—usually several hundred at a time, anyway, most from fresh ingredients.
He remembered exactly when cooking from scratch started to change. At first, it was expensive to get the packaged and processed food. But people wanted it. It was quick and easy and scientifically based. “Who wanted to peel all those potatoes every day, anyway?” he reminisced. If you added up the number of people it took to prepare food from scratch, the packaged food became cheaper and easier just to buy—preprocessed food in bulk. “We called it ‘industrial food’ because it came from the food industry, not our kitchens.” he said. Food budgets got thinner and the war mission started to accelerate. “The sailors didn’t have as much time to sit around and talk or eat. They needed food quickly and lots of it. They needed high-calorie food, and that’s when the cans and packages came in,” he reflected.
Instead of ordering pounds of potatoes and carrots, beans, and steak that he had to cut up himself, he received complete meals in packages. Packages of tasty high-fat, high-salt, high-calorie foods—just what the young sailors wanted. “The main drivers of this were the food companies that were selling packaged food at very low prices. And the military could negotiate even lower costs, so things got shifted into those packages,” he recalled. Efficiency increased by not having to make food from scratch; now it mostly required only opening and heating. Industrial food had arrived.
Meanwhile, what was labeled “industrial food” inside the military was called “fast food” outside the military. American families were getting conditioned to fast food—a trend that spread and is still spreading around the world. In 1970, only 27.9% of daily meals were eaten outside the home. By 2012, it was over 43%. Ads for high-sugar, high-fat foods began to flood television, further reinforcing fast food as both fun and cool for the modern life. Women, increasingly working outside the home, wanted more rapid ways to feed hungry children. After a full day at work, a drive-through food run became just the ticket.
“The new sailors wanted this food, which they were getting used to as children before they came to the military,” Ensign Rogers recalled. “It wasn’t too long before the sailors started asking for that kind of food. So, while the industry pushed it as more convenient and cheaper, soon it was the sailors themselves who were the pushers. If we didn’t supply it, they would go off base to get it. If they didn’t eat in the dining halls, then our budgets were cut further. We couldn’t have gone back to fresh foods if we wanted to.” He paused for a long time. “I guess now the military leaders want fresh food back again.” An even longer pause followed. Finally, he said with a sigh, “I wish them luck.”
As the United States entered WWII in 1941, they found so many young men underweight that the military feared they would not be strong enough to endure a grueling war. So the government started feeding programs in schools, including free school lunches, to try and bulk up young men before they entered the military. That, and the need for large amo
unts of nonperishable, shippable food during the war, had spurred the development of industrial food. What was originally supposed to be a special type of feeding needed for large numbers preparing for battle, soon became the basis for feeding the entire population all the time.
After the war, the military type of fast food was converted into the fast-food industry the succeeding generations now wanted. During this same period, the rate of obesity began rising. Soon being overweight, rather than underweight, became one of the top reasons potential military recruits were turned down. By 2008, over 27% of all recruits and 40% of women wanting to come into the military were too fat to fight. That meant that they were disqualified for entry because they didn’t meet the minimum standards for height/weight or fitness that the military considered essential to even start training.
“That is why they hired me as a consultant now, I guess,” Rogers said, “to help them reverse this trend. I had seen it happen.”
As Ensign Rogers looked up from his hospital bed, we discussed the health consequences of those shifts. He realized that in his career he’d done more than simply find cheaper food to fill the bellies of sailors in less expensive and more rapid ways. He had unwittingly become the architect of his own illness and converted many others into candidates for the costly, high-tech medical care he now received. He was grateful for the procedures, medications, hospital care, and stents that saved his life. He was grateful for the medications that controlled his diabetes and hypertension. He had developed hypertension in his mid-forties and had been put on several medications. He had already been on cholesterol medications. The diabetes medications came a bit later. Toward the end of his career, he didn’t meet even the Navy’s maximum weight standards, which are generous, and he was afraid he was going to get kicked out early. He starved himself before the biannual weigh-ins. After he retired, his weight ballooned, and that’s when the diabetes and hypertension got worse and hard to control. During his thirty years in the Navy, the obesity rates had increased to almost 25% of all service members. He realized now that when he got together with his buddies in the NCO Club, he wasn’t the only one with high blood pressure, diabetes, and heart problems. They were all talking about their doctor visits, and almost all were on cholesterol, hypertension, or diabetes medications. He just took it as a normal part of good medical care. After all, they had good medical care even after retirement.
But now, as an advisor to the military, when he recommended that a few million dollars be spent to try to prevent these diseases from happening to others, he heard that either the money was not available or they had to show that buying fresh food would reduce costs. In addition, most of the nutritionists worked at the hospital and didn’t have time to help redesign the purchasing and preparation of healthier food. However, he did see a nutritionist when he went in for his diabetes checks, and a great new cooking class had been added to the cardiac rehab program for those with a history of a heart attack. The nutritionists were hired by one part of our health care system—the acute treatment part—but they did not have time to bridge the gap to the other part of our systems—the health promotion and prevention part. The payment system also did not bridge the gap. Military leaders were including only costs for the supply, preparation, and delivery of the food—24/7, three meals a day, without fail. Food was fuel for these young service personnel; they had a mission to accomplish, and that mission came first. They didn’t count the cost from the medical consequences that would pop up years later. Nor did they count the personal costs Ensign Rogers now faced.
Like many military members, however, Ensign Rogers had always dedicated his life to service. So even as he talked from his hospital bed, he began to wonder if he could help the admirals and other ensigns with their situation. How could he help them see the long view—a view that had taken him nearly forty years to see himself?
After his discharge from the hospital, he started to attend cardiac rehab. While most of that focused on exercise, he also took a new twelve-week “healthy eating” class for heart patients that the base Community Wellness Center offered—an offshoot of the Total Force Fitness program. In that class, nutritionists and chefs joined forces to teach heart patients how to cook—from scratch, he noticed—in ways that were both healthy and delicious. In addition, the group culture of the class helped people help each other make the behavior changes permanent. If you had a challenge—be it with blanching vegetables or balancing your budget or getting your family on board—usually someone had a similar problem and could help you solve it.
“But,” Ensign Rogers told me in a follow-up visit about six months after his heart attack, “for most of these heart patients, the horse had already left the barn. That was not the time to start to prevent their disease. They already had it. I needed it thirty years ago. It can’t be just for people who have already had a heart attack.”
I agreed.
One year later, Ensign Rogers partnered with a chef and started such a course for everyone at the base Wellness Center. He volunteered his time. “Eat for Life,” he called it. Anyone with a risk factor for heart disease—overweight, diabetes, high blood pressure, high cholesterol, smoking, or a family history of early heart problems—could come. Family members could come, too. Meeting once a week for twelve weeks, participants learned how to select, buy, and prepare healthy food; how to make it taste great; and how to involve family and friends in the process.
Brilliant, I thought to myself. It was exactly what I was looking for to help Maria—to see if she could put meaning back into her medium of healthy food. I introduced her to the program as soon as I heard about it. She loved the idea and signed up for the next class.
After taking the class, Ensign Rogers and Maria decided to develop a version focused on Hispanic food—something Maria knew well and Ensign Rogers wanted to learn. With some help from a master chef, and a bit of guidance from a nutritionist, they began a community cooking class for prevention of the country’s leading disease killers. Maria found an outlet for her passion, Ensign Rogers for his experience—and both found a new purpose in life. The “side effects” were many. Their diabetes remained under control, their energy improved, and their life expectancy lengthened. And they were helping others do the same. They had tapped into their own healing agency using the “agents” of food and behavior change.
MAKING BEHAVIOR MEANINGFUL
People are creatures of habit. Whole systems science shows that self-regulating systems—like people—constantly work to return to the same form and behavior after they have been stressed or traumatized. That automatic rebound response—the same response that fuels healing and recovery—also makes behavioral changes uncomfortable and hard to implement for many people. Behavioral change can be much more difficult for some than for others. Difficulties implementing long-term behavioral change often occur because of experiences and patterns set in childhood. Maria found a process to merge her healthy eating needs with the contribution she made to family and friends through cooking—something she had learned to do and was rewarded for as a child. Once she linked that meaningful activity to healthy food, the change came naturally and easily.
My wife, Susan, found changing her behavior much more challenging, even when she had reason to do so. Healthy behavior not only prevents disease and reverses many chronic conditions, but it can also blunt the side effects of curative treatments like chemotherapy and surgery. Cancer patients who exercise, eat healthy food, and engage in stress management, tolerate and complete therapy better, recover faster, and suffer fewer consequences of treatment long term. Susan had firsthand experience with the long-term consequences of cancer and its treatment. After her first cancer, she suffered the long-term effects of chemotherapy, including weight gain, nerve damage, and fatigue. Had she been able to engage in extensive behavior change—intensive exercise, careful dietary control, and major stress management—some of the consequences from her disease and treatment could have been mitigated. But Susan was not able to engage in
that kind of intensive behavior change for several reasons. For one thing, our two health care systems—one for disease treatment and cure and one for healing and prevention—rarely bridge the gap and integrate, even in the crisis of cancer. During Susan’s first breast cancer, oncologists had made no recommendations on healthy lifestyle during or after her treatment, and some even minimized it. There were few places to find assistance in learning and engaging in these changes. There are no profits to be made from building systems to help people make behavior change, so those systems are minimal. We went on with our lives as before.
During her second breast cancer, twenty-five years later, things were somewhat better. There are now lectures on nutrition, yoga classes, and support groups for cancer patients. There is a Society for Integrative Oncology (SIO), where mainstream oncologists explore the integration of healing practices with the cure-focused treatments in cancer. The role of behavior is now at least acknowledged as important in cancer survivorship—although physicians are not trained in how to use behavior. Advances in the science of healthy behavior are still not integrated into the delivery of cancer care. Our oncologist, one of the best in the region, did not know about SIO. There were no health coaches or coverage for behavior change available to Susan.
The second reason behavior change is hard for Susan is because of her childhood. As Maria discovered, the ability to make behavior change was linked to her childhood experiences, but in a different way. In three major areas of healthy behavior, Susan’s childhood was stacked against her. First, while growing up, Susan frequently felt like she did not have enough food. Her family struggled financially, and food was carefully purchased and allocated to feed a family of six. As the “smart and most responsible one” and the oldest girl of four children, she was also expected to help take care of the family. By the time the food for dinner had been passed around, she often did not get enough. Her brother was a competitive swimmer and was constantly hungry, so she intentionally took smaller portions so he could have more. She said nothing about this, but later as an adult the idea of limiting food intake—especially food she could not get as a child—was very challenging to her. She experiences any change in possible food intake as a threat to her well-being, especially when things are stressful. Second, she was not encouraged to participate in sports and exercise. As was true for many girls of her generation, sports was something you watched boys do. She developed no skills or experience in keeping physically fit. Exercise was more difficult for her than for me; I had been involved in many sports. Finally, stress levels were high in her house. Her father had a volatile and unpredictable temper, often flying off the handle, yelling and screaming. She became the peacekeeper of the family, constantly on the alert to anything that might upset him and taking the emotional consequences of his abuse. Susan’s stress management tactic for this was to anticipate possible emotional discord and compromise her own needs and desires in order to keep things calm. The only time she was relaxed was when there was social and emotional peace in the family, which was rare. Even today, she still habitually (and automatically) scans the social environment for any developing discord. That makes it hard for her to breathe deeply and induce the relaxation response when awake. Sleep is her only escape, especially when faced with a major assault like chemotherapy and surgery.