Arthritis Prevalence Among Veterans — United States, 2017–2021

Arthritis is a chronic inflammatory condition and a leading cause of chronic pain and disability. Because arthritis prevalence is higher among U.S. military veterans (veterans), and because the veteran population has become more sexually, racially, ethnically, and geographically diverse, updated arthritis prevalence estimates are needed. CDC analyzed pooled 2017-2021 Behavioral Risk Factor Surveillance System data to estimate the prevalence of diagnosed arthritis among veterans and nonveterans, stratified by sex and selected demographic characteristics. Approximately one third of veterans had diagnosed arthritis (unadjusted prevalence = 34.7% [men] and 31.9% [women]). Among men aged 18-44 years, arthritis prevalence among veterans was double that of nonveterans (prevalence ratio [PR] = 2.1; 95% CI = 1.9-2.2), and among men aged 45-64 years, arthritis prevalence among veterans was 30% higher than that among nonveterans (PR = 1.3; 95% CI = 1.3-1.4). Among women aged 18-44 years, arthritis prevalence among veterans was 60% higher than that among nonveterans (PR = 1.6; 95% CI = 1.4-1.7); among women aged 45-64 years, arthritis prevalence among veterans was 20% higher than that among nonveterans (PR = 1.2; 95% CI = 1.1-1.3). Cultivating partnerships with veteran-serving organizations to promote or deliver arthritis-appropriate interventions might be advantageous, especially for states where arthritis prevalence among veterans is highest. The high prevalence of arthritis among female veterans, veterans aged ≥65 years, and veterans with disabilities highlights the importance of ensuring equitable access and inclusion when offering arthritis-appropriate interventions.


Introduction
Arthritis is a chronic inflammatory condition and a leading cause of chronic pain and disability (1,2).A recent report determined that arthritis prevalence is higher among U.S. military veterans (veterans) than among nonveterans; 35.2% of veterans (6.8 million) report diagnosed arthritis (3).Previous estimates indicate that arthritis prevalence is higher among female veterans, veterans self-identifying as non-Hispanic Black or African American or non-Hispanic White, and those living in southern and Appalachian states (4).Because arthritis prevalence is higher among veterans and the veteran population has become more sexually, racially, ethnically, and geographically diverse (5), a comprehensive understanding of arthritis prevalence estimates among veterans can guide strategic partnership development and equitable resource allocation for delivery of arthritis-appropriate, evidence-based interventions to veterans.ranged from 44.0% to 49.9%, § with a total analytic sample size of 2,087,387.¶ Crude, age-specific, and age-standardized** prevalences of diagnosed arthritis were estimated overall and by veteran status, sex, and selected sociodemographic, † †, § §, ¶ ¶, *** , † † †, § § § health, ¶ ¶ ¶, **** and disability characteristics.† † † † T-tests were used to assess differences between veterans and nonveterans overall and by subgroup, as well as to test differences in subgroup categories among veterans using a reference group.All differences are statistically significant at α = 0.05.Age-standardized diagnosed arthritis prevalences among male and female veterans and nonveterans were estimated in the 50 states, DC, and U.S. territories.Prevalence ratios (PRs) were calculated by dividing the prevalence of arthritis among veterans by the prevalence of arthritis among nonveterans.SAS (version 9.4; SAS Institute) and SUDAAN (version 11.0; RTI International) were used for analysis to account for complex design and weighting.This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.§ § § §

Results
Approximately one third of veterans had diagnosed arthritis (unadjusted prevalence = 34.7%[men] and 31.9%[women]).Age-adjusted prevalence was higher among women (30.5%) than among men (25.2%; p<0.001) (Table 1).Among men, age-specific arthritis prevalences were higher among veterans than among nonveterans across all age groups (18-44, 45-64, and ≥65 years; p<0.001); among women, prevalences were higher among veterans than among nonveterans in two age groups (18-44 and 45-64 years; p<0.001) Proportions for the response categories were similar across years.¶ ¶ Persons self-identifying as non-Hispanic American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, other race, or multiracial were combined into "other, non-Hispanic."*** Responses to the question, "What is the highest grade or year of school you completed?"were combined into the following groups: 1) less than high school graduate: never attended school or attended only kindergarten, grades 1-8, or grades 9-11; 2) high school graduate or equivalent: grade 12 or general educational development certificate; 3) technical school degree or some college: college 1-3 years; and 4) college degree or more: college ≥4 years.† † † The calculated variables for income were harmonized across years to create four groups.For 2021 data, the following responses were combined into the "≥$50,000" category: $50,000 to <$100,000, $100,000 to <$200,000, and ≥$200,000.§ § § The health care access module was optional; five, eight, 11, and seven U.S.
Geographically, the age-adjusted prevalence of arthritis among male veterans ranged from 18.1% in DC to 35.8% in West Virginia (male veteran state median = 25.5%)(Table 2).The age-adjusted prevalence of arthritis among female veterans ranged from 21.8% in Hawaii to 39.3% in Arkansas (female veteran state median = 31.2%).Generally, the highest ageadjusted arthritis prevalence quartile among veterans, for both men and women, includes U.S. states in the southern and Appalachian regions (Figure).Eight states were in the highest quartile for state-specific arthritis prevalence among male and female veterans (Alabama, Arkansas, Kentucky, Michigan, Oklahoma, Rhode Island, Tennessee, and West Virginia).

Discussion
In this study, approximately one third of veterans reported diagnosed arthritis.This report indicates that associations between sex, age, and disability status and arthritis prevalence reported for the general population (3) are also evident among veterans.Among veterans, the prevalence of arthritis was higher among women than men, and higher among veterans with disabilities than veterans without disabilities.Among men aged 18-44 years, the arthritis prevalence among veterans was double that among nonveterans, and among women aged 18-44 years, the arthritis prevalence among veterans was 60% higher than among nonveterans.This suggests that younger veterans might be living longer with arthritis and arthritis-attributable outcomes relative to nonveterans, which might result in higher rates and longer periods of work disability and lost wages (6,7).An analysis conducted using 2013 data estimated that among adults aged 18-64 years, adults with arthritis earned 9% ($3,361) less per year, compared with adults without arthritis (6).Therefore, younger veterans Abbreviations: BMI = body mass index; HS = high school; VA = Veterans Health Administration.* Age-standardized to the 2000 U.S. Census Bureau projected adult population, using three age groups: 18-44, 45-64, and ≥65 years.https://www.cdc.gov/nchs/data/statnt/statnt20.pdf † Responded "yes" to the question, "Have you ever been told by a doctor or other health professional that you had some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?"§ Veterans were defined as respondents who answered "yes" to the question, "Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?" ¶ Statistically significant (p≤0.05)difference between male veterans and male nonveterans (reference group).** Statistically significant (p≤0.05)difference between female veterans and female nonveterans (reference group).
† † Persons of Hispanic or Latino (Hispanic) origin might be of any race but are categorized as Hispanic; all racial groups are non-Hispanic.Persons self-identifying as American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, other race, or multiracial were combined into "Other." § § Responses to the question, "What is the highest grade or year of school you completed?"were combined into the following groups: 1) less than HS graduate: never attended school or attended only kindergarten, grades 1-8, or grades 9-11; 2) HS graduate or equivalent: grade 12 or general educational development certificate; 3) technical school degree or some college: college 1-3 years; and 4) college degree or more: college ≥4 years.¶ ¶ The calculated variables for income were harmonized across years to create four groups.For 2021 data, the following responses were combined into the "≥$50,000" category: $50,000 to <$100,000, $100,000 to <$200,000, and ≥$200,000.*** The calculated variable for BMI [weight (kg) / (height [m 2 ])] was used to create the following four categories: underweight/healthy weight (<25.0),overweight (25.0 to <30.0), obesity I (30.0 to <35.0), and obesity II (≥35.0).† † † The health care access module was optional; five, eight, 11, and seven U.S. states and territories contributed data in 2017, 2018, 2019, and 2020, respectively.In 2021, the following responses were harmonized with 2017-2020 health insurance/health care categories: 1) Medicare and Medigap (private health insurance plans sold to supplement Medicare), 2) Medicaid and state-sponsored programs, 3) other government programs and Indian Health Service.Persons reporting that Children's Health Insurance Program was their primary source of health care insurance or who did not know or refused were excluded from analysis.§ § § Statistically significant difference (p≤0.05) for health insurance type among male veterans.Employer-or union-sponsored is the reference group.¶ ¶ ¶ Statistically significant difference (p≤0.05) for health insurance type among female veterans.Employer-or union-sponsored is the reference group.**** Estimates are not included because they might be unreliable when the number of respondents is <50 or absolute CI width is >30%.
† † † † The sexual orientation and gender identity module was optional; 28, 29, 31, 33, and 32 U.S. states and territories contributed data in 2017, 2018, 2019, 2020, and 2021, respectively.§ § § § In 2017, sexual orientation was assessed using the question, "Do you consider yourself to be... " with the following response options: straight, lesbian or gay, bisexual, other, and don't know/not sure.During 2018-2021, sexual orientation was assessed using the question, "Which of the following best represents how you think of yourself?"and response options: gay, straight (that is, not gay), bisexual, something else, and I don't know.¶ ¶ ¶ ¶ Self-rated health was assessed using the question, "Would you say that in general your health is" with the following response options: excellent, very good, good, fair, and poor.These were then combined into the following three categories: excellent/very good, good, and fair/poor.***** Persons were categorized as having a disability if they answered "yes" to any of the six questions assessing the following disability types: vision, hearing, cognitive, mobility, self-care, or independent living.might be a prime population for prevention and interventions to help alleviate their symptoms and improve health outcomes.This report also describes geographic differences in arthritis prevalence among veterans, which can help to guide resource allocation and partnership development for the promotion or delivery of arthritis-appropriate interventions.

Limitations
The findings in this report are subject to at least six limitations.First, BRFSS data are self-reported, which can result in recall and social desirability biases.Second, the data are crosssectional; therefore, a causative relationship between military service and the development of arthritis cannot be inferred.Third, the BRFSS survey does not collect information on 33.0-39.330.9-32.9 28.1-30.8 16.2-28.0 26.5-35.8 25.5-26.4 23.4-25.4 13.8-23