Veterans’ unique heart-health risks call for personalized care

Veterans are special. When it comes to their sense of duty and service to their country, that’s worth celebrating. But when it comes to heart health, the differences can be concerning.

“Veterans are not unique in that they experience the same cardiovascular diseases that the general population experiences,” said Dr. Jennifer Ballard-Hernandez, a cardiology nurse practitioner who is also a major in the Air Force Reserve. But they also carry “a substantial cardiovascular risk burden that appears to be higher than the general population.”

Ballard-Hernandez helped write an American Heart Association scientific statement about veterans’ heart health that was published Nov. 11 in the journal Circulation. The statement, which assesses care at the Department of Veterans Affairs, also offers insights that veterans can apply to their own health.

How does military service affect veterans’ heart health?

According to the statement, veterans make up more than 5% of the adult population in the U.S. As a whole, they tend to be older, male and white, and more likely to live in a rural area or lack internet connectivity, said Dr. Neal Yuan, director of cardiovascular stress testing and cardiac rehabilitation at San Francisco VA Health Care System. Yuan, who also is an assistant professor of medicine at the University of California, San Francisco, led the statement’s writing group.

At the same time, veterans also are a diverse group, said Ballard-Hernandez, who works at the Long Beach VA Medical Center in California, but said she was speaking in her personal capacity, not on behalf of the VA. “Veterans come from all walks of life.”

They might face health effects related to their service time, she said, including:

• Stress from deployments. As a reservist, Ballard-Hernandez knows about this firsthand. She’s been called to work around the world, from South Korea to the Virgin Islands, helping ensure soldiers remain healthy and fit for duty.


• Stress from serving in extreme conditions, such as heat, cold or altitude combined with strenuous physical exertion and sleep deprivation.


• Military-related exposure to chemicals, such as Agent Orange, an herbicide used during the Vietnam War, or from burn pits used to dispose of waste. Certain deployment related exposures may contribute to long-term cardiovascular risk.


• The demands of combat, which can lead to problems such as post-traumatic stress disorder.

What heart-health risks do veterans face?

The statement evaluated how veterans compare with the general population on Life’s Essential 8, which are key measures the Heart Association identified to improve and maintain good cardiovascular health.

Those measures apply to veterans and non-veterans alike, Yuan said. Veterans, though, are more likely to fall short in the areas of:

• High blood pressure, or hypertension. Veterans have higher rates of many hypertension risk factors, including advanced age, and higher levels of related issues such as obesity, diabetes, chronic kidney disease and obstructive sleep apnea, Yuan said. “There are also military service-related conditions such as chronic pain that may increase hypertension risk.”


• Healthy diet. Veterans on average eat fewer fruits, vegetables and whole grains and more processed foods, unhealthy solid fats and sugar-sweetened beverages, the statement says. Among the reasons: poor access to healthy foods, limited dietary change support from family and friends and food insecurity.


• Physical activity. The statement lists barriers ranging from low socioeconomic status to high rates of chronic disease, pain and physical disability.


• Weight and other measures. Veterans struggle to maintain healthy weight, blood sugar levels and cholesterol levels. Many smoke.

Ballard-Hernandez noted that during their time in the service, members of the military are “very in tune” with healthy behaviors. “We have physical fitness standards that we have to keep, so they’re exercising, and they’re watching what they’re eating.” As people transition out of service, though, they may lose some of those heart-healthy habits.

What should veterans know about sleep and mental health?

Healthy sleep is essential for heart health. Mental health also influences heart health.

“These are two areas that are especially important in veteran populations but often receive significantly less attention in general populations,” Yuan said. “They also often go together.”

Veterans have higher rates of mental health conditions such as PTSD and substance use disorders as well as physical disability and chronic pain, “which are often directly related to their military service experience, and can have significant impacts on their ability to achieve ideal health measures,” Yuan said.

Almost half of veterans have a sleep disorder. “Insufficient sleep, in turn, can interfere with mental wellness,” Yuan said. “Sleep can also be disrupted by substance use, obesity-related conditions like sleep apnea, chronic pain, and other chronic health conditions that are highly prevalent among veterans.”

How can veterans protect their heart health?

The VA, Yuan said, has seen success with integrated care – a primary care team that might include a dietitian and pharmacist who can work with a veteran in person or by telehealth to talk through food choices and medications.

Yuan said the VA has also seen success with a weight management program called MOVE! that provides group sessions with other veterans. The sessions are led by teams of dietitians, psychologists, exercise physiologists and nurses. Mental health initiatives also are integrated into many facets of VA medical care, he said.

But many veterans get their care in the private sector instead of the VA, Ballard-Hernandez said. Her message to veterans is twofold:

• Whether it’s the VA or the private sector, get care somewhere, and ask questions about heart health.


• Wherever you get that care, let them know you’re a veteran. “We encourage all veterans to ensure that they tell all of their care team that they have had some military service, because they have those unique risk factors.”

Letting your healthcare team know your veteran status can make a big difference in how they approach something like stress, Ballard-Hernandez said. Any doctor, nurse practitioner or physician assistant will know how stress and heart health are related, but they might not dive down into some of the types of stress veterans face. “There may be additional screening that needs to be done.”

Also, there are many VA resources for veterans dealing with problems such as PTSD, she said.

At the end of the day, Ballard-Hernandez said, the basics of Life’s Essential 8 offer a roadmap to better heart health for non-veterans and veterans alike. But having full details about a veteran’s life can help a healthcare team provide individualized care using a risk calculator, such as the Association’s PREVENT equations, and if necessary, “getting them on appropriate medications for cholesterol, blood glucose and blood pressure control.”

For a closer look at your own heart health, My Life Check offers a starting point along that roadmap. The online tool uses Life’s Essential 8 to help you better understand your risk for heart disease and stroke.

Veterans don’t have to navigate their health conditions alone. Connect with others who understand the value of shared experience through the American Heart Association’s Support Network.