Journal of Racial and Ethnic Health Disparities

ABSTRACT: BACKGROUND: Cardiac arrest(CA) and acute respiratory failure(ARF) are collectively at high risk of causing deaths among adults aged 25 and older in the United States. However, long-term trends to prevent these two coexisting conditions among adults are not well defined. OBJECTIVES: The objective of this study was to analyse mortality trends for CA with ARF among U.S. adults aged 25 years and older from 1999 to 2023. METHODS: Using the CDC WONDER Multiple Cause of Death database, we conducted a retrospective analysis of death certificates listing relevant ICD-10 codes for CA (I46) and ARF (J80, J96) among adults aged 25 years and older. Age-adjusted mortality rates (AAMRs) per 100,000 persons and the annual percentage change (APC) were calculated and stratified by demographics and geography. Trends were assessed using Joinpoint regression to estimate annual percentage change with 95% confidence intervals. RESULTS: From 1999 to 2023, 807,236 deaths were recorded. The overall AAMR showed a significant upward trend (AAPC: 4.06%), rising sharply to a peak in 2021 (28.56) before declining. Males consistently had higher AAMRs than females. Both of them increased till 2021 and later decreased. Racial differences were observed in that Non-Hispanic (NH) Black individuals had the highest average AAMR, while NH Whites had the lowest. Geographically, the Western census region had the highest AAMR, increasing to 37.5 in 2021 (APC: 23.92; 95% CI: 16.21 to 28.35; p=0.0004), and rural areas demonstrated higher mortality than urban areas(13.45 vs 10.53). Adults aged 65 and older showed the highest AAMR, with a sudden rise to 96.7 in 2021 (APC: 17.4; 95% CI: 11.7 to 20.7, p<0.000001), followed by a subsequent decline, compared with the other age groups. CONCLUSIONS: There was a marked AAMR due to CA and ARF over the past 24-year period, with a surge around the COVID-19 pandemic. Significant differences were observed by sex, race, and geography. These findings highlight that efforts are needed to prevent and manage mortalities by interventions among high-risk populations who have both HF and ARF.

Importance: Chronic stress may contribute to adverse health outcomes through cumulative physiologic dysregulation. Allostatic load (AL), a composite measure of multisystem physiologic burden, may capture biologic effects of structural, social, and psychosocial stress not reflected by self-reported measures. Objective: To evaluate racial and ethnic differences in AL among women with familial cancer risk and examine how socioeconomic status, psychosocial factors, clinical characteristics, and health behaviors contribute to variations in AL. Design: Cross-sectional study of underrepresented minority participants enrolled in the HERSTORY cohort from October 2023 through September 2025, with comparison participants from the UCLA ATLAS biobank. Setting: UCLA academic health system. Participants: The study included 303 racially and ethnically diverse female HERSTORY participants aged [&ge;]35 years with a family history of cancer and matched non-Hispanic White female ATLAS participants (n=709). Exposures: Race and ethnicity, age, neighborhood deprivation, cancer history and stage, depression, perceived stress, cancer worry, and physical activity. Main Outcomes and Measures: The primary outcome was AL, calculated from cardiometabolic and organ-function measures. A secondary index incorporated race- and ethnicity-specific neutrophil-to-lymphocyte ratio (NLR) derived from 326,826 women in the UCLA Health population. Multivariable regression models evaluated factors associated with elevated AL. Results: Compared with matched non-Hispanic White participants, Black and Asian/Pacific Islander HERSTORY participants had significantly higher AL after adjustment. Hispanic/Latina participants did not have significantly elevated AL. Older age, greater area-level socioeconomic deprivation, and depression were independently associated with higher AL. Prior cancer diagnosis, cancer worry and perceived stress were not significantly associated with AL, whereas regular physical activity was associated with lower AL. Among cancer patients, advanced stage was associated with greater AL. Conclusions and Relevance: This study demonstrates elevated AL among understudied racial/ethnic minority groups with familial cancer risk and identifies associations with neighborhood deprivation, depression, and physical activity. The association between cancer stage and AL suggests that physiologic stress may reflect variation in cancer burden. The lack of association with perceived stress and cancer worry further indicates that physiologic and self-reported psychosocial measures capture distinct dimensions of stress. The development of race/ethnicity-specific NLR thresholds derived from large population samples provide a benchmark for future studies.

ABSTRACT Background: To examine trends in Indonesia's diabetes care cascade from 2013 to 2023, identify key determinants, and assess progress toward global targets of 80% diagnosis and 80% glycemic control among those diagnosed. Methods: We analyzed nationally representative data from Indonesia's Health Surveys in 2013, 2018, and 2023. Diabetes was defined using fasting plasma glucose and oral glucose tolerance tests. We estimated diagnosis, treatment, and control rates and examined sociodemographic predictors of cascade progression using survey-weighted logistic regression models. Results: Between 2013 and 2023, the prevalence of diabetes among adults aged [&ge;]15 years remained stable, ranging from 10.7% to 11.8%. Diagnosis increased from 15.1% (95% CI: 13.4-16.7) to 20.7% (18.5-22.9), treatment nearly doubled from 10.5% (9.1-11.9) to 19.0% (16.9-21.2), and control rose modestly from 4.6% (3.6-5.6) to 6.5% (5.2-7.8). Older age, urban residence, higher socioeconomic status, and insurance coverage were associated with greater progression through the cascade. Wealth-related inequalities persisted in 2023: one-third of cases were diagnosed among the richest (35.3% [29.0-41.7]) versus only 11.0% (7.9-14.2%) among the poorest. Compared with the lowest quintile, wealthier individuals had higher odds of diagnosis (AOR 3.55 [2.11-5.98] for diagnosis, 3.59 [2.01-6.41] for treatment, and 2.24 [1.12-4.51] for control). Conclusions: Indonesia achieved meaningful improvements in the diabetes care cascade over the past decade, yet remains far below global 80/80 targets, with nearly 80% of cases undiagnosed and control below 10%. Persistent wealth-based inequities highlight that near-universal insurance coverage has not been translated into equitable care access, underscoring the need for equity-focused screening and primary care strengthening. Keywords: Diabetes, Care Cascade, Health Services, Indonesia

Indiana still faces significant health challenges, ranking among the least healthy U.S. states due to high obesity rates, mental health issues, and other chronic conditions. These disparities are closely linked to inequities in healthcare access, which are largely shaped by social determinants of health. Using data from the Social Vulnerability Index and County Health Rankings and Roadmaps, this study analyzes trends in obesity, mental health, and premature death across Indiana counties before, during, and after the COVID-19 pandemic. Descriptive statistics, correlation analyses, and Negative Binomial regression models were used to evaluate county-level disparities. In 2018, higher rates of uninsured, obese, and physically inactive populations were associated with increased premature death. In 2020, diabetes, smoking, and alcohol consumption were significant factors. By 2022, unemployment, education, obesity, insurance, exercise access, and mental health provider availability were associated with premature death. Findings indicate that socially vulnerable counties experienced amplified health impacts, with obesity rising most sharply where exercise infrastructure was limited and poor mental health days increasing across all counties. These results highlight persistent service gaps and the critical need for targeted investments in recreational infrastructure and mental healthcare. Future research should examine policy influences and causal relationships to inform equity-focused interventions.

Background: Deaf and hard of hearing (HoH) experienced complex challenges during the COVID19 pandemic, including obscured visual communication from mask mandates, inaccessible public health messaging, and inadequate interpreter availability. We examined whether hearing status predicted nonmedical COVID19 impact on a global level. Methods: We conducted a nested cross-sectional analysis within a global study collecting data across two waves (April to May 2020 and July to August 2022) from 184 countries. Participants (N=7,998) were categorized as Deaf (n=304), Hard of Hearing (HoH; n=951), or Hearing (n=6,743). The primary outcome was a composite COVID-related non-medical Personal Impact TScore derived from 14 items across employment, resource access, and healthcare domains. Multinomial logistic regression models progressively adjusted for demographic, structural, and psychosocial variables. Results: Deaf participants reported substantially higher rates of pandemic-related job loss (28.9% vs. 9.6% hearing), healthcare cancellations (39.9% vs. 24.6%), and inability to obtain basic supplies. Over half (55.9%) of Deaf participants scored above the median composite impact index, compared to 39.2% of hearing participants. In the fully adjusted model, Deaf status remained an independent predictor of high non-medical impact (aOR=1.6, 95% CI: 1.1 to 2.4). HoH status showed no statistically significant difference from hearing participants in any model. Conclusions: People identifying as Deaf experienced significant disparities during COVID19 when compared with HoH or hearing people, driven by language access barriers and institutional exclusion rather than hearing loss per se. These experiences underscore the importance for systemic interventions centering on accessible communication, Deaf-centered needs, and reducing audism in Deaf-hearing interaction.

Background: Alcohol use disorder (AUD) is an underrecognized cardiovascular risk factor linked to accelerated atherosclerosis, arrhythmias, and ischemic heart disease (IHD). National trends in IHD mortality among adults with AUD, particularly during the COVID-19 pandemic, remain poorly characterized. We assessed temporal trends and demographic and geographic disparities in IHD-AUD mortality in the United States from 1999 to 2024. Methods: Mortality data for US adults aged [&ge;]25 years were obtained from the CDC WONDER Multiple Cause-of-Death database (1999-2024). Deaths listing both IHD (ICD-10 I20-I25) and AUD (F10) were included. Age-adjusted mortality rates (AAMRs) per 100,000 population were calculated, and Joinpoint regression was used to estimate annual percent changes (APCs) with 95% confidence intervals (CIs). Results: Between 1999 and 2024, 150,273 deaths involved both IHD and AUD. The AAMR declined slightly from 2.0 to 1.9 per 100,000 between 1999 and 2011, increased to 2.7 by 2018, and rose sharply to 3.7 during 2018-2021 (APC, +12.52% [95% CI, 4.97-20.61]; P=0.003), before stabilizing at 3.6 through 2024. Overall mortality increased by approximately 80% from baseline. Mortality increased persistently among adults aged 35-44 years after 2014 (APC, +8.33%) while adults aged 55-64 had the highest mortality rate. Rates were higher in men than women (peak 6.6 vs 1.2 per 100,000). American Indian or Alaska Native individuals had the highest mortality (peak 7.4), whereas Asian or Pacific Islander individuals had the lowest. Black or African American individuals experienced the steepest increase during 2018-2021 (APC, +16.54%). Rates were highest in the West, increased longest in the South, and remained higher in nonmetropolitan than metropolitan areas. Conclusion: IHD mortality among adults with AUD increased substantially over the study period, accelerating during the COVID-19 pandemic. Marked disparities among men, American Indian or Alaska Native and Black or African American individuals, younger adults, and rural populations highlight the need for integrated cardiovascular and addiction care.

Background Cardiovascular-Kidney-Metabolic (CKM) syndrome encompasses interconnected conditions such as type 2 diabetes (T2D), hypertension, hypertriglyceridemia, metabolic syndrome (MetS), and chronic kidney disease (CKD). As CKM progresses, cardiorenal risks increase. Although Glucagon-like peptide-1 receptor agonists (GLP-1 RA) have demonstrated cardiorenal and cardiometabolic benefits, offering an opportunity to slow CKM progression, their use may vary across social determinants of health (SDoH) and stage 2 CKM subgroups. Objective To evaluate the influence of SDoH on access to GLP-1 RA among patients with T2D and other stage 2 CKM conditions. Methods This cross-sectional study used data from the U.S. National Health and Nutrition Examination Survey (NHANES), 2005?2020. Adults aged [&ge;]30 years with T2D and/or other stage 2 CKM conditions were included. Weighted descriptive analysis, multivariable logistic regression and LASSO were applied to assess associations between SDoH and GLP-1 RA use. Results Among 4,520 participants (representing approximately 84.0 million U.S. adults), weighted mean age was 61.4 years, 48.9% were female, and 61.5% were non-Hispanic White. Among participants with T2D, GLP-1 RA use was higher among individuals with higher education (3.39% vs 1.43%), private insurance (3.00% vs 0.58%), and higher income (4.70% vs 1.87%), while no use was observed among those without routine places for care. In adjusted analyses, individuals with lower income, less than high school education, lack of insurance, and being unmarried had 64%, 51%, 81%, and 40% lower likelihood of GLP-1 RA use, respectively. LASSO identified income, education, insurance, and access to care as predictors. Lower income, lower educational attainment, and lack of insurance were associated with 48%, 34%, and 79% lower likelihood of GLP-1 RA use, respectively, adjusting for age, sex, and race/ethnicity. Conclusion SDoH-driven disparities limit GLP-1 RA access. Expanding GLP-1 RA access by addressing socioeconomic barriers is critical to slowing CKM progression, reducing cardiovascular risk, and mitigating health disparities.

Background: Returnee migrants in Nigeria often face significant psychosocial and economic challenges during reintegration, necessitating resilience to adapt and recover. This study examined factors influencing resilience among returnee migrants in Nigeria. Methodology: A mixed methods design was employed, involving 1316 returnees selected through multistage sampling across Nigeria six geopolitical zones. Quantitative data were collected using the Connor Davidson Resilience Scale and analyzed using SPSS version 28. Qualitative data was obtained through eight focus group discussions and analyzed thematically. Result: Social support from family and friends was inconsistent (70.8% reported occasional support), while community support was largely absent (85.9%). Financial insecurity was widespread (gt 90%). Male gender (AOR = 6.092, plt 0.001), ethnicity, and higher education were significant predictors of resilience. Qualitative findings highlighted the role of family support, faith, adaptive coping, and skill acquisition in strengthening resilience. Conclusion: Resilience among returnee migrants in Nigeria is limited by weak structural and economic support, despite moderate personal coping capacity. Strengthening economic opportunities, community integration, and access to mental health services is essential for sustainable reintegration. Keywords: Returnee migrants, resilience, Reintegration, and psychosocial factors.

People with Down syndrome have higher age-specific mortality rates compared to the general population as well as peers with other intellectual and developmental disabilities. While a large proportion of mortality is attributable to Alzheimers disease, many die prior to Alzheimers diagnosis and some live to old ages, dying without Alzheimers. Our objectives were to use 11 years of Medicaid and Medicare data to describe characteristics and factors related to death in adults with Down syndrome and use machine learning to identify which conditions most strongly predict death in the full population and stratified by age. We identified death using Center for Medicare and Medicaid Systems reported date of death health conditions using ICD 9 and 10 codes. We used a case-control design with risk set sampling to have that controls to mimic the distribution of times of incident Alzheimers disease. We trained gradient boosted trees to identify strongest predictors. Our cohort included 137,293 adults with Down syndrome. Among those, 30,894 (22.5%) died during the study period. Mean age at death among those who died was 55 years (SD=10). Mean age of death in those with Alzheimers disease was 59 (SD=7) and those without was 52 (SD=12). The most influential predictors of mortality were any claim for dementia, any claim for pneumonia, re-occurring claim for cardiovascular disease three years before index death, and any claim for heart failure and epilepsy. Our results align with previous clinical work and highlight intervenable areas to reduce mortality in the Down syndrome population.

C-Reactive Protein (hs-CRP) is a common marker for human inflammation, a response to perceived threat and precipitate to many compromising health conditions. Previous work demonstrated that in addition to other biological features that may be predictive and explanatory of variance in inflammation, psychosocial influences may play a role. The present work uses structural equation modeling to examine pathways including socioeconomic status (SES), psychological capital (PsyCap), and perceived discrimination (Discrim) -insofar as they explain variance in hs-CRP, potentially moderated by neurological lateralization (handedness). Body mass index (BMI), an indicator of body composition, stood as the strongest predictor of the obesity-related inflammatory marker (ORIM). On average, females are predicted to have higher hs- CRP scores than males. The psychosocial constructs were estimated to have little to no effect on inflammation (via hs-CRP) in the analysis sample (ADD Health Study) in either group (left and right-handers) although a small, statistically non-zero indirect path is found in the retained model for right-handed participants (given statistical power for estimation). With this finding, contextual effect estimates are provided with regard to the effect of perceived discrimination on hs-CRP given the range of SES and BMI.

Aim: Inequalities in diabetic foot ulcer (DFU) outcomes are driven by several factors including sociodemographic factors. This study examined the intersectional risks of ethnicity, sex, and deprivation on DFU progression, which prior research often evaluated in isolation. Methods: A retrospective cohort study (2009 - 2024) of 2,125 patients at Lancashire Teaching Hospitals Trust utilized flexible parametric survival modelling. Models assessed DFU onset, overall mortality, and post-clinic prognostic survival, adjusting for demographics and comorbidities. Results: The most deprived patients presented significantly younger (median 64 vs. 73 years). Male sex accelerated DFU onset (HR: 1.24) and increased overall mortality risk (HR: 1.14). Black patients presented older with higher comorbidity burdens but paradoxically exhibited lower overall mortality risk (HR: 0.49). Deprivation heavily impacted life expectancy as the most deprived group showed higher mortality rates (HR: 0.73) and reduced 5-year prognostic survival (48.7% vs. 59.1%). Presence of comorbidities linearly increased overall mortality risk. Furthermore, severe deprivation caused greater overall life-years lost in men (4.0) than women (2.5). Conclusions: Patient outcomes with DFU are heavily influenced by cumulative demographic and socioeconomic factors. Effective management requires accessible, holistic care that actively accommodates these complex biosocial-economic realities.

This cross-sectional study aimed to examine the prevalence of alcohol use and its sociodemographic correlates among adults with cardiovascular disease (CVD). We analyzed data from two large US cohorts: the All of Us Research Program (2017-2023) and the National Health and Nutrition Examination Survey (NHANES, 1999-2016). Both CVD diagnosis and past-year alcohol consumption were self-reported. Risky drinking was defined as exceeding moderate drinking or binge drinking (All of Us), or moderate/heavy drinking (NHANES). Multivariable logistic regression was used to exam associations with sociodemographic and lifestyle factors. Among 32,788 current drinkers with CVD in the All of Us cohort, 15% exceeded moderate drinking thresholds and 26% reported binge drinking. Older age, female sex, and higher socioeconomic status were inversely associated with risky drinking, while smoking was positively associated. In NHANES, moderate drinking rose from 47.3% to 57.2% and heavy drinking from 6.7% to 7.2%. Moderate/heavy drinking was positively associated with age <65 but inversely with age [&ge;]65. Higher education and income were linked to moderate drinking, while current smoking was strongly associated with heavy drinking. These results highlight the need to integrate holistic screening for alcohol use, tobacco use, and social context into routine cardiovascular care.

Objective: Type 1 diabetes is related to an increased risk of structural brain alterations, cerebral microbleeds (CMBs), and cognitive deficits. We explored brain volumes and their direct and combined associations with CMBs on cognitive performance in middle-aged individuals with type 1 diabetes. Research Design and Methods: Adults with type 1 diabetes (n=163; mean age 46+/-8 years; diabetes duration 31+/-10 years; 53% women) and 48 matched controls underwent brain MRI and clinical and neuropsychological evaluations. Volumetric MRI measures adjusted to intracranial volume included total brain volume (TBV), white matter volume (WMV), and total volumes of cortex, thalamus, hippocampus, nucleus accumbens, and choroid plexus. Results: Individuals with type 1 diabetes had smaller TBV, WMV, and volumes of cortex, thalamus, and nucleus accumbens, and larger choroid plexus compared to controls (Cohen d=0.39-0.54). Those with type 1 diabetes and 3 or more CMBs had smaller TBV, WMV, and volumes of cortex, thalamus, and nucleus accumbens, compared to those with 0-2 CMBs (Cohen d=0.54-0.92). We found no direct associations between brain volumes and processing speed or executive functions. However, TBV, WMV, nucleus accumbens, and choroid plexus volumes had significant negative synergistic interactions with CMBs on processing speed and executive functions (standardized betas: -0.61 to -0.51 and 0.54 to 0.75, FDR-corrected p=0.006-0.048). Conclusions: Smaller global and regional brain volumes and larger choroid plexus volumes were found in middle-aged individuals with type 1 diabetes compared to healthy controls. Together with CMB burden, structural brain volumetric alterations were associated with accelerated cognitive deficits.

Background Stroke remains one of the leading causes of mortality, disability, and healthcare burden worldwide. Identifying demographic, socioeconomic, lifestyle, and clinical factors associated with stroke is essential for improving prevention strategies and reducing disease burden. This study aimed to identify independent predictors of stroke among U.S. adults using nationally representative Behavioral Risk Factor Surveillance System (BRFSS) data collected between 2021 and 2023. Methods A cross-sectional analysis was conducted using pooled BRFSS data from 2021 to 2023. Adults with complete information on stroke status and study variables were included in the multivariable analysis. Stroke status was determined from self-reported physician diagnosis. Survey-weighted multivariable logistic regression was performed to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for demographic, socioeconomic, lifestyle, and clinical predictors while accounting for the complex BRFSS sampling design. Model discrimination was evaluated using receiver operating characteristic (ROC) curve analysis. Results Among 235,571 participants in the pooled dataset, stroke was more common among older adults and individuals with diabetes, poorer self-reported health, lower income, and smoking history. In the adjusted analysis, increasing age (aOR 1.04, 95% CI 1.04 to 1.04), diabetes (aOR 1.55, 95% CI 1.43 to 1.67), current smoking (aOR 1.44, 95% CI 1.31 to 1.58), multiracial ethnicity (aOR 1.44, 95% CI 1.12 to 1.82), Black race (aOR 1.31, 95% CI 1.15 to 1.50), and poorer general health (aOR 1.58, 95% CI 1.53 to 1.64) were independently associated with higher odds of stroke. Conversely, Asian race (aOR 0.65, 95% CI 0.43 to 0.94), Hispanic ethnicity (aOR 0.65, 95% CI 0.54 to 0.77), higher income (aOR 0.92, 95% CI 0.90 to 0.93), and regular physical activity (aOR 0.86, 95% CI 0.80 to 0.92) were associated with lower odds of stroke. The final model demonstrated good discrimination, with an area under the ROC curve of 0.781 (95% CI 0.774 to 0.788). Conclusions Stroke among U.S. adults is independently associated with a combination of demographic, socioeconomic, lifestyle, and clinical factors. Diabetes, smoking, poor general health, and socioeconomic disadvantage remain important potentially modifiable contributors to stroke risk, whereas regular physical activity appears protective. These findings support targeted public health interventions focused on improving cardiometabolic health, promoting smoking cessation and physical activity, and addressing socioeconomic disparities to reduce the burden of stroke in the United States.

Improving minority ethnic student retention is a global higher education priority. This mixed-methods study investigated how institutional belonging and socioeconomic status interact to shape dropout intentions among minority university students in the UK (N = 182). Quantitative results revealed that perceived course difficulty and lower subjective socioeconomic status were the strongest predictors of dropout intent. While the interaction between socioeconomic status and difficulty was non-significant, qualitative accounts showed distinct structural vulnerabilities. Financial strain restricted social integration, turning socioeconomic disparities into campus isolation. Conversely, representative curricula, diverse peer networks, and stable cultural in-groups (e.g., religious affiliations, living in the parental home) functioned as essential psychological buffers against academic exhaustion and alienation. Universities must shift from transactional models to sustained structural equity to protect vulnerable student groups.

Objective. This systematic review and meta-analysis synthesised the global prevalence of overweight and obesity in people with Down syndrome (DS) across the lifespan, characterised determinants of excess adiposity, and examined associations with adverse cardiometabolic outcomes. Methods. Six databases were searched without date or language restriction. Two independent reviewers screened studies, extracted data, and assessed quality using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Prevalence was pooled using a random-effects logit model. A pre-specified subgroup analysis by age band was conducted. Publication bias was assessed with Egger's test and certainty of evidence with Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results. Twenty-six studies (7,840 individuals; 14 countries) were included. The pooled prevalence was 18% (95% CI 15-22%) in children and adolescents, 36% (95% CI 26-47%) in adults, and 30% (95% CI 20-43%) in mixed-age cohorts; the test for subgroup differences was significant. The overall pooled prevalence was 22% (95% CI 18-26%; prediction interval 7-53%; I^2 = 95.3%). No publication bias was detected (Egger's t = 0.39, p = 0.6964). DS-specific growth charts yielded estimates 14-37 percentage points lower than general-population references applied to the same cohorts. Obesity more than doubled obstructive sleep apnea risk (RR 2.4; 95% CI 1.34-4.34) and non-alcoholic fatty liver disease was present in 82% of obese versus 45% of non-obese children with DS. GRADE certainty was Moderate for prevalence estimates. Conclusions. Overweight and obesity in DS are highly prevalent, age-progressive, and substantially exceed general-population rates at every life stage. Roughly one in five people with DS is affected overall, rising to more than one in three adults. The reference chart applied is the single largest source of heterogeneity in reported estimates. Cardiometabolic surveillance, adapted lifestyle interventions, and primary prevalence research from low- and middle-income countries are the highest-priority gaps.

Introduction Smoking prevalence remains higher in rural than in urban populations in the United States. To examine recent trends, we assessed state-level differences in cigarette smoking between urban and rural areas from 2018 to 2024. Methods Using repeated cross-sectional data from the Behavioral Risk Factor Surveillance System, we estimated state-specific logistic regression models to examine the relationship between urban-rural county residence and cigarette smoking. Unadjusted models (model 1) included urban-rural county status and year. Subsequent models (model 2) added age, sex, and race/ethnicity. A final model (model 3) included education and an interaction term between urban-rural county status and year to examine whether gaps in urban-rural smoking changed over time. In states with significant interactions, simple effects tests compared trends for urban-rural groups separately. Results Compared to urban adults, rural adults had higher unadjusted odds of cigarette smoking (odds ratio [OR] range:1.07-1.88) in 88.4% (38/43) of states. Adjusting for demographic covariates (model 2) increased the proportion of states with significant marginal effects of rurality to 90.7% (ORs:1.09-1.87). A final model that also controlled for education (model 3) decreased the proportion of states with significant marginal effects of rurality to 60.5% (ORs:1.10-1.54). Among the 14 states with significant interaction terms, the odds of smoking declined faster among urban than rural residents. Conclusion Urban-rural differences in smoking persist across most states. No state showed a reduction in urban-rural disparities over time, and the urban-rural gap widened in 14 states. Demographic variation accounted for some, but not the majority, of observed urban-rural differences.

Introduction Type 2 diabetes (T2D) prevalence, severity, duration, and control are associated with dementia incidence, but prior literature is focused on specific pharmacologic, dietary, and exercise interventions in isolation while controlling for other co-occurring factors. Accounting for comprehensive life course experiences of the timing of diabetes onset, severity, treatment, and progression over a period of decades would provide a more comprehensive description of how life course diabetes progression and control is associated with dementia. Trajectories of diabetes diagnosis, pharmacological management, and disease progression are heterogeneous, and classifying these trajectories presents a significant methodological challenge. Methods Using deidentified survey and electronic health record data from Kaiser Permanente Northern California (KPNC) from the Research Program on Genes, Environment, and Health (RPGEH), we defined annual "states" for each eligible participant with T2D diagnosed between ages 50 and 70 based on KPNC, diabetes diagnosis, glycated hemoglobin, antidiabetes prescription count, and kidney dysfunction. We then employed sequence and cluster analyses to group participants into clusters with similar trajectories of these states. Finally, we estimated hazard ratios for incidence of Alzheimer's disease and Alzheimer's disease related dementias (AD/ADRD) for each of these clusters as well as individuals with type 1 or other diabetes types, relative to participants without diabetes at age 70, using covariate-adjusted Cox proportional hazards models. Results Using the 18,688 participants with T2D included in the diabetes trajectory assessment, sequence and cluster analysis identified 9 clusters of T2D treatment and control histories between ages 50 and 70. Clusters differed markedly in timing of onset of T2D, glucose control, antidiabetes drug use and kidney function. Associations of these clusters with incident AD/ADRD after age 70 was heterogeneous and patterned by diabetes control and treatment history, particularly by diabetes duration and treatment regime. Conclusions In conclusion, in this real-world data context, we find increased diabetes severity, increased medication use, and faster progression to kidney disease is associated with increased risk of dementia. We find some patterns of diabetes severity and control are associated with greater dementia risk. This information may be useful in the context of targeted screening and allocation of preventative services for ADRD.

Objective: To determine whether continuous glucose monitoring (CGM) identifies clinically relevant glycemic heterogeneity and subclinical end-organ alterations in adults without diabetes. Research Design and Methods: We analyzed 1,017 AI-READI Year 3 participants without diabetes (558 with normoglycemia and 459 with prediabetes by A1C). Fifty-two metrics from 10-day blinded CGM were reduced to nonredundant glycemic axes. Partial Spearman correlations between representative CGM metrics and clinical measures across 13 domains were adjusted for age, sex, and BMI and controlled for false discovery rate. CGM-derived subphenotypes were identified using unsupervised UMAP-HDBSCAN-based clustering. Results: Among 462 glycemic-clinical associations tested, 99 (21.4%) remained significant after false discovery rate correction. Hyperglycemia-related metrics, including mean glucose, time above range, and time in tight range, showed more associations than variability metrics. The strongest signals involved cardiometabolic, cardiovascular, and cognitive measures. Greater hyperglycemia and glucose excursions were associated with lower language performance, slower processing speed, and lower cognitive efficiency ({rho} {approx} -0.10 to -0.14; all P < 0.01). Clustering identified four reproducible glycemic subphenotypes: Healthy, Mild Hyperglycemia, High Variability, and Hyperglycemia. CGM phenotypes reclassified A1C-defined groups: 58.1% of participants with normoglycemia fell into dysglycemic phenotypes, whereas 18.8% of participants with prediabetes fell into more favorable phenotypes. The Hyperglycemia phenotype had the most adverse cardiometabolic profile and lower cognitive performance. Conclusions: In adults without diabetes, CGM revealed glycemic patterns associated with distinct subclinical alterations. CGM-based phenotyping may complement A1C for characterizing early dysglycemia and selecting individuals for longitudinal risk-stratification studies.

Background Non-alcoholic fatty liver disease (NAFLD) has become a common metabolic disorder in paediatric age groups and is a major contributor to the burden of health economics. However, there is a lack of comprehensive data on the prevalence of this condition among children. Methods English language literature published from inception until April 2025 was searched from the electronic databases, i.e., PubMed/Medline, Scopus, Embase, and CINAHL. Original data published in any form that reported NAFLD prevalence among children and/or adolescents in India were included. The subgroup analysis of prevalence was done based on the risk category, i.e., average risk group and high risk group (obesity or overweight, metabolic syndrome, etc.). The prevalence estimates were pooled using the random-effects model. Results A total of 11 studies (six in high-risk populations and 5 in the average-risk general population) comprising data from 3512 individuals were found eligible and were included. The overall pooled estimate of NAFLD prevalence among the children and adolescents was 35.4% (95% CI: 19.7% to 52.9%) with very high heterogeneity(I2=99.0%). The pooled prevalence of NAFLD among average/low risk children and adolescents was 10.7% (95%CI: 5.2% to 20.5%) with high heterogeneity across the studies (I2= 96.6%, p=0.001) whereas the pooled prevalence of NAFLD in high risk overweight/obese children and adolescents was found to be 59.7% (95% CI:55.2% to 64.1%) with moderate heterogeneity across the studies (I2=50.90%; H2=2.04; Q (5) = 10.03; p=0.07) Conclusion This systematic review demonstrates that non-alcoholic fatty liver disease (NAFLD) poses a growing health concern among Indian children and adolescents, as 1 out of 3 children/adolescents is suffering from it, with a disproportionately high burden observed in those who are overweight or obese.