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Non-alcoholic Fatty Liver Disease (NAFLD), Active Component, U.S. Armed Forces, 2000–2017

Non-alcoholic fatty liver disease Examining the incidence rates of non-alcoholic fatty liver disease and their temporal trends among active component U.S. military
members can provide insights into the future burden of the disease Military Health System. Photo by iStock.

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Medical Surveillance Monthly Report

ABSTRACT

During 2000–2017, a total of 19,069 active component service members received incident diagnoses of non-alcoholic fatty liver disease (NAFLD), for a crude overall incidence rate of 77.7 cases per 100,000 person-years. The overall rate of incident NAFLD diagnoses among males was more than 1.5 times the rate among females. Overall incidence rates of NAFLD diagnoses increased with advancing age and were highest among service members aged 50 years  or older. Asian/Pacific Islander and Hispanic service members had the highest overall incidence of NAFLD diagnoses compared to those in other race/ethnicity groups. The lowest overall incidence by race/ethnicity was observed among non-Hispanic black service members. Crude annual incidence rates of NAFLD diagnoses increased 12-fold between 2000 and 2017. During this period, annual rates of incident NAFLD diagnoses increased in both sexes and in all age groups. Increases in annual rates were seen over time in all race/ethnicity groups and in all services. More than two-thirds of incident NAFLD cases had one or more diagnosed metabolic comorbidities, with dyslipidemia affecting the greatest percentage of cases, followed by obesity/overweight and hypertension. The percentage of NAFLD cases with 2 or more metabolic comorbidities increased 36.0% during the 18-year surveillance period from 22.2% in 2001 to 30.2% in 2017. Selected recommendations from the American Association for the Study of Liver Diseases 2018 practice guidance document for the diagnosis and management of NAFLD are discussed.

 

WHAT ARE THE NEW FINDINGS?

This is the first MSMR report of the incidence of non-alcoholic fatty liver disease (NAFLD) in the U.S. Armed Forces. This relatively rare disorder was diagnosed in 19,069 service members during 2000–2017 (rate: 77.7 cases per 100,000 person-years). However, incidence of NAFLD increased rapidly, from 12.6 to 152.8 cases per 100,000 person-years between 2000 and 2017.

 

WHAT IS THE IMPACT ON READINESS AND FORCE HEALTH PROTECTION?

Service members with severe NAFLD resulting in impaired liver function are unable to perform their military duties and are disqualified from service. There is no cure for NAFLD; instead, treatment is aimed at preventing risk factors and may include physical exercise and low fat diet to reduce body weight.

 

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a spectrum of disorders, beginning as simple non-alcoholic fatty liver (NAFL) which can progress into non-alcoholic steatohepatitis (NASH) and fibrosis, potentially resulting in cirrhosis and even hepatocellular carcinoma.1,2 A diagnosis of NAFL requires imaging or histologic evidence of >5% hepatic steatosis (without inflammation or fibrosis) in the absence of other secondary causes of hepatic fat accumulation such as heavy alcohol consumption, other liver disease, or hepatotoxic medications.2,3 In NASH, hepatic steatosis is associated with hepatocellular injury in the form of hepatocyte ballooning and/or lobular inflammation (with or without fibrosis) that may be histologically indistinguishable from alcoholic steatohepatitis.3 A diagnosis of NASH requires histological evidence of hepatic steatosis through liver biopsy. However, biopsy is expensive, requires expertise for interpretation, and carries some morbidity risk; as such, liver biopsy is generally restricted to more severe cases.3 The global prevalence of NASH in the general population is estimated to be approximately 2% to 7%.4

NAFLD is strongly associated with  the metabolic syndrome (MetS), a cluster of metabolic abnormalities that directly increases risk of multiple chronic diseases and mortality.5,6 MetS is characterized by abdominal obesity, dyslipidemia, elevated fasting plasma glucose level, and hypertension.6 There is a well-established bidirectional association between NAFLD and components of  MetS; features of MetS are highly prevalent in patients with NAFLD and MetS components increase the risk of developing NAFLD.4,7,8 A recent large U.S. administrative data-based study demonstrated that the costs associated with the care for NAFLD, independent of its metabolic comorbidities, are very high, especially at first diagnosis.9

Many of the studies of NAFLD in the general U.S. population employed imaging or other indirect methods to determine the prevalence of this condition.4,10-17 The prevalence of NAFLD in the U.S. diagnosed by ultrasonography was reported to be 24%.10-17 NAFLD prevalence, as determined by noninvasive methods such as the Fatty Liver Index, serum liver enzyme tests, or ICD diagnostic coding, was estimated at 21%.4

Despite an increasing recognition of NAFLD as the most common cause of chronic liver disease, few studies have systematically examined the incidence of this condition over time in the general U.S. population.3 One recent U.S. administrative data-based study found that the age- and sex-adjusted rate of incident NAFLD diagnoses increased 5-fold, from 62 cases per 100,000 person-years (p-yrs) in 1997 to 329 cases per 100,000 p-yrs in 2014.18 When stratified by age group, the increase in rates of incident NAFLD diagnoses was highest among young adults aged 18–39 years.18 A study of NAFLD among a cohort of U.S. veterans during 2003–2011 found that the annual age-adjusted incidence rates of the condition remained stable and ranged from 3.2 cases per 100 persons in 2003 to 2.5 cases per 100 persons in 2011.17 However, the incidence increased at significantly greater rates among those less than 45 years of age compared to those 45 years or older.17

At the time of this report, there were no published studies of NAFLD incidence over time among active component U.S. military personnel. Examining the incidence rates of NAFLD and their temporal trends among active component U.S. military members can provide insights into the future burden of NAFLD on the MHS. To address this gap, the current analysis summarizes the overall and annual incidence rates of NAFLD among active component U.S. service members during 2000–2017 by demographic and military characteristics and describes the percentages of NAFLD cases with selected metabolic comorbidities (type 2 diabetes mellitus, hypertension, dyslipidemia, obesity, and the metabolic syndrome) within 1 year of incident NAFLD diagnosis. In addition, trends in the percentages of NAFLD cases with 0, 1, or multiple metabolic comorbidities (not including the metabolic syndrome) within 1 year of incident NAFLD diagnosis are described.

 

METHODS

The surveillance period was 1 January 2000 through 31 December 2017. The surveillance population included all individuals who served in the active component of the Army, Navy, Air Force, or Marine Corps at any time during the surveillance period. Diagnoses were ascertained from administrative records of all medical encounters of individuals who received care in fixed (i.e., not deployed or at sea) medical facilities of the Military Health System (MHS) or civilian facilities in the Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care system documented in the Defense Medical Surveillance System (DMSS).

Cases of NAFLD were defined by at least one inpatient or outpatient medical encounter with a qualifying diagnosis in any diagnostic position. Qualifying diagnoses included other chronic non-alcoholic liver disease (ICD-9: 571.8), unspecified chronic liver disease without mention of alcohol (ICD-9: 571.9), other specified inflammatory liver diseases including non-alcoholic steatohepatitis (NASH) (ICD- 10: K75.81), other specified inflammatory liver diseases (ICD-10: K75.89), and fatty change of liver not elsewhere classified (ICD-10: K76.0). A similar case definition was employed in several large U.S. administrative data-based studies of NAFLD prevalence and incidence.9,19-22 The incident date was the date of the first qualifying medical encounter with a defining diagnosis of NAFLD. An individual could be counted as an incident case of NAFLD once per lifetime. Service members with case-defining NAFLD diagnoses before the start of the surveillance period (i.e., prevalent cases) were excluded from the analysis.

Consistent with several published studies of NAFLD incidence using data from electronic medical records, individuals with diagnoses of viral or autoimmune hepatitis, alcoholic liver disease, alcohol-related mental health disorders, disorders of copper metabolism (Wilson’s disease), or biliary cirrhosis recorded in any diagnostic position of any inpatient or outpatient medical encounter occurring on or prior to the incident NAFLD diagnosis were excluded from the analysis.9,18,20,23 A list of ICD codes for these excluded conditions is provided in Table 1.

Incidence rates were calculated as incident NAFLD diagnoses per 100,000 p-yrs of active component service. If a service member had more than one case-defining encounter on the same day, a diagnosis  of other specified inflammatory liver diseases (including NASH) was prioritized over other diagnoses. After this prioritization, if there were multiple case-defining encounters on the same day, inpatient encounters were prioritized over outpatient encounters. Median age at incident NAFLD diagnosis was computed overall, by sex, and by race/ethnicity group. In addition, the proportion of incident NAFLD cases during 2016–2017 who had NASH as the case-defining diagnosis was summarized by demographic characteristics.

Type and frequency of metabolic comorbidities among the incident NAFLD cases were described. Comorbidities were defined by at least one inpatient or outpatient medical encounter with a diagnosis for type 2 diabetes mellitus, hypertension, dyslipidemia, overweight/obesity, or the metabolic syndrome in any diagnostic position in the year before or the year after the incident case diagnosis for NAFLD (Table 2). The proportions of total NAFLD cases associated with 0, 1, or multiple metabolic comorbidities during each calendar year also were computed.

Finally, the annual numbers and rates of abdominal ultrasound testing were calculated to examine the potential impact of screening practices on the ascertainment and diagnosis of NAFLD. Abdominal ultrasound testing was defined by having a CPT code for real time complete (CPT: 76700) or limited (CPT: 76705) abdominal ultrasound with image documentation, or an inpatient procedure for diagnostic ultrasound of the abdomen and retroperitoneum (ICD-9 PR: 88.76) or ultrasonography of the abdomen (ICD-10 PR: BW40ZZZ). One test per person per day was counted.

 

RESULTS

During 2000–2017, a total of 19,069 active component service members received incident diagnoses of NAFLD, for a crude overall incidence rate of 77.7 cases per 100,000 p-yrs (Table 3). Affected service members had a total of 37,236 medical encounters that included a diagnosis for NAFLD during the surveillance period (data not shown). The vast majority of NAFLD cases (96%) were diagnosed in an outpatient setting (Table 3).

The overall rate of incident NAFLD diagnoses among males was more than 1.5 times the rate among females (82.6 cases per 100,000 p-yrs and 49.8 per 100,000 p-yrs, respectively) (Table 3). Overall incidence rates of NAFLD diagnoses increased with advancing age and the rate was highest among service members aged 50 years or older (353.0 per 100,000 p-yrs). Asian/Pacific Islander and Hispanic service members had the highest overall rates of NAFLD diagnoses compared to those in other race/ ethnicity groups, at 113.8 and 112.4 cases per 100,000 p-yrs, respectively. The lowest overall rate by race/ethnicity was observed among non-Hispanic black service members (48.5 per 100,000 p-yrs).

Across the services, the highest overall rate of incident NAFLD diagnoses was observed among Air Force members (99.4 per 100,000 p-yrs) and lowest among those in the Marine Corps (32.9 per 100,000 p-yrs). The overall incidence rate of NAFLD diagnoses among warrant officers (147.6 per 100,000 p-yrs) and senior officers (142.6 per 100,000 p-yrs) was markedly higher than the overall rates among junior enlisted service members (31.2 per 100,000 p-yrs) and junior officers (48.1 per 100,00 p-yrs). Service members working in healthcare occupations (101.3 per 100,000 p-yrs) had the highest incidence of NAFLD diagnoses compared to those in other military occupations.

Overall, the median age at case-defining NAFLD diagnosis was 36 years (interquartile range [IQR]=29–41) (data not shown). The median age at NAFLD diagnosis was 37 years (IQR=30–41) for males and 33 (IQR=25–41) years for females (data not shown). Crude comparisons of the age at NAFLD diagnosis by race/ethnicity group showed that Hispanic service members had the youngest median age at diagnosis (median 34 years, IQR=28–40), while Asian/Pacific Islander and non-Hispanic black service members had the oldest median ages at diagnosis (median 38 years, IQR=32–43 for both groups) (data not shown).

Crude annual incidence rates of NAFLD diagnoses increased approximately linearly from 12.6 per 100,000 p-yrs in 2000 to 152.8 per 100,000 p-yrs in 2017 (Figure 1). This increasing trend was observed among both male and female service members, with annual rates of NAFLD among males consistently higher than rates among females (Figure 2). Increases in rates of incident NAFLD diagnoses over time occurred among all age groups, although the most pronounced increases occurred among service members who were 51 years or older and among those aged 41–50 years (data not shown). During the 18-year surveillance period, increases in annual rates of incident NAFLD diagnoses were seen in all race/ethnicity groups; Asian/Pacific Islander and Hispanic service members showed the greatest increases over time and non-Hispanic black service members showed the smallest increase (Figure 3). Annual incidence rates of NAFLD diagnoses increased in each service during the surveillance period (Figure 4). During each year of the period, rates of incident NAFLD diagnoses were highest among Air Force members and lowest among Marine Corps members. 

Between 2000 and 2017, more than a third of the 19,069 incident cases of NAFLD had a comorbid diagnosis of dyslipidemia (n=7,954, 41.7%) recorded during a medical encounter in the year before or the year after the case-defining NAFLD diagnosis; most of these dyslipidemia diagnoses occurred in the year prior to the incident NAFLD diagnosis (n=6,316, 33.1%) (Table 4). Obesity/overweight (n=7,540, 39.5%) and hypertension (n=7,136, 37.4%) were the next most frequently diagnosed comorbidities, with the majority of these diagnoses preceding the case-defining diagnosis of NAFLD (n=5,393, 28.3% and n=5,845, 30.7%, respectively). Type 2 diabetes was diagnosed within a year of the case-defining NAFLD diagnosis among 4.8% (n=909) of cases and metabolic syndrome was diagnosed among 1.8% (n=348).

More than two-thirds (n=13,474, 70.7%) of incident NAFLD cases had one or more diagnosed metabolic comorbidities including hypertension, dyslipidemia, obesity, or type 2 diabetes. Among all incident NAFLD cases during 2000–2017, the proportions affected by 1, 2, 3, or 4 metabolic comorbidities were 32.9%, 24.6%, 11.3%, and 1.9%, respectively (Table 5). Most cases of NAFLD had at least one metabolic comorbidity diagnosed within the year prior to their incident NAFLD diagnoses (n=11,318, 59.4%). From 2000 through 2017, the percentage of incident NAFLD cases with at least one metabolic comorbidity fluctuated between 55.4% in 2001 and 74.8% in 2012. The percentage of NAFLD cases with 2 or more metabolic comorbidities increased 36.0% during the 18-year period from 22.2% in 2001 to 30.2% in 2017 (Figure 5). The percentage of NAFLD cases with 3 or more metabolic comorbidities increased from 5.3% in 2000 to 11.2% in 2017.

Of the 3,622 incident NAFLD cases diagnosed during 2016–2017, 278 (7.7%) had NASH (ICD-10: 75.8) as the casedefining diagnosis (data not shown). More than half (56.8%) of these cases were 35 years or older at NASH diagnosis. The majority of NAFLD cases with NASH as the case-defining diagnosis were non-Hispanic white (56.1%) and over one-fifth were Hispanic (21.9%) (data not shown).

The incidence rate of abdominal ultrasound testing more than doubled from 217.8 tests per 100,000 p-yrs in 2000 to a peak of 591.7 tests per 100,000 p-yrs in 2015. This peak in rates was followed by a marked decrease to 391.1 tests per 100,000 p-yrs in 2017 (Figure 6).


EDITORIAL COMMENT

In this large and demographically diverse population of active component U.S. service members, crude annual rates of incident NAFLD diagnoses increased 12-fold between 2000 and 2017. During this period, annual rates of NAFLD increased in both sexes and in all age groups. Increases in annual rates were seen over time in all race/ethnicity groups, with the greatest increases seen among Asian/Pacific Islander and Hispanic service members and the smallest increases seen in non-Hispanic black service members. The findings by sex and race/ethnicity mirror the results of NAFLD incidence studies in the general U.S. population.12-18 As in the general population, the increase in NAFLD incidence among active component service members may be due, at least in part, to an increase in median BMI and increasing rates of clinical overweight.18,24 However, given the increasing trend in abdominal ultrasound testing seen in the MHS during 2000–2015, increased use of such imaging may also be a contributor to the increasing trend in NAFLD diagnosis rates observed among active component service members in the current study.

The overall incidence of NAFLD diagnoses increased with advancing age and was higher among males than females. The agerelated rise of NAFLD incidence  observed in many other studies has been attributed to increasing prevalence of MetS components with increasing age in the general population.25,26 However, some recent administrative data-based studies of the general U.S. population show that the greatest increases in incidence of NAFLD occur among  adults 45 years of age or younger.17,18 Results of population-based studies carried out in the U.S. indicate that NAFLD is more common among men than among women.4,10-13,27 The effect of sex hormones as well as sex-based differences in lifestyle and physiology (e.g., body fat distribution) have consistently been proposed to account for sex differences in NAFLD prevalence.11,28 Results of longitudinal studies indicate that women tend to develop NAFLD up to 10 years later than men, due to the putative protective effect of estrogens.28 In the current study, however,  the median age at NAFLD diagnosis among male active component service members was 4 years older than among females.

The overall incidence rates of NAFLD were highest among Asian/Pacific Islanders and Hispanics, intermediate among nonHispanic whites, and lowest among non-Hispanic blacks. U.S. population-based studies have found similar differences  among race/ethnicity groups in the risk of NAFLD.4,10,13,17,27 A high prevalence of a polymorphism in the gene that encodes patatin-like phospholipase domain-containing 3 (PNPLA3) in Hispanics has been posited as a contributing factor to the higher prevalence of NAFLD observed  in this  group.29  Moreover, results of several studies indicate that  Hispanics are more susceptible to advanced NAFLD disease than non-Hispanic whites with the lowest susceptibility observed among nonHispanic blacks.30-32 Genetic differences in lipid metabolism (i.e., lower serum triglyceride levels and higher serum HDL cholesterol levels) are leading explanations for the lowest incidence and prevalence of both NAFLD and NASH among non-Hispanic blacks compared to those in other race/ethnicity groups.32 Other possible explanations for these risk differences include differences in dietary habits (increased consumption of low-nutrient, high sodium and high-fat foods—especially meat-derived fats and lower amounts of fresh fruit) and physical activity levels.12,33-35

The  pattern of higher overall rates of NAFLD observed among warrant officers and senior officers compared to junior enlisted service members and junior officers is likely highly associated with and confounded by age. The finding that overall incidence of NAFLD was lowest among Marine Corps members may be related to differences in the age and overweight/obesity distributions of the services.36,37 In addition, the finding that the highest overall incidence rate of NAFLD was observed among service members in healthcare occupations is likely due, at least in part, to heightened medical awareness and easier access to care compared to their respective counterparts in other occupations. It is important to note that results of a recent MSMR  analysis  of the incidence of MetS among active component service members during 2002–2017 showed that the highest overall incidence of MetS (as indicated by ICD diagnostic codes for MetS) was observed among Asian/Pacific Islanders, Air Force members, warrant officers, and those in healthcare occupations; the lowest overall incidence rates were seen among Marine Corps members and junior enlisted personnel and officers.38

More than two-thirds of incident NAFLD cases had one or more diagnosed metabolic comorbidities, with dyslipidemia affecting the greatest percentage of cases, followed by obesity/overweight and hypertension. Moreover, the percentage of NAFLD cases with 2 or more metabolic comorbidities increased 36.0% during the 18-year surveillance period from 22.2% in 2001 to 30.2% in 2017. A similar trend in metabolic comorbidities over time has been noted in  at least one large administrative data-based U.S. study; however, the magnitude of the increase over time seen in the general population was greater (21% to 53%).18 This difference in magnitude is likely due to differences between the populations in terms of age and overall health status. Regardless of this difference, the slight trend of increasing dysmetabolic burden over time observed among incident NAFLD cases in the current study suggests that the clinical profile of those with NAFLD is becoming more complex, because of the presence of more metabolic comorbidities near the time of NAFLD diagnosis.

The American Association for the Study of Liver Diseases (AASLD) 2018 practice guidance document for the diagnosis and management of NAFLD recommends that the management of this condition consist of treating liver disease as well as the associated metabolic comorbidities. However, pharmacological treatments aimed mainly at improving liver disease should generally be restricted to those cases with biopsy-proven NASH and fibrosis.3 Lifestyle modification including diet, exercise, and weight loss is advocated to treat patients with NAFLD. Weight loss of at least 3%–5% of body weight seems necessary to improve steatosis, but loss of 7%–10% of body weight is required to improve most of the histopathological features of NASH.3 It is further recommended that aggressive modification of cardiovascular disease risk factors be considered in all patients with NAFLD.3 Because patients with NAFLD or NASH are not at higher risk for serious liver injury from statins, these medications can be used to treat dyslipidemia in individuals with these conditions.3

Results of the current study  must be interpreted in the context of several limitations. First, it is important to note that the use of diagnostic codes for case ascertainment can limit disease specificity, especially with a diagnosis of exclusion such as NAFLD. To address this limitation, the current analysis refined the case definition by excluding individuals with alternative liver diseases and those with diagnoses of alcohol-related mental health disorders. Using a similar case definition and exclusion list as the current study, Allen and colleagues found that 85% of incident NAFLD cases identified using ICD-9 codes were true cases of NAFLD based on chart review; the remaining 15% were determined to be cases of alternative liver diseases.18 Chart review also showed that, of the cases that were excluded based on codes for alternative liver diseases and/or alcohol-related mental health disorders, 87% were true non-NALFD liver disease and 13% were NAFLD. It is important to note, however, that a large proportion of outpatient incident cases (approximately 58%) identified in this study were single outpatient visits without any follow-up encounters during the surveillance period. It is possible that many of these are miscoded screening visits, in which case the analysis would overestimate the true incidence of NAFLD. At the time of this report, there were no U.S. population-based studies of NAFLD incidence using other indirect methods (e.g., ultrasonography, serum liver enzyme tests) available for comparison.

Another limitation of the current analysis is related to the implementation of MHS GENESIS, the new electronic health record for the Military Health System. For 2017, medical data from sites that were using MHS GENESIS are not available in DMSS. These sites include Naval Hospital Oak Harbor, Naval Hospital Bremerton, Air Force Medical Services Fairchild, and Madigan Army Medical Center. Therefore, medical encounter and person-time data for individuals seeking care at one of these facilities during 2017 were not included in the analysis.

As one of the few published U.S. studies of NAFLD incidence among a large demographically diverse population, this study makes a useful contribution to the literature on temporal changes in the incidence of NAFLD by sex and race/ethnicity. Observed differences in incidence rates of NAFLD diagnoses by race/ethnicity and service warrant further analysis to examine adjusted (e.g., by age, sex) incidence rates among service members within these groups. Results indicating that Asian/Pacific Islanders and Hispanics have higher incidence of NAFLD diagnoses than those in other race/ethnicity groups underscore the importance of effective prevention and management programs targeting these higher risk groups. Moreover, the substantial rise in rates of incident NAFLD diagnoses coupled with cases who may present with an increasing number of comorbid dysmetabolic conditions, suggests the need for heightened efforts toward awareness, early intervention, and multidisciplinary management.

 

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35. McCarthy EM, Rinella ME. The role of diet and nutrient composition in nonalcoholic Fatty liver disease. J Acad Nutr Diet. 2012;112,401–409.

36. Department of Defense, Office of the Deputy Assistant Secretary of Defense for Military Community and Family Policy (ODASD (MC&FP)). (2017). 2016 Demographics: Profile of the Military Community. Washington, DC.

37. Department of Defense. DoD Health Related Behaviors Survey of Active-Duty Service Members: Final Report. (2015). Santa Monica, CA: RAND Corporation.

38. Williams VF, Oh G, Stahlman S. Incidence and prevalence of the metabolic syndrome using ICD-9 and ICD-10 diagnostic codes, active component, U.S. Armed Forces, 2002–2017. MSMR. 2018;25(12)20–24.

Annual incidence rates of NAFLD, active component, U.S. Armed Forces, 2000–2017Annual incidence rates of NAFLD, by sex, active component, U.S. Armed Forces, 2000–2017Annual incidence rates of NAFLD, by race/ethnicity, active component, U.S. Armed Forces, 2000–2017Annual incidence rates of NAFLD, by service, active component, U.S. Armed Forces, 2000–2017Percentage of NAFLD cases with 0, 1, 2, or 3+ comorbidities within 1 year of incident NAFLD diagnosis, active component, 2000-2017

ICD-9 and ICD-10 diagnostic codes for excluded conditions

ICD-9 and ICD-10 codes for comorbidities

Incident cases and incidence rates a of NAFLD by demographic and military characteristics, active component, U.S. Armed Forces, 2000–2017

Number and percentage a of NAFLD cases with selected comorbidities within 1 year of incident NAFLD diagnosis

Percentage of NAFLD cases with zero, one, two, three or four comorbidities a within 1 year of the incident NAFLD diagnosis

 

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U.S. Air Force Tech Sgt. Ryan Marr, 18th Medical Group pharmacy craftsman, processes prescriptions, June 8, 2018, at Kadena Air Base, Japan. The pharmacy processes and fills prescriptions for hundreds of different medical needs. (U.S. Air Force photo by Staff Sergeant Jessica H. Smith) Merriam/Released)

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Measles, Mumps, Rubella, and Varicella Among Service Members and Other Beneficiaries of the Military Health System, 1 January 2016–30 June 2019

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10/1/2019
U.S. Air Force Airmen of the 163d Attack Wing line up to  receive a flu vaccine at March Air Reserve Base, California, Nov. 4, 2018. The flu vaccine is an annual requirement for military members to help curb the spread of the flu and limit its impact within the unit. (U.S. Air National Guard photo by Tech. Sgt. Julianne M. Showalter)

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Surveillance Snapshot: Influenza Immunization Among U.S. Armed Forces Healthcare Workers, August 2014–April 2019

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181129-N-GR847-3000 ARABIAN GULF (Nov. 29, 2018) Hospitalman Jay Meadows, from Weaver, Ala., administers an influenza vaccine to a Sailor during a regularly scheduled deployment of the Essex Amphibious Ready Group (ARG) and 13th Marine Expeditionary Unit (MEU). The Essex ARG/13th MEU is flexible and persistent Navy-Marine Corps team deployed to the U.S. 5th Fleet area of operations in support of naval operations to ensure maritime stability and security in the Central Region, connecting to the Mediterranean and the Pacific through the western Indian Ocean and three strategic choke points. (U.S. Navy photo by Mass Communication Specialist 3rd Class Reymundo A. Villegas III)

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Animal Bites and Rabies Post-exposure Prophylaxis, Active and Reserve Components, U.S. Armed Forces, 2011–2018

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Big Brown Bat stock photo (iStock.com)

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Editorial: The Department of Defense/Veterans Affairs Vision Center of Excellence

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9/1/2019
U.S. Army Spc. Angel Gomez, right, assigned to Charlie Company, 173rd Brigade Support Battalion, wraps the eye of a fellow Soldier with a simulated injury, for a training exercise as part of exercise Saber Junction 16 at the U.S. Army’s Joint Multinational Readiness Center in Hohenfels, Germany, April 5, 2016. Saber Junction is a U.S. Army Europe-led exercise designed to prepare U.S., NATO and international partner forces for unified land operations. The exercise was conducted March 31-April 24. (U.S. Army photo by Pfc. Joshua Morris)

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Absolute and Relative Morbidity Burdens Attributable to Ocular and Vision-Related Conditions, Active Component, U.S. Armed Forces, 2018

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Senior Airman Breanna Daniels, 559th Medical Group optometry technician, takes images of Tech. Sgt. Stephanie Edmiston, 559th MDG trainee health flight chief, during an eye exam Oct. 19 at the Reid Clinic on Joint Base San Antonio-Lackland, Texas. The 559th MDG is home to the largest optometry and public health flight in the Department of Defense; the DOD's first military training consultation service. (U.S. Air Force photo/Staff Sgt. Kevin Iinuma)

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Incident and Recurrent Cases of Central Serous Chorioretinopathy, Active Component, U.S. Armed Forces, 2001–2018

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A phoropter is an instrument used to determine an individual’s eyeglass prescription by measuring the eye’s refractive error and switching through various lens until the persons vision is normal. (U.S. Air Force photo by Airman Dennis Spain)

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Incidence and Prevalence of Selected Refractive Errors, Active Component, U.S. Armed Forces, 2001–2018

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U.S. Army Spc. Angel Gomez, right, assigned to Charlie Company, 173rd Brigade Support Battalion, wraps the eye of a fellow Soldier with a simulated injury, for a training exercise as part of exercise Saber Junction 16 at the U.S. Army’s Joint Multinational Readiness Center in Hohenfels, Germany, April 5, 2016. Saber Junction is a U.S. Army Europe-led exercise designed to prepare U.S., NATO and international partner forces for unified land operations. The exercise was conducted March 31-April 24. (U.S. Army photo by Pfc. Joshua Morris)

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Incidence and Temporal Presentation of Visual Dysfunction Following Diagnosis of Traumatic Brain Injury, Active Component, U.S. Armed Forces, 2006–2017

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SAN DIEGO (April 6, 2017) Cmdr. John Cason, program director Navy Refractive Surgery, performs the second Small Incision Lenticular Extraction (SMILE) procedure at Naval Medical Center San Diego. The SMILE procedure is the latest advancement in refractive surgery for correcting myopia or nearsightedness. (U.S. Navy photo by Mass Communication Specialist 1st Class Elizabeth Merriam/Released)

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Commentary: Gaps in Reportable Medical Event Surveillance Across the Department of the Army and Recommended Training Tools to Improve Surveillance Practices

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A U.S. naval officer listens through his stethoscope to hear his patient’s lungs at Camp Schwab in Okinawa, Japan in 2018. (Photo courtesy of U.S. Marine Corps) photo by Lance Cpl. Cameron Parks)

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Evaluation of Serological Testing for Lyme Disease in Military Health System Beneficiaries in Germany, 2013–2017

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Digitally colorized scanning electron microscope image depicting a grouping of numerous, Gram-negative anaerobic Borrelia burgdorferi bacteria derived from a pure culture. Credit: CDC/Claudia Molins

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Update: Routine Screening for Antibodies to Human Immunodeficiency Virus, Civilian Applicants for U.S. Military Service and U.S. Armed Forces, Active and Reserve Components, January 2014–June 2019

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A hospitalman draws blood at Naval Medical Center Portsmouth’s Laboratory Department. DoD Photo

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Surveillance Snapshot: Incidence of Rickettsial Diseases Among Active and Reserve Component Service Members, U.S. Armed Forces, 2010–2018

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Dorsal view of a female American dog tick, Dermacentor variabilis. Credit: CDC/Gary O. Maupin

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Historical Review: Rickettsial Diseases and Their Impact on U.S. Military Forces

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Dorsal view of a female American dog tick, Dermacentor variabilis. Credit: CDC/Gary O. Maupin

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Epidemiology of Impulse Control Disorders and Association With Dopamine Agonist Exposure, Active Component, U.S. Armed Forces, 2014–2018

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A dopamine molecule

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