The original article, ‘Hypertension in Military Veterans is Associated with Combat Exposure and Combat Injury,’ represents an insightful analysis of existing data to generate novel insights on the relationship of combat exposure and injury to incident hypertension and its pathogenesis . The analysis was undertaken to assess the intensity of combat exposure and incident hypertension as well as the potential role of biobehavioral and mental health factors in mediating the association. The authors collectively provide rich and complementary expertise across the military services, applied information technology, health services research, and multiple factors impacting health and disease. With deployed military personnel as the reference group (N = 19 708), their analysis indicates that combat exposure (N = 18 813) raises the risk of hypertension and that combat-related injury (N = 213, 0.6%) appears to augment that risk.
Key findings from this original research are represented in Table 1. Compared with military personnel who were deployed but experienced neither combat nor injury, the incremental risk of hypertension was moderate and progressive from those in combat without injury to those with combat-related injury. The odds ratio point estimate for incident hypertension changed minimally from unadjusted to fully adjusted (1.32 vs. 1.28) for those with combat exposure alone. In contrast, the point estimate for those with combat injury fell nearly 50% (1.87 vs. 1.46) between unadjusted and fully adjusted. Although recognizing the limitation of widely overlapping 95% confidence intervals, the findings suggest incremental risk for hypertension with combat exposure alone is not significantly related to the sociodemographic, biobehavioral or mental health factors as assessed in this report. In contrast, the incremental risk associated with combat-related injury is mediated in part by some combination and interaction of sociodemographic, biobehavioral and mental health factors in the analysis.
Factors in the multivariate analysis that were both independently associated with risk of hypertension in the fully adjusted model and had a more adverse distribution in those with combat-related injury included male sex, active military duty, Army and enlisted service, reduced sleep duration, obesity and posttraumatic stress disorder (PTSD). One might hypothesize, somewhat along lines the authors have suggested, that enlisted men on active duty in the military were at greater risk for combat injury, had less control in mitigating risk, and experienced more stress leading to poorer sleep duration, a risk factor for obesity-related cardiometabolic disease including hypertension [2,3], and greater risk for PTSD.
Given the comparatively small number of military personnel with combat-related injuries, the authors were unable to further assess the role of these and potentially other factors in their greater risk for hypertension. Although not promoting combat or injuries, future, large prospective studies are important in confirming the incremental risk for incident hypertension associated with combat-related injury compared with combat exposure alone and elucidating the mediating and moderating factors contributing to the incremental risk. A widened and more refined search of associated and explanatory factors is required to better understand how exposure to combat without injury increases the risk for incident hypertension compared with deployment alone.
From a practical perspective and while awaiting further insights from subsequent studies on intensity of combat exposure, incident hypertension, and explanatory factors, I endorse the authors’ recommendation for a practical, holistic approach to preventing the excess of chronic disease including hypertension in those with combat exposure and combat-related injury.
Disclaimer: The comments in this editorial are those of the author and do not necessarily represent the official position of the American Medical Association.
Conflicts of interest
There are no conflicts of interest.
1. Howard JT, Stewart IJ, Kolaja CA, Sosnov JA, Rull RP, Torres I, et al. Hypertension in military veterans is associated with combat exposure and combat injury. J Hypertens
2. Xi B, He D, Zhang M, Xue J, Zhou D. Short sleep duration predicts risk of metabolic syndrome: a systematic review and meta-analysis. Sleep Rev Med
3. Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Krier F, Pickering TG, et al. Short sleep duration as a risk factor for hypertension: analyses of the First National Health and Nutrition Examination Survey. Hypertension