Women Veterans Have Higher Prevalence of Arthritis than Male Colleagues

by U.S. Medicine

February 2, 2015

Systemic Factors May Explain Sex Differences

By Annette M. Boyle

Heavy equipment may be contributing to higher rates of arthritis in female servicemembers. New body armor has been designed specifically for the needs of female soldiers. In this photo, Spc. Arielle Mailloux gets some help adjusting her protoype Generation III Improved Outer Tactical Vest from Capt. Lindsey Pawlowski, at Fort Campbell, KY. Army photo by Megal Locke Simpson

Heavy equipment may be contributing to higher rates of arthritis in female servicemembers. New body armor has been designed specifically for the needs of female soldiers. In this photo, Spc. Arielle Mailloux gets some help adjusting her protoype Generation III Improved Outer Tactical Vest from Capt. Lindsey Pawlowski, at Fort Campbell, KY. Army photo by Megal Locke Simpson

DURHAM, NC – While the commitment to physical fitness demanded of active duty forces can keep many ailments at bay, the rigors of service also bring an increased risk of arthritis and other rheumatic diseases, especially for young women entering (and exiting) the military.

As the major rheumatic diseases disproportionately affect women, the increasing number of women in uniform means military rheumatologists are likely to see many more patients and primary care providers will need to screen for those diseases more aggressively.

In 1980, women accounted for 8.4% of all servicemembers. Today, women make up more than 14% of active duty forces, and 20% of all new enlistees are female. About 10% of veterans are female.

A recent study published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report (MMWR) found that nearly one-third of female veterans suffer with arthritis and other rheumatic diseases compared with about one-quarter of male veterans. 1

“We don’t completely understand why women are more likely to develop arthritis,” said study co-author Kelli Allen, PhD, health services researcher and exercise physiologist with the VA’s Durham Center for Health Services R

Kelli Allen, PhD

Kelli Allen, PhD

esearch in Primary Care and an associate research professor at Duke University. “Generally, the highest risk tends to be in post-menopausal women and may be related to the estrogen receptors in cartilage as well as other factors. For both men and women, osteoarthritis in young active duty personnel and veterans is likely related to both injuries and occupational overuse.”

Previous studies have shown a higher rate of arthritis in young servicemembers than in their age-matched civilian counterparts, with about 11,000 new cases diagnosed each year. Those numbers will likely increase sharply as the number of women in the military continues to rise.2

The researchers analyzed data from the 2011, 2012 and 2013 Behavioral Risk Factor Surveillance System (BRFSS) for individuals who self-identified as veterans.

To clarify the use of “arthritis” in the article, the authors noted that “BRFSS respondents were defined as having arthritis if they responded ‘yes’ to the question, ‘Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?’”

The five conditions were grouped together, as “it’s common to ask this type of question when looking at a big picture public health perspective, since these are all arthritis-related/rheumatic diseases,” Allen explained. While the American College of Rheumatology (ACR) classifies nearly 100 different disorders as rheumatic diseases, osteoarthritis accounts for about 70% of all patients with any rheumatic disorder.

The study updates previous figures which “predate the Persian Gulf War, were small, or studied men only, despite the fact that women comprise an increasing proportion of military personnel and typically have a higher prevalence of arthritis than men,” noted the authors.

When it comes to arthritis, the study found some significant variances between men and women and between veterans and nonveterans. “There’s a very interesting difference in younger age groups, in particular,” Allen told U.S. Medicine. Allen and researchers at the CDC found that arthritis was 50% more prevalent among female veterans ages 20-24 (17.3%) than among male veterans of the same age (11.6%).

That age group also presented the most striking difference between women veterans and nonveterans, with the women veterans having nearly twice the rate of arthritis compared to women who had not been in the military (17.3% and 9.8%, respectively). “In younger women, the difference may be due to more joint-injury exposures among veterans,” Allen said.

Between women veterans and nonveterans, the numbers become more comparable as they get older. Among women over the age of 65, the difference between women veterans and their nonveteran sisters is negligible; 58.9% of the veterans have arthritis compared to 58.2% of those who never served.

The higher rates of arthritis among female veterans compared to male veterans persisted over time, however. In the 45- to 64year-old age group, women veterans had a 40.3% prevalence rate, while their male counterparts had a 36.0% rate. Among veterans over age 65, the spread widened to almost 12 percentage points, 58.9% for women and 47.1% for men.

Risk Factors

In the general population, women develop osteoarthritis and rheumatic arthritis at two to three times the rate of men and are 10 times more likely to be diagnosed with fibromyalgia and lupus. Of the five conditions surveyed, only gout is more common in men, in whom it occurs at six times the rate seen in women.

Several hypotheses explain why arthritis and other common rheumatic diseases are more prevalent in women. “There’s a hormonal hypothesis, that inflammation may increase the risk of some types of arthritis and estrogen protects against inflammation. As estrogen levels decrease, inflammation increases and may put women at a higher risk of arthritis,” said Lt. Cmdr. (USPHS) Kamil Barbour, PhD, of the CDC.

Kamil Barbour, PhD

Kamil Barbour, PhD

According to the ACR, that inflammation, along with “changes in the joints and pain in the surrounding structures,” are not only a factor in osteoarthritis and rheumatoid arthritis but also characteristic of other rheumatic diseases such as gout, fibromyalgia and lupus.

“There’s also a biological hypothesis that attributes the increase in some types of osteoarthritis to varying alignment of the knee joints between men and women. Women’s knee joint are not aligned as straight as men, which can result in greater cartilage resorption and a higher rate of injury per incident,” Barbour noted.

Arthritis and related rheumatic diseases also have a strong genetic component, Barbour told U.S. Medicine. Specific genes have been implicated in rheumatoid arthritis (RA). Lupus, ankylosing spondylitis, another rheumatic disease and rheumatoid arthritis are thought to share a common autoimmune pathogenesis based on genome-wide association studies. Research is ongoing to identify a genetic component to osteoarthritis.3

Prevention and Management

As more servicemembers and veterans develop arthritis and related rheumatic diseases, the VA and DoD are focusing on diagnosing the conditions and working with those who have it to mitigate its impact on their lives.

“In general, we don’t have a good way of screening for arthritis, and when pain is not severe or consistent, it often goes unreported. It’s important to recognize that, as women’s roles in the military have changed, they have increased risk of injuries and arthritis, so physicians need to consider arthritis not only for older male veterans but for younger female veterans, too,” Allen said.

Veterans also can reduce their risk of developing arthritis by taking two steps, according to Barbour. “There are two modifiable risk factors: Maintain a healthy weight with a body mass index (BMI) of 18.5 to 25 and avoid joint injury,” he advises.

The ACR also recommends physical activity as an essential part of fibromyalgia treatment to reduce pain symptoms and fatigue and regular exercise for patients with osteoarthritis and rheumatoid arthritis to maintain mobility and increase muscle strength, which can reduce pressure on the joints. Lupus patients are advised to exercise regularly, but not intensely, and to take frequent breaks.

“Another big piece is helping people rehabilitate well if they are injured. For veterans, that can mean engaging them in healthy lifestyles so they maintain physical activity and avoid the stress obesity places on the joints,” Allen added. 

1 Murphy LB, Helmick CG, Allen KD, Theis KA, Baker NA, Murray GR, Qin J, Hootman JM, Brady TJ, Barbour KE; Centers for Disease Control and Prevention (CDC). Arthritis among veterans – United States, 2011-2013. MMWR Morb Mortal Wkly Rep. 2014 Nov 7;63(44):999-1003.

2 Cameron KL, Hsiao MS, Owens BD, Burks R, Svoboda SJ. Incidence of physician-diagnosed osteoarthritis among active duty United States military service members. Arthritis Rheum. 2011 Oct;63(10):2974-82.

3 Dieudé P. Rheumatic diseases: environment and genetics. Joint Bone Spine. 2009 Dec;76(6):602-7.


6 Comments

  • Merrill Anderson says:

    For several decades the WACs were headquartered and trained at Fort McClellan, Alabama where there was a confluence of factors which might contribute to these findings. Monsanto’s long term manufacturing of PCBs was located close by and pollution from the plant so affected the groundwater for the City of Anniston from which drinking water for both the city and the Fort was drawn that Monsanto settled a lawsuit with the civilian residents for hundreds of millions. Also located at the Fort was the Army chemical school, which did live agent training and testing on site At the Anniston Army Depot radiological, chemical and biological agents were stored and disposed of in large quantities by incineration, which is now known to produce aerosol vapors in the process. Also exposed at the Fort were decades of Military Police classes, since it was their headquarters and training staqtion also. The cumulant mixture of toxic factors is mind boggling….and the public is only now becoming aware that there has been a tremendous cover up. Many Veterans are unaware that this may be the prime source of their maladies. 60 Minutes called Anniston one of the most polluted sites in America and Fort McClellan Vets have been battling for years for recognition that their mystery illnesses are not imaginary. The base was found to be a toxic site and closed down by the EPA, but the Veterans and their claims are still not being serviced. The VA’s response has been to advise Congress the problem is stoo expensive to be dealt with. Shameful.

  • Merrill Anderson says:

    For several decades the WACs were headquartered and trained at Fort McClellan, Alabama where there was a confluence of factors which might contribute to these findings. Monsanto’s long term manufacturing of PCBs was located close by and pollution from the plant so affected the groundwater for the City of Anniston from which drinking water for both the city and the Fort was drawn that Monsanto settled a lawsuit with the civilian residents for hundreds of millions. Also located at the Fort was the Army chemical school, which did live agent training and testing on site At the Anniston Army Depot radiological, chemical and biological agents were stored and disposed of in large quantities by incineration, which is now known to produce aerosol vapors in the process. Also exposed at the Fort were decades of Military Police classes, since it was their headquarters and training staqtion also. The cumulant mixture of toxic factors is mind boggling….and the public is only now becoming aware that there has been a tremendous cover up. Many Veterans are unaware that this may be the prime source of their maladies. 60 Minutes called Anniston one of the most polluted sites in America and Fort McClellan Vets have been battling for years for recognition that their mystery illnesses are not imaginary. The base was found to be a toxic site and closed down by the EPA, but the Veterans and their claims are still not being serviced. The VA’s response has been to advise Congress the problem is stoo expensive to be dealt with. Shameful.

  • Merrill Anderson says:

    Veterans of Foreign Wars Veterans Affairs Appearance

    Excerpt from National VFW testimony given in re toxic Fort McClellan, Alabama before the Veterans Affairs Committee in Washington, D.C.

    Fort McClellan: From 1943 to its closure in 1999, Fort McClellan, Alabama, was home to thousands of soldiers in the Women’s Army Corps, the Army’sMilitary Police Corps, and the Army’sChemical Corps. It was forced to close in 1999 due to investigations by the Alabama Department of Public Health, the Alabama Department of Environmental Management, the Agency for Toxic Substances and Disease Registry, and the EPA, which discovered evidence of Polychlorinated Biphenyl (PCB) contamination in Fort McClellan’s neighboring town, Anniston.

    The VFW has heard from several veterans, who suffer from deteriorating health conditions that are consistent with exposure to PCBs, that they are unable to obtain the care and benefits they need because their service at Fort McClellan is not considered presumptive exposure to toxic substances. Despite continued pressure by Congress and veterans service organizations, the Army and VA have failed to establish a health registry to conduct comprehensive studies on the effects of toxic exposure at Fort McClellan, which would be necessary in order to justify the extension of any presumptive service connection or health care benefits to veterans who may be suffering from such exposure.

    The VFW appreciates Congressman Tonko’s leadership and advocacy regarding the Fort McClellan Health Registry Act. Through his work, we have discovered the true rational for the Army’s hesitance – the budgetary burden that would come with identifying these veterans. Cost should never be a factor when considering benefits that veterans deserve. Their sacrifice to our country outweighs any cost. These veterans have waited long enough. It is time for Congress, VA, and DOD to establish the Fort McClellan Health Registry

  • Deanna Schlabach says:

    This explains a lot. I served in the USMC for 5 years and while I wouldn’t trade that experience for the world, I have progressed symptoms of arthritis. Despite having a very healthy lifestyle, I have joint pain and stiffness equivalent to women in my family decades older than me. Until now, this was perplexing. I guess it’s also no wonder that the physical training people receive in the Marines predisposes them to a much more active and intense regime once out of the military-which also probably contributes to the advancement of arthritis. Oh well, still going strong and loving life! Very revealing article. Thanks!

  • Deanna Schlabach says:

    This explains a lot. I served in the USMC for 5 years and while I wouldn’t trade that experience for the world, I have progressed symptoms of arthritis. Despite having a very healthy lifestyle, I have joint pain and stiffness equivalent to women in my family decades older than me. Until now, this was perplexing. I guess it’s also no wonder that the physical training people receive in the Marines predisposes them to a much more active and intense regime once out of the military-which also probably contributes to the advancement of arthritis. Oh well, still going strong and loving life! Very revealing article. Thanks!

  • Merrill Anderson says:

    Veterans of Foreign Wars Veterans Affairs Appearance

    Excerpt from National VFW testimony given in re toxic Fort McClellan, Alabama before the Veterans Affairs Committee in Washington, D.C.

    Fort McClellan: From 1943 to its closure in 1999, Fort McClellan, Alabama, was home to thousands of soldiers in the Women’s Army Corps, the Army’sMilitary Police Corps, and the Army’sChemical Corps. It was forced to close in 1999 due to investigations by the Alabama Department of Public Health, the Alabama Department of Environmental Management, the Agency for Toxic Substances and Disease Registry, and the EPA, which discovered evidence of Polychlorinated Biphenyl (PCB) contamination in Fort McClellan’s neighboring town, Anniston.

    The VFW has heard from several veterans, who suffer from deteriorating health conditions that are consistent with exposure to PCBs, that they are unable to obtain the care and benefits they need because their service at Fort McClellan is not considered presumptive exposure to toxic substances. Despite continued pressure by Congress and veterans service organizations, the Army and VA have failed to establish a health registry to conduct comprehensive studies on the effects of toxic exposure at Fort McClellan, which would be necessary in order to justify the extension of any presumptive service connection or health care benefits to veterans who may be suffering from such exposure.

    The VFW appreciates Congressman Tonko’s leadership and advocacy regarding the Fort McClellan Health Registry Act. Through his work, we have discovered the true rational for the Army’s hesitance – the budgetary burden that would come with identifying these veterans. Cost should never be a factor when considering benefits that veterans deserve. Their sacrifice to our country outweighs any cost. These veterans have waited long enough. It is time for Congress, VA, and DOD to establish the Fort McClellan Health Registry


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