Chronic Disease| Volume 29, ISSUE 6, P471-479, November 2019

Download started.


Four Decades after War: Incident Diabetes among Women Vietnam-Era Veterans in the HealthViEWS Study

Published:September 10, 2019DOI:



      We analyzed long-term differences in incident diabetes associated with military service in a warzone among women who served during the Vietnam War era.


      For HealthViEWS, the largest later-life study of women Vietnam War-era U.S. veterans, a population-based retrospective cohort who served during 1965–1973 completed a health interview in 2011–2012. This cohort included women deployed to Vietnam, near Vietnam, or who served primarily in the United States. We hypothesized a warzone exposure gradient: Vietnam (highest exposure), near Vietnam, and the United States (lowest exposure). We used an extended Cox regression to test for differences in incident diabetes by location of wartime service.


      Of 4,503 women in the analysis, 17.7% developed diabetes. Adjusting for demographics and military service characteristics, hazard of incident diabetes was significantly lower initially in the Vietnam group compared with the U.S. group (hazard ratio, 0.33; 95% confidence interval, 0.15–0.69). However, lower diabetes hazard in the Vietnam group was not constant over time; rather, hazard accumulated faster over time in the Vietnam group compared with the U.S. group (hazard ratio, 1.38; 95% confidence interval, 1.11–1.72). No significant difference in diabetes hazard was found between the near Vietnam and U.S. groups. Older age during military service, minority race/ethnicity, and lower military rank were associated with a higher diabetes hazard.


      Women deployed to a warzone might have protective health factors that lower risk for diabetes early in their military career, but delivery systems for long-term health should consider that a lower risk for chronic diseases like diabetes can wane quickly in the decades that follow warzone service.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Almond N.
        • Kahwati L.
        • Kinsinger L.
        • Porterfield D.
        Prevalence of overweight and obesity among U.S. military veterans.
        Military Medicine. 2008; 173: 544-549
        • Bean-Mayberry B.
        • Huang C.
        • Batuman F.
        • Goldzweig C.
        • Washington D.L.
        • Yano E.M.
        • Miake-Lye I.M.
        Systematic review of women veterans health research 2004-2008.
        in: Systematic Review of Women Veterans Health Research 2004-2008. Department of Veterans Affairs (US), Washington (DC)2010
        • Boscarino J.A.
        Posttraumatic stress disorder and physical illness: Results from clinical and epidemiologic studies.
        Annals of the New York Academy of Science. 2004; 1032: 141-153
        • Bowlin S.J.
        • Morrill B.D.
        • Nafziger A.N.
        • Jenkins P.L.
        • Lewis C.
        • Pearson T.A.
        Validity of cardiovascular disease risk factors assessed by telephone survey: The Behavioral Risk Factor Survey.
        Journal of Clinical Epidemiology. 1993; 46: 561-571
        • Bowlin S.J.
        • Morrill B.D.
        • Nafziger A.N.
        • Lewis C.
        • Pearson T.A.
        Reliability and changes in validity of self-reported cardiovascular disease risk factors using dual response: The behavioral risk factor survey.
        Journal of Clinical Epidemiology. 1996; 49: 511-517
        • Boyko E.J.
        • Jacobson I.G.
        • Smith B.
        • Ryan M.A.
        • Hooper T.I.
        • Amoroso P.J.
        • Millennium Cohort Study Team
        Risk of diabetes in U.S. military service members in relation to combat deployment and mental health.
        Diabetes Care. 2010; 33: 1771-1777
        • Brancati F.L.
        • Wang N.Y.
        • Mead L.A.
        • Liang K.Y.
        • Klag M.J.
        Body weight patterns from 20 to 49 years of age and subsequent risk for diabetes mellitus: The Johns Hopkins Precursors Study.
        Archives of Internal Medicine. 1999; 159: 957-963
        • Bray R.M.
        • Fairbank J.A.
        • Marsden M.E.
        Stress and substance use among military women and men.
        American Journal of Drug Alcohol Abuse. 1999; 25: 239-256
        • Breland J.Y.
        • Phibbs C.S.
        • Hoggatt K.J.
        • Washington D.L.
        • Lee J.
        • Haskell S.
        • Frayne S.M.
        The obesity epidemic in the Veterans Health Administration: Prevalence among key populations of women and men veterans.
        Journal of General Internal Medicine. 2017; 32: 11-17
        • Capes S.E.
        • Hunt D.
        • Malmberg K.
        • Gerstein H.C.
        Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: A systematic overview.
        Lancet. 2000; 355: 773-778
        • Centers for Disease Control and Prevention
        Health status of Vietnam veterans. II. Physical health. The Centers for Disease Control Vietnam Experience Study.
        JAMA. 1988; 259: 2708-2714
        • Centers for Disease Control and Prevention
        Diabetes report card 2014. Atlanta, GA: Centers for Disease Control and Prevention.
        • Cucciare M.A.
        • Simpson T.
        • Hoggatt K.J.
        • Gifford E.
        • Timko C.
        Substance use among women veterans: Epidemiology to evidence-based treatment.
        Journal of Addictive Diseases. 2013; 32: 119-139
        • Dahn J.R.
        • Fitzpatrick S.L.
        • Llabre M.M.
        • Apterbach G.S.
        • Helms R.L.
        • Cugnetto M.L.
        • Lawler T.
        Weight management for veterans: Examining change in weight before and after MOVE!.
        Obesity (Silver Spring). 2011; 19: 977-981
        • Danan E.
        • Ensrud K.
        • Krebs E.
        • Koeller E.
        • Greer N.
        • Velasquez T.
        • Wilt T.J.
        An evidence map of the women Veterans' health research literature (2008-2015).
        Journal of General Internal Medicine. 2017; 32: 1359-1376
        • Das S.R.
        • Kinsinger L.S.
        • Yancy Jr., W.S.
        • Wang A.
        • Ciesco E.
        • Burdick M.
        • Yevich S.J.
        Obesity prevalence among veterans at Veterans Affairs medical facilities.
        American Journal of Preventive Medicine. 2005; 28: 291-294
        • Department of Defense
        DoDI 6490.07, Deployment-limiting medical conditions for service members and DoD civilian employees. Washington, DC: Department of Defense.
        • Dobie D.J.
        • Kivlahan D.R.
        • Maynard C.
        • Bush K.R.
        • Davis T.M.
        • Bradley K.A.
        Posttraumatic stress disorder in female veterans: Association with self-reported health problems and functional impairment.
        Archives of Internal Medicine. 2004; 164: 394-400
        • Dursa E.K.
        • Barth S.K.
        • Schneiderman A.I.
        • Bossarte R.M.
        Physical and mental health status of Gulf War and Gulf Era veterans: Results from a large population-based epidemiological study.
        Journal of Occupational and Environmental Medicine. 2016; 58: 41-46
        • Figgs L.W.
        • Bloom Y.
        • Dugbatey K.
        • Stanwyck C.A.
        • Nelson D.E.
        • Brownson R.C.
        Uses of Behavioral Risk Factor Surveillance System data, 1993-1997.
        American Journal of Public Health. 2000; 90: 774-776
        • Frayne S.
        • Halanych J.H.
        • Miller D.R.
        • Wang F.
        • Lin H.
        • Pogach L.
        • Berlowitz D.R.
        Disparities in diabetes care: Impact of mental illness.
        Archives of Internal Medicine. 2005; 165: 2631-2638
        • Frayne S.
        • Phibbs C.S.
        • Saechao F.
        • Maisel N.C.
        • Friedman S.A.
        • Finlay A.
        • Haskell S.
        Sourcebook: Women veteran in the Veterans Health Administration.
        in: Sociodemographics, utilization, costs of care, and health profile. Washington, DC: Women's Health Evaluation Initiative, Women's Health Services, Veterans Health Administration. 3. 2014 (Available:)
        • Goldberg R.B.
        Hyperlipidemia and cardiovascular risk factors in patients with type 2 diabetes.
        Amercian Journal of Managed Care. 2000; 6 (discussion S692-S686): S682-S691
        • Haibach J.P.
        • Haibach M.A.
        • Hall K.S.
        • Masheb R.M.
        • Little M.A.
        • Shepardson R.L.
        • Goldstein M.G.
        Military and veteran health behavior research and practice: Challenges and opportunities.
        Journal of Behavioral Medicine. 2017; 40: 175-193
        • Hess K.R.
        Graphical methods for assessing violations of the proportional hazards assumption in Cox regression.
        Statistics in Medicine. 1995; 14: 1707-1723
        • Himmelfarb N.
        • Yaeger D.
        • Mintz J.
        Posttraumatic stress disorder in female veterans with military and civilian sexual trauma.
        Journal of Traumatic Stress. 2006; 19: 837-846
        • Hoerster K.D.
        • Millstein R.A.
        • Hall K.S.
        • Gray K.E.
        • Reiber G.E.
        • Nelson K.M.
        • Saelens B.E.
        Individual and contextual correlates of physical activity among a clinical sample of United States Veterans.
        Social Science and Medicine. 2015; 142: 100-108
        • Hoggatt K.J.
        • Jamison A.L.
        • Lehavot K.
        • Cucciare M.A.
        • Timko C.
        • Simpson T.L.
        Alcohol and drug misuse, abuse, and dependence in women veterans.
        Epidemiologic Reviews. 2015; 37: 23-37
        • Hu F.B.
        • Manson J.E.
        • Stampfer M.J.
        • Colditz G.
        • Liu S.
        • Solomon C.G.
        • Willett W.C.
        Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.
        New England Journal of Medicine. 2001; 345: 790-797
        • Jordan B.K.
        • Schlenger W.E.
        • Hough R.
        • Kulka R.A.
        • Weiss D.
        • Fairbank J.A.
        • Marmar C.R.
        Lifetime and current prevalence of specific psychiatric disorders among Vietnam veterans and controls.
        Archives of General Psychiatry. 1991; 48: 207-215
        • Kang H.K.
        • Cypel Y.
        • Kilbourne A.M.
        • Magruder K.M.
        • Serpi T.
        • Collins J.F.
        • Spiro 3rd., A.
        HealthViEWS: Mortality study of female US Vietnam era veterans, 1965-2010.
        American Journal of Epidemiology. 2014; 179: 721-730
        • Kazis L.E.
        • Miller D.R.
        • Clark J.
        • Skinner K.
        • Lee A.
        • Rogers W.
        • Linzer M.
        Health-related quality of life in patients served by the Department of Veterans Affairs: Results from the Veterans Health Study.
        Archives of Internal Medicine. 1998; 158: 626-632
        • Kilbourne A.M.
        • Schumacher K.
        • Frayne S.M.
        • Cypel Y.
        • Barbaresso M.M.
        • Nord K.M.
        • Magruder K.M.
        Physical health conditions among a population-based cohort of Vietnam-era women veterans: Agreement between self-report and medical mecords.
        Journal of Womens Health (Larchmont). 2017; 26: 1244-1251
        • Kimerling R.
        • Gima K.
        • Smith M.W.
        • Street A.
        • Frayne S.
        The Veterans Health Administration and military sexual trauma.
        American Journal of Public Health. 2007; 97: 2160-2166
        • King D.W.
        • King L.A.
        • Foy D.W.
        • Keane T.M.
        • Fairbank J.A.
        Posttraumatic stress disorder in a national sample of female and male Vietnam veterans: Risk factors, war-zone stressors, and resilience-recovery variables.
        Journal of Abnormal Psychology. 1999; 108: 164-170
        • Kudielka B.M.
        • Kirschbaum C.
        Sex differences in HPA axis responses to stress: A review.
        Biological Psychology. 2005; 69: 113-132
        • Kulka R.A.
        • Schlenger W.E.
        • Fairbank J.A.
        • Hough R.L.
        • Jordan B.K.
        • Marmar C.R.
        • Weiss D.S.
        Contractual report of findings from the National Vietnam Veterans' Readjustment Study: Volumes 1-4. Research Triangle Park, NC: Research Triangle Institute.
        • MacGregor C.
        • Hamilton A.B.
        • Oishi S.M.
        • Yano E.M.
        Description, development, and philosophies of mental health service delivery for female veterans in the VA: a qualitative study..
        Womens Health Issues. 2011; 21: S138-S144
        • Magruder K.
        • Serpi T.
        • Kimerling R.
        • Kilbourne A.M.
        • Collins J.F.
        • Cypel Y.
        • Kang H.
        Prevalence of posttraumatic stress disorder in Vietnam-era women veterans: The Health of Vietnam-Era Women's Study (HealthVIEWS).
        JAMA Psychiatry. 2015; 72: 1127-1134
        • McLaughlin R.
        • Nielsen L.
        • Waller M.
        An evaluation of the effect of military service on mortality: Quantifying the healthy soldier effect.
        Annals of Epidemiology. 2008; 18: 928-936
        • Meigs J.B.
        • Larson M.G.
        • Fox C.S.
        • Keaney Jr., J.F.
        • Vasan R.S.
        • Benjamin E.J.
        Association of oxidative stress, insulin resistance, and diabetes risk phenotypes: The Framingham Offspring Study.
        Diabetes Care. 2007; 30: 2529-2535
        • Miller D.R.
        • Safford M.M.
        • Pogach L.M.
        Who has diabetes? Best estimates of diabetes prevalence in the Department of Veterans Affairs based on computerized patient data.
        Diabetes Care. 2004; 27: B10-B21
        • Morris M.C.
        • Compas B.E.
        • Garber J.
        Relations among posttraumatic stress disorder, comorbid major depression, and HPA function: A systematic review and meta-analysis.
        Clinical Psychology Review. 2012; 32: 301-315
        • National Academies of Sciences, Engineering, and Medicine
        Veterans and Agent Orange: Update 11 (2018).
        The National Academies Press, Washington, DC2018
        • Neel S.
        Medical support of the U.S. Army in Vietnam 1965-1970.
        in: Washington, DC: Department of the Army. 1973 (Available:)
        • Norris S.L.
        • McNally T.K.
        • Zhang X.
        • Burda B.
        • Chan B.
        • Chowdhury F.M.
        • Patrick D.
        Published norms underestimate the health-related quality of life among persons with type 2 diabetes.
        Journal of Clinical Epidemiology. 2011; 64: 358-365
        • Oishi S.M.
        • Rose D.E.
        • Washington D.L.
        • MacGregor C.
        • Bean-Mayberry B.
        • Yano E.M.
        National variations in VA mental health care for women veterans..
        Womens Health Issues. 2011; 21: S130-S137
        • Quickel Jr., K.E.
        Diabetes in a managed care system.
        Annals of Internal Medicine. 1996; 124: 160-163
        • Remington P.L.
        • Smith M.Y.
        • Williamson D.F.
        • Anda R.F.
        • Gentry E.M.
        • Hogelin G.C.
        Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87.
        Public Health Reports. 1988; 103: 366-375
        • Roberts A.L.
        • Agnew-Blais J.C.
        • Spiegelman D.
        • Kubzansky L.D.
        • Mason S.M.
        • Galea S.
        • Koenen K.C.
        Posttraumatic stress disorder and incidence of type 2 diabetes mellitus in a sample of women: A 22-year longitudinal study.
        JAMA Psychiatry. 2015; 72: 203-210
        • Saegusa T.
        • Di C.
        • Chen Y.Q.
        Hypothesis testing for an extended cox model with time-varying coefficients.
        Biometrics. 2014; 70: 619-628
        • Sanderson P.W.
        • Clemes S.A.
        • Biddle S.J.
        The correlates and treatment of obesity in military populations: A systematic review.
        Obesity Facts. 2011; 4: 229-237
        • Scannell-Desch E.A.
        The culture of war: A study of women military nurses in Vietnam.
        Journal of Transcultural Nursing. 2000; 11: 87-95
        • Scannell-Desch E.A.
        Lessons learned and advice from Vietnam War nurses: A qualitative study.
        Journal of Advanced Nursing. 2005; 49: 600-607
        • Seal K.H.
        • Cohen G.
        • Waldrop A.
        • Cohen B.E.
        • Maguen S.
        • Ren L.
        Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001-2010: Implications for screening, diagnosis and treatment.
        Drug and Alcohol Dependence. 2011; 116: 93-101
        • Singer J.D.
        • Willett J.B.
        Applied longitudinal data analysis: Modeling change and event occurrence.
        Oxford University Press, Inc, New York, NY2003
        • Skinner K.M.
        • Miller D.R.
        • Lincoln E.
        • Lee A.
        • Kazis L.E.
        Concordance between respondent self-reports and medical records for chronic conditions: Experience from the Veterans Health Study.
        Journal of Ambulatory Care Management. 2005; 28: 102-110
        • Smith T.C.
        • Zamorski M.
        • Smith B.
        • Riddle J.R.
        • Leardmann C.A.
        • Wells T.S.
        • Blaze D.
        The physical and mental health of a large military cohort: Baseline functional health status of the Millennium Cohort.
        BMC Public Health. 2007; 7: 340
        • Stephens M.A.
        • Wand G.
        Stress and the HPA axis: Role of glucocorticoids in alcohol dependence.
        Alcohol Research. 2012; 34: 468-483
        • Sternke L.M.
        • Serpi T.
        • Spiro III, A.
        • Kimerling R.
        • Kilbourne A.M.
        • Cypel Y.
        • Magruder K.
        Assessment of a revised wartime experiences scale for Vietnam-era women: The Health of Vietnam-Era Women's Study (HealthViEWS).
        Women's Health Issues. 2017; 27: 471-477
        • Trafton J.A.
        • Greenberg G.
        • Harris A.H.
        • Tavakoli S.
        • Kearney L.
        • McCarthy J.
        • Schohn M.
        VHA mental health information system: Applying health information technology to monitor and facilitate implementation of VHA Uniform Mental Health Services Handbook requirements.
        Medical Care. 2013; 51: S29-S36
        • U.S. Department of Defense
        Department of Defense health related behaviors survey of active duty military personnel.
        in: Prepared by ICF International (Contract No. GS-23F-8182H) for the Assistant Secretary of Defense - Health Affairs and the U.S. Coast Guard. 2011 (Available:)
        • U.S. Department of Defense and U.S. Department of Veterans Affairs
        DoD/VA Interagency Care Coordination Committee (IC3). Falls Church, VA: Department of Defense, Department of Veterans Affairs.
        • U.S. Department of Health and Human Services
        Women's health USA 2013.
        in: Rockville, MD: U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. 2013 (Available:)
        Date accessed: July 17, 2019
        • Vaccarino V.
        • Goldberg J.
        • Magruder K.M.
        • Forsberg C.W.
        • Friedman M.J.
        • Litz B.T.
        • Smith N.L.
        Posttraumatic stress disorder and incidence of type-2 diabetes: A prospective twin study.
        Jouranl of Psychiatric Research. 2014; 56: 158-164
        • Wellen K.E.
        • Hotamisligil G.S.
        Inflammation, stress, and diabetes.
        Journal of Clinical Investigation. 2005; 115: 1111-1119
        • Wolfe J.
        • Brown P.J.
        • Furey J.
        • Levin K.B.
        Development of a wartime stressor scale for women.
        Psychological Assessment. 1993; 5: 330-335
        • Wolfe J.
        • Sharkansky E.J.
        • Read J.P.
        • Dawson R.
        • Martin J.A.
        • Ouimette P.C.
        Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel.
        Journal of Interpersonal Violence. 1998; 13: 40-57
        • Yaeger D.
        • Himmelfarb N.
        • Cammack A.
        • Mintz J.
        DSM-IV diagnosed posttraumatic stress disorder in women veterans with and without military sexual trauma.
        Journal of General Internal Medicine. 2006; 21: S65-S69
        • Yano E.M.
        • Darling J.E.
        • Hamilton A.B.
        • Canelo I.
        • Chuang E.
        • Meredith L.S.
        • Rubenstein L.V.
        Cluster randomized trial of a multilevel evidence-based quality improvement approach to tailoring VA Patient Aligned Care Teams to the needs of women Veterans..
        Implementation Science. 2016; 11: 101
        • Yoon J.
        • Zulman D.
        • Scott J.Y.
        • Maciejewski M.L.
        Costs associated with multimorbidity among VA patients.
        Medical Care. 2014; 52: S31-S36


      Eric M. Schmidt, PhD, is a Senior Evaluator and health services researcher with the Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, Veterans Affairs Central Office.


      Kathryn Magruder, PhD, MPH, is Professor, Department of Psychiatry and Behavioral Sciences, College of Medicine at the Medical University of South Carolina.


      Amy M. Kilbourne, PhD, MPH, is Professor, Department of Psychiatry, University of Michigan, and Director of the Veterans Affairs Quality Enhancement Research Initiative.


      Eileen M. Stock, PhD, is a Statistician with the Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs.


      Yasmin Cypel, PhD, MS, is a Statistician and Researcher with the Epidemiology Program, Post-Deployment Health Services, Office of Patient Care Services, U.S. Department of Veterans Affairs.


      Suad El Burai Félix, MPH, is an Analyst with the Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs.


      Tracey Serpi, PhD, was a Statistician with the Perry Point/Baltimore Coordinating Center, Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs.


      Rachel Kimerling, PhD, is a Research Psychologist and health services researcher for the National Center for Posttraumatic Stress Disorder and the Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System.


      Beth Cohen, MD, MAS, is Associate Professor, Department of Medicine, University of California at San Francisco, and a General Internist at the San Francisco Veterans Affairs Health Care System.


      Avron Spiro, PhD, is Professor, Department of Epidemiology, School of Public Health, and Department of Psychiatry, School of Medicine, Boston University, and a Research Scientist with the Massachusetts Veterans Epidemiology Research and Information Center, Veterans Affairs Boston Health Care System.


      Joan Furey, RN, MA, is a Registered Nurse and a veteran of the U.S. Military who served during the Vietnam War.


      Grant D. Huang, MPH, PhD, is Director of the Cooperative Studies Program, Office of Research and Development, U.S. Department of Veterans Affairs.


      Susan M. Frayne, MD, MPH, is a Professor, Division of General Medical Disciplines, Stanford University, and a Health Scientist at Center for Innovation to Implementation, Veterans Affairs Palo Alto Health Care System.