Preventive Medicine

Background YouTube highlights packages are a major and growing route to football consumption, particularly among children and young people, but brand exposure within them has not been quantified. We measured unhealthy commodity brand exposure in English Premier League (EPL) and FIFA World Cup (WC) highlights. Methods We coded brand appearances lasting two or more seconds in 10 Sky Sports EPL highlights (final 10 games of the 2025/26 season) and 19 official FIFA 2026 WC highlights, recording commodity category, placement, and match moment, alongside pre-roll YouTube adverts. Data were collected between 4 June and 27 July 2026. Five highlights were double-coded (Cohen's kappa 0.85). Results Overall brand density was similar across competitions (13.1 vs 13.9 references per minute), but composition differed markedly. Unhealthy commodity branding occupied 38.0% of EPL screen time versus 18.7% at the WC, a difference driven almost entirely by gambling (32.6% vs 1.5%). Gambling appeared in every EPL package, mainly on pitchside boards and LED screens (50.4%), with front-of-shirt accounting for 27.1%. WC exposure was more evenly spread across HFSS food (13%), alcohol (4%) and trading/crypto/prediction markets (3.7%), and appeared almost exclusively pitchside. Gambling brands accounted for ten of twelve pre-roll EPL adverts (123 of 153 seconds); no gambling adverts preceded WC highlights. Conclusions Gambling dominates unhealthy commodity exposure in EPL highlights, both in-video and in pre-roll advertising. Because most appearances occur away from the front of shirt, the voluntary front-of-shirt sponsorship withdrawal will leave the majority of this exposure intact. The WC comparison shows that tighter central control of the advertising environment produces lower and more diffuse exposure, and that governments and governing bodies with such control could restrict unhealthy categories altogether.

BackgroundObservational comparisons of former smokers who use non-combusted nicotine products with former smokers who quit without them require that two quantities be measured precisely: which product is being used, and how long ago cigarette smoking stopped. Neither quantity is recorded by the National Health Insurance Service (NHIS) screening instrument used in a recent Korean cohort study of post-cessation e-cigarette use and lung cancer risk. We characterized both quantities in a contemporaneous, nationally representative survey of the same population. MethodsWe analyzed the public-release microdata of the Korea National Health and Nutrition Examination Survey (KNHANES), 2018 to 2023, restricted to adults aged 19 years and older. Former smokers were identified by smoking status, and cessation duration was taken from the item recording months since the last cigarette. Former smokers currently using a heated tobacco product (HTP) or an e-cigarette (EC) were compared with former smokers using neither. KNHANES 2018 asked a generic e-cigarette question and, separately, a checklist naming HTP brands, allowing the two product classes to be separated. Distributions were compared with rank-based methods, the age-duration relationship with Theil-Sen regression, and residual imbalance by restricting the comparison group to respondents age-matched to within two years. ResultsThe 2018 analytic sample comprised 1,348 former smokers, of whom 43 currently used HTP or EC and 1,305 used neither. Among the product-using former smokers, 58% reported HTP use without e-cigarette use, 21% reported both, and 21% reported e-cigarette use without HTP use; 79% reported any HTP use. Median cessation duration was 0.7 years (IQR 0.25 to 1.5) among product users and 12.0 years (IQR 5.0 to 20.0) among those using neither (Kolmogorov- Smirnov D = 0.76, P < 0.001), with the product user having quit more recently in 92% of cross-group pairs. The separation persisted within the short-term (<5 year) stratum (D = 0.34, P < 0.001; 73% of pairs) and after age matching, where the residual gap was 9.3 years. Cessation duration rose with age among those using no product (Theil-Sen slope +0.30 years per year) but was flat among product users (-0.01). Restricting to the screening-eligible stratum used in the cohorts high-risk analysis did not attenuate the imbalance: among those aged 50 to 80, median cessation among no-product quitters rose to 15.5 years (n = 858), and adding a 20 pack-year criterion left 421 no-product quitters with a median of 11.0 years against three HTP/EC users who had quit 0.25, 1.0 and 2.0 years earlier, despite closely matched cumulative exposure (mean 37.6 vs 37.7 pack-years). The overall contrast reproduced in every wave from 2018 to 2023, with an age-matched residual of 9 to 11 years. ConclusionsIn a nationally representative survey of the same population and the same calendar year as the NHIS screening cohort analyzed by Kim et al., Korean former smokers using non-combusted nicotine products differed from other former smokers in two respects that bear directly on how such comparisons should be read. First, they were predominantly HTP users: 79% reported any HTP use, and only 21% reported e-cigarette use without HTP use. Second, they had stopped smoking approximately a decade more recently, a difference that survived stratification at five years and exact age matching. Neither quantity is recorded in the NHIS screening instrument. Cohort estimates comparing post-cessation product users with other quitters should therefore be interpreted with caution if they do not precisely characterize product composition and to time since cessation, and future studies should measure both directly.

Introduction: Breast, cervical, and colorectal cancer screening guidelines changed substantially between 2010 and 2019. We examined trends in the annual utilization of these screenings among commercially insured enrollees in the United States from 2010 to 2019 by age group, geographic region, and screening modality. Methods: We conducted a retrospective, serial cross-sectional analysis of the MarketScan Commercial Claims Database from 2010 through 2019, comprising approximately 141.2 million privately insured enrollees. Annual screening rates, defined as the proportion of eligible enrollees receiving a given test within each calendar year, were estimated for cervical, breast, and colorectal cancer using procedure codes, stratified by age group, screening modality, and geographic residence. These reflect annual utilization rather than up-to-date (guideline-concordant) screening. Temporal trends were evaluated using two-sided Poisson regression, and urban-rural disparities in 2019 were assessed using multivariate generalized estimating equations. Results: Cancer screening utilization remained stagnant or declined across all three cancer types over the study period. Among women aged 30-64 years, cervical cytology alone declined substantially from 28.2% in 2010 to 8.8% in 2019, while co-testing increased from 11.4% to 20.3%. Screening mammography among women aged 50-64 showed minimal change, remaining stable at 45.7% in 2010 and 45.8% in 2019. Colorectal cancer screening across enrollees aged <64 decreased modestly from 7.7% in 2010 to 6.5% in 2019, with a more pronounced decline among adults aged 45-49 years. Across all three cancer types, screening utilization was higher among urban residents than rural residents, with incidence rate ratios ranging from 1.02 to 1.05 in 2019. Conclusions: Utilization of cervical, breast, and colorectal cancer screening among commercially insured adults did not improve between 2010 and 2019. Persistent urban-rural disparities highlight ongoing gaps in preventive care delivery. Targeted interventions may help improve screening utilization, particularly in rural and underserved populations.

Importance: While increased physical activity (PA) and decreased sedentary behavior (SB) are associated with favorable health outcomes, evidence regarding their causal effects on healthcare costs remains limited. Objective: To assess the causal effects of PA and SB on healthcare costs. Design: A two-sample Mendelian randomization (MR) study. Setting: Separate, non-overlapping cohorts with genetic instruments for self-reported and device-based PA and SB, and healthcare costs. Participants: The instruments used to assess self-reported PA were derived from a genome-wide meta-analysis of 606,820 individuals across 51 cohorts. Two large genome-wide association studies (GWASs) were used for self-reported SB (leisure screen time N=526,725; television watching N=408,815), while accelerometer-based GWASs (N=89,683-91,105) were used for device-based PA and SB. The instruments used to assess the outcome data were obtained from the FinnGen cohort (N=373,160). Exposures: Genetically predicted PA and SB. Main Outcomes and Measures: Validated genetic instruments for log-transformed annual healthcare costs derived from registers, including primary care, secondary care, and medication costs. Inverse variance weighting was used as the primary MR measure, while the sensitivity analyses included MR-Egger, weighted median, simple mode, weighted mode, F-score, Cochran's Q, and leave-one-out analysis. Results: Higher genetically predicted self-reported PA was associated with lower healthcare costs (causal estimate, {beta} = -0.166; 95% CI, -0.270 to -0.062). In contrast, higher genetically predicted SB (leisure screen time or television watching) was associated with higher healthcare costs across self-reported datasets ({beta} = 0.097; 95% CI, 0.064 to 0.130; {beta} = 0.114; 95% CI, 0.063 to 0.165, respectively). No associations were observed for device-based PA ({beta} = -0.014; 95% CI, -0.040 to 0.014) or SB ({beta} = -0.009; 95% CI, -0.197 to 0.179). Conclusions and Relevance: Findings based on genetically predicted PA and SB support a causal association between these behaviors and healthcare costs, suggesting that increasing population's leisure-time PA and reducing SB may decrease healthcare expenditure. This highlights the importance of promoting PA for both population health and long-term sustainability of healthcare systems. However, causal evidence remains partly limited, particularly for device-based measures of these behaviors.

Seasonal Influenza and COVID-19 vaccination programmes are critical for reducing morbidity and mortality in older adults, yet uptake remains uneven across populations. We aimed to profile vaccination attitudes and examine predictors of COVID-19/influenza vaccination uptake among a UK participatory surveillance system - FluSurvey. We analysed FluSurvey data from participants aged [&ge;]65 years who were eligible for both vaccines in the 2023-2024 and 2024-2025 Autumn - Winter seasonal campaigns. Descriptive analyses examined self-reported attitudes to influenza vaccination. Logistic regression examined factors (age, sex, socioeconomic status, education, employment, transport, smoking and chronic conditions) associated with influenza and COVID-19 vaccination uptake in each season, adjusting for confounders. Belonging to a risk group and reducing risk of influenza were frequently reported motivations for influenza vaccination, while building natural immunity and concerns around safety and adverse effects were frequently reported barriers. Individuals vaccinated against COVID-19 were more likely to receive an influenza vaccination (aOR2023-2024=13.90 [9.28-21.17]; aOR2024-2025=8.54 [5.82-12.60]), and vice-versa (aOR2023-2024=13.91 [9.30-21.19]; aOR2024-2025=8.52 [5.81-12.58]). Lower educational attainment was associated with lower odds of COVID-19 vaccination (aOR2023-2024=0.59 [0.45-0.78], aOR2024-2025: 0.56 [0.39-0.79]). Other results were weaker or demonstrated variation by season. Our findings highlight recent attitudes and barriers to influenza and COVID-19 vaccination among the FluSurvey cohort, which may inform approaches to improve vaccination coverage in the population.

Long COVID (LC) impacts quality of life, daily functioning, and healthcare utilization. Understanding the onset and duration of symptoms, characteristics of those at higher risk, and the barriers and facilitators for healthcare access and therapeutics are key to addressing this growing disease burden. In 2024 the Arizona CoVHORT, an ongoing 6-year longitudinal study, distributed a cross-sectional LC survey to gain additional in-depth information. Of 1,543 participants, 700 reported LC symptoms lasting 2-49 months. Following their first infection, LC+ participants had a 21% higher risk for a second infection and were 3.2 times more likely to report LC symptoms after that second infection compared to LC- participants. Significant factors associated with LC included female sex (OR=2.3), Hispanic ethnicity (OR=1.5), BMI>34.5 (OR= 1.7) and >2 infections (OR=3.2), while vaccination prior to first infection decreased the odds of reporting LC by 51% (R=0.49). Qualitative analyses detailed significant barriers to care and encounters with providers who lacked knowledge to test for or treat LC symptoms. With an estimated 400 million people impacted globally by LC, it is critical to gain in-depth information from patients to improve both access and quality of care, improve messaging, and target mitigation strategies to decrease the burden over time.

Unhealthy retail outlets, including liquor stores, bars, convenience stores, and fast food, are concentrated in lower-income neighbourhoods. This is a well-documented cross-sectional fact; the process that sustains it is not. A neighbourhood can hold more because more open there or because those already there survive longer, and these point to different responses. We assembled an establishment-level panel of every business in Rhode Island from 2016 to 2025 (480,923 geocoded establishment-years across nine annual cross-sections), following the same outlets year to year, and classified and counted unhealthy outlets by census tract. We estimated the tract income gradient three ways (negative binomial regression, a concentration index, and a Bayesian spatial model), tested its stability, and decomposed it into openings and closures. The gradient was strong, stable, and robust: about 30 percent fewer unhealthy outlets per resident per standard deviation of higher income, with racial composition and poverty no longer associated once income was included. It was reproduced through entry, not survival: closures were even-handed across income, while new unhealthy outlets opened about 2.2 times as often per resident in the lowest-income tracts as in the highest. This entry was not unhealthy-specific: new healthy food retail tilted toward lower-income tracts at least as strongly, and the unhealthy share of openings did not rise as income fell. The standing burden was nonetheless dominated by convenience stores and off-premise alcohol. Efforts to reshape the retail environment will have more leverage on new openings than on the existing stock, through instruments defined by outlet type.

Background: High rates of young people who are not in education, employment or training (NEET) are a major societal concern in the UK. Whilst other studies have highlighted that adolescent health can predict NEET status in young adulthood, robust and recent longitudinal evidence remains limited. Methods: This study used data from the Millennium Cohort Study, a longitudinal study of people born in the UK in the early 2000s, to estimate the extent to which mental health conditions, physical health conditions and health behaviours during adolescence predict NEET status in early adulthood (median age: 23). Co-occurrence of exposures was also considered and population attributable fractions were calculated to account for differences in exposure prevalence. Results: Among 8,374 young people, 12.5% were NEET at age 23; approximately two thirds were seeking work and one third were economically inactive. Estimates adjusted for demographic factors indicated that multiple health exposures increased risk of being NEET at age 23, with mental health conditions predicting greater risk than physical health conditions and health behaviours. For instance, a longstanding mental health condition more than doubled the risk of being NEET (adjusted relative risk [aRR] = 2.39, 95% CIs = 1.85, 3.09), while autism (aRR = 3.60, 95% CIs = 2.69, 4.83) and ADHD (aRR = 3.25, 95% CIs = 2.38, 4.44) more than tripled the risk. A greater number of reported adolescent mental health conditions was associated with greater risk of being NEET in young adulthood. Obesity predicted being NEET at age 23 (aRR = 1.54, 95% CIs = 1.18, 2.01) and obesity accompanied by a mental health condition further increased risk (aRR = 2.01, 95% CIs = 1.38, 2.93). Follow-up analyses indicated that associations between adolescent mental health and young adult NEET status were more pronounced for females than males and for the economically inactive than those seeking work. Conclusions: Findings indicate that adolescent health, especially mental health, strongly predicts being NEET in early adulthood. Early, integrated health and education interventions may help reduce later educational and labour market disengagement.

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.

Childhood peer victimization is increasingly recognized as an adverse childhood experience (ACE) with long-term consequences for population health. Most existing research treats bullying as a binary exposure, obscuring the dose-response mechanisms through which cumulative victimization generates escalating health risks. This methodological gap is particularly consequential for prevention, and evidence from the Gulf Cooperation Council (GCC) region remains systematically sparse. This study conducts a national dose-response analysis of childhood bullying and adult health outcomes in Saudi Arabia using the WHO Adverse Childhood Experiences International Questionnaire (ACE-IQ), administered to a nationally representative sample of 10,156 adults by the King Abdullah International Medical Research Center (KAIMRC) and the National Family Safety Program (NFSP), Ministry of National Guard Health Affairs (2013). We conducted a cross-sectional secondary analysis examining associations between bullying frequency and five adult health outcomes: physician-diagnosed anxiety disorder, suicidal ideation, sleep disturbance, tobacco smoking, and substance use. The analytical sample comprised 4,632 adults reporting any childhood peer victimization. Binary logistic regression models adjusted for socioeconomic status, gender, age cohort, parental supervision, and family structure were estimated separately for each outcome. Three pre-specified hypotheses were tested: (H1) any bullying exposure is associated with higher odds of adverse adult health outcomes; (H2) increasing frequency follows a dose-response gradient; and (H3) associations are amplified among socioeconomically disadvantaged respondents and attenuated among those reporting higher parental attention. A consistent dose-response gradient was observed. Frequent victims showed substantially higher adjusted odds of tobacco smoking (OR = 6.55, 95% CI 5.81-7.32) and substance use (OR = 2.71, 95% CI 2.26-3.31) compared to those never bullied. Internalizing outcomes showed significant gradients for anxiety disorder (OR = 0.37, 95% CI 0.16-0.86) and sleep disturbance (OR = 0.39, 95% CI 0.20-0.76). Religion-targeted verbal victimization was the strongest independent predictor of suicidal ideation (OR = 3.01, 95% CI 1.83-4.97) and substance use (OR = 3.24, 95% CI 1.92-5.46), independent of bullying frequency. Bullying-health associations were significantly amplified among socioeconomically disadvantaged respondents, consistent with fundamental cause theory. Parental supervision was protective against substance use (OR = 0.45, 95% CI 0.30-0.67) but showed a paradoxical positive association with suicidal ideation, interpreted as a reactive parenting effect in the cross-sectional design. These findings establish childhood bullying as a cumulative, graded public health risk whose consequences are amplified by structural disadvantage. Prevention strategies must extend beyond school-level programs to address structural inequalities and integrate family-based and community-level protective factors. This study contributes population-level ACE evidence from the underrepresented GCC region and provides a foundation for integrating bullying prevention into Saudi Arabia's Vision 2030 national health agenda.

Objectives: To describe age-group differences in inability to afford dental treatment and cost related dental delay, among the US community-dwelling population. Study design: Descriptive analysis of nationally representative survey data. Methods: Using nationally representative Medical Expenditure Panel Survey data (2018-2021), we examined trends in inability to afford dental treatment and cost-related dental treatment delays across four age groups (2-17, 18-39, 40-64, [&ge;]65 years). Weighted analyses accounted for the complex survey design; statistical significance was set at p<0.001. Results: Cost-related delays declined modestly from 2018 to 2021 but remained most prevalent among adults aged 40-64 (4.8% for ages 40-64, 3.4% for ages 18- 64, 2.2% for ages>65 in 2021; p<0.001). Conclusion: Middle-aged adults seem to experience delays due to cost, underscoring the need for dental coverage to expand dental coverage for this group and to reduce their out-of-pocket costs.

Background: Patient-reported measures (PRMs), including patient-reported outcome and experience measures, capture patients perspectives on their health status and healthcare experiences. In cancer genetics, PRMs have been used to assess genetic knowledge, psychosocial outcomes, and decision-making. However, patients must understand these measures to provide useful information, an ability which is influenced by general and health literacy levels. Readability guidelines recommend that patient-facing materials be written at or below a Grade 6 level. This study evaluated the readability of PRMs used in a cancer genetic testing context. Objective: To assess whether PRMs used in heritable cancer genetic testing meet recommended readability levels using validated indices. Methods: PRMs were identified from a recent systematic review of PRMs used in heritable cancer genetic testing, which reported 83 instruments across eight categories. English-language PRMs containing structured question items and response scales were eligible for extraction and converted into plain text for analysis. Readability was assessed using four validated indices: Flesch Kincaid Grading Level (FKGL), FORd, CAylor, and STicht (FORCAST) formula, Flesch Reading Ease Score (FRES), and Simple Measure of Gobbledygook (SMOG) via an automated readability software. Descriptive analysis and numerical comparison evaluated readability levels across PRM categories and against the recommended Grade 6 reading level. Results: Sixty-five PRMs met the eligibility criteria, with most, including validated instruments, exceeding the recommended Grade 6 reading level. Across the eight categories, genetics-specific PRMs required the highest readability levels, indicating higher readability demands. Conclusions: Most PRMs, particularly those specific to genetics, do not meet readability guidelines. This may limit their accessibility to individuals with limited general and health literacy. Development of PRMs specific to genetics should consider strategies to improve readability, such as plain-language approaches and involvement of individuals with limited general or health literacy. Keywords: readability, patient-reported measures, cancer, genetic testing, health literacy

Introduction: Research has documented that obesity and morbidity are associated. Black persons in the United States (U.S.) incur higher financial costs of obesity-related multimorbidity (ORM). However, lifetime healthcare costs (LHCs) remain underexamined for these populations. Objective: We quantified racial differences in 1) LHCs and 2) lifetime healthcare cost differential (LCD) associated with ORM for ages > 40 years. Methods: We used the 2008- 2012 Medical Expenditure Panel Survey Household Component to examine unique obesity-related diseases (ORDs): high blood sugar, hypertension, coronary heart disease, and stroke. We used a prior published Markov model to simulate a person's life history of ORDs and compute LHCs among ages > 40 years. We computed LCD-associated ORM as the difference in LHC for those with ORM and LHC for members without ORDs. We quantified differences in race as the difference between LHC or LCD among White and Black men and women. Results: Our analytic sample included 53,035 Black and White persons representing 97,229,611 (S.E., 2,104,365), 12.4% as Black and 87.6% as White persons. ORM was more prevalent in the Black (21.2%) than the White group (13.4%). LHCs by race (Black/White) for women/men with ORM and LCDs associated with ORM (2012$) were $3 1,035/43,595 and $11,350/26,948 for age 40-49, $2 1,567/25,6 115 and $3,846/9,808 for 50-59, $9,863/18,515 and -$2,566/7,426 for 60-69, -$8,220/16,285 and -$11,524/3,865 for 70-79. Conclusions: Racial Differences in LHCs and LCDs related to ORM persist and vary across subpopulations. Future interventions designed to prevent/manage ORM are crucial for prioritizing populations with high LHCs and advancing health equity.

Introduction: Childrens exposure to second hand tobacco smoke is a preventable global public health issue, yet there is no consensus on how best to support families to create a smoke free home. This pilot randomised controlled trial tested the feasibility of use of free nicotine replacement therapy combined with telephone delivered support to reduce childrens exposure to second hand smoke in the home, and inform a future full scale trial. Methods: Parents and carers aged 18 and over, who smoke in the home and care for one or more children aged 0 to 16 years were recruited through existing initiatives and social media. Participants were randomised to either the intervention or control arm. Group A received free posted to home nicotine replacement therapy, alongside fortnightly telephone calls to support smoking abstinence in the home. Group B were signposted to the Scottish Government Take it Right Outside website which provides interactive advice on creating a smoke free home. To measure second-hand smoke levels, participants installed an air quality monitor in their living room for 7 days to measure fine particulate matter at baseline and 12 week follow-up. Results: Approximately one-quarter (27 of 100) of the intended sample size was recruited. Median fine particulate matter concentrations reduced in both the intervention (by 36mg per cubic metre) and control (by 16mg per cubic metre) groups. Retention rates and adherence rates to nicotine replacement therapy were 70 percent and above, with no risks and or safety concerns reported, suggesting this approach is feasible and acceptable to participants. The estimated cost of delivering this 12 week intervention was two hundred and forty four pounds per individual. Conclusions: Although recruitment rates were insufficient to recommend progression to a larger trial to test effectiveness of this approach in Scotland, this study could inform trial development in other countries where smoking in the home is commonplace. Insights regarding the alignment of smoke free home interventions with broader smoking cessation initiatives could inform future policy and public health approaches.

Objective: To examine if food insecurity moderates the relationship between rurality and mental health outcomes (suicide mortality, poor mental health days, frequent mental distress) and to assess if these effects vary across U.S. Census divisions. Methods: This county-level (n=2,397) cross-sectional study used OLS and spatial error regression to analyze public data from sources including the County Health Rankings and USDA. We modeled suicide mortality, poor mental health days, and frequent mental distress as functions of the Index of Relative Rurality (IRR) and food insecurity, controlling for median income and provider rates. The suicide model was also tested across nine U.S. Census divisions. Results: Baseline models revealed a paradox: rurality was a direct risk factor for suicide (B=0.400) but protective for poor mental health days (B=-0.224). The national multivariable model revealed a significant, positive rurality-food insecurity interaction for suicide mortality (B=0.861), indicating a synergistic risk. This interaction was not significant for general mental distress, which was more strongly predicted by income and food insecurity. Regional analysis confirmed the suicide interaction was potent in five divisions, including the Pacific (B=3.048) and Mountain (B=1.712) , but absent in others (e.g., South Atlantic). Conclusions: The drivers of suicide are distinct from those of general mental distress and are geographically heterogeneous. The interaction of rurality and food insecurity creates a compounded risk for suicide. Suicide prevention must be regionally-tailored and address structural inequalities, such as food insecurity, alongside clinical care.

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.

Importance: The ASPREE randomized trial found no overall benefit of low-dose aspirin for disability-free survival among older adults. However, individual estimates in pre-specified subgroups indicated potential benefit among racial and ethnic minoritized participants in the United States (US). Objective: To evaluate whether the effect of low-dose aspirin vs placebo on disability-free survival differed across US Black and Hispanic ASPREE participants using individualized treatment-effect estimation. Design, Setting, and Participants: Post hoc clinical trial analysis of ASPREE, a randomized, double-blind, placebo-controlled clinical trial of daily low-dose aspirin vs placebo. This analysis included US ASPREE participants who self-identified as non-Hispanic Black or Hispanic, were aged 65 years or older, and had complete baseline predictor and outcome data. Interventions: Randomization to daily 100-mg aspirin or placebo. Main Outcomes and Measures: The primary outcome was loss of disability-free survival, defined as death, persistent physical disability, or dementia. Individualized treatment effects were estimated post hoc using a Random Survival Forest X-learner. Heterogeneity was evaluated on the relative scale with Cox proportional hazards models and on the absolute scale with 5-year risk differences. Results: Among 2411 US ASPREE participants, 1270 were included in the Black and Hispanic analytic cohort (897 non-Hispanic Black and 373 Hispanic participants; mean age, 71.8 years). Aspirin was associated with lower risk of disability-free survival loss compared with placebo (hazard ratio [HR], 0.65; 95% CI, 0.45-0.93). In model-derived tertiles, aspirin was associated with lower risk in the greatest predicted-benefit group (HR, 0.36; 95% CI, 0.19-0.71; 5-year absolute risk difference [ARD], -11.1 percentage points; 95% CI, -22.0 to -0.1) but not in the lowest predicted-benefit group (HR, 1.26; 95% CI, 0.70-2.27; ARD, +3.9 percentage points; 95% CI, -5.9 to 13.6). Conclusions and Relevance: In these analyses of US Black and Hispanic ASPREE participants, aspirin effects on disability-free survival appear to be heterogeneous, with benefit concentrated in a subset of participants. Because these findings are from post-hoc models, they should be externally validated before being incorporated into clinical decision-making. Trial Registration: ClinicalTrials.gov Identifier: NCT01038583; https://clinicaltrials.gov/study/NCT01038583

Adverse experiences in childhood (AEs) typically refer to undesirable events, including child maltreatment and household challenges. Various survey measures and linked routine data in the Born in Bradford Birth Cohort (BiB) datasets can provide a contemporary understanding of the distribution of AEs in the population and the factors related to their occurrence. This study aimed to identify relevant survey data on AEs collected from BiB families and to summarise the prevalence of AEs from birth to early adolescence (ages 12-15) among BiB children. We included BiB children who participated in the follow-ups - Growing Up (GUp, n=5253) and Age of Wonder (AoW, n=2662). Four AEs were identified - parental mental illness, parental substance use, children not living with both parents in the same home, and being bullied by peers. The survey data included 1) health, substance use, living arrangements, and children's bullying experience reported by parent(s) at baseline (2007-2011, around birth) and/or GUp (2017-2022, during mid-childhood), and 2) bullying experience and living arrangements self-reported by children at AoW (2022-2024, during early adolescence). Additionally, we included parents' primary care records regarding any mental illness or substance use. Overall, 3371 (64.2%) children experienced at least one of the four AEs between birth and early adolescence. The most common AE was parental mental illness, whereas parental substance use was the least common. Children across all sociodemographic groups experienced AEs. Asian children, or those whose mothers were not materially deprived, appeared less likely to experience AEs. Conversely, children of White or Mixed ethnicities, or whose mothers were materially deprived, were more likely to experience AEs. Consistent with similar studies, our findings show that AEs are widespread but disproportionately affect certain sociodemographic subgroups among BiB children. These disparities can be reduced by early-years policies that provide practical family support, guided by continuously collected AE data.

Reduced nicotinamide mononucleotide (NMNH) is a reduced NAD precursor with reported NAD- augmenting activity in preclinical models; however, controlled human data remain limited. This was a randomized, double-blind, placebo-controlled, parallel-group phase I trial evaluating oral NMNH-Ca in healthy adults aged 40-65 years. Eighty participants received placebo or NMNH-Ca 125, 250, or 500 mg once daily for 90 days. The primary objective was safety and tolerability. Whole-blood NAD was assessed as the key pharmacodynamic endpoint, including a 24-hour post-dose substudy, with biomarker-derived blood phenotypic age, treadmill-based six-minute walk distance, body mass index, and SF-36 domains analyzed as exploratory outcomes. NMNH-Ca was well tolerated at all doses, with no serious adverse events, treatment-related adverse events, or discontinuations. In the acute substudy, whole-blood NAD increased after single-dose NMNH-Ca, with peak mean concentrations at 12 hours. Over 90 days, NAD increased in a dose-related pattern; Day 90 mean changes from baseline were 2.33 {+/-} 18.53 M with placebo and 8.22 {+/-} 10.25, 15.85 {+/-} 11.16, and 39.90 {+/-} 14.11 M with NMNH-Ca 125, 250, and 500 mg, respectively. Exploratory analyses showed hypothesis-generating favorable signals in blood phenotypic age, treadmill-based six-minute walk distance, and health-related quality of life, most consistently at 500 mg. Oral NMNH-Ca was safe and pharmacodynamically active over 90 days, supporting larger and longer confirmatory trials with prespecified geroscience endpoints and tissue-relevant NAD metabolomics.

Background: Cardiovascular disease (CVD) disproportionately burdens underserved communities, where social determinants of health (SDOH) perpetuate persistent disparities. Family-based interventions leveraging social support represent a promising yet understudied approach. We describe the rationale, design, and methods of the Skills-based Educational strategies for the Reduction of Vascular Events in Orange County (SERVE OC) RCT and present baseline characteristics of enrolled families. Methods: SERVE OC is a 2-arm RCT of 190 Latino and Vietnamese families (486 individuals) randomized to the family-based intervention or individual self-management. The intervention was grounded in social network theory while employing community engaged strategies. Primary outcomes include achieving ideal cardiovascular health (CVH) defined by AHA Life's Essential 8 (LE8) and systolic blood pressure reduction at 12, 24, and 36 months. Baseline assessments include demographics, LE8, psychosocial factors, food security, and SDOH. Descriptive statistics and regression analyses examined cohort characteristics and associations between SDOH, food security, and LE8. Results: Over 83% of participants had suboptimal LE8 scores. Average adult total LE8 scores were 66.61 {plus minus}11.96, with physical activity as the weakest domain, compared to an average of 76.52{plus minus}10.15 in children. Greater SDOH burden and food security were associated with significantly lower odds of ideal CVH and lower LE8 scores respectively. Conclusions: SERVE OC demonstrates the feasibility of enrolling families in community-engaged RCT targeting CVD disparities in underserved population. Baseline findings confirm substantial CVD risk and SDOH burden underscoring the need for multi-level, culturally tailored interventions. Trials results will inform scalable, family-focused strategies for CVD prevention across the life course. Clinical Trial Registration: URL: https://www.clinicaltrials.gov/; Unique Identifier: NCT05641519.