HUMAN PERFORMANCE OPTIMIZATION: CULTURE
CHANGE AND PARADIGM SHIFT
PATRICIA A. DEUSTER AND FRANCIS G. O’CONNOR
Consortium for Health and Military Performance, Department of Military and Emergency Medicine, Uniformed Services
University of the Health Sciences, Bethesda, Maryland
ABSTRACT
Deuster, PA and O’Connor, FG. Human performance optimi-
zation: culture change and paradigm shift. J Strength Cond
Res 29(11S): S52–S56, 2015—The term “Human Perfor-
mance Optimization” (HPO) emerged across the Department
of Defense (DoD) around 2006 when the importance of human
performance for military success on the battlefield was
acknowledged. Likewise, the term Total Force Fitness (TFF)
arose as a conceptual framework within DoD in response to
the need for a more holistic approach to the unparalleled oper-
ational demands with multiple deployments and strains on the
United States Armed Forces. Both HPO and TFF are frame-
works for enhancing and sustaining the health, well-being, and
performance among our warriors and their families; they are
fundamental to accomplishing our nation’s mission. A
demands-resources model for HPO is presented within the
context of TFF to assist in operationalizing actions to enhance
performance. In addition, the role leaders can serve is dis-
cussed; leaders are uniquely postured in the military chain of
command to directly influence a culture of fitness for a ready
force, and promote the concept that service members are ulti-
mately responsible for their fitness and performance.
KEY WORDS total force fitness, demands-resources model,
Consortium for Health and Military Performance
INTRODUCTION
W
arriors—active duty, reserves and National
Guard and their families—are the Department
of Defense’s (DoD), and arguably the na-
tion’s, most valuable assets: without them
the mission of protecting and defending the country cannot
be effectively accomplished. This complex undertaking has
resulted in unparalleled operational demands with multiple
deployments and strains on the United States Armed Forces,
Address correspondence to Patricia A. Deuster, patricia.deuster@
usuhs.edu.
29(11S)/S52–S56
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as well as their family members (15-17,26). In addition, the
changing battlefield with the emergence of unconventional,
asymmetric, and hybrid warfare, has limited the technolog-
ical advantage of our forces and increasingly called upon
optimal performance of the individual warrior and teams.
Although extensive resources have always been expended
to ensure equipment and materials are both state-of-the-art
and in good repair, resources for maintaining and improving
human resilience, performance, well-being, and health have
been more limited. In 2006, it had become clear that the
demands on warriors and their families were overwhelming
the capacity of our service members (15,16). The prevalence
of posttraumatic stress disorder, scores of injuries, family
casualties, and increasing suicide rates became critical con-
cerns; a new framework to match the circumstances or
needs of the DoD family was deemed essential.
In reaction to the aforementioned stressors and changing
battlefield paradigms, the terms Human Performance Opti-
mization (HPO) and Total Force Fitness (TFF) emerged as
conceptual frameworks within DoD to enhance health, well-
being, and performance among our warriors and their families
(8). The health and well-being of the whole person, the family,
the community, and the enterprise were viewed as fundamen-
tal to accomplishing our nation’s mission (19). Since that time,
the terms HPO and TFF have become recognized as corner-
stones of an effective and efficient military community, and
are ingrained throughout the DoD as a holistic concept that
must be embraced. We will define the terms associated with
human performance, provide a brief historical background,
describe a holistic model for HPO, personnel, and conclude
by identifying resources for both HPO and TFF.
BACKGROUND
Historical Context
Although new terminologies and phrases emerge over the
course of time, the concept of HPO and the importance of
the “human” for military success on the battlefield have been
appreciated for a long time. Following are selected examples
of statements made by past military leaders emphasizing the
same concepts being promoted today, just in different words
and different contexts.
 In 1870, a French army officer and military theorist,
Ardant du Picq stated: “The man is the first weapon

of battle. Let us study the soldier, for it is he who brings
reality to it” (4).
 In 1866, Dr. Jonathan Letterman stated that “the leading
idea (for the medical corps), which should be constantly
kept in view, is to strengthen the hands of the Com-
manding General by keeping his army in the most vig-
orous health, thus rendering it, in the highest degree,
efficient for enduring fatigue and privation, and for
fighting.”
 In 1933, US Army General (then COL) George S.
Patton wrote, “Wars may be fought with weapons, but
they are won by men. It is the spirit of the men who follow
and of the man who leads that gains the victory” (22).
 In 1946, General Dwight D. Eisenhower said, “Guns
and tanks and planes are nothing unless there is a solid
spirit, a solid heart, and great productiveness behind
it” (11).
 In 1987, US Army SF COL (ret.) John Collins empha-
sized that “hardware” is only a tool and that it is the
person, who determines success or failure. He is
credited with developing the Special Operations Forces
5 truths, of which one is, “Humans are more important
than hardware and their quality is more important than
quantities.”
It was not until 2006 that the term HPO actually emerged
with energy within the DoD. An Office of Net Assessment
report came out in 2005 challenging the Department of
Defense to take a look at how our most important resources—
our service members—were being prepared for the challenges
and demands of the modern and future battlefield (24). In June
2006, the Consortium for Health and Military Performance
(CHAMP) at the Uniformed Services University hosted
a workshop entitled “Human performance optimization: an
evolving charge to the Department of Defense,” with the
findings published in Military Medicine (8). The recognition
by multiple authorities over the course of several years helped
change the course of how DoD views human performance;
one product that emerged from the multiple discussions and
debates was the Human Performance Resource Center
(HPRC), the DoD website for information relating to trans-
lational human performance (hprc-online.org).
Although the concept of human performance improve-
ment is now well-recognized, various phrases and terms
have been adopted and are commonly employed in the
literature to describe these initiatives. Table 1 provides def-
initions for a number of terms related to human perfor-
mance. Although the literature on Human Performance
Modification (HPM) typically addresses methods that
enhance performance, another possible focus is methods
that degrade performance or negatively affect a military
force’s ability to “fight” (1). We favor the term “Human
Performance Optimization” because it is all encompassing—
optimal is the end result—either through enhancement, mod-
ification, sustainment, or restoration. Human performance
should be optimized, whenever possible.
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TABLE 1. Definitions of various terms.
Human performance optimization (HPO): the
process of applying knowledge, skills, and
emerging technologies to improve and preserve
the capabilities of military personnel to execute
essential tasks.
Performance enhancement: optimizing and
enhancing every system to the fullest degree
possible predeployment.
Performance sustainment: sustaining performance
at predeployment levels during deployment.
Performance restoration: restoring or returning
performance to predeployment levels
postdeployment.
Human performance modification (HPM):
encompasses actions ranging from the use of
“natural” materials, such as caffeine or khat as
a stimulant, to the application of nanotechnology
as a drug delivery mechanism or an invasive brain
implant (1).
Although the literature on HPM typically addresses
methods that enhance performance, another
possible focus is methods that degrade
performance or negatively affect a military force’s
ability to “fight” (1). We favor the term “Human
Performance Optimization” because it is all
encompassing—optimal is the end result—either
through enhancement, modification, and
sustainment, or restoration. Human performance
should be optimized, whenever possible.
Total force fitness (TFF): a framework for
understanding, assessing, and maintaining the
fitness of the Armed Forces. The TFF framework
consists of 8 distinct domains (medical and dental,
nutritional, social, behavioral, environmental,
psychological, spiritual, and physical) whose
interrelated functionality is informed by 5
overarching tenets (described below).
Total Force Fitness Model
Importantly, CHAMP was tasked by the office of the
Chairman of the Joint Chiefs of Staff (CJCS) in 2009 to
host a workshop to develop a new holistic framework
addressing fitness–this effort led to the development of
TFF and specifically resulted in a published instruction from
the CJCSI, which can be found on the HPRC website at
http://hprc-online.org/total-force-fitness/total-force-fitness-
articles-2. This guidance extended the concept of “physical
fitness” to include body, mind, social, and spiritual domains; it
created a more comprehensive and holistic framework to
support and integrate joint- and service-specific efforts that
seek to promote health, enhance the resilience of service
personnel and improve effectiveness and efficiency of the
force. Table 2 presents the tenets of TFF, which strives to
integrate all aspects of health, well-being, and performance
and recognizes the important contributions of families,
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TABLE 2. Tenets of total force fitness (TFF).
Total fitness extends beyond the service member;
total fitness should strengthen resilience in
families, communities, and organizations.
The health of a service member’s family plays a key
role in sustained success and must be
incorporated into any definition of total fitness.
Total fitness metrics must measure positive and
negative outcomes, and must show movement
toward total fitness.
Total fitness is linked to the fitness of the society
from which the service members are drawn and
to which they will return.
Leadership is essential in achieving total fitness.
friends, communities, and units. In its application, the TFF
framework and its tenets (described above) are designed to
keep service members and their families resilient and flour-
ishing in the environment of all aspects of military life, as well
as during sustained deployments and military operations.
Thus, TFF and HPO are synergistic: TFF effectively identi-
fies the components of the desired endstate—a culture that
optimizes recruitment, retention, readiness, and resilience of
the entire military community—with HPO providing the con-
struct and means for achievement. TFF and HPO go
together and must be considered as a unit.
Any evaluation of TFF must be context specific because
teams, units, families, and/or communities may be very
effective at particular selected tasks, and less effective at
others. For example, a military unit may be very successful
with mission efforts, but lost upon return from a deployment
or during reintegration. Although the TFF framework
identifies 8 mind–body domains, social fitness has been high-
lighted as particularly critical for unit fitness, because it is
a robust resilience factor (5). A 2013 Rand report (http://
www.rand.org/pubs/research_reports/RR108.html) identi-
fied social support as a key factor that can affect an individ-
ual’s resilience. Social fitness is also very important for
unit, family, peer, and community well-being—key signatures
of military culture and operational success—because
people are primary drivers for effectiveness. Overall TFF
is conceptualized in terms of healthy relationships
between and among people and teams that contribute to
optimal unit, family and community well-being, resilience,
and performance.
FRAMEWORK FOR HPO
The demands-resources model (DRM) was chosen as
a framework for HPO, because it was developed to evaluate
work performance (2,6). The model proposed in Figure 1A
(modified from the original (6)) allows for performance
metrics in multiple venues i.e., family, relationships, and
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work (7). This framework includes multiple resources
(individual, family, community, and external environment)
and well-established demands (e.g., work, family, financial,
medical, and social). Overall, the concept is that perfor-
mance will be optimized when resources (individual, family,
and external) match or exceed demands.
Figure 1B presents an overview of the multiple and com-
peting individual, family, and other resources or demands by
various categories that contribute to performance in diverse
venues. These various factors and environmental issues dem-
onstrate the holistic approach–from cognitive to genetic and
physiologic, from behavioral and individual skills and prac-
tices to social, financial, and physical environment factors.
Some of the resources are inherent, whereas others may be
“situation”-dependent. Likewise, some of the multiple factors
impose heavy demands. The intricacies, interactions, and
intersections of who, how and what impacts performance,
are many. Importantly, numerous resources are available that
an individual can use to mitigate the perceived demands. For
example, Herzog et al. (13) describe 2 specific mental skills—
executing a goal setting process and using mental imagery to
rehearse technical, tactical, and strategic tasks—that can be
used to improve performance and augment psychological
fitness. Likewise, mindfulness is receiving increased attention
as a self-care resource to improve performance and enhance
resilience and overall health (9). Finally, the importance of
sleep as a key resource (or lack of sleep as a substantial
demand) is being more closely considered, with approaches
for mitigating insufficient sleep (12,23).
Given optimal resources and reasonable demands, how
can we intentionally manage the resources and moderate the
demands to ensure optimal performance? This is not a simple
process, as it requires a 3608 approach: inputs and outputs
from the individual service member, the unit, leaders at every
level, and support from family and friends (14,27). In the end,
the intent of HPO is to assist our service members and their
families in being successful in their occupational tasks and at
home; in every sense HPO’s ultimate goal is to enhance and
increase the agility of the individual’s ability to perform. Many
real life examples could be provided of how various compet-
ing family and work demands can negatively impact perfor-
mance, as well as achieving work or personal goals. Although
the overall contribution of any 1 particular factor may not be
known, the intersection of multiple competing demands with
insufficient resources is key. One important reason for assess-
ing TFF is to provide immediate feedback to leaders, families,
and units in relation to specific contexts defined by demands,
resources, and desired outcomes. Ultimately for the warrior,
HPO directly translates into the ability to execute mission
essential tasks in a battlefield setting that may well be com-
pounded by chaos and ambiguity.
Role of Leaders
The military officers have an important role in HPO and
TFF in that they must provide opportunities to support all
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As noted by Nindl et al. (19),

military leaders must under-
stand that many problems ser-
vice members face are likely
avoidable and preventable, in
particular, musculoskeletal in-
juries. A strategic paradigm
shift in the military’s approach
to overall readiness, in terms of
culture, leadership, and policies
regarding optimizing health,
well-being, and performance is
needed. CHAMP has tried to
help move this forward by
building consensus and making
recommendations on multiple
topics ranging from Warfighter
nutrition (10) and sickle cell
trait (20) to exertional heat
illness (3,21), extreme condi-
tioning programs (3), and func-
tional movement assessments
(25). All the recommendations
emerged based on current sci-
entific evidence and discus-
sions among subject matter
experts and then were pre-
sented to senior leadership for
support, prioritization, and
implementation. Importantly,
senior leaders must make diffi-
cult decisions and begin to
allocate critical resources to
HPO, as the service member
is the future of our military.
Figure 1. A) A brief pictorial description of the Demand-Resources Model (DRM) for HPO, where individual
Role of Service Members
characteristics and capabilities, families, and other social support systems can serve as resources to buffer the
effects of various demands and together contribute to overall performance of particular and specific tasks. B) A The individual service member
summary of the multiple factors that serve as competing and interacting individual, family, and other demands andhas the most critical role–at the
resources and contribute to performance outcomes.
personal level, the family level,
and the unit level. They must
ultimately be responsible for
efforts that can maximize the health, well-being, and doing their part in staying physically fit, fueling for optimal
performance of the operational community in which they health and performance, maintaining healthy relationships,
work. Perhaps one of the most important issues is being living the creed of their Military Service, and engaging to
a responsible leader–this requires both setting an example the best of their abilities in healthy lifestyles. Without each
and being a mentor. If a leader wants the service members service member being committed to a culture of TFF and
to buy into HPO and TFF, they must be role models, which embracing the importance of their individual and team role,
means maintaining physical fitness, nutritional fitness, med- HPO will only be a concept and not an active process. Lead-
ical and dental fitness and fitness for the other domains, and ership is clearly important for role modeling, policy, doctrine,
being versed in other aspects of TFF and HPO. The leader and resources, but ultimately the service member is key and
must walk the walk–they must embrace the culture of TFF. the infrastructure must provide the requisite support.
Ultimately embracing TFF and HPO gives the commander Role of the Medical Community
the best opportunity for success on the modern day The medical community functions in the key role of assisting
battlefield. the leader in operationalizing HPO in achieving TFF.

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 Moving Toward Human Performance Optimization
Medical providers and affiliated health specialists are critical
resources in identifying the tools that will be used to execute
HPO, assess metrics to readjust efforts, and in many cases,
leverage these efforts on an individual level with warriors
and units. The medical community, in their doctrinal role as
special and support staff, importantly function— as originally
described by Letterman (18)— to “strengthen the hand of the
Commander.”
SUMMARY
Sustained combat operations for over a decade generated the
need for a new paradigm for understanding, developing, and
assessing fitness. HPO and TFF emerged from thoughtful
discussions and innovative actions; they reflect the vision
and reality that “people” are our most valuable resource.
HPO and TFF provide a holistic approach to fitness and
performance and must be the foundation for a vision,
wherein the military culture and environment seeks to opti-
mize recruitment, retention, readiness, and resilience of the
entire military community. TFF is published in joint military
doctrine and represents a desired end state for current ser-
vice members and their families. HPO is the process
whereby TFF can be achieved as knowledge, skills, and
emerging technologies are leveraged to improve and pre-
serve the capabilities of military personnel to execute essen-
tial tasks. In the execution of any HPO effort to achieve TFF,
the DRM provides a framework with the principal concept
that performance will be optimized when resources (individ-
ual, family, and external) match or exceed demands. Leaders
are uniquely postured in the military chain of command to
directly influence a culture of fitness for a ready force, and
service members must be responsible for their fitness.
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