Commentary 5 Creating a Healthy Ship L Morrow, C Abrams, A Shaw

Abstract

In 2015 HMS DUNCAN was chosen as the intervention ship for an Institute of Naval Medicine (INM)-led project entitled Sec- ond Sea Lord (2SL)’s Feeding the Fleet Initiative. During her nine-month maiden deployment on Operation KIPION, a healthy lifestyle intervention was initiated, encompassing executive health, catering services, medical services and physical training. The key enabler of the success of the intervention was the formation of an effective Unit Health Committee. This article presents the lessons identified and provides useful examples from the intervention, which aimed to create a healthy lifestyle culture on board a deployed ship.

Morrow L et al. J R Nav Med Serv 2017;103(1):5–9

Introduction work was endorsed by the Second Sea Lord (2SL) and brand- The prevalence of obesity in the (UK) is at ed as 2SL’s Feeding the Fleet Initiative. a concerning and increasing level, rising from 15% in 1993 to 26% in 2014.1 With the UK reporting one of the lowest The environment aboard a warship provides an ideal oppor- physical activity levels worldwide and poor dietary habits, tunity to monitor and improve the health behaviours (eating, measures are being taken nationally to tackle this crisis.2 physical activity, alcohol and smoking) of RN personnel, Worryingly, this societal trend appears to be replicated with- especially over the duration of a deployment. Moreover, if in the (RN). Two recent studies have been un- a culture of healthy living can be created within an environ- dertaken investigating the prevalence of RN personnel at risk ment that is conducive to prudent health behaviours, person- of obesity-related diseases. These studies utilise the National al goals for weight loss and the achievement of a healthy Institute of Health and Care Excellence (NICE) classification lifestyle are more likely to be realised. system, which combines body mass index (BMI) and waist circumference measurements. The first study, undertaken in Members of the Royal Naval Medical Service (RNMS) have 2012, reported that 30% of participants were classified as at a key role to play in health promotion and reducing the health risk.3 Furthermore, the initial results relating to the healthy burden of imprudent behaviours within the RN. Commonly lifestyle initiative discussed in this article concluded that within a unit or ship the medical team will be required to take from a population of 285 RN personnel, 32% of male and the lead on health promotion within the Unit Health Commit- 43% of female participants were classified as at risk. 4 These tee (UHC). This article, which has a medical focus, will pres- findings are not unique to the RN; in 2011, in a sample of UK ent the lessons identified from the implementation of a healthy Armed Forces personnel, 23% of male and 37% of female lifestyle intervention, which aimed to create a healthy lifestyle participants were classified as being at risk of obesity-related culture aboard a deployed ship. The article will provide exam- diseases.5 ples from the intervention and will discuss the importance of the UHC, and the requirement for whole ship and specialisa- The health and economic implications of obesity to the UK tion cooperation within the UHC. Armed Forces are considerable. In the RN a high BMI has been associated with being medically downgraded as unfit for Executive health duty,6 and the development of self-reported back problems, A key element of the success of the healthy ship initiative was musculoskeletal disorders and high blood pressure.7 It is es- the UHC. The UHC is a team of representatives, who formally sential that UK military personnel are ready and fit to deploy. meet and plan activities to promote good health and wellbe- For this reason, these statistics prompted Navy Command ing for their unit focused on the nine executive health topics Logistics and Infrastructure to task the Institute of Naval Med- (Table 1). It is a mandatory executive function and ideally all icine (INM) to undertake a programme of work to: improve the members of the medical team should be included and play an healthiness of the provision of food aboard RN ships; improve active role in it.8 Additionally the Senior Medical Branch Rat- the healthy lifestyle education provided to Service personnel ing or Medical Officer (MO) may be asked to lead on certain aboard RN ships; implement and evaluate a healthy lifestyle tasks, such as Unit Health Promotion boards. Collaboration intervention aboard a RN ship; and, improve the nutrition ed- between all departments was key and the UHC provided the ucation delivered to RN chefs during training and throughout ideal opportunity for intervention ideas to be discussed and their military careers. In November 2014, the programme of ensured that relevant stakeholders were working towards the 6 Journal of the Royal Naval Medical Service 2017; 103(1) same goal. For example, one of the key areas of change was participants to contemplate and prepare for potential lifestyle improving the healthiness of the food; the attendance of the changes. A competitive element was included by calculating Logistics Department at a management level and a chef repre- the scores departmentally on a monthly basis and awarding a sentative were essential. prize for the highest departmental relative waist reduction and weight loss. It was probably as a result of peer encouragement (1) Fitness. and a mid-deployment recruitment drive that participant num- (2) Nutrition. bers increased significantly over the course of deployment to a (3) Alcohol Consumption and Substance Misuse. final number of 70 participants. One of the aspects which ap- (4) Smoking Cessation. peared to be successful was that the ‘weigh-ins’ were available (5) Mental Health. to everyone in all categories, not just those at risk, therefore (6) Sexual Health. perhaps reducing prejudice compared to a traditional weight- (7) Maternity Health. loss clinic. (8) Oral Health. (9) Injury Prevention Practicalities At the initial attendance, individual SMART (specific, meas- Table 1: Executive health topics. ureable, achievable, realistic and timely) goals were set along with motivation and potential barriers to weight loss; these A UHC is required to meet at least three times a year, but for factors were reviewed as required at subsequent clinic attend- the successful delivery of the intervention, HMS DUNCAN’s ances. Participants were weighed and had their waist circum- UHC met monthly to allow the previous month’s programme ference measured and recorded on a regular basis (weekly, to be reviewed alongside feedback from the ship’s company. fortnightly or monthly). Results were discussed with the par- Changes were then made for the upcoming month and to fu- ticipants and if relevant, participants were shown their risk ac- ture intervention activities. cording to the NICE obesity risk classification. An opportun- istic discussion then took place between the participant, MO In order to increase the impact of the UHC messages on inter- and Unit PTI about the previous time period in relation to their vention activities and events, representatives from each mess results. The benefit of having both the MO and Unit PTI avail- (wardroom, senior rates and junior rates) were recruited to the able meant that the discussion could be tailored depending UHC. These Healthy Lifestyle Representatives were able to on whether difficulties or barriers were related to nutrition or provide direct feedback on intervention activities from and to physical activity. For those participants who required further their messes. This was particularly useful for gathering feed- support, helpful advice sheets were distributed from the De- back on menu changes and ideas to promote involvement. fence Nutrition Advisory Service (DNAS). Participants were Engaging members of the ship’s company who would not oth- given a copy of their results with any improvement points and erwise be involved helped to create buy-in and provided role a generic message, including a fact of the week and informa- models for the intervention activities. tion to sign up to other intervention activities, to reinforce their weight loss success. Medical department One of the key deliverables of the healthy lifestyle interven- Behaviour change workshops were trialled to prepare partic- tion for the Medical Department was a weight management ipants for their mid-deployment leave period and for the end clinic, which was run in the sickbay in collaboration with of the deployment. These workshops aimed to provide partici- the Unit Physical Training Instructor (PTI). INM supported pants with ideas and strategies to enable them to maintain their this activity by providing additional guidance and behaviour new body weight and behavioural changes when they returned change resources. Whilst time consuming, the weight man- home. These workshops were most beneficial for participants agement clinic delivered statistically significant reductions in struggling to maintain their weight loss or physical fitness, weight, waist circumference and BMI measurements. 49 per- and used ideas from the Nutrition Practitioner Handbook and 9 sonnel participated for the entirety of the deployment, report- DNAS factsheets. ing a reduction from 45% pre-deployment to 29% at the end of the deployment in those classified at risk of obesity-related It was essential that accurate height, weight and waist cir- diseases. cumference measurements were obtained in order to measure changes over time. Waist circumference was measured ac- Running a weight management clinic cording to the NICE guidelines (at the mid-point between the This drop-in clinic was held in the sickbay ward area and was highest point of the iliac crest and the lowest rib) using a metal ® conducted by the MO and the Unit PTI at the same time every Lufkin . week, covering both watches. The sickbay was used rather than the gym spaces, as it allowed participants to be meas- Health promotion and calendar ured in a clinical setting and provided space for participants The Medical Department of a unit is normally responsible for to discuss behavioural change, physical training and nutrition a health promotion calendar. The new NAVYfit portal, which programmes. It was advertised through posters, pipes and is accessible through the Defence Gateway, contains details of daily orders. Sign-up took place prior to deployment to allow RN-specific monthly health campaigns that can be download- Commentary 7 ed and adapted for each ship.10 Additionally, larger Defence the gym equipment on board or by attending ship ­circuits. campaigns (e.g. Stoptober) send out promotional material di- ­Conducting these challenges for a maximum of a week main- rectly to units. tained motivation; daily running totals were announced on daily orders and update pipes to encourage participation. A Physical activity scoreboard was displayed at ship circuits showing those with When looking to increase the physical activity levels of per- the highest attendance rate. sonnel it was essential to identify barriers to being active, and to develop new ways of engaging personnel. For all activities, Nutrition timing was important, and had to take into account operational In addition to improving the physical activity and healthy life- activities and port visits. Good co-ordination with heads of style education provided on board the intervention ship, the department and departmental co-ordinators was essential to availability of healthy food was vital to success. Although the achieve maximal participation. Circuits took place four times intervention ship was provided with an increase in the Dai- per day with additional one-to-one sessions offered for partic- ly Messing Rate (DMR) for the intervention period (which is ipants. currently under review), there are numerous actions that can be taken to improve the healthiness of the provision of food within the current DMR. In order to enact change in this area Port Stop Walks it is essential that the logistics team are key members of the Port Stop Walks were held in four ports, providing an oppor- UHC. tunity for a different type of physical activity coupled with a cultural activity. The evening before the ship sailed was an Menu swaps ideal time for this, as most members of the ship’s company The breakfast menu was changed so that a full (five-item) were on board before leave was piped. This type of activity cooked breakfast was offered on only two days of the week. motivated those not normally likely to attend more vigorous On other days, while a cooked breakfast with three cooked exercise such as flight deck circuits, but also encouraged them items was offered, healthier alternatives such as fruit, yoghurt, to get involved with other activities on offer as part of the in- porridge and breakfast wraps were also available. tervention.

At lunchtime a salad bar was offered, where possible, and at Fleet Challenges the request of the ship’s company personnel could have the hot Fleet Challenges engage the ship’s company in physical ac- protein option accompanied by mixed salad instead of vegeta- tivity and do not require a Unit PTI to be present, so can bles. For one lunchtime per week a 100% salad bar was pro- be run by the medical team on smaller platforms. All events vided, which required innovative salad recipes to be created, cover short distances and are therefore 1) accessible to per- but also required a fresh supply of salad to be obtained whilst sonnel who would not normally participate in regular ac- at sea. tivity, 2) easy to fit into a busy routine. Examples include Row the Suez (two-kilometre row) and the Mike Till trophy (one-mile run). The intervention ship aimed to complete a Evening menus contained healthier options such as lamb tag- Fleet Challenge or similar event each month. Completing the ine, tomato-based pastas (instead of cheese- or cream-based) Fleet Challenges twice over the course of deployment also and fruit-based puddings. In addition to the regular themed allowed personnel to see how their physical fitness had pro- meals (Chinese, Indian, steak night, fish and chips), Greek, gressed. Inter-ship and inter-departmental competitiveness, Italian, Moroccan and Thai themes were adopted to add vari- prizes for the winners in each category and holding the event ety and promote new healthy recipes. A healthy main course, in a prominent location on the ship all appeared to increase starchy food and vegetable option were provided at each meal participation. time. Healthy options were highlighted on the menus and at the servery counter. Whole ship events In addition to the Fleet Challenges, the UHC designed its own The ship’s company was asked to provide feedback at various whole ship physical activity challenges. Examples included a time points throughout the deployment. This information was ‘Pedometer Challenge’, where participants downloaded a free collated by the MO and reported back to the UHC, along with walking app such as Pacer and were challenged to complete feedback from the Mess Healthy Lifestyle Representatives. 10,000 steps every day for a week, and ‘Lift the Ship’, where Adjustments were made to the menus accordingly. One of the participants combined their weight sessions to achieve their most significant changes in the provision of food following goal. On some occasions whole ship events were combined feedback was the removal of a pudding on two nights of the with charity fundraising, such as the Royal Navy and Roy- week. Instead this was replaced with a healthy ‘four o’clock- al Marines Charity (RNRMC) ‘Road to Twickenham’ event, er’ snack, which included fruit platters, yoghurt muffins, apple which meant that the charity provided promotional material bread and crudités and hummus with pitta bread. and prizes, and allowed the ship to involve families in the UK through a donation website. It is recommended that there are Before the menus were signed off, the UHC was able to review levels of challenge to increase inclusivity; for example: 3 km, them, voice concerns and make suggestions for improvements. 5 km or 8 km a day, each of which could be achieved using The Armed Forces Food Based Standards11 can be used as a 8 Journal of the Royal Naval Medical Service 2017; 103(1) basis to review monthly menus. Ultimately, the decision to Healthy lifestyle intervention top tips change the menus is made by the Logistics Officer, but where Table 2 contains a short summary of the top tips identified possible the UHC and catering services should work together when running a healthy lifestyle intervention on board a de- to ensure that the feeding provision is as healthy as possible. ployed ship.

Navy Army Air Force Institutes (NAAFI) Take into account the unit’s programme, especially port Aboard the intervention ship the UHC worked in collabora- visits tion with the NAAFI manager to increase the provision of Advertise well in advance and recruit approximately one healthy snack food and drink in the NAAFI shop and in the week before an event vending machines. Prior to deployment the NAAFI stocked Whole ship interventions and challenges work best if less up on the healthier snack food items (e.g. nuts, tins of tuna, than a week in length seeds and dried fruit). These items were popular and sold Get families involved by advertising initiatives in Families­ out; resupplying them was difficult as they were more ex- Newsletter or fundraising pensive overseas. It is therefore recommended that the shop Listen and react to feedback from the ship’s company on increases the percentage of stocks that are healthy items be- initiatives fore deployment, in the knowledge that unhealthier items Initiatives don’t have to be big or involve large amounts of can be resupplied more easily. It is also recommended that: physical training; simply getting people to move more is the majority of beverage options should be sugar-free; sug- important ar-sweetened beverage options should not be available in a Try and identify your ‘at risk’ group and tailor initiatives­ to portion size larger than 330 ml; savoury snacks should only them be available in packet sizes of 30 g or less; and packets of Use opportunistic health promotion e.g. new joiner sweet snack items should only be available in the smallest ­medicals, to sign people up to weight management and standard single portion size available, and should not exceed smoking cessation clinics. 250 kcal per portion. Table 2: Running a healthy lifestyle intervention - top tips. Healthy lifestyle education In order to reach the whole ship a fact of the week, which was Conclusion typically nutrition-related, was publicised on Daily Orders. In Action needs to be taken to reduce obesity levels within addition, one-line facts were displayed in the gym, at galley the RN, and a deployment is often an ideal opportunity for serving hatches and outside the sickbay. Prior­ to each port vis- Command and personnel to create healthy lifestyle change. it, the MO delivered a short brief to the ship’s company using The Medical Department, alongside other departments, has a DNAS factsheets,9 where the topic was thought to be relevant key role to play in educating and facilitating change within a (e.g. alcohol and energy content, hydration). Furthermore, nu- unit. As a result of 2SL’s Feeding the Fleet Initiative a UHC trition education briefs were delivered by the Unit PTI (e.g. toolkit has been created on the NAVYfit portal, which contains nutrition for military performance, supplements). health promotion resources, information and ideas to promote a healthy ship. Additionally, the INM team delivered a nutrition brief to ca- tering services on board prior to the ship’s deployment. This Further information and all resources mentioned in this ar- brief focussed on the importance of nutrition for military ticle can be obtained from the UHC toolkit on the ­NAVYfit performance and on menu planning, and gave tips on how to portal on the Defence Gateway, located at: https://www.roy- promote behaviour change. Subsequently, the INM team has alnavy.mod.uk/sports/physical-education/executive-health/ delivered a similar workshop to chefs based in the health-and-wellbeing/health-promotion-tools, or by contact- area. Devonport and Faslane Base Port areas will be addressed ing [email protected] or NA- in the near future. [email protected].

References

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Acknowledgements Dr Jo Fallowfield, Institute of Naval Medicine

Authors

Surgeon Lieutenant L Morrow RN Emergency Department, Derriford Hospital, , UK [email protected]

Sgt C Abrams RM PT1, Commando Training Unit

Miss A Shaw, Institute of Naval Medicine, Alverstoke, UK