Table Of ContentFEASIBILITY AND EFFECTIVENESS OF HEALTHY MENU CHANGES FOR NON-
TRAINEE MILITARY DINING FACILITIES
by
BETHANY ANN BELANGER
B.A., Concordia College, 2001
M.B.A., Webster University, 2005
AN ABSTRACT OF A DISSERTATION
submitted in partial fulfillment of the requirements for the degree
DOCTOR OF PHILOSOPHY
Department of Hospitality Management and Dietetics
College of Human Ecology
KANSAS STATE UNIVERSITY
Manhattan, Kansas
2014
Abstract
The purpose of this study was to assess the food choices and consumption of soldiers and
their satisfaction with current and initial military training (IMT) menu standards through a
survey and analysis of food selection and consumption. Participants were recruited during lunch
periods before and three weeks after implementing IMT menu standards, which are healthier
than current menu standards, in an Army dining facility (DFAC). Direct observations, digital
photography, and plate waste methods were used to assess soldiers’ food selection and
consumption. A survey was also administered to determine soldiers’ attitudes toward health,
nutrition knowledge, reported food selection and consumption behaviors, and overall satisfaction
with meals served under the two menu standards. Food selection and consumption were
evaluated using the Army’s Go for Green Nutrition Labeling Program and the Military Dietary
Reference Intakes (MDRIs). Descriptive and inferential statistics were calculated to summarize
and compare data, and to identify potential associations among variables. A total of 172 and 140
soldiers participated before and after the menu change, respectively. Soldiers’ food selection
patterns were similar to the proportion of green-, yellow-, and red-labeled items offered in the
DFAC under both menu standards and significantly improved after the intervention (p<0.001).
Soldiers consumed 886 kcal (38.6% from total fat and 11.2% from saturated fat) and 1784 mg of
sodium before the menu change. Three weeks after the change, all figures improved (705 kcals,
31% of kcals from total and 9% from saturated fat, and 1339 mg of sodium) (p<0.01). Overall
satisfaction and meal acceptability before and after the intervention were not different, and “food
appeal” ratings actually improved. With the exception of sugar-sweetened beverage
consumption, attitudes toward health were significantly associated with all reported food
behaviors (p<0.01) but not with actual behaviors (p>0.05). Nutrition knowledge significantly
influenced some but not all aspects related to attitudes toward health. Perceived hunger levels
were positively associated with intakes of calories, protein, total fat, sodium, and cholesterol
(p<0.05). Findings suggest that implementing the IMT menu standards in non-trainee Army
DFACs is feasible and has the potential to improve the overall healthfulness of soldiers’ food
selection and consumption.
FEASIBILITY AND EFFECTIVENESS OF HEALTHY MENU CHANGES FOR NON-
TRAINEE MILITARY DINING FACILITIES
by
BETHANY ANN BELANGER
B.A., Concordia College, 2001
M.B.A., Webster University, 2005
A DISSERTATION
submitted in partial fulfillment of the requirements for the degree
DOCTOR OF PHILOSOPHY
Department of Hospitality Management and Dietetics
College of Human Ecology
KANSAS STATE UNIVERSITY
Manhattan, Kansas
2014
Approved by:
Major Professor
Dr. Junehee Kwon
Abstract
The purpose of this study was to assess the food choices and consumption of soldiers and
their satisfaction with current and initial military training (IMT) menu standards through a
survey and analysis of food selection and consumption. Participants were recruited during lunch
periods before and three weeks after implementing IMT menu standards, which are healthier
than current menu standards, in an Army dining facility (DFAC). Direct observations, digital
photography, and plate waste methods were used to assess soldiers’ food selection and
consumption. A survey was also administered to determine soldiers’ attitudes toward health,
nutrition knowledge, reported food selection and consumption behaviors, and overall satisfaction
with meals served under the two menu standards. Food selection and consumption were
evaluated using the Army’s Go for Green Nutrition Labeling Program and the Military Dietary
Reference Intakes (MDRIs). Descriptive and inferential statistics were calculated to summarize
and compare data, and to identify potential associations among variables. A total of 172 and 140
soldiers participated before and after the menu change, respectively. Soldiers’ food selection
patterns were similar to the proportion of green-, yellow-, and red-labeled items offered in the
DFAC under both menu standards and significantly improved after the intervention (p<0.001).
Soldiers consumed 886 kcal (38.6% from total fat and 11.2% from saturated fat) and 1784 mg of
sodium before the menu change. Three weeks after the change, all figures improved (705 kcals,
31% of kcals from total and 9% from saturated fat, and 1339 mg of sodium) (p<0.01). Overall
satisfaction and meal acceptability before and after the intervention were not different, and “food
appeal” ratings actually improved. With the exception of sugar-sweetened beverage
consumption, attitudes toward health were significantly associated with all reported food
behaviors (p<0.01) but not with actual behaviors (p>0.05). Nutrition knowledge significantly
influenced some but not all aspects related to attitudes toward health. Perceived hunger levels
were positively associated with intakes of calories, protein, total fat, sodium, and cholesterol
(p<0.05). Findings suggest that implementing the IMT menu standards in non-trainee Army
DFACs is feasible and has the potential to improve the overall healthfulness of soldiers’ food
selection and consumption.
Table of Contents
List of Figures ................................................................................................................................ ix
List of Tables .................................................................................................................................. x
Acknowledgements ........................................................................................................................ xi
Dedication ..................................................................................................................................... xii
Chapter 1 - Introduction .................................................................................................................. 1
Background ................................................................................................................................. 1
Statement of the Problem ............................................................................................................ 3
Justification ................................................................................................................................. 4
Purpose ........................................................................................................................................ 5
Objectives ................................................................................................................................... 5
Hypotheses .................................................................................................................................. 6
Assumptions and Limitations of the Study ................................................................................. 7
Assumptions ............................................................................................................................ 7
Limitations .............................................................................................................................. 7
Definition of Terms .................................................................................................................... 8
Chapter 2 - Review of Literature .................................................................................................. 13
Obesity Trends in the United States ......................................................................................... 13
U.S. Military Obesity Trends .................................................................................................... 15
Energy-Density of Foods and Obesity Trends .......................................................................... 16
Diet Quality and Food-Away-From-Home ............................................................................... 19
Strategies to Improve Food Choices Away From Home .......................................................... 21
Nutrition Labeling and Education Act (NLEA) .................................................................... 21
Nutrition Labeling in Eating Establishments ........................................................................ 22
Food Labeling Systems ......................................................................................................... 24
Changes to Foodservice Menu Standards ............................................................................. 25
U.S. Military Nutrition Intervention Strategies ........................................................................ 27
Calorie Labeling .................................................................................................................... 27
Go for Green ......................................................................................................................... 27
v
Initial Military Training Menu Standards ............................................................................. 29
Factors Influencing Food Choices ............................................................................................ 31
Customer Satisfaction and Return Intentions ........................................................................... 34
Assessment of Food Intake ....................................................................................................... 36
Chapter 3 - Methodology .............................................................................................................. 49
Introduction ............................................................................................................................... 49
Data Collection Location and Study Participants ..................................................................... 49
Preliminary Investigation of Current Practices ......................................................................... 51
Recipe Nutrient Analysis ...................................................................................................... 51
Nutrient Analysis and Comparison Between Two Menu Systems ....................................... 53
Menu Nutrient Comparison with MDRIs ............................................................................. 54
Reference Portion Size Determination .................................................................................. 58
Intervention and Data Collection for Food Selection and Consumption .................................. 61
Overview ............................................................................................................................... 61
Pilot Study ............................................................................................................................. 61
Reference Portion Size Determination .................................................................................. 63
Data Collection ..................................................................................................................... 64
Data Analysis ........................................................................................................................ 65
Assessment of Soldiers’ Perception of Their Health Status and Meal Satisfaction ................. 66
Overview ............................................................................................................................... 66
Instrument Constructs ........................................................................................................... 66
Reported Eating Behaviors ............................................................................................... 66
Nutrition Knowledge ........................................................................................................ 67
Attitudes Toward Health ................................................................................................... 67
Satisfaction with Overall Dining Experience ................................................................... 68
Expert Review and Validity Determination .......................................................................... 69
Pilot Test ............................................................................................................................... 69
Data Collection ..................................................................................................................... 69
Data Recoding and Analysis ................................................................................................. 70
Reported Food Behaviors ...................................................................................................... 70
Attitudes Toward Health ....................................................................................................... 71
vi
Nutrition Knowledge ............................................................................................................. 71
Satisfaction with Overall Dining Experience ........................................................................ 72
Overall Data Analysis ........................................................................................................... 72
Chapter 4 - Factors Influencing Selection and Nutrient Intakes of Non-Training Army Dining
Facility Patrons ...................................................................................................................... 75
Abstract ..................................................................................................................................... 75
Background ............................................................................................................................... 76
Methods .................................................................................................................................... 77
Subjects ................................................................................................................................. 77
Instrument and Study Protocol Development ....................................................................... 78
Food Selection and Consumption ..................................................................................... 78
Food Behaviors, Nutrition Knowledge and Attitudes Toward Health Assessment .......... 80
Data Collection ..................................................................................................................... 81
Data Recoding and Statistical Analysis ................................................................................ 81
Nutrient Quality ................................................................................................................ 81
Nutrition Knowledge, Attitudes toward Health, and Reported Behaviors ....................... 82
Results ....................................................................................................................................... 83
Factors Associated with Food Selection and Consumption Behaviors ................................. 84
Reported Food Behaviors and Attitudes toward Health ....................................................... 85
Discussion ................................................................................................................................. 86
Conclusion ................................................................................................................................ 88
Tables and Figures .................................................................................................................... 94
Chapter 5 - Effectiveness of Healthy Menu Changes in a Non-Trainee Military Dining Facility
............................................................................................................................................. 100
Abstract ................................................................................................................................... 100
Introduction ............................................................................................................................. 101
Methods .................................................................................................................................. 102
Subjects ............................................................................................................................... 102
Instrument and Study Protocol Development ..................................................................... 103
Food Selection and Consumption ................................................................................... 103
Customer Satisfaction and Meal Acceptability Assessment ........................................... 105
vii
The Intervention .................................................................................................................. 105
Data Collection ................................................................................................................... 106
Statistical Analysis .............................................................................................................. 107
Nutrient Quality .............................................................................................................. 107
Results ..................................................................................................................................... 107
Discussion ............................................................................................................................... 109
Conclusion .............................................................................................................................. 111
Tables and Figures .................................................................................................................. 117
Chapter 6 - Summary and Conclusions ...................................................................................... 121
Summary of Major Findings ................................................................................................... 123
Implications ............................................................................................................................ 129
Limitations and Recommendations for Future Research ........................................................ 130
Appendix A - Kansas State University IRB Approval ............................................................... 135
Appendix B - Military IRB Approval ......................................................................................... 137
Appendix C - Comparison of Garrison and IMT Menu Standards ............................................. 140
Appendix D - Informed Consent ................................................................................................. 145
Appendix E - Quantitative Survey .............................................................................................. 147
Appendix F - Salad Bar Observation Form ................................................................................ 153
Appendix G - Plate Waste Record Sheet .................................................................................... 155
viii
List of Figures
Figure 2.1 Go for Green program criteria ..................................................................................... 28
Figure 3.1 Overview of methodology ........................................................................................... 50
Figure 5.1 Summary of changes made to the selected DFAC during the IMT menu standards
implementation period ........................................................................................................ 117
ix
List of Tables
Table 3.1 Comparison of nutrient analysis methods using IMT and garrison lunch menus ........ 53
Table 3.2 Comparison of sample lunch menus' nutrient composition using straight average
method ................................................................................................................................... 55
Table 3.3 Selected MDRIs for men and women ........................................................................... 57
Table 3.4 Comparison of nutrient contents of the menu planned using IMT and garrison menu
standards with established MDRIs ........................................................................................ 58
Table 3.5 Consistency and accuracy of selected food items served ............................................. 60
Table 3.6 Selected nutrition knowledge questions and answers ................................................... 68
Table 4.1 Summary of non-training military diners' lunch meal nutrient intakes ........................ 94
Table 4.2 Frequencies and percentages of non-training soldiers' endorsed items for attitudes
toward health ......................................................................................................................... 95
Table 4.3 Correlations and significance between non-training diners' perceived hunger levels and
primary outcome variables .................................................................................................... 97
Table 4.4 Multiple regression analysis predicting non-training diners' reported food behaviors
from attitudes toward health ................................................................................................. 98
Table 4.5 Summary of non-trainee DFAC meal offerings based on Go for Green labeling criteria
............................................................................................................................................... 99
Table 5.1 Difference in nutrient intake before and after implementation of the IMT menu
standards .............................................................................................................................. 118
Table 5.2 Summary of non-trainee DFAC meal offerings based on Go for Green labeling criteria
before and after three-week IMT implementation period ................................................... 119
Table 5.3 Summary of mean differences in satisfaction scores for baseline and intervention menu
groups .................................................................................................................................. 120
x
Description:obesity among adults: United States, trends 1960-1962 through 2007-2008. Retrieved and Dietetics, 2012; American Dietetic Association [ADA], 2007, 2008), and those currently analyzed by photograph station was equipped with a digital camera (e.g., Nikon D3100) positioned on a tripod and
