Holistic Health and Fitness is a performance optimization system created to maximize soldiers’ ability to deploy, fight and win the United States’ wars. Placing people first, Holistic Health and Fitness provides the building blocks that enable leaders, soldiers and units to improve performance and mitigate risk.

Holistic Health and Fitness (H2F) leverages an embedded model to create an interdisciplinary, cross-functional team at the brigade level that provides support across the following domains: physical, nutrition, mental, spiritual and sleep. This is a proactive approach to improve soldier performance, readiness and resiliency.

H2F contrasts with the standard health care model, which is reactive in nature, and provides coaching for soldiers across the spectrum, from pathology to performance optimization.

The following summary of the H2F domains seeks to provide an operational framework for leaders to understand how the interdisciplinary team works to improve health and optimize performance in a proactive, active and reactive manner.

Physical Fitness

Physical readiness training (PRT) prepares soldiers for combat, shows leaders can plan, helps units know their people and builds perseverance. Although the U.S. Army has executed PRT for decades, the service continues to miss the mark when it comes to providing a well-balanced program that hits all the domains of fitness as outlined in Field Manual 7-22: Holistic Health and Fitness. These domains include muscular strength, power, endurance and aerobic/anaerobic endurance.

A lack of accountability and structure has left many Army units wanting, with approximately 65% of musculoskeletal injuries resulting from poor programming within PRT, according to a 2020 multipart study in Military Medicine led by researcher Joseph Molloy. Many of these injuries are a result of overuse and are largely preventable. This is multifaceted and likely due to a combination of a lack of knowledge and resources on how to appropriately write and execute a strength and conditioning program.

For years, the Army has been unsuccessful in appropriately leveraging NCOs and master fitness trainers in a meaningful way to address these issues. As a result, the Army has sought to impact this head-on by assigning 14 strength and conditioning coaches per brigade for units resourced with H2F.

Through leveraging their knowledge, skills and experience, commanders should expect a precipitous decrease in injuries when their soldiers are consistently executing plans co-developed with these professionals. To be the most beneficial, the plans should align with the unit’s long-range training calendar and mission-essential task list. Injury rates from PRT while working with strength coaches is less than 5%, according to data from the 82nd Airborne Division and another light infantry airborne unit tracked in 2020–23 and 2012–16, respectively.

Physical therapists serve as injury-control directors and the physical domain lead on the H2F team. They track injury trends and mechanisms, and provide objective data for commanders to make informed decisions. Through a systematic approach, they proactively engage those at high risk and provide early interventions, while focusing efforts to maximize the performance for most of the military formation that is not identified as high-risk.

Athletic trainers are integral to this team. They not only assist with sick call operations, but they also are present during field training to provide “on-the-field” care ranging from orthopedic care, screening for traumatic brain injuries and fueling, to name a few. They collaborate closely with the physical trainer, physical trainer assistant and strength and conditioning coach, and serve as the ideal conduit along the spectrum from point of injury to return to duty.

Nutrition Information

The physical demands imposed by Army training and combat require a nutrition strategy to optimize physical and cognitive function. The nutrition team works to develop a comprehensive fueling strategy tailored to the unit and individual soldiers to improve performance and overall readiness. Focus areas include body composition, injury recovery and mitigation, improving the nutrition environment and performance fueling.

H2F dietitians advise Warrior Restaurant managers on nutrition, improving food quality and appeal to improve the nutrition environment. They also are involved in field feeding, ration planning and education to ensure that soldiers have the resources and knowledge to fuel for any mission set.

Dietitians partner with installation food merchants to improve access to healthy options at a unit, including vending machines and markets, so it’s easier for soldiers to make healthy choices.

H2F nutrition teams influence policy and standard operating procedures, such as performance fueling recommendations for specific operations, ensuring that leaders from the top down have the tools and knowledge to fuel soldiers optimally for specific tasks, such as ruck marches or airborne operations.

It has been shown by poster presenters at the 2023 Military Health System Research Symposium that overweight soldiers exceeding Army body composition standards are approximately twofold more likely to sustain a musculoskeletal injury, independent of cardiovascular fitness level. There is an inverse correlation between Army Combat Fitness Test performance and body fat percentage: Higher body fat equates to lower ACFT scores.

Providing nutrition education and training—coupled with an improved nutrition environment—is imperative for injury prevention and recovery. Injured soldiers need precise nutrition to facilitate healing, recovery and negative body composition changes. During times of injury, H2F dietitians symbiotically work with the H2F performance team to facilitate rapid recovery and expedite return to duty.

Soldiers conducting field training and deployment operations, particularly in the heat, are at an increased risk for dehydration, low energy availability and heat injuries. Recent data indicates over half of soldiers with a diagnosed heat injury do not properly hydrate or eat before training events; both are easily modifiable with leadership oversight. By providing event-specific fueling guidance codified in unit policy and standard operating procedures that are nested in proper exercise programming and progression, H2F dietitians can proactively prevent injury and facilitate expedited recovery.

Mental Performance

The mental readiness team consists of occupational therapists and a cognitive performance specialist who focus on combat/operational stress and mental performance. A multidisciplinary approach is utilized to improve operational performance, ensure soldier deployability and well-being, and build tenacity. Mental readiness experts develop, empower, teach, enhance and coach cognitive, emotional and interpersonal skills to promote optimal performance across life domains. The development and enhancement of mind, brain and relationships through holistic approaches can support the unit in fostering a safe environment that optimizes soldier lethality and increases resilience.

The mental readiness team’s mission is to assist soldiers in minimizing the impact of stress on physiological, psychological and social health to promote mission success. The team also aids in concussion/traumatic brain injury recovery and educating soldiers on behavioral changes needed to enhance overall performance that comes from an efficient night of sleep.

The cognitive performance specialist provides mental performance education on relaxation techniques, mindfulness, visualization, self-talk, goal-setting, routine development, cognitive and behavioral assessments and biofeedback techniques to enhance a soldier’s warrior mindset, motivation, focus and emotional regulation.

These proactive measures take soldiers to the next level to ensure they are in the present moment and can maintain focus when it counts. Preliminary data for marksmanship training being collected by a team led by one of the co-authors of this article has demonstrated a 31% increase in shooting accuracy over the course of three days when leveraging these experts and the mental skills/tools taught. These cognitive enhancement strategies help soldiers “aim small and miss small.”

Sleep for Performance

Sleep is considered paramount for a soldier’s health and promotes peak performance. However, sleep debt is prevalent across the Army, leading to possible deadly consequences. Sleep problems and inadequate sleep are linked to poor cognition, physical health and emotional regulation. Insufficient sleep slows the recovery process and decreases motivation to maintain a PRT regimen and healthy diet, which can lead to weight gain.

Additionally, lack of sleep is associated with heightened pain sensitivity, and it impairs the inflammatory response, resulting in slower healing time. Insufficient sleep also degrades the ability to work and resolve conflicts with co-workers and family members, and increases a soldier’s risk of developing behavioral health problems. Soldiers who get five hours of sleep per night are twice as likely to make a mission-critical mistake compared with those with seven hours of sleep per night, according to a 2016 study in Military Behavioral Health led by Matthew LoPresti. Less sleep results in degraded readiness and performance. No matter how much you train, you cannot avoid the impact of sleep loss.

To address sleep debt and change the circadian culture in the military, H2F provides education and recommendations to soldiers and leadership. By educating leaders, they can target sleep outcomes that will help their units function more effectively and be healthier. Sleep leadership begins with managing soldiers in a way that builds awareness of the importance of sleep, optimizes sleep and reduces ongoing fatigue.

Sometimes soldiers have to sacrifice sleep, but that does not diminish its importance. The Army and its leaders must challenge commonly held beliefs such as “sleep is for the weak” and “you can train yourself to go without sleep.” Soldiers are dying because of this type of thinking, or, in the best case, their health and performance are declining.

Strong in Spirit

Spiritual fitness assessments provide leaders with a proactive readiness measurement and forecast for their formation instead of relying on reactionary measures alone. Unit ministry teams, as integrated members of the H2F system, are doctrinally implementing a spiritual fitness and readiness assessment for commanders.

During a late 2021 pilot program with the 82nd Airborne Division, for soldiers completing Advanced Individual Training and the Basic Officer Leader Course, 26% of new arrivals scored moderately low on spiritual fitness when measuring three core attributes: pursuing meaning, purpose and value; service and sacrifice; and personal connection to a higher power. These three attributes were developed by a working group of Army chaplains to collect data about soldiers who may be at risk when confronted with natural and unforeseen life circumstances, as low spiritual fitness scores are correlated with Serious Incident Reports and Commander’s Critical Information Reports.

This data may be leveraged to advise leaders on the need for readiness training in the spiritual domain. Spiritual readiness training provided by the unit ministry team includes core spirituality education that is nonreligious but focused on spiritual capacity, practices, development and resilience. Over 80% of soldiers who were identified with low spiritual fitness scores demonstrated improvement after attending chaplain-led spiritual fitness training with their unit. Research shows that a low spiritual core will negatively impact the other readiness domains. Therefore, commanders must integrate a holistic approach to the assessment and readiness of their formation.

Cultural Shift

The H2F system embeds performance readiness experts within brigades to assess soldiers’ physical and nonphysical status, develop and implement programs and ultimately improve soldiers’ longevity in the Army. H2F is initiating a cultural shift across the Army that will leave a long-lasting positive impact.

While still early in the implementation phase, preliminary data supports outcomes to include enhancing soldier performance on the ACFT and marksmanship, reducing injury rates and time lost to injury, decreased medication use, improved spiritual fitness and decreased suicides.

This investment in soldiers’ health and well-being is an example of the Army “putting its money where its mouth is” and truly placing people first to ensure soldiers are physically and mentally prepared to fight and win our nation’s wars.

Maj. Carlos Ruiz, Maj. Kimberly Gordon and Capt. Curtis Lubic contributed to this article.

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Lt. Col. Matthew Helton is the chief of physical therapy and clinical internship director at Tripler Army Medical Center, Honolulu. Previously, he was the Holistic Health and Fitness director for the 82nd Airborne Division, Fort Liberty, North Carolina, formerly known as Fort Bragg. He deployed twice to Afghanistan. He holds a doctorate in physical therapy from the University of Montana and a doctorate of science in orthopaedics and manual physical therapy from Baylor University, Texas.

Maj. Christina Deehl is the Holistic Health and Fitness dietitian with the Division Sustainment Brigade, 101st Airborne Division (Air Assault), Fort Campbell, Kentucky.

Matthew Hood is a cognitive performance specialist with the 1st Brigade Combat Team, 82nd Airborne Division.