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MILITARYMEDICINE,00,0/0:1,2022
®
GoforGreen NutritionProgram:Translating Evidence Into
Practice
Carolyn A. Kleinberger, MS*,†; LTC Asma S. Bukhari, PhD, SP, USA‡; Katie M. Kirkpatrick, MS*,†;
Elizabeth M. Moylan, MPH*,†; Jennifer L. Billington, MS§; Nicholes J. Armstrong, MS‡;
COLReneeE.Cole,PhD,SP,USA‡,∥;PatriciaA.Deuster, PhD, MPH* Downloaded from https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usab503/6535528 by guest on 13 January 2023
ABSTRACT
Introduction:
®
GoforGreen (G4G)isanevidence-based,multi-componentnutritionprogramformilitarydiningfacilities (DFAC) to
improvenutritionalfitnessamongServiceMembers.Theprogramevolvedfromsupporting“fueling”duringinitialArmy
training into a robust intervention across all U.S. Military branches. The current G4G program consists of eight program
requirementstooptimizethenutritionenvironment,includingtrafficlightlabeling,nutritiousmenus,choicearchitecture,
foodpromotion,marketing,andstafftraining. TheevolutionoftheG4Gprogram,developmentofstandardizedprogram
requirements, and lessons learned are described.
Materials and Methods:
The latest scientific evidence, best practices in health promotion and nutrition education, results and data from G4G
implementationinthemilitarycommunitysupportthecurrentversionofG4G.Feedbackandobservationsfromprogram
developers, military branch foodservice headquarters, installation leadership, and local G4G DFAC teams provided
insight into implementation challenges, successes, facilitators, and barriers.
Results:
TheG4Gprogramhasevolvedandexpandedfromitsinitialinceptionover10yearsagotoitscurrentversion.Research
studies, nutrition science, and feedback from military community stakeholders have informed programmatic changes
and improvements.
Conclusions:
G4G2.0isarobust, innovative, multi-component, performance nutrition program with clear program element require-
ments. Value was added to elevate the G4G program by setting program requirements, expanding program components,
andestablishingacentralizedresourcehub. PerformancenutritioninitiativesinlocalmilitaryDFACfordiningfacilities,
such as G4G 2.0, has great potential to impact the health and well-being of Service Members.
INTRODUCTION
*
Optimal nutrition contributes to mission readiness of
Consortium for Health and Military Performance, Department of
´
Military and Emergency Medicine, F. Edward Hebert School of Medicine, warfighters(ServiceMember)bysustainingphysicalandcog-
Uniformed Services University, Bethesda, MD 20814, USA
nitive performance during military operational stress. To that
†
Henry M. Jackson Foundation for the Advancement of Military
end, in 2007, the Consortium for Health and Military Perfor-
Medicine, Rockville, MD 20817, USA
mance at the Uniformed Services University of the Health
‡
US Army Research Institute of Environmental Medicine, Natick, MA
Sciences hosted a workshop entitled “Warfighter Nutrition:
01760, USA
1
§
Current Opportunities and Advanced Technologies”. The
Combat Capabilities Development Command Soldier Center, Natick,
MA01760,USA goal of the workshop was to identify research and technol-
∥US Military-Baylor University Graduate Program in Nutrition, Med-
ogy gaps in nutrition areas impacting the health, well-being,
ical Center of Excellence Joint Base San Antonio-Fort Sam Houston, San
and performance of Service Member (SMs). Two research
Antonio, TX 78234, USA
objectives identified were as follows: (1) evolve military
Information pertaining to this manuscript have been presented:
dining facilities (referred to as DFAC) into twenty-first cen-
®
• Oral presentation: Go for Green : A Performance Nutrition Initia- tury warfighter nutrition centers and (2) identify effective
tive. Understanding and Overcoming the Challenge of Obesity and
Overweight in the Armed Forces: A Workshop, National Academy of
Science, May 7, 2018.
• Aplatform presentations on “Go for Green® program Updates” was
the Advancement of Military Medicine, Inc. Any citation of trade names,
provided at the Department of Defense Nutrition Subcommittee key
commercial products, or organizations does not imply endorsement or
stakeholders in March and September 2021.
approval by the U.S. Government.
doi:https://doi.org/10.1093/milmed/usab503
The views expressed in this manuscript are those of the author(s) alone
and do not reflect the official views, opinions or policies of the Depart- Published by Oxford University Press on behalf of the Association of
ment of Army, the Department of Defense, the U.S. Government, the Military Surgeons of the United States 2022. This work is written by (a) US
Uniformed Services University, or The Henry M. Jackson Foundation for Government employee(s) and is in the public domain in the US.
MILITARYMEDICINE,Vol.00,Month/Month2022 1
GoforGreen®NutritionProgram
®
“cafeteria” interventions to promote healthy eating in DFAC TABLEI. EvolutionoftheGoforGreen Program
bymilitary consumers.
Original
To address those objectives, military DFAC began testing
G4G G4G1.5 G4G2.0
nutrition programs based on the U.S. Dietary Guidelines for
Program requirement (PR) (2008) (2015) (current)
Americanswithspecialconsiderationforthemilitaryenviron- √ √
2
PR1:Standardized Training –
ment and its mission. The mission of nutrition interventions
for Management
and education, much like in athletics, is to optimize mental √ √ √
PR2:AssignTraffic Light Downloaded from https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usab503/6535528 by guest on 13 January 2023
and physical performance. The chosen intervention, a traffic
Color Codes Based Only on
light style labeling system, was founded on social cogni-
Approved Coding Algorithm √ √
3–8
tive theory. It is intended to standardize labeling programs • Codingbyonlydesignated –
across the Department of Defense (DoD) to simplify SMs’
professionals √ √
food choice decisions and prompt more nutritious options
PR3:MenuTargets:Min- –
to support performance optimization in addition to military imumGreen-coded
Items
weight control and health promotion programs. The U.S. √ √ √
PR4:Standardized Food
Army2010SoldierFuelingInitiativewasdevelopedforusein
Cards √ √
Initial Military Training to establish a “fueling” standard for
PR5:FoodPlacement –
9
Soldiers. The Soldier Fueling Initiative development group
Strategies √
recognizedthatwithoutappropriatefuelingandperformance- PR6:PromotionofGreen- – –
coded Items
based dietary menu standards, Soldiers would be unable
PR7:Marketingand
to maintain their health or sustain core mission competen-
Education √ √ √
cies. They identified a number of aspects of DFAC feeding
that could be modified to enhance nutrition quality and pro- • Printed material √
– –
mote healthier eating, including menus, recipes, preparation • Social media, other media,
methods, and portion sizes. A process was developed for and press √
– –
DFAC patrons to identify and discriminate between nutri- • Nutrition education for
tious and less nutritious options. The most nutritious items
diners
were coded “Green” and the least nutritious as “Red.” This PR8:Standardized Training
®
for all Staff
intervention was the initial Go for Green (G4G) program, √ √
–
7,8,10–13
which is based upon other food labeling programs. • Initial
√
The traffic light color-coding system employed in G4G has – –
been shown to be more effective at shifting attention toward • Ongoing
®
nutritious items and away from less healthy items compared Abbreviations: PR=Program Requirement; G4G=Go for Green .
to other numerical labeling (e.g., calories) and other meth-
11,14,15
ods for increasing healthy food choices. This initial
the U.S. Dietary Guidelines for Americans, Military Dietary
versionalsoincludedamarketingcampaignemphasizingcon-
Reference Intakes, and DoD nutrition and foodservice stan-
nections among nutrition quality, well-being, health, and
2,18,19
dards/regulations. Because the G4G nutrition program
performance.
is intended to support mental and physical performance and
An evaluation of G4G by the Army Public Health Cen-
improve the nutrition environment on military installations,
ter confirmed that Soldiers reported using the color labels
programrequirements(PRs)wereestablishedtoverifydining
9
to guide their food choices. Nearly 2/3 (66.0%) reported
facilities using the G4G logo met program goals. The objec-
9,16
using the labels at least once a day. Soldiers also stated
tive of this report is to provide an overview of the evolution of
that the performance nutrition education provided to them
the G4Gprogramusinganevidence-basedapproachtoutilize
generally helped them make performance enhancing food
military dining avenues as a platform to optimize warfighter
5
choices. Another important finding from the evaluation was
nutrition fitness, performance and military readiness. This
that unit and command level leadership were key influencers
report doesnotrepresenthumansubject’sresearchbutinstead
of food choice and eating behaviors of Soldiers in the train-
provides the methodological context to understand the G4G
ingenvironment,whichindicatesthatleadersateveryechelon
2.0 program. However, the U.S. Army Research Institute of
should be educated on performance nutrition and good eating
Environmental Medicine and U.S. Army Medical Research
9,17
habits.
and Materiel Command Institutional Review Boards granted
Since 2008, the G4G program has evolved based on
approval to the G4G 2.0 evaluation research.
nutrition science, changes in nutrition guidance, data from
conducted research, and feedback from key stakeholders
(Table I). The G4G version 2.0 (G4G 2.0) is a rebrand of the GOFORGREENPROGRAMREQUIREMENTS
original G4G with a new and trademarked logo, which may METHODOLOGY
not be used by commercial entities in advertising or prod- Eight PRs were established to achieve the program goals of
uct packaging labels. The G4G menu guidelines are based on improvingthefoodenvironmentwhereSMsliveandworkand
2 MILITARYMEDICINE,Vol.00,Month/Month2022
GoforGreen®NutritionProgram
increasing the variety of and access to more nutritious options PR2:AssignTraffic Light Color Codes Based on
to optimize performance, readiness, and health. Additionally, ApprovedCodingAlgorithm
standardized PRs help maintain the integrity and accuracy
The G4G 2.0 Coding Algorithm includes the algorithm,
of G4G 2.0 across hundreds of facilities in the military. By
criteria and calculator, and was developed by a joint ser-
achieving these requirements, programs build trust across the
vice team of dietitians to ensure replicable code assignment
intendedSMpatronsandensurethesameminimumstandards
quality control maintenance. The evidence-based nutritional
are achieved, regardless of service branch or location. New
criteria on which the algorithm is based were also determined Downloaded from https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usab503/6535528 by guest on 13 January 2023
science, best practices in health promotion, G4G pilot tests,
by a joint service team of dietitians and align with the U.S.
and feedback from key stakeholders guided the inclusion and
Dietary Guidelines for Americans, Military Dietary Refer-
necessity of eight PRs. The “Program Fidelity Assessment” 2,18,19
enceIntakes,andDoDmenuregulations. Thealgorithm
outlines the requirements for displaying G4G 2.0 program
is expected to be reviewed and updated every five years or
logo and materials. This tool can be used during planning to
as needed, such as when dietary recommendations or criteria
outline major action steps necessary for program implemen-
change (Fig. 1).
tation and upon implementation to evaluate fidelity of each
Thealgorithm assigns points to food items based on nutri-
PR. Currently, G4G 2.0 is intended for government-funded
tional information including trans fatty acids content, total
military DFAC,galleys, andmedicaltreatmentfacilities, with
calories, percent calories from fat, fiber content, sugar con-
expected expansion to other food service entities (e.g., non-
tent, degree of processing, additives, and preparation method.
government commercial cafes and restaurants and ready-to-
If an item receives 0–4 points, it is coded Red, 5–8 points
use-foods) located on installations. Description of each PR
is coded Yellow, and 9–13 points is coded Green. The algo-
follows.
rithm also assigns a sodium code based on sodium content
per serving in each food category. Beverage codes are not
assigned through the coding algorithm, but instead are pre-
PR1:StandardizedTraining for Management
coded based on added sugar content, presence of artificial
ingredients, saturated fat content, and amount of naturally
Standardized training is a key aspect of successful imple-
occurring healthful nutrients, such as vitamins and minerals
mentation of G4G 2.0. Online training was determined as
(details available: https://www.hprc-online.org/nutrition/go-
the most accessible and feasible way to disseminate the
green/getting-started-implementation/prep-your-facility/prog
G4G program across multiple branches of the military and
ram-requirements-1). TheArmedForcesRecipeServiceveri-
installations with DFAC throughout the world. Training for
fied the coding with more than 2,000recipestoensurethecal-
local DFAC G4G team leaders to plan and execute G4G 2.0
culatorconsistentlyassignedthesamecolorcode.Toimprove
involves completing online modules on PRs and staff train-
reliability across users, the coding algorithm was deployed in
ing on the Human Performance Resources by Consortium for
a protected manner. First, the algorithm is available in two
Health and Military Performance website (https://www.hprc-
user-friendly formats, locked spreadsheet and web-based cal-
online.org/nutrition/go-green/training/classes). Best practices
culator. Second, “coder” certification training was created for
support a local G4G team of at least two to four members
nutrition or food product subject matter experts to preserve
depending on the size of the facility and the structure of
the integrity of the code assignment in the decentralized DoD
the military branch’s foodservice operations, including where
menusystem.Third,ateamofexpertcodersisavailableupon
aspects such as menu creation and recipe coding are cen-
request (g4gteam@usuhs.edu) for hard-to-code products and
tralized. Installation or headquarters nutrition assets, such
to help food programs who choose to monitor for coding
as registered dietitians, health promotion educators, or diet
discrepancies.
technicians along with DFAC managers and assistant man-
agers, staff shift supervisors, and installation leadership are
PR3:MenuTargets:MinimumGreen-CodedItems
the intended audiences for the different G4G trainings. Train-
ing modules include (1) G4G 2.0 Coder; (2) G4G 2.0 Staff Each DFAC must offer a sufficient number of Green-coded
Trainer; (3) G4G2.0ProgramRequirements;and(4)G4G2.0 food options to use the G4G 2.0 trademarked logo; the target
ExecutiveSummary(high-leveloverviewofG4G2.0forlead- for Green-coded food items offered is modest. Specifically, a
ership). All modules allow opportunity for course evaluation minimumof30%Green-codeditemsmustbeofferedatevery
whereas the G4G 2.0 Coder training has two learning assess- meal, within every station and within each food category
ments (coding recipes, coding ready-to-use items) in which a (i.e., entrees, starchy sides, non-starchy sides or vegetables,
score of ≥75% is required for course completion. Addition- dressings, beverages, and desserts). Additionally, some max-
ally, tips and guidance are provided to those leading G4G imums for Red-coded food items were set; for example, no
2.0 implementation, including sample timelines, planning morethanthree Red-coded items on a breakfast bar.
team templates, position descriptions, and sample briefs to Several new DoD food service features assist DFAC in
leadership. achieving these menu targets. Most notably, the Armed
MILITARYMEDICINE,Vol.00,Month/Month2022 3
GoforGreen®NutritionProgram
Downloaded from https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usab503/6535528 by guest on 13 January 2023
FIGURE1.G4G2.0standardizedtraffic light labeling criteria and logos. Check mark=Green, caution sign=Yellow, stop sign=Red.
Forces Recipe Service has increased the availability of or digital menu boards. Individual DFAC are responsible for
Green-coded recipes from 377 (20%) to 819 (37%) across populatingstandardizedG4Gtemplateswiththeirmenuoffer-
2017–2020. Recipes now incorporate more nutritious food ings. Across military DFAC, digital menu boards are rare;
items (e.g., lentils, beans, Greek yogurt, vegetables), thus, a combination of the analog food cards and coding signs
healthier cooking methods (e.g., roasted vegetables), and are used in most facilities.
enhanced seasonings to increase flavor in lieu of excess
salt, sugar, and less healthy fats (e.g., saturated) com-
PR5:FoodPlacementStrategies
pared to earlier recipes. Many plant-based and vegetarian
Numerous studies have shown that choice architecture, also
options are now available for menus. Furthermore, sam-
knownasstrategic placement of foods, encourages the selec-
ple menus that adhere to G4G 2.0 menu targets are eas-
20–22
tionofhealthyfoods. Choicearchitecturewaswoveninto
ily accessible (https://www.hprc-online.org/nutrition/go-gr
the G4G 2.0 concept to encourage diners to select Green-
een/g4g-getting-started/menus-and-guidelines).
coded foods and beverages. The DFAC is often limited in
its ability to move certain food service equipment and struc-
PR4:StandardizedFoodCards
tures, such as salad bars. Therefore, more feasible changes
TheG4G2.0programfoodlabelsutilize a standardized tem- wereencouraged,suchasmakingplatesavailableatthesalad
´
platewithtwodistinctidentifiers: Green, Yellow, orRedcolor bar for entree salads, displaying infused water in clear visu-
codes for nutritional quality and a salt shaker shown as Low, ally appealing cannisters, placing fruit in attractive bowls,
Medium,orHighcodetodesignatesodiumcontent.Thesep- and modifying the serving spaces at existing bars to display
aration of sodium content from the overall color code was Red-coded items in physically smaller containers.
deemed important for SMs because their sodium needs vary For each menu, a planogram or “visual menu” is used
based on general health, environmental conditions, physical to depict where and how food service staff could optimally
14
demands, and assigned operational duties. The color and place foods at each station. The G4G program instructs
sodium codes offer separate, but complementary, labels to that Green-coded items are placed first for diners to view
inform and guide the diners to make healthy choices. Infor- easily at each station, followed by Yellow, and then Red.
mation is displayed to diners by using one of three options at Additional strategies to encourage selection of Green-coded
the point of selection: food and beverage cards, coding signs, items include (1) placing Red-coded items out of sight for
4 MILITARYMEDICINE,Vol.00,Month/Month2022
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