Elizabeth R. Packnett

Body mass index, medical qualification status, and discharge during the first year of US Army service

BACKGROUND The high prevalence of overweight and obesity in military recruits and in the US population as a whole necessitates understanding the health effects of body composition and associated morbidity. OBJECTIVE In this study, we examined the effect of body mass index (BMI; in kg/m(2)) and medical status on premature discharge from the US Army in a large cohort of first-time-enlisted, active-duty soldiers. DESIGN We determined the odds ratios (ORs) associated with BMI and medical status at enlistment by using a retrospective cohort of first-time, active-duty army recruits. RESULTS ORs for BMI, calculated by using 24-24.9 as a reference, exhibited a U-shaped pattern. Soldiers with a BMI >34 had the highest ORs for all-cause (OR: 1.47; 95% CI: 1.32, 1.64) and medical (OR: 1.68; 95% CI: 1.46, 1.93) discharges. A BMI <17 was 1.35 times as likely (95% CI: 1.02, 1.80) to result in an all-cause discharge and 1.45 times as likely (95% CI: 1.01, 2.08) to result in a medical discharge. ORs for soldiers who required a medical reexamination did not vary when all-cause discharge (OR: 1.10; 95% CI: 1.06, 1.14) and medical discharge (OR: 1.10; 95% CI: 1.05, 1.15) were compared. The medical discharge OR for soldiers who required a medical waiver to enter the army (OR: 1.56; 95% CI: 1.48, 1.64) was higher than the OR for all-cause discharge (OR: 1.27; 95% CI: 1.22, 1.32). CONCLUSION Enlistment BMI and medical qualification status play an important role in early discharge and may provide a valuable tool in the development of fitness, nutrition, and injury-prevention interventions in higher-risk groups.

Trends in the epidemiology of disability related to traumatic brain injury in the US Army and Marine Corps: 2005 to 2010

Background:Traumatic brain injury (TBI) has been recognized as a major public health issue for several decades. Despite technological advancements in protective equipment and medical care available during recent military conflicts, TBI is the most common neurological condition among Soldiers and Marines evaluated for discharge from service. This study describes the demographic, service-related, and disability characteristics of Soldiers and Marines referred for combat-related TBI disability evaluation. Methods:Cross-sectional analysis of Soldiers and Marines evaluated for combat-related disability between October 1, 2004 and September 30, 2010 was performed. Traumatic brain injury cases were identified using the Veterans Affairs Schedule for Rating Disabilities code for TBI and compared with other combat-related disabilities. Results:Combat-related TBI disability rates have significantly increased in both the Army and the Marine Corps since 2005. Significantly more unfitting conditions are present on average in combat-related TBI cases than in other combat-related disability cases. Combat-related TBI disability cases are more likely to be medically retired than other types of combat-related disability. Conclusions:Because veterans with combat-related TBI disabilities are likely to require chronic care for TBI-associated medical conditions, disability evaluation policy and programs must ensure that combat-related TBI disabilities are accurately identified and compensated, and the potential long-term care needs are addressed.

Temporal Trends in the Epidemiology of Disabilities Related to Posttraumatic Stress Disorder in the U.S. Army and Marine Corps From 2005–2010

Since the start of Operation Iraqi Freedom and Operation Enduring Freedom, over 2 million U.S. military members were deployed to Iraq and Afghanistan. The estimated prevalence of posttraumatic stress disorder (PTSD) among soldiers and Marines returning from combat zones varies from 5%-20%; little is known about those individuals whose PTSD renders them unfit for duty. This report describes the rates and correlates of PTSD in soldiers and Marines evaluated for disability. Data for service members who underwent disability evaluation between fiscal years 2005-2010 were analyzed for trends in disability rates, ratings, retirement, and comorbid disability. PTSD rates varied by age, sex, race, rank, branch of service, and component. Most cases were deployed and were considered combat-related. Over the study period, the rate and severity of disability from PTSD increased substantially. Significant increases in disability from PTSD incidence, rating, and retirement were observed in both services. Other medical conditions, largely musculoskeletal and neurological, were present in the majority of cases indicating many cases also experienced disabling physical injuries. Further research is needed to target interventions accurately for redeploying service members to minimize comorbidity associated with disability from PTSD and facilitate continuation in military service or successful transition to civilian life.

Military occupation and deployment: descriptive epidemiology of active duty U.S. Army men evaluated for a disability discharge

OBJECTIVE Physically demanding jobs and history of deployment put Soldiers at increased risk for injury, hospitalizations, and disability. Characterizing differences in disability outcomes by occupation and deployment history may identify specific military populations for targeted prevention and intervention programs as well as potential areas of future research. METHODS A cross-sectional analysis was conducted on U.S. Army enlisted men evaluated in the Department of Defenses Disability Evaluation System (DES) between fiscal years 2005 and 2011, comparing those assigned a Combat Arms military occupational specialty (MOS) to individuals with any other MOS (Other). RESULTS Among deployed Soldiers, those with Combat Arms MOS were substantially and significantly more likely to receive medical disability retirement than Other MOS and were more likely to be evaluated for conditions compatible with combat exposures, including post-traumatic stress disorder, residuals of traumatic brain injury, and paralysis. Among nondeployed Soldiers, Combat Arms MOS were only slightly more likely to receive medical disability than Other MOS, and no substantial differences in medical conditions were noted between the two MOS groups. CONCLUSIONS Combat Arms MOS is a significant risk factor for disability retirement primarily among deployed men. Further research is needed to identify specific military occupations most at risk for disability retirement.

Pre‑enlistment hearing loss and hearing loss disability among US soldiers and marines

Hearing loss is a common condition among US adults, with some evidence of increasing prevalence in young adults. Noise-induced hearing loss attributable to employment is a significant source of preventable morbidity world-wide. The US military population is largely comprised of young adult males serving in a wide variety of occupations, many in high noise-level conditions, at least episodically. To identify accession and service-related risk factors for hearing-related disability, matched case-control study of US military personnel was conducted. Individuals evaluated for hearing loss disability in the US Army and Marine Corps were frequency matched to controls without history of disability evaluation on service and enlistment year. Conditional logistic regression was used to examine the association between accession and service-related factors and hearing-related disability evaluations between October 2002 and September 2010. Individuals with medically disqualifying audiograms or hearing loss diagnoses at application for military service were 8 and 4 times more likely, respectively, to have a disability evaluation related to hearing loss, after controlling for relevant accession, demographic, and service-related factors. Conservative hearing loss thresholds on pre-enlistment audiograms, stricter hearing loss medical waiver policies or qualified baseline audiograms pre-enlistment are needed in the U.S military. Industrial corporations or labor unions may also benefit from identifying individuals with moderate hearing loss at the time of employment to ensure use of personal protective equipment and engineer controls of noise.

Risk factors for disability retirement among active duty Air Force personnel.

OBJECTIVE To determine risk factors for disability retirement in Air Force personnel, as well as the conditions contributing to disability retirement. METHODS A matched case-control study was conducted. Air Force personnel with accession records who were disability retired between 2002 and 2011 were included as cases. Controls were matched by accession year from the population of accessions not evaluated for disability at a ratio of 2:1. Conditional logistic regression was used to determine the odds of disability retirement. RESULTS Women and those aged 25 or older were significantly more likely to be disability retired. Deployment was also associated with disability retirement but was significantly protective. Among women, the odds of disability retirement did not vary when stratified by deployment history. Preexisting medical conditions were not associated with disability retirement. Psychiatric conditions were the most common condition type among those who were disability retired in the Air Force. CONCLUSIONS Additional studies are needed to assess risk factors for psychiatric disability, the most common disability retired condition, as well as to describe the role of occupation and combat exposure in disability retirement from the Air Force.

Temporal trends in disability evaluation and retirement in the Army, Navy, and Marine Corps: 2005-2011.

BACKGROUND Surveillance of trends in disability is necessary to determine the burden of disability on the U.S. military, the most common types of disability conditions, and the prevalence of combat exposures in the disability population. Previous studies of disability in the U.S. military have focused on a particular service or condition rather than examining the epidemiology of disability in the military overall. OBJECTIVE This studys objective is to describe rates of disability evaluation and retirement in U.S. Army, Navy, and Marine Corps. METHODS A cross-sectional study of 126,170 service members evaluated for disability discharge from the U.S. military in fiscal years 2005-2011 was conducted. Crude and standardized rates of disability evaluation and retirement were calculated per 10,000 service members by year of disability, demographic characteristics, and type of disability evaluation or retirement. Temporal trends in the prevalence of combat-related disability in the disability evaluated and retired population were also examined. RESULTS Rates of disability evaluation and retirement were highest among female, enlisted, and active duty service members. Overall rates of disability evaluation significantly decreased, while rates of disability retirement increased. Rates of psychiatric disability evaluation and retirement significantly increased in all services during the same time period from 2005 to 2011. Combat-related disability evaluations and retirements have substantially increased in all services particularly among psychiatric disability cases. CONCLUSIONS Psychiatric disability, combat-related disability, and disability retirement continue to increase in the military, despite observed decreases in the rates of disability the Department of Defense since 2005.

Temporary Disability Retirement Cases: Variations in Time to Final Disposition and Disability Rating by Service and Medical Condition

OBJECTIVE Service members undergoing disability evaluation are placed on the temporary disability retirement list (TDRL) when their disabling medical condition(s) may change in severity over time. Information is sparse on the epidemiology of the TDRL population and factors influencing time spent on the TDRL or changes in compensation ratings before final disability outcome. METHODS A cross-sectional study was conducted on U.S. Army, Navy, and Marine Corps personnel placed on the TDRL between fiscal years 2005 to 2009. RESULTS Approximately 85% of cases were finalized at first re-evaluation and more than 75% were permanently retired. Overall, about 50% of cases retained the same disability rating throughout the process. Cases with medical conditions within two or more body systems were more likely to be permanently retired and receive a change in disability rating than those with medical condition(s) within a single body system. CONCLUSIONS Most cases retained the same disability rating and were permanently retired by the first re-evaluation. Important areas of future research include cost-benefit analyses to determine if length of time currently allowable on the TDRL can be shortened or if repeated evaluations are necessary and exploration of specific medical conditions likely to change in severity over time.

Risk factors for back-related disability in the US Army and Marine Corps.

Study Design. Matched case-control epidemiological study. Objective. To identify pre-enlistment, demographic, and service-related risk factors for back-related disability in enlisted US soldiers and Marines comparing those who were deployed with those who did not deploy during the service term. Summary of Background Data. Back conditions are a major cause of morbidity and lost work days in both the US working population and military. Back-related conditions are among the most prevalent causes of military disability discharge but little research has been conducted to identify risk factors for back-related disabilities in this population. Methods. Cases included enlisted Army and Marine Corps service members evaluated for back-related disability. Controls, frequency matched by year of military entrance and service, were selected from the enlisted service member population. Pre-enlistment demographic and medical characteristics, deployment, and ambulatory care data collected from existing military databases were used. Crude and adjusted odds of back-related disability were modeled using conditional logistic regression. Results. In adjusted models, service members who were overweight (odds ratio [OR]: 1.17; 95% confidence interval [95% CI]: 1.12–1.23) and obese (OR: 1.35; 95% CI: 1.26–1.44), between ages 25 and 29 years (OR: 1.23; 95% CI: 1.16–1.31), or 30 years or older (OR: 1.43; 95% CI: 1.34–1.52) at military entrance were at increased odds of a back-related disability. History of a back diagnosis at the pre-enlistment medical examination (OR: 1.94; 95% CI: 1.50–2.50) and deploying once (OR: 1.09; 95% CI: 1.05–1.14) were also associated with increased odds of a back-related disability. Conclusion. Enlisted soldiers and marines with back-related disabilities were more likely to be older, have a higher body mass index, have a history of pre-enlistment back conditions, and were deployed once, compared with controls without a back-related disability. Additional research is necessary to further examine the complex relationship between deployment to combat zones, onset of musculoskeletal symptoms, and back-related disability in soldiers and marines. Level of Evidence: 4

Epidemiology of asthma-related disability in the U.S. Armed Forces: 2007–2012

Abstract Objective: To characterize the demographic, disability and deployment characteristics of U.S. Armed Forces personnel with an asthma-related disability discharge, which includes separation (without benefits) and retirement (with disability benefits). Methods: Incidence rates for personnel evaluated for disability discharge and/or disability retired due to asthma and due to all other causes of disability discharge were calculated per 100,000 active duty enlisted service members by year. Multivariate logistical regression was used to examine the associations between disability retirement and several demographic and disability characteristics of service members evaluated for asthma-related disability discharge versus those evaluated for any other non-respiratory condition for each branch of military service. Results: Service members evaluated for disability discharge related to asthma most often do not have comorbidity and are disability retired rather than separated, with rates of disability retirement increasing over time. Groups with a significantly higher incidence of evaluation for asthma-related disability include females, individuals who entered the military prior to the age of 20, non-Whites, and those with a history of deployment to Iraq or Afghanistan. The characteristic most associated with the odds of disability retirement was a history of deployment. Conclusions: New-onset asthma occurring after military entry often causes occupational impairment in service members, especially in those that have been deployed to Iraq or Afghanistan.